EuroTimes Vol. 20 - Issue 6 by EUROTIMES

SPECIAL FOCUS GLAUCOMA CORNEA

EARLY KERATOCONUS DIAGNOSIS CAN IMPROVE OUTCOMES AND AVOID DISASTERS June 2015 | Vol 20 Issue 6

RESIDENT’S DIARY

THE THRILL AND FEAR OF FACING INTO SURGERY WITHOUT SUPERVISION

EARLY INTERVENTION

PATHWAYS TO GLAUCOMA TREATMENT NEW DRUGS ROCK INHIBITORS

OPTIC NERVE PATHWAY

RESEARCH

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon

CONTENTS

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

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS GLAUCOMA 4

Cover Story: New developments suggest the battle against glaucoma is turning

8 Device shows potential for IOP-lowering in difficult cases

10 Dual procedure can

deliver long-lasting results

11 ‘Common preconceptions of pseudoexfoliative glaucoma are too pessimistic’

12 Recent advances

could make new neuroprotection trials feasible

FEATURES CATARACT & REFRACTIVE 13 Rates of PCR range

CORNEA 22 New agent shows

promise in treatment of corneal melting

23 Keratoconus: early

diagnosis may improve outcomes and prevent surgery disasters

24 ‘CXL in keratoconus can produce phenomenal improvement in vision’

RETINA 25 Complement inhibition

opens new pathway to AMD treatment

brachytherapy device may improve outcomes for AMD

OCULAR 31 ICOI Preview: ‘The Olympics’ of ocular infectious diseases

greatly in cases of posterior polar cataract

MEETING REPORT 33 ASCRS honours Philippe Sourdille for his enormous contribution

REGULARS 39 Resident’s Diary 40 Outlook on Industry 43 Book Reviews 44 ESASO update 45 JCRS Highlights 46 Review 48 Industry News 51 Travel 52 Calendar

19 ‘Surface ablation

may yet keep pace with advances in intrastromal techniques’

20 Using adaptive optics to help identify patient-specific presbyLASIK treatment

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

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26 Minimally invasive

P.39 EUROTIMES | JUNE 2015

EDITORIAL A WORD FROM CLIVE PECKAR MSc, FRCS, FRCOphth

GLAUCOMA UPDATE

In this issue we focus on a number of glaucoma-related issues

ooking to the future of glaucoma treatment, Sean Henahan reports the latest news on some new theoretical and actual treatments for glaucoma in this month’s cover story (Page 4-6). Hidenobu Tanihara discusses the role of Rho Kinase inhibitors and some of the products that are in use or undergoing clinical trials, and Jeffrey Goldberg describes the use of an implant to deliver ciliary neurotrophic factor (CNTF) to “promote both retinal ganglion cell survival and optic nerve regeneration in glaucoma patients”. Neeru Gupta has previously proposed that “glaucoma should be seen as a neurodegenerative disease” and reports that “a rise in IOP affected not only the retinal ganglion cells and nerve fibres but also extended to the major vision centres in the brain”. On the subject of drugs for neuroprotection, Robert Weinreb (Page 12) draws attention to the failed Memantine Glaucoma Trial, despite the success of this drug in “animal models”, and suggests that “new trials could be feasible with changes that address previous trial weaknesses”. Fotis Topouzis’ article (Page 11) presents the key results of the Thessalonica Eye Study and examines the relative incidence of pseudoexfoliation and pseudoexfoliative-glaucoma together with open-angle glaucoma, in that population. He reports that, unlike the Blue Mountain Eye Study, the Thessalonica Eye Study showed no significant associations between pseudoexfoliation or pseudoexfoliative glaucoma and cardiovascular disease, heart attack, coronary bypass or vascular surgery. He concludes that “current evidence indicates that only a minority of pseudoexfoliation patients have glaucoma and that when pseudoexfoliative glaucoma occurs, it is less likely than primary open-angle glaucoma to remain undiagnosed”. Galina Dushina (Page 8-9) describes the use of a “spiral stainless steel intracanalicular implant”, in 12 eyes with open-angle glaucoma and a one-year follow-up. The article describes a viscocanalostomy dissection without the use of a Descemet’s Window (bypassing the trabecular meshwork outflow resistance was overcome in four eyes, however, by inadvertent traumatic puncture produced by the steel implant). It is hoped that longer-term follow-up will continue to produce good results, in the absence of extrusion of the metallic implant. It is also hoped that the patients receiving this implant were warned not to undergo MRI scanning in the future.

