EuroTimes Vol. 20 | Issue 3 by EUROTIMES

SPECIAL FOCUS CATARACT & REFRACTIVE LENS CORNEA

A TALE OF TWO BUBBLES 窶的MPORTANT CLINICAL IMPLICATIONS March 2015 | Vol 20 Issue 3

ROBOTIC DEVICE BRINGS NEW LEVEL OF PRECISION TO VR SURGERY

XIS

E M CO

INNOVATION

CIS

ION

CAPSULORHEXIS RECONSIDERED EX

IE R PE

The Essence of Perfection For Retina, Cataract and Glaucoma Surgery • Newly developed vacuum and flow tri-pump system • SPEEP® mode for very precise maneuvers • Active- and gravity infusion • Up to 10’000 cuts with Twin-Blade Cutters • Double light source with color adjustable LED technology • Fully integrated 532 nm green endolaser • Brand new phaco engine for even more efficiency and safety • Wireless, dual linear all-in-one foot switch • Intuitive user interface with Direct Access® • Designed for fast and sterile work flow • Utmost system performance thanks to latest Embedded Controller Technology

Ecknauer+Schoch ASW. Not available for sales in the US. ID1002.E-2015.02

www.oertli-os4.com

P.14

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

FEATURES

CATARACT & REFRACTIVE LENS 4 Cover Story: As IOLs

CORNEA

for FS-cut capsulotomy emerge, is the laser useful?

7 Supracor treatment a

good option but has high regression rate, finds study

8 Aphakic wavefront

refraction measurements in surgery

11 ‘Secondary IOL procedures can provide visual improvements’

with newly discovered layer of cornea

14 Nerve growth factor

– ocular healing and regeneration

GLAUCOMA 16 Phaco: long-term

IOP-lowering effect in glaucoma

17 Goldmann applanation tonometry – can it be replaced?

P.39

18 Uveolymphatic

outflow offers new therapeutic targets

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2013 and 31 December 2013 is 40,878.

12 Vital clinical implications

REGULARS 27 Innovation

RETINA

28 Industry News

20 ‘Home monitoring device

29 Ophthalmologica update

could be a useful ally in detecting CNV’

21 Implant can significantly improve vision for DME patients, according to studies

P.27

22 Better screening urgently needed for diabetic retinopathy

31 Book Reviews 33 Outlook on Industry 34 Eye on Technology 36 ESASO update 37 JCRS Highlights 39 Travel 40 Calendar

EUROTIMES | MARCH 2015

EDITORIAL A WORD FROM OLIVER FINDL MD

TECHNOLOGY BENEFITS Are there any limits to what we as surgeons and doctors can achieve in ophthalmology?

his month’s cover story looks at how new lenses But I would also urge EuroTimes readers to look at the wider designed to take advantage of the precise capsulotomies question of the limits to what we as surgeons and doctors can made possible by femtosecond lasers hold the potential achieve in ophthalmology using the new technologies and devices to solve many refractive issues with intraocular lenses that are coming on the market. (IOLs). They may do everything from enhancing the predictability of lens position to reducing higher DUTY OF CARE order aberrations and eliminating lens dislocation and tilt, edge We must not forget that our first duty of care is to our patients. dysphotopsias and PCO. We must work closely with industry to make sure that new devices In our cover story we look at the various lenses now on the and technologies will result in better outcomes. We must also market with grooves designed to snap into a precisely sized remember that as doctors we must follow our own instincts and capsulotomy as well as devices and pharmaceuticals that might be decide what works best for us as individual doctors. used with them to enhance their inherent stability, such In other words, we all have as capsule tension rings and antifibrotics that modulate different skill sets and while an healing responses. We must not forget that individual laser, for example, may So where do we go from here? Early data from the our first duty of care is to work very well for one doctor, ongoing ESCRS Femtosecond Laser-Assisted Cataract it might not work as well for his our patients. We must work Surgery Study show that nearly 98 per cent of more than colleague in another clinic or 2,000 FLACS procedures reported through August 6, closely with industry to hospital. My colleague Dr Peter 2014 involved laser-cut capsulotomy, with laser nuclear Barry addressed this subject recently make sure that new devices fragmentation second at 90 per cent. By comparison, in EuroTimes (Vol 19, Issue 4, P44, only one in three FLACS procedures involved laserand technologies will result April 2014) when he pointed out cut corneal incisions and one in five astigmatism that quality can only be achieved by in better outcomes correcting incisions. listening to patient feedback. As one of the doctors who contributed to the As chairman of the ESCRS Young Ophthalmologists Committee, cover story, I would agree that laser cut capsulotomy has I have repeated this message to doctors in training but it also holds exciting possibilities. But I would also urge caution based on true for those colleagues who have years of experience and who are a 2013 retrospective study of manual capsulorhexes involving well established in their practices. 635 patients which I carried out. My study compared cases In conclusion, there is much to consider and to debate and I with “optimal” rhexes of 4.5mm to 5.5mm and 360-degree hope you enjoy the continuing discussion in this issue and future optic overlap with eccentric and smaller rhexes and found no issues of EuroTimes. significant difference in lens tilt or anterior chamber depth change, and a mean difference in centration of just 0.08mm in the eccentric group, three months after surgery. This would not result in any benefit for patients. My colleagues Dr Julian Stevens, Dr Jack Holladay, Dr Ludger Hanneken and Dr Samuel Masket also make excellent contributions to the discussion on this subject in our cover story and I would encourage you to read and digest * Oliver Findl is secretary of ESCRS and chairman their comments. of the Young Ophthalmologists Committee

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 | MARCH 2015

YOUR REPUTATION IS BUILT ON EVERY SUCCESSFUL CASE. SO IS OURS.

THE ACRYSOF® ADVANTAGE

BioMachanics BioMachanics BioMachanics BioMaterial BioMaterial BioMaterial

BioOptics BioOptics BioOptics

Bio O pBtiiocO sBipotO icps tics

BioMaterial

Bio

Bio Bio

Bio O pBtiiocO sBipotO icps tics

BioMechanics

BioM ate ri BioM ate BioM ri ate ri

Bio Bio

BioM ate ri BioM ate BioM ri ate ri

Bio

Bio Bio

ics han ec M anics h ec M ics han ec M

Bio O pBtiiocO sBipotO icps tics

BioOptics

COVER STORY: CATARACT & REFRACTIVE LENS

CAPSULORHEXIS RECONSIDERED As IOLs for FS-cut capsulotomy emerge, is the laser or its precision useful? Howard Larkin reports EUROTIMES | MARCH 2015

COVER STORY: CATARACT & REFRACTIVE LENS

n the six years since the dawn of femtosecond laser-assisted cataract surgery (FLACS), precise capsulotomies have been touted as one of its biggest advantages. Perfectly sized, shaped and centred anterior capsule openings should help position and stabilise intraocular lenses (IOLs), leading to more predictable effective lens position and better visual outcomes, proponents say. “A large capsulotomy or capsulorhexis allows the IOL to bulge forward very slightly and a small capsulotomy keeps the lens more posterior, about a halfdioptre difference. Removing that variation is helpful,” Julian Stevens MRCP, FRCS, FRCOphth, DO, consultant surgeon at Moorfields Eye Hospital, London, told the XXXII Congress of the ESCRS in London, UK. This reasoning appears to resonate. Early data from the ongoing ESCRS Femtosecond Laser-Assisted Cataract Surgery Study show it is the most frequently used FLACS capability. Nearly 98 per cent of more than 2,000 FLACS procedures reported through August 6th, 2014 involved laser-cut capsulotomy, with laser nuclear fragmentation second at 90 per cent. By comparison, only one in three FLACS procedures involved laser-cut corneal incisions and one in five astigmatism correcting incisions. Yet data on the subject are mixed. Many studies document the clear superiority of FS capsulotomies over manual rhexes

in terms of circularity, intended size and centration. A few even show slightly better mean visual outcomes for FS laser capsulotomies. For example, a 2012 prospective study involving 372 patients by Harvey Uy MD, Manila, Philippines and Warren E Hill MD, Mesa, Arizona, US, showed a mean advantage of about 0.2 dioptres for FS-treated eyes. Other studies cast doubt on the impact of capsulotomy perfection on lens position. A 2013 retrospective study of manual capsulorhexes involving 635 patients by Oliver Findl MD of Hanush Eye Hospital, Vienna, and Moorfields, comparing cases with “optimal” rhexes of 4.5mm to 5.5mm and 360-degree optic overlap with eccentric and smaller rhexes found no significant difference in lens tilt or anterior chamber depth change, and a mean difference in centration of just 0.08mm in the eccentric group, three months after surgery. Dr Findl said its not surprising rhexis morphology has little effect on lens position because most modern IOLs fixate in the capsular bag equator, centring the optic in the bag. “But it becomes a different issue if you fixate the optic in the capsulotomy. You would think that such a lens is not going to change position,” he noted. Inspired in part by the precision offered by laser-cut capsulotomies, at least two new lenses designed to clip into anterior capsule openings are now available in Europe, with large-scale clinical trials pending. Proponents say they hold the potential to solve many IOL refractive issues, from enhancing predictability of effective lens position to reducing higher order aberrations to eliminating negative dysphotopsias along with lens tilt and decentration. Only large prospective trials will determine whether these and other capsulotomy-fixated lenses will fulfil the tantalising refractive promise of femtosecond laser-assisted surgery. But even if they succeed, they still may not completely vindicate FLACS. Technologies that enhance the precision of manual capsulorhexis as well as anterior capsulotomy lasers that bolt on to surgical microscopes may well deliver the benefits – without the steep femtosecond laser price.

ON THE VISUAL AXIS One problem with IOLs that centre in the capsular bag is the bag centre is usually not in line with the visual axis, and therefore the lens is not centred on the visual axis, where it provides the best optical

A large capsulotomy or capsulorhexis allows the IOL to bulge forward very slightly and a small capsulotomy keeps the lens more posterior Julian Stevens MRCP, FRCS, FRCOphth, DO performance, said Jack T Holladay MD, Bellaire, Texas, US. While every patient is different, on average the bag centre is about 0.3mm temporal to the pupil centre while the visual axis is about 0.3mm nasal and slightly inferior to the pupil centre. The resulting displacement of the lens centre off the visual axis by about 0.6mm is inconsequential with monofocal lenses, inducing a slight horizontal coma, Dr Holladay said. But it is critical for multifocal diffractive optics, where even a small misalignment results in patient complaints of glare, “waxy” vision and decreased corrected visual acuity. The solution is moving the lens centre as close to the visual axis as possible, Dr Holladay said. In experiments conducted with Paolo Vinciguerra MD and Eric Donnenfeld MD, glare and blur disappeared and vision improved from 20/30 to 20/20 or better in several patients after their lenses were pushed nasally on to the visual axis using a 30-guage needle or moving the pupil using an argon laser. Indeed, experienced refractive surgeons often nudge the superior haptic of multifocal lenses slightly nasally during initial implantation to achieve this effect, Dr Holladay noted. The manoeuvre generally works but it is more art than science and is not always stable. The lens may shift after surgery as the haptics settle and push the optic back toward the centre of the bag. Lenses that fixate on a capsulotomy centred over the visual axis will likely be more reliable and precise, Dr Holladay said. “It should stabilise the lens so it cannot decentre with respect to the visual axis and that is good.”

It should stabilise the lens so it cannot decentre with respect to the visual axis and that is good Jack T Holladay MD EUROTIMES | MARCH 2015

COVER STORY: CATARACT & REFRACTIVE LENS Creating such a capsulotomy with a femtosecond laser system should also be simple, requiring no more than using a coaxial light source to the capsulotomy on the first Purkinje image, which marks the visual axis on the corneal surface. The Oculentis Femtis lens appears to be truly capsulotomy fixated, Dr Holladay said. An aspheric lens designed to be aberration neutral, it features a groove around the optic edge into which the capsulotomy edge fits much as a bicycle tyre fits on a rim. Small anterior haptics and larger posterior haptics keep the lens in place, which has an overall length of 10.5mm. It is entering large-scale clinical trials this year, said Ludger Hanneken MD, Cologne, Germany, who implanted Femtis in several patients in early clinical trials.