ESCRS SYMPOSIUM Robert Stegmann, in his lecture on Canaloplasty in Cataract Patients delivered at the ESCRS Symposium (Page 10), “Combined surgery for cataract and glaucoma”, highlighted his long-term results of ab externo Schlemm’s canal surgery (viscocanalostomy), with some paediatric patients having up to 20 years of followup. Whilst this symposium focused on “combined surgery”, his lecture draws attention to his excellent long-term results, in both adult and paediatric glaucoma patients. His long-term success, in patients with open-angle glaucoma, has recently been published as part of a retrospective study of 729 viscocanalostomy patients (Grieshaber MC, Peckar CO, Pienaar A, Körber N, Stegmann RC: Long-term results of up to 12 years of over 700 cases of viscocanalostomy for open angle glaucoma: Acta Ophthalmologica 1st Oct 2014 (online): DOI; 10.1111/aos). More recently, the evolution of his viscocanalostomy procedure, into firstly canaloplasty and then the ‘implantation of intracanalicular polyimide implants’ (Stegmann Canal Expanders™), demonstrates that this approach not only works in the long-term but is the only ‘bleb-independent procedure’, with a long track record, which addresses the three pathological anatomical pathways involved in open-angle glaucoma and congenital glaucoma (ie obstruction of the aqueous outflow into Schlemm’s canal, collapse of Schlemm’s canal, collapse or closure of collector channels), combined with the re-establishment of the normal aqueous outflow via the collector channels. Whilst there has been recent increased interest in Schlemm’s canal surgery, most of this has been directed towards the use of MIGS (micro-invasive glaucoma surgery) in “mild to moderate glaucoma”. Further long-term data with MIGS is eagerly awaited, to determine its success in a larger range of glaucoma patients, particularly those with higher IOPs, in order to establish whether MIGS presents us with an equally successful, simpler and shorter option that his ab externo approach.

* Clive Peckar is a Medical Editor for EuroTimes

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 | JUNE 2015

COVER STORY: GLAUCOMA

90 per cent of retinal ganglion cell axons project to the lateral geniculate nucleus

Courtesy of Hubel, 1991

THE FUTURE OF GLAUCOMA TREATMENT Gene therapy holds the ultimate promise to eliminate glaucoma-induced visual disability across a spectrum of possibilities. Sean Henahan reports any new developments on the research front suggest the battle against glaucoma is turning. New drugs are now entering the clinic, along with new ways to deliver them. There is growing consensus that the future of glaucoma management will be based more on the optic nerve pathway from the retina to the visual cortex, and not strictly limited to improving outflow. EuroTimes takes a look at what glaucoma treatment may look like in the not-too-distant future. EUROTIMES | JUNE 2015

NEAR-TERM â&#x20AC;&#x201C; ROCK With intraocular pressure (IOP) being the only known modifiable factor in glaucoma, current therapy continues to emphasise drugs and surgical methods of keeping pressures under control. The mainstays are prostaglandin analogues, which increase uveoscleral outflow, and beta blockers, which reduce aqueous production. Considerable activity suggesting that a new class of agents known as Rho Kinase (ROCK) inhibitors, which act mainly on trabecular meshwork outflow, will play a key role in future glaucoma management either alone or in combination with current treatments. ROCK inhibitors are also considered to offer

potential in the treatment of heart disease, erectile dysfunction and cancer. ROCK inhibitors are thought to enhance aqueous drainage by acting on the actin cytoskeleton and cellular motility in the trabecular meshwork, Schlemmâ&#x20AC;&#x2122;s canal and in ciliary muscle. These drugs appear to lower IOP by decreasing resistance to aqueous outflow by cellular relaxation in the trabecular meshwork. There is now considerable clinical trial data confirming that ROCK inhibitors do indeed lower IOP. One drug in this class, ripasudil (Glanatec, Kowa), recently received regulatory approval in Japan for the treatment of glaucoma and ocular hypertension.

COVER STORY: GLAUCOMA

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The optic nerve is really just the cable composed of axons of multiple different RGC types within the eye Neeru Gupta MD, PhD, MBA

In human glaucoma, neural degeneration extends throughout the visual system, in the intracranial optic nerve, the lateral geniculate nucleus and the visual cortex

EUROTIMES | JUNE 2015

Courtesy of Hubel, 1991

There is a consensus among glaucoma researchers that controlling IOP with drops and surgery will simply never be adequate to deal with the underlying causes of the disease. Rather, the new direction is to look at the relationship between the various types of retinal ganglion cells (RGCs), the optic nerve and the visual cortex. More than a decade ago, Neeru Gupta MD, PhD, MBA, Professor and Dorothy Pitts Chair of Ophthalmology & Vision Science, St Michael’s Hospital, and Chief of Glaucoma, University of Toronto, Canada, proposed that glaucoma should