ELIMINATING NEGATIVE DYSPHOTOPSIA A second lens designed with femtosecond laser-cut capsulotomies in mind is the Morcher 90S. It also features a groove around the optic into which the capsulotomy edge is inserted. However, its purpose is primarily preventing negative dysphotopsias, said Samuel Masket MD, Los Angeles, US, who holds a patent on the design. The literature suggests that up to 15 per cent of IOL patients experience negative dysphotopsia immediately after surgery, with the number declining to about two per cent after one year, Dr Masket said. He developed the grooved lens concept after conducting extensive examinations of the anatomic relationships of pseudophakic eyes of patients experiencing pronounced peripheral shadows. He concluded that the 360-degree overlap of the capsulotomy on to the IOL optic is the common pathway leading to negative dysphotopsia regardless of lens design or temporal incision placement. This conclusion has been borne out by clinical experience that shows negative dysphotopsia can persist even after an in-the-bag lens exchange, but is invariably eliminated by placing the optic in front of the capsulotomy, Dr Masket said. This can be done either by reverse capturing the optic in front of the bag with the haptics in the bag, or implanting a lens in the ciliary sulcus. However, both techniques risk iris chafing and virtually guarantee rapid bag shrinkage with fibrotic PCO. “My thought was to develop a lens implant that remains in the bag and has the stability to prevent fibrotic PCO, but with a portion of the optic overlaying the anterior capsule to prevent negative

dysphotopsia,” Dr Masket said. The Morcher lens is based on the concept and includes these features, including a square posterior edge to impede lens epithelial cell migration, he added. As of the end of 2014, about two dozen of the lenses had been implanted in humans, Dr Masket said. While a prospective trial involving 70 to 100 patients will be needed to statistically demonstrate the effect, so far no patients have suffered negative dysphotopsias or iris chafe. Dr Masket allows that the design also enables centring the optic on the visual axis and that this might reduce higher order aberrations as well as lens tilt and decentration. It might also improve the predictability of effective lens position by preventing phimosis and the axial displacement that may result, though these effects also have yet to be demonstrated. “My primary interest is eliminating negative dysphotopsia. We are pleased there are other advantages to the design and we hope surgeons will take advantage of them.”

IS FS LASER REALLY NEEDED? In Dr Masket’s mind the only question remaining is whether a femtosecond laser is really required. Indeed, Dr Findl has successfully implanted six of the Morcher 90S lenses using a manual capsulorhexis guided by a Zeiss Callisto system that superimposes an outline of the proposed opening through the surgical microscope, and holds it on target with an eye tracker. Dr Findl believes that while following the projected guide requires a little extra effort, most surgeons should be able to do it. “Maybe a trainee or someone who does less surgery may have more difficulty, but for an experienced surgeon it is not a big deal,” he said. Other observers are less confident that most surgeons can execute a manual capsulotomy with sufficient precision. “Dr Findl is an exceptionally skilled surgeon,” Dr Masket noted. “To have the capsulorhexis perfectly round and centred on the visual axis – you can’t do that by hand,” Dr Holladay said. Other technologies might also help attain the precision required without resorting to a femtosecond laser. A doughnut-shaped silicone ring with a sizing scale incised on the surface that adheres to the capsule surface designed by Malik Kahook MD, Denver, US, is helping residents and skilled surgeons create more

My thought was to develop a lens implant that remains in the bag and has the stability to prevent fibrotic PCO... Samuel Masket MD

precisely sized and shaped capsulotomies. A YAG laser for anterior capsulotomies that bolts on to the surgical microscope is also in development. The utility of capsulotomy-fixated lenses may also be limited. Dr Findl noted that bothersome negative dysphotopsia is rare, presenting in just a handful of the 6,500 cases his centre operates annually. Therefore, a dysphotopsia-preventing lens might be reserved for those requiring a lens exchange, or in the fellow eye of a patient with severe negative dysphotopsia. Dr Holladay believes capsulotomy fixation may be really useful only for premium lenses that are sensitive to precise lens placement. In descending order of sensitivity, these include multifocal diffractive, extended depth of focus and highly aspheric lenses. Toric lenses may also benefit from capsulotomy fixation. Dr Holladay also sees potential for reduced surgical variation eventually leading to better visual outcomes. “We have all the ingredients to put the lens where we want it and have a 360-degree overlap even though it is decentred in the bag a little bit. It will improve the performance of multifocal and premium lenses. What we don’t know is if it will actually reduce the prediction error of where the lens ends up (axially). We don’t know if the repeatability of the femtosecond laser will actually do that,” he said. Julian Stevens: julianstevens@compuserve.com Jack Holladay: holladay@docholladay.com Samuel Masket: avcmasket@aol.com Oliver Findl: oliver@findl.at Ludger Hanneken: hanneken@sehkraft.de Warren Hill: hill@doctor-hill.com

Türkiye TURKISH LANGUAGE EDITION ONLINE Visit: www.eurotimesturkey.org EUROTIMES | MARCH 2015

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

SUPRACOR STUDY

OCULUS Keratograph 5M

Treatment effective but has high re-treatment rates, finds Irish study. Priscilla Lynch reports

Topography and advanced external imaging for dry eye assessment

TECHNIQUE The aim of the Irish study was to investigate the safety and efficacy of the technique in treating hyperopic presbyopia, as well as measuring the need for enhancement procedures. The Irish study series included 30 males and 28 females. The patients’ mean age was 56 years. The minimum followup time was three months, and the mean follow-up time was seven months. The study’s main outcome measures were unaided binocular vocational reading test performance, post-Supracor best corrected visual acuity, and the re-treatment rate. Following treatment, 95 per cent of the studied patients were able to read N8 or better three months after the procedure. In addition, 97 per cent of patients were able to read LogMAR 0.1 or better three months following the procedure.

RESULTS Corrected distance visual acuity results overall were very good, though there was a loss of one line or more in a sizeable proportion of patients, he reported. However, more than half (a total of 34) of the 58 patients required a re-treatment, Dr Doyle reported. Of these patients, 24 required one enhancement, six required two, three required three, and one patient required four enhancements. Although near and distance visual results were good with the Supracor procedure, there is a high regression rate and a high need for enhancement following the procedure, he concluded. Further strategies must therefore be devised to reduce the re-treatment rate, and currently its usage is debatable, Dr Doyle maintained. “Supracor is not CE approved currently in Ireland. In our centre we have actually stopped using it due to the high regression rate so there is certainly ongoing debate on it,” he told EuroTimes.

•

High-resolution color camera

•

Imaging of the upper and lower meibomian glands

•

Non-invasive tear film break-up time and tear meniscus height measurements

•

Assessment of the lipid layer and tear film particles

•

Grading of the bulbar redness

•

Comprehensive JEVIS Dry Eye Report

Please note: The availability of the products and features may differ in your country. Specifications and design are subject to change. Please contact your local distributor for details.

upracor (multifocal excimer laser in situ keratomileusis) is a good treatment option for hyperopic presbyopia but has a high regression rate, which needs to be improved before it can be considered as standard practice, according to Fergus Doyle MD, Ophthalmic Surgery Registrar, St Vincent's Hospital, Dublin, Ireland. At the 2014 Irish College of Ophthalmologists Annual Conference, Dr Doyle and colleagues presented the threemonth follow-up results of 58 patients following Supracor hyperopia and presbyopia correction. The Supracor technique uses an excimer laser to steepen the central part of the cornea in an attempt to correct presbyopia. The surgeon uses the Supracor algorithm to reshape the cornea using a proprietary multifocal corneal ablation profile.

www.oculus.de

Fergus Doyle: fergus.doyle@gmail.com EUROTIMES | MARCH 2015

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

ABERROMETRY Aphakic wavefront refraction measurements in cataract surgery. Roibeard O’hEineachain reports

ntraoperative wavefront aberrometry measurements of refraction in the aphakic stage of a cataract procedure show good reproducibility, but good measurements are only possible in about half of attempts and the range of error appears to be too large to be used in a clinical setting, according to the results of a study presented by Jan O Huelle MD at the XXXII Congress of the ESCRS in London. “More efforts are required to improve the precision and quality of measurements before intraoperative wavefront aberrometry can be used to guide the surgical refractive plan in cataract surgery,” said Dr Huelle, South West Peninsula Deanery, NHS South West Peninsula, UK, and Dr Stephan Linke, University Medical Centre Hamburg-Eppendorf (UKE), Germany. Dr Huelle noted that studies have shown that wavefront aberrometry refraction measurements agree closely with manifest refraction. There are reports in the literature suggesting that intraoperative biometry during cataract surgery can provide a very good estimation of the appropriate intraocular lens (IOL) dioptric power needed for optimum visual outcome in a given eye. However, the aphakia formulas used in those studies are all based on a different method of measurement, namely autorefractive retinoscopy. “Up until now there has been no data on the precision of intraoperative wavefront aberrometry measurements for IOL

Positions of fellowships available in

Paediatric and Refractive Ophthalmology Under the Direction of Professor Michael O’Keeffe FRCS At the Mater Private Hospital and The Children’s University Hospital, Temple Street, Dublin. Fellowships for one year commencing 1st February and 1st July 2015. Candidates must have at least 3 years experience FRCS or equivalent in clinical ophthalmology and have surgical experience. Candidates must have or be eligible for full registration with the Irish Medical Council. For further information contact: Helen Murphy Suite 5 Mater Private Hospital, Eccles Street, Dublin 7 Tel: 00353 1 8858626 Email: mokeefe@materprivate.ie

Courtesy of Jan O Huelle MD

Figure 1: Linear regression analysis on the distribution of adjusted IOL power (calculated with Holladay’s refractive vergence formula) and predicted IOL power as derived from our formula, differentiating between axial length <25.5mm and >25.5mm

estimation when used with published aphakia formulas for IOL calculations. We wanted to fill that gap,” Dr Huelle said. Their study included in 74 eyes of 74 consecutive patients with a mean age of 69 years who were undergoing straightforward cataract surgery. All eyes underwent preoperative biometry measurements with the IOL master V. All eyes also underwent seven intraoperative wavefront aberrometry measurements performed at different stages during cataract surgery. Manifest refraction at three months after surgery served as the best estimate for the refractive outcome. In their analysis, they used automated wavefront map area calculation to obtain an objective quality grading of the aberrometry measurement. They also used Holladay refractive vergence formula to retrospectively calculate the IOL that would have provided the target refraction. They also performed regression analysis to generate formulas to predict the adjusted IOL, based on the aphakic spherical equivalent. (Figure 1) The researchers found that, out of 814 intraoperative wavefront measurement attempts, only 478 were successful and in only 40.6 per cent of eyes were all three measurements at the aphakic stage successful. The most successful readings were in aphakia with OVD. The highest quality wavefront measurements were achieved after clear corneal incision and the lowest when the eyes were pseudophakic with OVD. The quality of the wavefront measurements at the aphakic stage was somewhere around the middle. Dr Huelle noted that if they had used the published autorefractive retinoscopy based aphakia formulas among those with three successful aphakic wavefront measurements, less than 20 per cent would have been within 0.5D of target refraction, and less than 30 per cent would have been within 1.0D. However, when using the aphakia formula derived from their regression analysis, 25 per cent of eyes would have been within 0.5D of target and 53.1 per cent would have been within one dioptre. Moreover, when they modified their formula to take the axial length into account, 40.6 per cent and 70.3 per cent would have been within 0.5D and 1.0D of target refraction respectively. “Intraoperative wavefront aberrometry shows good reproducibility in aphakia if the measurement succeeds. But clinically the ranges appear to be too large, and that is why the measurement precision needs improving,” said Dr Huelle and Dr Linke. Jan O Huelle: jan.huelle@doctors.org.uk Stephan Linke: s.linke@uke.de

EUROTIMES | MARCH 2015

XXXIII Congress of the ESCRS 5–9 September 2015

Fira Barcelona Gran Via, Spain North Access Hall 8

Registration & Hotel Bookings Open Abstract Submission Deadline 15 March 2015

www.escrs.org /ESCRS @ESCRSOfﬁcial

ESCRS

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

SECONDARY IOL Visual outcomes usually good despite complex case mix. Roibeard O’hEineachain reports

econdary intraocular lens (IOL) procedures with modern surgical techniques can provide visual improvements in most patients, although ocular comorbidities double the risk of a poor visual outcome, suggests a long-term retrospective study. “Despite the risk of postoperative complications, our complex case mix from a tertiary referral population shows that good final visual acuity outcomes can still be safely achieved from carefully planned secondary intraocular lens surgical procedures in challenging eyes,” Jason Ho MBBS reported at the XXXII Congress of the ESCRS in London. The study reviewed 197 eyes of 172 consecutive patients who underwent secondary IOL procedures at Moorfields Hospital from 2003-2012 and a mean follow-up of around five years, said Dr Ho, an ophthalmology resident at Moorfields Eye Hospital and Academic Clinical Fellow at the Institute of Ophthalmology, University College London. The most common procedures were secondary IOL insertion for aphakia, which included 76 anterior chamber IOL implantations, 65 sulcus IOL implantations, and three secondary in-the-bag implantations. In addition, 39 eyes underwent IOL exchange and 14 underwent IOL repositioning (23.5 per cent). Dr Ho noted that approximately two-thirds of the patients had significant ocular comorbidities, including penetrating intraocular trauma, intraocular foreign body cases. Nearly half of patients had undergone complicated cataract surgery with complications. In addition, 14 per cent had already undergone previous vitreoretinal interventions for retinal detachments occurring either before or after cataract surgery or as a result of complicated phaco. Nonetheless, despite the two-thirds comorbidity rate, two-thirds of patients achieved vision of 6/12 or better. The median best corrected visual acuity (BCVA) improved from 6/60 preoperatively to 6/16 postoperatively among those undergoing IOL exchange or repositioning, and from 6/69 to 6/13 among those receiving the lenses for aphakia or other reasons. Around half of those with final BCVA worse than 6/12 had a contributing ocular comorbidity.

LEGACY APHAKES Among patients undergoing the procedures for aphakia, typically three months after removal of the crystalline lens, those who received posterior chamber implants achieved slightly better final acuity than those with anterior chamber implants, although the difference did not reach statistical significance, Dr Ho said. The “legacy” aphakes who had undergone intracapsular cataract surgery in the 1980s had significant gains in vision following the secondary lens implantation, with mean visual acuity improving from 6/21 preoperatively to 6/15 postoperatively (p=0.006). Visual acuity was also significantly improved for those who underwent secondary lens implantation to correct aphakia resulting from complicated phaco procedures, with a mean final value of 6/15, compared to 6/280 preoperatively (p=0.0001). Among those 36 patients who underwent the secondary procedures for refractive reasons, the significant improvement in mean spherical equivalent, from 3.23D to 0.96D (p=0.02) was not matched by a statistically significant improvement in mean visual acuity (6/32 preoperatively to 6/12 postoperatively, p=0.466). Their indications for the surgery included anisometropia, astigmatism and refractive surprises, and most received sulcus piggyback lenses. The overall complication rate was 29 per cent. Early complications included uveitis in 16 eyes, cystoid macular oedema in 10 eyes, elevated IOP in eight eyes, hyphaema in three eyes and wound healing problems in two eyes. The late complications included glaucoma in 10 eyes, nine IOL dislocations, five cases of PCO and four cases of corneal decompensation. Among the nine eyes with IOL dislocations, there were seven with significant comorbidities, including four eyes for which penetrating trauma was the original indication for the secondary IOL. “While these procedures do significantly improve vision in our complex cohort of patients, two-thirds of our cases had significant comorbidities and it is important to counsel carefully that the presence of ocular comorbidity doubles the risk of a poor visual outcome,” Dr Ho added. * Dr Ho has asked us to credit Mr Alex Ionides and Mr Badrul Hussain, consultants at Moorfields Eye Hospital, as senior authors of the study Jason Ho: Jason.ho@moorfields.nhs.uk EUROTIMES | MARCH 2015

CORNEA

A TALE OF TWO BUBBLES Newly discovered layer of cornea has important clinical implications. Roibeard O’hEineachain reports

hough some remain skeptical, there is increasing evidence to support the existence of the “Dua Layer”, a tough acellular layer of stroma-like tissue immediately adjacent to the Descemet’s membrane, said Harminder Dua MD, PhD, in his Rayner Medal Lecture delivered at the UKISCRS 38th Annual Congress in London, UK. “I have chosen a topic that is still a little controversial, but I'm still sticking to the evidence my team and I have generated, and with some trepidation to the name,” said Dr Dua, Nottingham University, Nottingham, UK. He noted that the origin of the hypothesis of the presence of this layer of tissue stemmed from several observations. One observation was that in deep anterior lamellar keratoplasty procedures the apparently bared Descemet’s membrane is generally much more sturdy and resilient than Descemet’s membrane when it is removed from the posterior stroma. When a suture is passed through a button used in penetrating keratoplasty a EUROTIMES | MARCH 2015

distinct sharp edge is seen as the needle emerges from the deep stroma. This has been attributed to the Descemet’s membrane. When suturing a button prepared for deep anterior lamellar keratoplasty (DALK) by removing the Descemet’s membrane, such an edge is still visible, indicating that there is another layer of tissue that produces this edge in addition to the Descemet’s membrane. Moreover, when Descemet’s membrane is peeled from the back surface of a donor button it comes off easily but when deep stroma is separated from the front surface of the Descemet’s membrane, which essentially is the same thing, more resistance and strands of collagen are encountered. This suggested that the two planes were different, the latter being between deep stroma and the new layer. Furthermore, many corneal surgeons who perform lamellar keratoplasty find that there are two different types of bubbles that occur when using the big bubble technique. There are bubbles that start at the centre but do not extend all the way to the periphery, which Dr Dua terms as Type 1 bubbles (Figure 1), and there are bubbles that start on the periphery and

spread from there across the centre, termed Type 2 bubbles (Figure 2). The Type 1 bubbles generally have a diameter no greater than 8.5mm and the Type 2 bubbles have a diameter up to 12.0mm. On occasions the two types of bubbles occur at the same time with the Type 1 being usually complete and the Type 2 being partial. Such bubbles are termed “mixed bubbles” (Figure 3). Until Dr Dua reported his findings it was believed that mixed bubbles were due to a split in the banded and non-banded zones of the Descemet’s membrane. That misconception has now been dispelled. In a series of experiments using donor eyes, Dr Dua and his associates were able to demonstrate that the Type 1 bubbles occur between the posterior stroma and what appears to be a previously undiscovered layer of tissue. Among their findings was that although Type 2 bubbles deflate when Descemet’s membrane is removed, the Type 1 bubbles do not (video). In addition, they showed that it is still possible to create a Type 1 bubble in corneas where the Descemet’s membrane has been removed, whereas it is not

CORNEA

Courtesy of Harminder Dua MD, PhD

Figure 1 - Type 1 big bubble

Figure 2 - Type 2 big bubble

Figure 3 - Mixed bubble

possible to create a Type 2 bubble under those conditions. Histological examination of this layer indicates that it is around 10 microns in thickness and is composed of acellular tissue consisting of predominantly Type 1 collagen bundles but with higher concentrations of collagen 6 than is present in other parts of the cornea. They also showed that the periphery (approximately half a millimetre) of this layer along its circumference is populated by trabecular cells which lie between lamellae of the layer and lay down basement membrane. At this point the lamellae start to split and continue as the collagen core of the trabecular meshwork. Dr Dua noted that to take advantage of the sturdy and resilient nature of the newly discovered layer, he and his associate

Dr Amar Agarwal MD have developed a technique for deliberately including the pre-Descemet’s or Dua’s layer with the donor endothelium in a modification of Descemet’s membrane endothelial keratoplasty (DMEK) that has been christened pre-Descemet’s endothelial keratoplasty or PDEK. Results in the first few patients have been published and appear promising, with good graft attachment and good postoperative visual recovery in all cases. Similarly with another colleague, Dr Ahmed Atef Zaki, he has published results to show that the toughness of the layer allows a complete cataract extraction with lens implant to be carried out during the DALK operation, a procedure termed “triple DALK”. He added that the presence of Dua’s layer can help explain the otherwise

unaccountable superior strength of DALK grafts compared to penetrating grafts; why some descemetoceles (covered with this layer) resist perforation and have some evidence to suggest that this layer also splits together with the Descemet’s membrane during acute hydrops in keratoconus.

TRENDS IN SURGICAL & MEDICAL RETINA

Harminder Singh Dua: harminder.dua@nottingham.ac.uk

Scan this QR code to go to video link for surgery

3rd Meeting IMO, Barcelona 29th & 30th May 2015

• LIve Surgery (9 caSeS In 5 dIfferent OperatIng rOOMS) • panneL dIScuSSIOnS • rOund taBLeS Organized by: Borja corcóstegui, Md

For further information, please contact the secretary office of the Meeting: Marta rodríguez: prensa@imo.es ana cristina de arriba: events@imo.es carlota guinart: comunicacion@imo.es

early bird registration (before april 1st): 300€ after april 1st: 350€

tel. (+34) 93 253 15 00

Online registration: www.imo.es/retinabarcelona2015

EUROTIMES | MARCH 2015

CORNEA

NGF & CORNEAL DISEASE Nerve growth factor stimulates ocular healing and regeneration.

Image 1: Neurotrophic corneal ulcer resistant to all conventional treatments

Image 2: Ulcer healed after topical NGF treatment

Dr Rama noted that preliminary data from the phase 1-2 REPARO study, the first international clinical trial evaluating rhNGF eye drops in neurotrophic keratitis, shows corneal healing in more than 70 per cent of masked subjects at eight weeks, with observed reductions in lesion size and symptom improvements. This efficacy is even more impressive, said Dr Rama, when one considers that the randomisation schedule for phase 2 was 7:2 (rhNGF versus placebo control). “Four patients that were unmasked for aggravation of their lesions were all under placebo and they all healed when they switched to rhNGF. The key point is that NGF induced not just healing of the corneal lesion but also promoted the restoration of corneal sensitivity,” he said. Dr Rama said that the manufacturers hope to commence a similar study with 48 patients enrolled in 11 centres in the United States in the coming months. Other potential ocular applications for NGF include dry eye, with an open label cohort study in 20 patients currently ongoing in Austria. The posterior segment also holds rich potential, said Dr Rama, with the LUMOS phase 1-2 multicentre study in five Italian centres now under way to study rhNGF drops in retinitis pigmentosa, and another one scheduled to commence shortly in Milan. Plans are also at an advanced stage to assess rhNGF in glaucoma in a phase 1b trial involving 20 patients at two centres in the United States. As well as these trials, other possible targets for NGF treatment in the future include ocular inflammation, herpetic disease, immune stromal keratitis, neuropathies and keratoconus, said Dr Rama.

ecent clinical trials of topically administrated nerve growth factor (NGF) demonstrate that the ocular surface healing and immune-modulating actions of NGF could have widespread therapeutic applications in a wide range of ocular diseases, according to Paolo Rama MD. “Exogenous NGF is very effective in promoting healing and regeneration and specifically in treating neurotrophic corneal ulcers. In ocular surface diseases, topical NGF may play a role in restoring corneal innervation, improving the tear film and modulating inflammation. It may also be useful for several other ocular disorders such as herpetic keratitis, autoimmune ulcers, glaucoma, various neuropathies, diabetic retinopathy and agerelated macular degeneration,” he told delegates attending the 5th EuCornea Congress in London. Dr Rama explained that NGF was first discovered in the early 1950s by Nobel Prize winner Prof Rita Levi Montalcini and serves as an endogenous human protein that stimulates the growth, maintenance and survival of neurons in the central nervous system. Surveying the clinical evidence to date, Dr Rama said that NGF was shown to be both safe and effective in the treatment of neurotrophic keratitis in over 100 patients in an open-label study published in 2000. All patients in that trial demonstrated complete healing with only mild transient side effects. In January 2011, the Italian company Dompé acquired the worldwide rights for the development and commercialisation of NGF and succeeded in producing an enhanced recombinant human (rhNGF) form of the compound.

Scientific Programme organised by

Paolo Rama: rama.paolo@hsr.it

Friday 4 September

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

EUROTIMES | MARCH 2015

Courtesy of Paolo Rama MD

Dermot McGrath reports

ESCRS

www.escrs.org

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

THE PRESBYOPIA SOLUTION THEY’VE BEEN WAITING FOR. SNELLEN ACUITY

20/12.5

INLAY EYE

20/20

20/32

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

UNCORRECTED NEAR VISUAL ACUITY (INLAY EYE ONLY)*

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

30 MONTH

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

Visit us at ASCRS Booth #317 KAMRA; the KAMRA logo; Across the page. Across the room. Across the years; and The Presbyopia Solution are trademarks of AcuFocus, Inc. ©2015 AcuFocus, Inc. CE Mark since 2005. The KAMRA inlay is an investigational device in the United States. It is limited by United States federal law to investigational use. All rights reserved. MKU-115 Rev A

GLAUCOMA

PHACO AND IOP Cataract surgery is an IOP-lowering therapy for most glaucoma patients. Roibeard O’hEineachain reports

hacoemulsification has a long-term intraocular pressure-lowering effect in both primary openangle and angle closure glaucoma and can actually make subsequent glaucoma surgery safer. However, in eyes that have already undergone trabeculectomy, cataract surgery can imperil the functionality of the bleb, said Ingeborg Stalmans MD, PhD, UZ Leuven, Belgium. “I think that we can say the cataract surgery does indeed play a significant role in glaucoma management,” she told attendees at a Glaucoma Day session at the XXXII Congress of the ESCRS in London. She noted that review of literature shows that over the long term phacoemulsification reduces IOP by 1.0mmHg to 5.0mmHg in patients with primary open-angle glaucoma, and by 4.0mmHg to 13.0mmHg in patients with angle closure glaucoma. The IOP-lowering effect is also very persistent. A chart review of patients who had undergone phacoemulsification showed that the IOP reductions measured at one year postoperatively persisted throughout six to 10 years of follow-up (Poley et al, J Cataract Refract Surg 2008 ; 34:735-742). The proposed mechanism whereby cataract extraction produces these IOP reductions is that the removal of the lens deepens the anterior chamber and widens the iridocorneal angle. The result is an increased rearward traction from the zonule on the ciliary body, which in turn increases the outflow of aqueous through the trabecular meshwork.

IOP REDUCTION Research supports that theory because it shows that the narrower the iridocorneal angle is before surgery, the greater will be the reduction of IOP after phacoemulsification. Similarly, research also shows that the higher the IOP is before surgery, the greater will be the reduction in IOP afterwards. She noted that, in eyes with angle-closure glaucoma, phacoemulsification may preclude the need for further surgery. Furthermore, if surgery is necessary, the reopened angle will simplify the performance of a trabeculoplasty and also reduce the risk of malignant glaucoma after filtration procedures. Phacoemulsification confers many of the same benefits to primary open-angle glaucoma patients. However, it does not reduce IOP to the same extent as trabeculectomy. Phacotrabeculectomy reduces IOP more than phacoemulsification alone, but not as much as trabeculectomy alone. Therefore trabeculectomy alone may be necessary in patients who require greater reductions in IOP. However, subsequent phacoemulsification can alter the morphology and functionality of the bleb and should therefore be delayed by at least six months after trabeculectomy to allow time for healing. A new option, minimally invasive glaucoma surgery (MIGS), which includes a range of mainly ab interno techniques, appears to have a good safety profile when combined with cataract surgery and seems to provide some additional reduction in IOP. More trials are necessary comparing phacoemulsification with and without MIGS to assess the clinical value of the new procedures, Dr Stalmans added. Ingeborg Stalmans: ingeborg.stalmans@uzleuven.be EUROTIMES | MARCH 2015

GLAUCOMA

IMPORTANT YARDSTICK GAT has become the gold standard for IOP measurement. Roibeard O’hEineachain reports

onometers with measurements that are less affected by corneal thickness and rigidity are likely to replace Goldmann applanation tonometry (GAT) eventually, but a greater consensus is needed in terms of how to interpret the measurements of the new devices in the management of the glaucoma patient, said Aachal Kotecha PhD, Moorfields Eye Hospital, London, UK, at a Glaucoma Day session of the XXXII Congress of the ESCRS in London. Since its introduction in 1957, GAT has become the gold standard for intraocular pressure (IOP) measurement. It has been used in epidemiological population studies and randomised controlled trials comparing different glaucoma treatment strategies. It is also the standard in terms of accuracy and precision against which any new tonometer is compared. Thus, all our knowledge regarding IOP is based on the GAT. However, the accuracy of GAT is inherently limited by the principle on which it is based, the Imbert-Fick law of applanation, a speculative theory empirically derived in order to explain the workings of the GAT. A large body of research shows that the curvature and the thickness, rigidity and elasticity of the cornea all influence the accuracy of IOP measurements performed with GAT. “If you have a rigid, steep cornea and you use the Goldmann applanation tonometer you overestimate the IOP; conversely if you have a soft flat cornea it will underestimate the IOP,” Dr Kotecha said. Two of the main alternatives to GAT introduced over the past decade, to address the inaccuracy and imprecision of GAT, are the Pascal® Dynamic Contour Tonometer (Ziemer) and the Ocular Response Analyzer® (ORA, Reichert). The measurements of both devices are less influenced than GAT by the cornea’s thickness, curvature or elasticity. Studies have also shown that the Pascal device measurements are very close to those obtained with intracameral measurements in patients undergoing cataract surgery. A consistent finding with both the ORA and Pascal tonometer is that they measure IOP as being 2.0mmHg higher than that measured with GAT, suggesting a need for a re-evaluation of what is ‘normal’ and ‘abnormal’ IOP. In terms of reproducibility, she noted that research she and her associates have conducted showed that the differences between individual clinicians’ measurements with GAT, Pascal and ORA in the same patient varied on average by less than 0.5mmHg with all three tonometers. However, the range of the differences can be as high as 5.4mmHg for GAT, 7.1mmHg for Pascal and 4.0mmHg for ORA IOPcc. “The Dynamic Contour Tonometer and the Ocular Response Analyzer are possible contenders to replace GAT, but clinicians need a little bit more information to reach a consensus agreement about how we interpret their measurements,” Dr Kotecha said.

Nd:YAG Laser Our Q-LAS 2015 EDITION

PerfectView slit lamp Trigger at Joystick Made in Germany

www.arclaser.com info@arclaser.com

Bessemerstr. 14 90411 Nuremberg Germany  +49 (0) 911 217 79 -0

Aachal Kotecha: aachalkotecha@gmail.com

Anzeigenserie-ESCRS EuroTimes_2015_halfPage.indd 2

EUROTIMES | MARCH 2015

06.02.2015 14:32:34

GLAUCOMA

GLAUCOMA Henderson Instruments RESEARCH for toric IOLs

marking pattern

Mark the patient

Using this marker the surgeon impresses three dot-shaped landmarks at the 3, 6, & 9 o’clock positions. The tips of the prongs are flattened to prevent damage to the epithelium even if the patient inadvertently moves. K3-7908 Henderson Alignment Marker

Orient the gauge to the marks

To correctly position the gauge, the surgeon simply aligns the notches on the inside edge of this instrument with the dots produced by the Henderson Alignment Marker. Also available with teeth for better fixation. K3-7904 Henderson Degree Gauge K3-7905 Henderson Degree Gauge, with teeth

Mark the axis of astigmatism

Once the gauge is oriented, the surgeon simply aligns the marks of this instrument with the desired degree lines on the gauge. This produces two thin lines along the axis of astigmatism which can be used to correctly align the toric IOL. K3-7912 Henderson Toric IOL Marker

Instruments designed by Bonnie Henderson, MD of Boston, Massachusetts

EUROTIMES | MARCH 2015

973-989-1600 • 800-225-1195 • www.katena.com

Uveolymphatic outflow offers new targets. Sean Henahan reports

he lymphatic system appears to play a hitherto unappreciated role in aqueous outflow, a finding that could lead to new therapeutic approaches for glaucoma, Professor Neeru Gupta, Chief of Glaucoma at the University of Toronto, Canada, told a session of the World Ophthalmology Congress in Tokyo. The lymphatic system pumps three litres of lymph throughout the human body every day. This is important because it drains extracellular solutes, removes fluids from our extracellular space, and plays an important role in immune surveillance, she explained. The lymphatic system accomplishes its functions through capillaries in the tissues. These capillaries have one-way valves that propel fluid through the smaller lymphatic capillaries, then merge to form larger lymphatic vessels, pass through the lymph nodes and eventually drain back into the subclavian vein at the base of the neck. “We don’t often talk about lymphatics in the eye. It was believed for a long time that they didn’t exist. But if you think about it, the aqueous is transparent and ocular tissues are highly metabolically active. For example, the accommodative mechanism in the ciliary body is very dynamic. This means that surely there must be metabolites that are being released, there must be some system for removing waste Neeru Gupta products,” said Dr Gupta. Prof Gupta described a series of experiments in collaboration with Prof Yeni Yucel, Director of Eye Pathology at the University of Toronto, that appear to confirm the existence of lymphatics in the eye. Coining this the “uveolymphatic outflow pathway”, with the potential to manipulate the process for therapeutic purposes, they pursued a series of investigations. First she and colleagues reviewed pathological section studies demonstrating the presence of lymphatic vessels in human ciliary body. These were subsequently confirmed with electron microscopy studies (Yucel YH et al, Exp Eye Research, 89: 810-819, 2009). But does aqueous flow through lymphatics? To address this question, her group designed studies with living sheep. These are a preferred animal model for studying the lymph system because of their large size. Radioactive tracer studies indicated that radioactive albumin injected in the eye was cleared from the eye and ended up in the cervical lymph nodes. Can lymphatic drainage from the eye be measured? Additional studies in sheep showed that this was indeed the case (Kim M et al, Exp Eye Research. Nov;93(5):586-91, 2011). “So we know the lymphatic vessels are in the eye. We know that they have a role in aqueous flow. We have developed a method for measuring this, and this is the beginning of much more work that is needed to understand this system. “We believe the lymphatic system in the eye offers an exciting potential to improve our understanding of aqueous outflow, the role of the uveolymphatic pathway in glaucoma, and to develop new therapeutic targets. We look forward to seeing many new studies in this area,” Dr Gupta told the conference. Neeru Gupta: GuptaN@smh.ca

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

Registration & Hotel Bookings Open

RETINA

World Society of Paediatric Ophthalmology and Strabismus

CNV DETECTION Home monitoring device reveals early changes. Dermot McGrath reports

World Congress of Paediatric Ophthalmology and Strabismus 4–6 September 2015 Fira Barcelona Gran Via, Spain North Access Hall 8

www.wspos.org

/WSPOS @WSPOS

Registration & Hotel Bookings Open

Expertise Resides ALL Around the World EUROTIMES | MARCH 2015

home monitoring device could prove a useful ally in detecting the development of choroidal neovascularisation (CNV) at an earlier stage than current standard of care approaches, and ultimately lead to better preservation of visual acuity at the time of CNV detection, according to Usha Chakravarthy MD. “The latest results confirmed a previous smaller study that we carried out, which showed that the home monitoring device could detect conversion to wet AMD at a stage when visual acuity was unaffected,” Dr Chakravarthy told delegates attending the 14th EURETINA Congress in London. Dr Chakravarthy, professor of ophthalmology and vision sciences, Queen’s University Belfast, Northern Ireland, said that even in the current era of anti-VEGF treatments it is still important to consider the fact that early treatment results in better maintenance of visual acuity. “It is very obvious looking at recent data that, even when patients are included in various AMD studies, they still present late with CNV, with high proportions of them having lower visual acuity outcomes as a result,” she said. Presenting the results of the Age-Related Eye Disease Study 2 (AREDS2) – Home Monitoring of the Eye (HOME) study, Dr Chakravarthy said that the researchers wanted to determine whether home monitoring with the ForeseeHome device (Notal Vision Ltd) resulted in earlier detection of AMD-related CNV, reflected in better visual acuity, when compared with standard care. The ForeseeHome device uses macular visual field testing with preferential hyperacuity perimetry techniques and telemonitoring to detect early signs of CNV, said Dr Chakravarthy. Each scan takes about three minutes per eye, with the resulting data used to establish a baseline for the patient. Data analysis compares the patient’s readings to a normative database and leads to the identification of new visual field defects. If the device detects significant

change over time, an alert is triggered which is then transmitted to the clinician. The study population included AREDS2 and non-AREDS2 patients with at least one large drusen greater than 125 microns in one or both eyes and a visual acuity of at least 20/60 and absence of advanced AMD. A total of 1,970 participants, between 53 and 90 years of age and at high risk of developing CNV, were screened at 44 different centres, with 1,520 meeting the inclusion criteria. Patients were randomised into two groups - 763 participants in the ForeseeHome device monitoring arm and 757 participants who followed standard care procedures in the control group.

SCORES The main outcome measure was the difference in best corrected visual acuity scores between baseline and detection of CNV. The event was determined by investigators based on clinical examination, colour fundus photography, fluorescein angiography and optical coherence tomography findings. The results showed that 51 patients progressed to CNV in the device arm and 31 in the control arm at the time of analysis. For the standard care group, the mean visual acuity at the time of detection was a -9 letter change from baseline, compared to -4 letters for the device arm. The proportion of eyes maintaining visual acuity of 20/40 or better at the time of CNV detection was 62 per cent for standard care and up to 94 per cent for those patients who followed the device usage protocol as instructed. There was also a decreased likelihood of between 50 and 76 per cent of losing three lines of vision for patients in the device monitoring group. The study results also showed that the first modality to alert to CNV development was the device arm. “The data showed that, if the device is used as instructed, the likelihood that it will be the first to alert to CNV increases,” said Dr Chakravarthy. Usha Chakravarthy: u.chakravarthy@qub.ac.uk

...even when patients are included in various AMD studies, they still present late with CNV... Usha Chakravarthy MD

RETINA

INTRAVITREAL IMPLANT Sustained improvements shown in DME patients. Roibeard O’hEineachain reports

esults of two identical FDA studies conducted by the MEAD study group indicate that the dexamethasone intravitreal implant, Ozurdex® (Allergan), can bring about significant and sustained improvements in vision in patients with diabetic macular oedema (DME), with generally only transient increases in intraocular pressure (IOP), but with a high incidence of cataract in phakic patients, Francesco Bandello MD told attendees at the 14th EURETINA Congress in London. “In this study, an average of only four to five injections of the 0.7mg or 0.35mg dexamethasone implant over three years provided long-term improvement in vision and macular oedema in patients with DME. The DEX implants met the primary efficacy endpoint for improvement in BCVA. And although development of cataract decreased the benefit of treatment in phakic eyes during the second year of the study, the treatment benefit was restored following cataract extraction,” said Dr Bandello, University Vita Salute, Hospital San Raffaele, Milan, Italy. The two MEAD studies were identical in Francesco Bandello design, and involved a total of 1,048 DME patients treated at 131 sites in 22 countries. Selection criteria included vision ranging from 20/50 to 20/200, and a central retinal thickness (CRT) of 300µm or more, determined by optical coherence tomography. The patients were randomised into three groups to receive Ozurdex at a dosage of 0.7mg or 0.35mg, or sham treatment, with repeated injections when indicated, at intervals no shorter than six months. At a follow-up of three years, 22.2 per cent of patients in the 7.0mg group and 18.4 per cent in 3.5mg group had an improvement of 15 or more letters in best corrected visual acuity (BCVA). That compared to only 12.0 per cent in the sham group (p < 0.018). In addition, the dexamethasone groups gained an average of 3.5 letters of BCVA, compared to an average gain of only two letters in the sham treatment group. Furthermore, the mean reduction in central retinal thickness was 111.6μm in the 0.7mg group and 107.9μm in the 3.5mg group, compared to only 41.9μm in the sham group (P< 0.001). Elevations of IOP were fairly mild in most cases where they occurred and were manageable with topical medication in all but three patients, who required trabeculectomy. “By the end of the study, treatment with the dexamethasone implant resulted in clinically meaningful improvement in BCVA independent of lens status at baseline. The safety profile of DEX implant was better than the reported safety profile of other intraocular corticosteroids and consistent with previous reports,” Dr Bandello added. Ozurdex was first approved by the US FDA in 2009 for the treatment of macular oedema following branch retinal vein occlusion. Following the release of the MEAD results in late 2014, the FDA extended the approval to include the treatment of DME. Francesco Bandello: bandello.francesco@hsr.it EUROTIMES | MARCH 2015

RETINA

State of Retinopathy

Duration of Diabetes

diabetes, nopathy, se levels (HbA1c), ure, etes der

Patient Gender

Multifactorial Risk Assessment

Type of Diabetes

Blood Glucose Levels (HbA1c)

Blood Pressure

RISK PREDICTION ALGORITHM

Better screening on the horizon for diabetic retinopathy. Dermot McGrath reports

ore cost-effective screening programmes are urgently needed to deal with the expected increase in diabetes worldwide over the coming decades, Einar Stefánsson MD, PhD told delegates attending the 14th EURETINA Congress in London. “We need smarter screening in order to reduce costs and to allocate health care resources according to patient risk. If we are going to deal with the coming global epidemic of diabetes and screen 400 to 500 million people and treat them prophylactically in a timely manner, we have to develop better and more cost-effective methods to do so,” said Dr Stefánsson. With this in mind, Dr Stefánsson and co-workers have developed a risk prediction algorithm for sight-threatening diabetic retinopathy that has already proven effective in validation trials in Denmark, the Netherlands and the UK. “We currently screen high- and low-risk patients as if they were identical, which is clearly not the case. So we decided to introduce more risk factors in the algorithm to allow for individualised risk assessment and move away from one-size-fitsall screening towards a more personalised approach to medicine. The multifactorial risk assessment that we have developed EUROTIMES | MARCH 2015

takes into account six risk factors: duration of diabetes, state of retinopathy, blood glucose levels (HbA1c), blood pressure, type of diabetes and the gender of the patient,” he said. The program is available on www.retinarisk.com. The introduction of national diabetic retinopathy screening programmes from the 1970s onwards has dramatically reduced the risk of blindness stemming from macular oedema and/or proliferative diabetic retinopathy, said Dr Stefánsson. “Combining laser photocoagulation and diabetic eye screening turned out to be a marriage made in heaven because the screening would catch the diabetic patients at a time where the laser treatment was optimal at the very beginning of sightthreatening characteristics, be they proliferative or oedematous,” he said. This still holds true for newer treatments in use today such as intravitreal drugs and vitreous surgery.

TIMING OF TREATMENT While screening optimises the timing of treatment and has been enormously beneficial, it is only a very small percentage of patients who actually need treatment for sight-threatening retinopathy, said Dr Stefánsson. “If you screen all diabetic patients once a year, only three out of 100 will actually need treatment for sight-threatening

RETINA

Barcelona Oculoplastics Trends in Eyelid Surgery Dr Ramón Medel IMO - Barcelona

Barcelona, April 17th 18th, 2015

Courtesy of Risk Medical Solutions

Live Surgery & Rejuvenation Workshop

retinopathy. So the other 97 that come in for annual screening are simply told to come back again the following year. Screening is enormously useful and is a great public health tool but it could also be made much more costeffective,” he said. More discriminating screening methods have already been shown to be safe and effective, said Dr Stefánsson, citing a study by his group published in 2007 which showed that every-other year screening for diabetics without retinopathy reduced the number of screening visits by more than 25 per cent without any loss in safety. The new algorithm, which draws on data from several landmark epidemiological studies in diabetes, will lead to further improvements, said Dr Stefánsson. “Using these risk factors in an algorithm we can predict 80 per cent of the risk of developing sight-threatening retinopathy. We can use the individual risk measurement to control screening intervals and frequency, with more screening in high-risk patients and less frequent screening in low-risk patients,” he said. The algorithm has already been validated and tested in diabetic cohorts in Denmark, Netherlands and the UK, predicting 76 per cent to 80 per cent of the risk of developing sight-threatening diabetic retinopathy. “Using this algorithm means about 60 per cent reduced screening frequency than using an annual screening programme. This cuts the costs by more than half but without compromising safety,” he said. Dr Stefánsson said that promoting diabetic eye screening has received the official backing of EURETINA. “While the details are still being worked out, I think the initiative should include pan-European advocacy to use EURETINA’s influence to spread the word and induce ophthalmologists to get involved in introducing this screening method in their respective countries. The organisation is also interested in supporting model systems for screening in eastern Europe, with the first one scheduled in Szeged, Hungary,” he said.

Registration fee: 350€ Residents: 250€ Online registration is available at: www.imo.es/barcelonaoculoplastics For further information, please contact: Ana Cristina de Arriba: events@imo.es Tel: (+34) 93 253 15 00

Einar Stefánsson: einarste@landspitali.is EUROTIMES | MARCH 2015

ADVERTORIAL

INNOVATION

ABSOLUTE PRECISION Robotic device may revolutionise vitreoretinal surgery.

device designed to provide robotic assistance with micrometre precision in vitreoretinal surgery should enable surgeons to both improve the reproducibility and speed of existing procedures as well as develop treatments for diseases that have no adequate treatment today, according to Marc D de Smet MD, CM, PhD, FRCOphth. “Vitreoretinal procedures have reached the limits of human precision movement. The micro-precision provided by this robotic device can facilitate research in new therapies for currently incurable diseases and can also help to reduce the learning curve for existing and new procedures and therapies. Furthermore, a well-operated integrated system could execute and speed up procedures such as vitrectomy, macular peeling or laser photocoagulation,” he said. The device, developed by PRECEYES BV, was the recipient of first prize in the recent EURETINA Innovation Awards in London. Presenting the evolution of the PRECEYES system, Prof de Smet said it is the fruit of over 10 years’ research in collaboration with Eindhoven University of Technology, drawing on intelligent use of existing mechatronic components with clearly-defined parameters for optimal miniaturised components. A prototype of the device has already been developed and successfully used in in vivo applications in animals, with research contracts with two major pharmaceutical companies underlining the feasibility and utility of the project, he said. The advantages of using such a robotic system are multiple, said Prof de Smet. It can be used to automate certain steps of a typical VR procedure such as delivery of pan-retinal photocoagulation during surgery on a diabetic patient or it can be used as an assistive device. In initial trials of the device, reproducibility tests show that the robotic system could provide an intrinsic precision of two to 10 microns, depending on the degree of freedom. This precision is calibrated at the tip of the instrument when positioned at the retina, which represents an improvement of 10 to 20 times compared to the human hand. As such, the system enables treatment of manually untreatable levels, he said. “In addition to high precision, the device also enables us to filter out tremor, which is very useful for delicate VR surgery, and it is also possible to scale motion depending on the type of procedure you want to carry out with high precision,” said Prof de Smet. The system was also designed to allow for instrument exchange, which is a major advantage in VR surgery, positional memory means that at each instrument change, you return to the exact same position you left when you decided to change instruments. In fact, you can maintain your sight on the surgical field and plan your next move as

the instrument is being changed, according to Prof de Smet. “It is very intuitive to use and it has excellent positional stability and memory. It does not replace the surgeon who continually monitors the surgical field inside the eye and performs manoeuvres with one hand as required. The system allows the surgeon to perform delicate procedures such as getting through very thin retina to inject fluid or cells, with much more precision and safety than is currently possible,” he said. The possibility of automating individual steps within a vitreoretinal procedure is another major advantage of the system, said Prof de Smet. To illustrate the device’s precision, Prof de Smet showed in vivo images of a small vein of a porcine eye that was cannulated with a 20-micron cannula. “The cannula is left in place and we inject fluid. There is an occlusion present that was created artificially. With the cannula in place, we can remove the occlusion and blood flow is re-established within a few minutes. The fact that we can cannulate such a small vein, when we typically have about 100 microns of physiologic tremor, and be able to leave it in place and not have to hold it while performing the fluid injection is a major advantage. We really think that will help improve and extend existing vitreoretinal procedures and allow new treatments to be developed,” he said. Prof de Smet added that integration with 3-D digital imaging, intraoperative optical coherence tomography (OCT), and smart sensors will lead to the automation of precise procedures that will ultimately revolutionise the field. “Surgical dissection with a precision unheard of before, will be possible,” he said. About 1.3 million vitreoretinal procedures are carried out worldwide every year in approximately 2,700 operating theatres, with a growth rate of four per cent per year, said Prof de Smet. “At 1,000 vitreoretinal procedures a year per operating theatre, a PRECEYES system would add a cost of less than 60 euros per procedure. This would be financially attractive if it leads to five per cent more procedures through reduced Scan the QR code theatre time, additional procedures for to go to video link currently under-treated patients and use on PRECEYES of smaller, less complex operating room Surgical System facilities,” he said. Prof de Smet pointed out, however, that the nature of breakthrough innovations means that the patient and financial benefits of the device have still to be proven in practice by clinical research. PRECEYES Surgical System

Courtesy of PRECEYES

Dermot McGrath reports

Marc D de Smet: mddesmet1@mac.com EUROTIMES | MARCH 2015

INDUSTRY NEWS

INDUSTRY

NEWS

INNOVATIVE HEAVY OIL

ACCUJECT TM SCREW For smooth and controlled injections Please welcome Medicel’s first single - use screw - type Injector ACCUJECT TM SCREW. • fully disposable • Easy to prefold any backloaded hydrophobic lens or toploaded hydrophilic lens • Push function for quick advancement • Screw function for controlled lens injection • Available cartridge sizes for incisions of 1.8 mm to 3.2 mm

Medicel AG 9427 Wolfhalden SWITZERLAND

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

EUROTIMES | MARCH 2015

Alamedics say the ala®heavy 1.07 is an innovative, heavy oil which can be used for the treatment of inferior retinal detachments as well as persistent macula holes. “What has to be highlighted is the renouncement of surfactants, density enhancers or other additives. ala®heavy 1.07 is made of one single component: pure, transparent, fluorinated silicone oil,” said a company spokesman. “The optimised viscosity of ala®heavy 1.07 (up to 1,100 mPas) allows an easy and fast insertion and removal. Due to the density of 1.07g/cm3 the product is ‘heavier’ than water, the head-downposition becomes redundant and the chances of healing are increased,” he said. Ala®heavy1.07 is now available in 10ml ready-for-use syringes. www.alamedics.eu

LICENCE AGREEMENT Nicox S.A. has announced the signature of a licence agreement with InSite Vision Inc. for the development, manufacture and commercialisation of InSite’s innovative ophthalmic therapeutics AzaSite® (one per cent azithromycin), BromSiteTM (0.075 per cent bromfenac) and AzaSite XtraTM (two per cent azithromycin). All three products are based on InSite’s proprietary Durasite® drug delivery technology, which is designed to extend the duration of a drug in the eye. The agreement grants Nicox exclusive rights to all three products in Europe, Middle East and Africa. European Marketing Authorisation Applications (MAAs) for AzaSite® and BromSiteTM are expected to be filed by Q1 2016. www.nicox.com

SIGHT AGAIN FUNDING GenSight Biologics, Pixium Vision and Fondation Voir et Entendre have joined forces and announced that the SIGHT AGAIN project will receive a total of €18.5million funding over five years as part of the Investment for the Future. SIGHT AGAIN, a collaborative research and development project, aims to restore vision to legally blind patients with retinitis pigmentosa at different stages. The estimated overall budget of SIGHT AGAIN, also including private investment, is €47million. www.gensightbiologics.com www.pixium-vision.com www.fondave.org

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 233 ISSUE: 1 MONTH: JANUARY 2015

RANIBIZUMAB PRESERVES GOOD ACUITY IN AMD Intravitreal ranibizumab (IVR) can preserve visual acuity and improve retinal morphology in patients who have maintained good vision despite the presence of early neovascular AMD, according to the results of a prospective study. The eyes treated in the study had a mean acuity of 0.11 logMAR at baseline and all had acuity better than 0.22 logMAR. At one year of follow-up and with a mean of 3.3 injections, the mean BCVA was not significantly changed, with a value of 0.12 logMAR. Moreover, the mean central retinal thickness improved significantly, from 320μm at baseline to 254μm at month 12 (p < 0.01). A Kato, “Intravitreal Ranibizumab for Patients with Neovascular AgeRelated Macular Degeneration with Good Baseline Visual Acuity”, Ophthalmologica 2015; Volume 233, Issue 1 (DOI: 10.1159/000368249).

HAEMODILUTION-ANTI-VEGF COMBO PROMISING A combination of intravitreal ranibizumab injection and isovolemic haemodilution (IH) appears to be very efficacious in improving visual acuity in eyes with macular oedema secondary to central retinal vein occlusion, and IH alone might be a useful treatment option in patients with early CRVO, the results of a randomised multicentre trial suggest. Among 28 eyes randomised to receive the combined treatment initially, there was an average gain of 28 letters at a follow-up of one year. Among 30 eyes receiving IH alone initially there was an average gain of 25 letters. TC Kreutzer et al, “Intravitreal Ranibizumab versus Isovolemic Hemodilution in the Treatment of Macular Edema Secondary to Central Retinal Vein Occlusion: TwelveMonth Results of a Prospective, Randomized, Multicenter Trial”, Ophthalmologica 2015; Volume 233, Issue 1 (DOI: 10.1159/000369566).

The ONE laser platform for all your needs

It's Time to make a Move It has never been so simple to adapt new technology into your daily workflow. The truly mobile FEMTO LDV Z8 finally enables you to use next generation femtosecond laser technology for your cataract and refractive surgeries. www.femtoldv.com

Perfect integration for a streamlined cataract workflow

DEXAMETHASONE IMPLANT: GOOD EFFICACY AND SAFETY Repeat injections with the Ozurdex 0.7mg dexamethasone implant appear to be a well-tolerated and effective treatment for macular oedema (ME) due to retinal vein occlusion (RVO) clinical practice, according to the results of a retrospective multicentre study. The study’s authors reviewed anonymised observational data collected from 87 patients. All were over 18 years old, had a diagnosis of ME secondary to branch or central RVO, and had received at least two 0.7mg dexamethasone implant injections during routine practice. The mean time between the first and second injection of the steroidal treatments was 5.03 months overall, and 5.46 and 4.52 months for the branch and central RVO subpopulations, respectively. An IOP increase to 25.0mmHg or greater occurred in 20 per cent of patients. None of the patients required IOP-lowering surgery. AJ Augustin et al, “Retrospective, Observational Study in Patients Receiving a Dexamethasone Intravitreal Implant 0.7 mg for Macular Oedema Secondary to Retinal Vein Occlusion”, Ophthalmologica 2015; Volume 233, Issue 1 (DOI:10.1159/000368840).

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

Compact and mobile for a multi-site use

all in one Modular platform for laser cataract and cornea procedures

The FEMTO LDV Z8 is CE marked but not yet cleared by the FDA for the use in the United States. For other countries, availability may be restricted due to regulatory requirements; please contact Ziemer for details.

EUROTIMES | MARCH 2015

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 ·Spanish language symposia and courses ·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

BOOK REVIEWS

VIEW FOR THE FEW Within the field of ophthalmology, vitreoretinal surgery stands alone in that very few general ophthalmologists perform these operations. Whereas many generalists carry out trabeculectomies, oculoplastic procedures, ocular surface treatments and strabismus corrections, most do PUBLICATION not proceed further than argon VITREORETINAL SURGERY: laser treatment of a retinal tear. SECOND EDITION Thus, many have only a vague AUTHOR and often outdated idea of how THOMAS H WILLIAMSON a VR surgeon spends his or her time in the operating room, and PUBLISHED BY SPRINGER what is actually done inside the posterior segment. Vitreoretinal Surgery: Second Edition, by Thomas H Williamson (Springer), provides valuable insight. In contrast to many multi-author books coordinated by one or more editors, this text “has been deliberately written singlehandedly by the author to prevent the duplication that makes multi-author texts often unwieldy”, the preface reads. The decision was a wise one, as the book reads smoothly in a consistent tone. But let us not overlook the intended use of this book, namely “to allow a trainee or professional vitreoretinal surgeon to determine the best methodology in individual cases”. Starting with a lucid description of the clinical examination of the eye, the text moves on to a 40-page intro to VR surgery, which covers details such as where to place the sclerotomies and how to manage peroperative complications. Legitimately useful peroperative photographs, uncomplicated drawings and high-quality fundus photographs, OCTs and fluorescein angiographies complement the text. Overall, this is a very useful book and is ideally suited for vitreoretinal fellows, but might also be useful for residents during their VR rotation as well as early-career VR surgeons and generalists looking to broaden the scope of their knowledge about this subspecialty.

BOOK

REVIEWS

Nano Laser The only real Laser Cataract Surgery

My cataracts have been removed with the new Nano Laser. I trust this unique Laser technology!

USEFUL POCKET MANUAL With the accessibility of information online, there seems to be a trend towards discarding the pocket manual for quick reference in the clinic. The Moorfields Manual of Ophthalmology: Second Edition, edited by Timothy L Jackson (JP Medical Publishers), might question the wisdom of this abandonment. This 700-page book fits into the pocket of a white lab coat. It is arranged logically, according to the ocular anatomy, which is useful for the determination of a differential diagnosis. Its clear, crisp design both accelerates the user’s search for specific pathologies, and its combination of prose and lists makes the use of the manual a pleasure. Particularly useful are the “Differential Diagnoses” lists of ocular fundus tumours and medical retinal conditions. This will become one of my more commonly used books and will join (and perhaps replace?) the Wills Eye Manual in my examination room.

Reinhardt Thyzel

info@arclaser.com Surgery performed by: PD Dr. Gangolf Sauder, Stuttgart, Germany

www.arclaser.com info@arclaser.com

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

Anzeigenserie-ESCRS EuroTimes_2015_halfPage.indd 1

Bessemerstr. 14 90411 Nuremberg Germany  +49 (0) 911 217 79 -0

EUROTIMES | MARCH 2015

04.02.2015 14:18:45

Make the most of your time at the ASCRS•ASOA Symposium & Congress and attend EyeWorld’s educational programs. A great opportunity to network with your colleagues.

Don’t wait until you are onsite to view EyeWorld’s extensive schedule. Available soon!

Available on tablets, desktops, and mobile devices ... EducationalEvents.EyeWorld.org

OUTLOOK ON INDUSTRY

SYMFONY IOL Extended range of vision lens corrects presbyopia with better vision quality.

EXTENDED DEPTH, CHROMATIC CORRECTION The Tecnis Symfony IOL uses three optical approaches to maximise quality of vision while providing up to 2.5 dioptres of usable depth of focus, says Patricia Piers PhD, who led development of the lens. First, the Tecnis Symfony IOL uses the proven Tecnis aspheric surface profile, which introduces just enough negative spherical aberration to offset the positive spherical aberration of the typical cornea. “We have shown that correcting spherical aberration improves contrast sensitivity and functional vision as measured in driving simulators,” Piers says. The Tecnis Symfony IOL also applies diffractive principles in two new ways through a diffractive element on the lens’ posterior surface. First, rather than splitting incoming light into two or three separate focal points, it elongates depth of focus, much as a small aperture or adding spherical aberration might. However, because it is a diffractive effect it does not restrict incoming light as an aperture device does, nor is it affected by pupil diameter, as spherical aberration is. The result is extended depth of focus under all light and pupil conditions.

The TECNIS® Symfony Extended Range of Vision IOL

Our goal with the Symfony project was to find a solution for a full range of vision... Leonard Borrmann PhD Nonetheless, extending depth of field always comes at the cost of reduced image sharpness, and this diffractive approach is no exception. However, a second diffractive effect, chromatic aberration correction, helps offset this loss, Piers says. In the natural eye, chromatic aberration results in a spread in focal length of about two dioptres between the shortest and longest visible wavelengths, making the eye myopic for blue and hyperopic for red, Piers notes. The resulting blur is attenuated by the eye being much more sensitive to green, and our brains are used to filtering out chromatic distortion, Piers explains. Even so chromatic blur remains, degrading image quality. Bench studies show that diffractively correcting chromatic aberration improves modulation

Courtesy of Abbott Medical Optics

bbott Medical Optics think their new Tecnis Symfony intraocular lens (IOL), approved for use in Europe, can do what multifocal IOLs have not – convince more cataract patients to try presbyopia-correcting lenses. Currently, presbyopia-correcting IOLs make up just seven per cent of the US market and even less in Europe, says Leonard Borrmann PhD, Abbott Medical Optics’ divisional vice president of research and development. He puts this down to the challenges of multifocal IOLs. “Multifocal lenses do a great job of enabling patients to read, but some multifocal lenses come at the expense of intermediate vision,” Borrmann says. Splitting incoming light into two or three distinct focal points can also create glare and haloes at night, and reduce image quality and contrast sensitivity. “Our goal with the Symfony project was to find a solution for a full range of vision without the challenges that may come with today’s options. By significantly reducing the visual disturbances we may be able to expand the use of presbyopia-correcting technology,” Borrmann says.

Howard Larkin reports transfer function beyond what is achieved with aspheric lenses alone. More important, clinical studies find that it improves contrast sensitivity. Tests of bilateral implants of the Tecnis Symfony lenses compared with standard monofocal aspheric Tecnis lenses find no difference in contrast sensitivity across all frequencies three months after surgery. Yet the extended focus in the Tecnis Symfony IOL adds about 1.0 dioptre in depth of focus across the entire defocus range. This results in a mean of 20/20 vision or better across 1.5 dioptres defocus, and 20/40 to 2.5 dioptres – enough to allow spectacle independence under most circumstances for most patients. Glare, haloes and other dysphotopsias are also similar between Tecnis Symfony IOL and monofocal Tecnis lens patients. Nearly 98 per cent reported no night glare or haloes, and those who did reported it as mild to moderate at one month. These figures are comparable to monofocal lenses. Implanting the Tecnis Symfony IOL in a mini-monovision arrangement, with the non-dominant eye -0.75 to -1.0 dioptres, further expands functional vision to about 3.5 dioptres total accommodation, Bormmann says. A trial of mini-monovision is ongoing in Europe.

CATALYS UPDATES AMO also upgraded the software and liquid interface for its Catalys femtosecond laser for cataract surgery. The upgrade features automated docking that makes preparing patients for surgery easier, and streaming OCT during surgery to ensure the system remains on target. “The ease of operation makes it so memorable. In the past you had five critical steps and now it is three,” says Eric Donnenfeld MD, Long Island, New York, US. “All you have to do is verify your fluences and line up your landmarks and all your incisions are exactly where you want them. You see it all happen in real time.” Abbott Medical Optics also announced a joint distribution agreement with Carl Zeiss Meditec to distribute Zeiss products alongside the Abbott Medical Optics cataract and refractive products in the US. Investing in new technology helps keep Abbott Medical Optics at the forefront, says Abbott Medical Optics chief Murthy Simhambhatla PhD. “The earlier you make the right investment in science the better it pays off for you in terms of patient outcomes and surgeon satisfaction.” EUROTIMES | MARCH 2015

EYE ON TECHNOLOGY

Figure A: Flaps created should not be too broad

Figure B: In large flaps, sclerotomies may be skewed to opposite sides of the scleral bed

GLUED IOL

This has become a popular technique for secondary IOL fixation in the absence of capsular support. Dr Soosan Jacob reports

erforming a glued intraocular lens (IOL) is a challenge in patients who have either larger or smaller than normal eyes. The challenge in large eyes is to get a sufficient degree of haptic exteriorised, resulting in insufficient haptic tuck and a potentially unstable IOL. The challenge in small eyes on the other hand is an unnecessary extent of haptic that is exteriorised. Large optics relative to the eye may also become significant in patients who have severe micro cornea.

LARGER THAN NORMAL EYES As it is the haptic tuck that is responsible for the stability of the glued IOL, obtaining a sufficient length of haptic to tuck is crucial. When planning for a glued IOL, it is important to first measure the horizontal white to white diameter of the cornea and if more than 11.5mm, it may be preferable to opt for a vertically oriented glued IOL. For this, the surgeon shifts to the temporal side of the patient and the two scleral flaps are created diametrically opposite each other in the vertical axes. Ideally, broad flaps should not be created as this results in a significant length of haptic traversing under the flap and less available haptic at the flap edge to be tucked. Ideal flaps should not be more than 2 to 2.5mm in width along the limbus (Figure A). This allows a greater length of haptic that can be tucked intrasclerally and thereby increases the stability of the IOL. In case broad flaps have been created, the sclerotomies are skewed to the opposite edges of the flap in such a manner that they still stay 180 degrees opposite each other. (Figure B) As this brings the sclerotomy closer to one end of the flap, the degree of haptic tuck proportionally increases. If the sclerotomies have already been placed centrally under broad flaps, the intrascleral tunnel may be initiated through the bed of the scleral flap. (Figure C) Another option that can be utilised for increasing the degree of haptic tuck is creating the sclerotomy closer to the limbus. A sclerotomy placed about 1 to 1.5mm posterior to the limbus is ideal. Going more posterior to this displaces the plane of the entire IOL backwards towards the posterior pole of the globe, and thereby decreases the length of haptic available for tucking. (Figure D) EUROTIMES | MARCH 2015

With anteriorly displaced sclerotomies, the advancing edge of the needle used to create the sclerotomy passes close to the iris base and unless performed carefully can result in an iridodialysis. Certain precautions may be utilised to avoid this. A blunt needle should not be used. In case the surgeon is operating with an anterior chamber maintainer (ACM) in place, the flow of fluid from the ACM pushes the iris backwards bringing the advancing edge of the needle close to the iris base. To avoid this, the ACM should be turned off while creating the sclerotomy. On the other hand, with an infusion cannula fixed through the pars plana, the direction of fluid flow tends to bellow the iris forwards and therefore it is easier to create a sclerotomy without causing damage to the iris base. In this case the infusion may be left on while creating the sclerotomy. The direction in which the needle is introduced into the eye is also important - the tip of the needle should be facing perpendicularly down towards the floor rather than towards the centre of the eye in order to avoid the iris root. Once the resistance of the eye wall has been crossed, the needle is again pointed towards the centre of the eye till the tip is visualised. Both sclerotomies should be kept at the same distance from the limbus in order to avoid an IOL tilt. A too posteriorly placed sclerotomy resulting in an inadequate length of haptic exteriorised may be corrected by creating a new sclerotomy anterior to the old one, taking care to utilise all the precautions mentioned to avoid damaging the iris base. Using the hand shake technique the externalised haptic is then re-internalised into the eye and then again re-externalised through the freshly created anteriorly placed sclerotomy. Two end gripping micro forceps are utilised in a bimanual manner. One of the forceps is introduced through the limbal paracentesis. The haptic is then internalised through the sclerotomy into the jaws of the first forceps. The second forceps is then introduced through the anterior sclerotomy and the haptic is transferred from hand to hand in a bimanual manner till it is held at the tip and is externalised out through the anterior sclerotomy. On entering the eye through the anterior sclerotomy, the ACM should be momentarily put off. This anteriorisation of the haptic also brings the plane of the IOL optic anteriorly and therefore the final position of the sclerotomy should be symmetrical on both sides to avoid an IOL tilt.

EYE ON TECHNOLOGY

Figure C: In large flaps, intra-scleral tunnel is initiated under flap bed

Care should also be taken to not take it anterior enough to cause optic capture. Another option available for larger eyes is to use an IOL that has a larger overall diameter. The Staar AQ2010V IOL has a larger overall IOL diameter of 13.5mm and thereby increases available haptic to be tucked. Customised IOLs may also be ordered. In eyes smaller than normal, especially with microcornea, other associated abnormalities may co-exist and might end up requiring placement of an IOL in the presence of defective capsule. The problem here is exactly opposite - the length of haptic externalised is excessive. Long intra-scleral tunnels are then required, which are difficult and dangerous to create. This situation may easily be managed by trimming the haptic to the desired length with a Vannas scissor and then tucking the rest of the haptic in. An IOL with smaller diameter optic may also be preferable to avoid crowding of the anterior chamber.

Figure D: Length of haptic tuck decreases on posterior displacement

Thus we see, though challenging to perform the glued IOL in smaller and larger than normal eyes, it can be successfully performed provided required precautions are taken. * Dr Soosan Jacob is a Senior Consultant Ophthalmologist at Dr Agarwalâ&#x20AC;&#x2122;s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com

Scan the QR codes to view live surgeries

SCIENCE RELAXATION FRIENDSHIP Brazilian Association of Cataract and Refractive Surgery

Brazilian Congress of Cataract and Refractive Surgery - 2015

WHERE: Costa do SauĂpe, Bahia - Brazil WHEN: June 3 to 6, 2015

brascrs2015.com.br EUROTIMES | MARCH 2015

ESASO

EDUCATION Advanced courses in ophthalmology

alented young ophthalmologists are invited to take part in ESASO’s international postgraduate modules. The ESASO community encourages prestigious universities and hospitals to team up and develop a higher curriculum and enable young ophthalmologists to advance their career paths. It provides an intercontinental network of alliances and friendships, of life-long professional and personal bonds. While the majority of participants come from diverse European countries, attendees also originate from Asia, South America, the Middle East and Africa, among others. ESASO promotes and supports internationalism by providing courses in different countries (Switzerland, Malta, Spain, Turkey, Russia, Israel, United Arab Emirates, Singapore and China). “We receive enthusiastic feedback not only from participants but also from faculty who enjoy working with their young colleagues from different backgrounds in a supportive, friendly and inspiring atmosphere,” says Borja Corcóstegui, the President of the Foundation. Borja Corcóstegui

2015 PROGRAMME A broad range of cutting-edge modules cover the entire field of ophthalmology. In densely packed five-day training programmes participants profit from shared knowledge with leading faculty and exchange with aspiring colleagues from all over the world. Facilities include wet labs equipped with stateof-the-art and innovative technology, which are provided and professionally maintained.

OCULOPLASTIC SURGERY The first module of 2015 was held in January and was dedicated to oculoplastic surgery in La Valletta, Malta. The programme directors Ramón Medel and Luz María Vásquez from Spain together with faculty from Belgium, Germany and the UK provided insights into orbital, lacrimal and ophthalmic plastic surgery. Theoretical and practical training covered a broad spectrum of anatomical and physiological, diagnostic and therapeutic subjects: from facial nerve palsy to eyelid and orbital tumours, from upper and lower eyelid blepharoplasty to trauma and fractures management. A recently published ESASO Course Series book on that topic can be ordered online at http://www. esaso.org/esaso-course-series/.

MEDICAL RETINA The second module on Medical Retina was organised in early February. The programme directors Borja Corcóstegui and Bruno Falcomatà compiled an exciting programme on DME, neovascular maculopathies, macular dystrophies, ME in RVO, and micropulse laser. Colleagues from the UK, France, Germany, Italy, the Netherlands, Switzerland and Israel came to Lugano, Switzerland to teach state-of-the-art expertise to help diagnose and treat pathologies in this speciality. The ESASO educational programme is open to all young ophthalmologists who have completed residency training and work in ophthalmic hospital departments or clinics. Visit the website at www.esaso.org to find out more and take your ophthalmological expertise to the next level! EUROTIMES | MARCH 2015 08_1502_03 ES_Anz_EUT_93x266_RZ.indd 1

04.02.15 11:57

JCRS

JCRS SYMPOSIUM

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 2 MONTH: FEBRUARY 2015

RAINDROP INLAY PLUS LASIK A hydrogel corneal inlay (Raindrop, Near Vision) with concurrent LASIK is safe and effective for treating myopic presbyopia, suggest the results of a prospective non-randomised clinical trial. Thirty eyes received the implant with concurrent LASIK. The inlay was implanted in the non-dominant eye under a flap created using a femtosecond laser. At each postoperative visit, the mean CDVA and CNVA were within one half line of preoperative measurements and no eye lost two or more lines of CDVA. The mean binocular UDVA, UIVA and UNVA were better than 20/25 Snellen at all postoperative visits. By six months, 93 per cent of patients had a binocular Snellen acuity of 20/25 or better across all visual ranges. EB Garza et al, JCRS, “Safety and efficacy of a hydrogel inlay with laser in situ keratomileusis to improve vision in myopic presbyopic patients: One year results”, Volume 41, Issue 2, 306-312.

DEMOGRAPHICS OF CATARACT SURGERY AFTER LASIK Researchers evaluated 40 eyes of consecutive patients scheduled for cataract surgery after previous LASIK. One control group included 606 eyes of matched axial lengths. A second control group included 3,642 eyes scheduled for cataract surgery. Patients in the study group were significantly younger. They were also more likely to be male, and had higher rates of higher order aberrations. K Iijima et al, JCRS, “Demographics of patients having cataract surgery after laser in situ keratomileusis”, Volume 41, Issue 2, 334-338.

KERATITIS AFTER SMILE? Diffuse lamellar keratitis (DLK) is a potential complication after small-incision lenticule extraction, although it had a low incidence, Chinese researchers report. The study enrolled 1,112 eyes of 590 patients. Eighteen eyes (1.6 per cent) developed DLK. These patients presented one to three days postoperatively with mild to moderate inflammation. Thirteen eyes (72.2 per cent) had Stage 1 DLK, four (22.2 per cent) had Stage 2, and one (5.6 per cent) had Stage 3. After intensive treatment with topical corticosteroids, the Stage 1 and Stage 2 cases resolved within three weeks and the Stage 3 case resolved in one month. The postoperative CDVA was the same or better than preoperatively in all eyes. There was a statistically significant increase in the incidence of DLK with thinner lenticules and larger diameter lenticules. J Zhao et al, JCRS, “Diffuse lamellar keratitis after smallincision lenticule extraction”, Volume 41, Issue 2, 400-407.

THOMAS KOHNEN European editor of JCRS

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

CONTROVERSIES IN OPHTHALMIC SURGERY: HEAD TO HEAD

– Prevention of Endophthalmitis: – U.S. Versus Rest of the World David F. Chang, MD Peter J. Barry, MD

– Femtosecond Lenticule Extraction – Versus LASIK Steven E. Wilson, MD Jodhbir S. Mehta, MD, FRCS(Ed)

– Astigmatism Correction: – Femtosecond Laser or Blade? Elizabeth Yeu, MD Eric D. Donnenfeld, MD

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

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

FOUR EVENTS

ONE VENUE Fira Barcelona Gran Via, Spain

North Access Hall 8

XXXIII Congress of the ESCRS

6th EuCornea Congress

5–9 September www.escrs.org

4–5 September www.eucornea.org

WSPOS

3rd World Congress of Paediatric Ophthalmology and Strabismus

The 7th International Conference on Ocular Infections

4–6 September www.wspos.org

3–4 September www.ocularinfections.com

TRAVEL

The Sail Hotel

Barcelona

TO TRY IN...

BARCELONA

LANGUAGE: Catalan plus Spanish CURRENCY: Euro AVERAGE SEPTEMBER TEMPERATURE: 26C/78.8F MIES PAVELO No fan of modern architecture would ever leave Barcelona without visiting or revisiting the Mies van der Rohe pavilion. The original structure, built at the entrance to the German section of the 1929 Barcelona International Exhibition, was meticulously reconstructed in 1983-6 having been dismantled after the exhibition. The thrones designed for the use of the King and Queen of Spain on their arrival at the exhibition were the original “Barcelona chairs”. At Mies’ insistence, they were the only furnishings in the building. They still are. The pavilion can be visited daily from 10.00 to 20.00, but check ahead as it is sometimes closed for a special event, visit www.miesbcn.com

CASA BLOC Catalan architects of the Second Republic (19311939) created Casa Bloc as one of the first steps towards dignifying workers’ living conditions. The Spanish Civil war put an end to the initiative and to the philosophy behind it. After the war, the building was occupied by families of Franco’s armed forces and later the police. In 1992, the Generalitat de Catalunya declared the building as protected, and, in 2012, after careful restoration of the original kitchen, bathroom and laundry room and the installation of period furniture, apartment number 1/11 was opened, looking just as its creators had originally envisioned it. Visits are organised by the Disseny Design Museum on Saturdays at 11.00 and 12.30. Book online at www.museudeldisseny.cat

GEHRY’S FISH In an interview in the PBS American Masters series, architect Frank Gehry revealed that it was his colleagues’ postmodern interest in recreating Greek temples that sparked his interest in fish: “Greek temples are anthropomorphic. And three hundred million years before man was fish. If you gotta go back, and you’re insecure about going forward...go back three hundred million years ago. Why are you stopping at the Greeks? So I started drawing fish in my sketchbook, and then I started to realize that there was something in it.” Gehry’s huge copper-coloured fish, constructed in the Olympic Village in 1992, is a Barceloneta landmark. See it at Career de Ramon, Trias Fargas 1.

REACH FOR THE SKY

New buildings capture attention of Barcelona’s urban view. Maryalicia Post reports To Barcelona’s own “Gherkin”, add the “Stapler” and the “Sail”, three noteworthy contemporary buildings in an old city. It’s easy to assume that Barcelona’s Torre Agbar was inspired by the Gherkin, Norman Foster’s Swiss Re tower in the City of London. It wasn’t. Both are tapered glass cylinders, but there the similarity ends. London’s Gherkin, completed in 2004, is a well-mannered skyscraper that happens to be cylindrical. Jean Nouvel’s 2005 structure, smaller than Foster’s, is an exuberant cylinder that seems about to disintegrate, to explode into fragments of colour. The architect was inspired by the concept of a geyser bursting forth from the earth, an apt analogy as the building was commissioned by Agua Barcelona, the city’s water supplier. The tower’s surface is sheathed in aluminium panels in forty shades of blue, green, red and yellow; they are covered in glass scales that deflect and filter the light and give the exterior the appearance of rippling water. At night, shifting patterns of an LED display illuminate the building’s surface. The illuminations are scheduled from March 28 to September 30, 21.00 to 24.00. Unfortunately, the Torre Agbar is not open to the public. For details about the building visit www.torreagbar.com

live up to its tag as ‘the innovation district’. The four-storey museum houses definitive historic and contemporary collections of decorative art, ceramics, design, textiles and clothing, plus graphic art. Opening times: Monday 16.00 to 20.30 pm, Tuesday to Sunday from 10.00 to 20.30. For details about the building visit www.museudeldisseny.cat

ON THE WATERFRONT The W Hotel on the waterfront in the Barceloneta area joins a small fleet of sail-shaped buildings that are moored on shorelines around the world; the first and still most famous is Dubai’s Burj al Arab. Barcelona’s more modest W hotel, completed in 2009, stands on a spit of land on a terrace leading down to the sea. From a distance it evokes a billowing sail and well deserves its nickname, the “Sail” hotel or Hotel Vela. Enjoy the spectacular view from a VIP table in the rooftop bar. Book at www.eclipse-barcelona.com

The Gherkin of Barcelona

INNOVATION DISTRICT The Disseny Design Museum, nicknamed the Stapler, opened at the end of 2014. The work of MBM, the local architectural team that developed the design for the Barcelona Olympics in 1992, the building is as angular as the Torre Agbar, is curved. Together they suggest that the Poblenau area, a former industrial area that is undergoing major redevelopment as “22@Barcelona”, will EUROTIMES | MARCH 2015

CALENDAR

APRIL

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

↙

Barcelona Oculoplastics Meeting

LAST CALL

MARCH 2015

6th World Congress on Controversies in Ophthalmology (COPHy) 26–29 March Sorrento, Italy www.comtecmed.com/cophy/2015/

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

JUNE

SOE 2015 Congress 6–9 June Vienna, Austria www.soe2015.org

JUNE

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

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

MAY

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

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

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

6th Baltic Congress

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

NEW ENTRY 5th Balkan Ophthalmic Wetlab Course 20–23 May Sofia, Bulgaria www.bow.bg

NEW ENTRY Trends in Surgical and Medical Retina 3rd Meeting 29–30 May Barcelona, Spain www.imo.es/retinabarcelona2015

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

NEW ENTRY Maculart Meeting

28–30 June Paris, France www.maculart-meeting.com

AUGUST

28th APACRS Annual Meeting 5–8 August Kuala Lumpur, Malaysia http://www.apacrs.org

Vienna

SEPTEMBER

3rd World Congress of Paediatric Ophthalmology and Strabismus 4–6 September Barcelona, Spain www.wspos.org

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

15th EURETINA Congress 17–20 September Nice, France www.euretina.org

OCTOBER

NEW ENTRY 113th DOG Congress

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

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

SEPTEMBER

International Conference on Ocular Infections (ICOI)

6th EuCornea Congress 4–5 September Barcelona, Spain www.eucornea.org

↙

3–4 September Barcelona, Spain www.ocularinfections.com

6th EuCornea Congress

BARCELONA 4-5 September 2015

Fira Barcelona Gran Via, Spain North Access Hall 8

/EuCornea @EuCornea

Abstract Submission Deadline 15 March 2015

www.eucornea.org

Registration & Hotel Bookings Open

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

Become an ESCRS Member Catch up on what you missed at the Istanbul Winter Meeting with ESCRS On Demand An Online Library of Congress Presentations Also free to members: Access to iLearn Online interactive courses Subscription to Journal of Cataract & Refractive Surgery Reduced ESCRS Congress Fees

Visit www.escrs.org today

ESCRS

NANO LASER The only real Laser Cataract Surgery

Meet us at our lunch symposium

XXXIII Congress of the ESCRS Saturday Sept. 05th Get in touch with the latest news about

Laser Cataract Surgery info@arclaser.com

www.arclaser.com info@arclaser.com

Bessemerstr. 14 90411 Nürnberg Germany  +49 (0) 911 217 79 -0