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LONG-TERM – FOLLOW THE OPTIC PATHWAY

be seen as a neurodegenerative The loss of retinal ganglion cell axons in this patient is picked up clinically by disease. She reported research the retinal nerve fibre layer defect at 7 o’clock emanating from the disc indicating that a rise in IOP affected not only the RGCs and nerve fibres, but also extended to major vision centres in the brain, experimentally, and in patients with glaucoma. “There is no question that high pressure causes injury to RGCs. What are the exact pathways of insult that cause this? We don’t know. The big push now is to do something beyond pressure. We are trying to attack the fundamental problem. The optic nerve is really just the cable composed of axons of multiple different RGC types within the eye. We are blood and aqueous humour. In addition, still learning the specific role of RGCs and major advances in imaging capability will other cell players including glial cells. The allow researchers to study actual damage to optic nerve is a highway to the brain and we visual centres in the brain. are only just beginning to understand how “We can look forward to a more personal everything is segregated and integrated in and proactive approach to choices and visual processing,” she told EuroTimes. timing of treatments, to prevent damage She emphasised the importance of throughout the visual system, and to keep thinking of glaucoma as a disorder of the glaucoma patients seeing for a lifetime,” entire visual system. The role of RGCs says Dr Gupta. needs to be considered in relation to the Researchers are looking at treatment rest of the brain. This will be the basis of strategies that might approach RGC loss at therapies that boost the ability of RGCs different stages in the disease process. Early to connect, to understanding which cells intervention would aim to preserve existing are most susceptible to damage, and under which circumstances. She predicted that future glaucoma treatment would involve more personalised care, where phenotyping and genotyping will help guide a pharmacogenetic approach. This will allow for the treatment of specific genetic defects with an appropriate individual therapy. “We will see new agents and therapeutic cocktails that will address the RGC sickness. We are starting to discover that there may be intrinsic fundamental distress in areas of the brain that process vision, so we will need to be looking at therapies that make the system more robust,” she explained. The road to discovering these new treatments will in turn depend on clinical studies that will help find more clues about glaucoma pathogenesis, such as biomarkers in Co

Hidenobu Tanihara MD, Professor of Ophthalmology, Kumamoto University, Kumamoto, Japan, has been involved from the beginning in trials leading to the approval of the drug. He has reported clinical trial results indicating that the drug produced significant, dose-dependent reductions in IOP in eyes with glaucoma and ocular hypertension. The effects were additive when combined with a prostaglandin agent and beta blocker (timolol). The new drug was well tolerated but did produce transient hyperaemia in a majority of patients. “Ripasudil is now prescribed as the second-line drug for glaucoma treatment in Japan. I think ripasudil can add IOPlowering effects to the first-line drugs such as beta blockers and prostaglandins. Patients seem to be accepting the hyperaemia because of its transient nature,” he told EuroTimes. Another drug in this class, Rhopressa (Aerie Pharmaceuticals), is now in phase III studies. In phase II studies the drug produced sustained reductions in IOP with once daily dosing. However, in phase III studies the drug did not meet its primary efficacy endpoint of non-inferiority to twice daily timolol above 26mmHg IOP. The company is also developing Roclatan, a single-drop fixed-dose combination of Rhopressa and latanoprost. A third candidate, AR-13533, is in preclinical testing. The Belgian company Amakem also has a ROCK inhibitor in phase II testing for glaucoma treatment. The mechanism of action of ROCK inhibitors suggests there may be benefits beyond IOP lowering. Studies indicate that drugs in this class increase retinal blood flow by relaxing vascular smooth muscle cells. This could provide a neuroprotective effect. A better understanding of how these drugs work will also provide new insights into the pathology of glaucoma, says Dr Tanihara.

RGCs by using neuroprotective agents. A related approach would involve introducing neurotrophic factors and growth factors that could help the cells regenerate. Some factors under investigation include ciliary neurotrophic factor (CNTF), endothelin-1, TGF-b, connective tissue growth factor (CTGF), and ghrelin. Jeffrey Goldberg MD, Director of Clinical Research, Shiley Eye Institute, UCSD, San Diego, US, is another investigator pushing the boundaries of glaucoma research. His team is involved in looking at how and why RGCs die after optic nerve injury. “Learning about the molecular pathways that, during early development, turn off RGC intrinsic capacity for rapid axon growth has led to new therapeutic approaches to reverse regenerative failure and promote axon growth in the injured or degenerating optic nerve. Such therapeutic approaches are just beginning to enter human clinical testing in early phase trials,” he told EuroTimes. Dr Goldberg was involved in some of the first trials testing the ability of a growth factor, CNTF, to promote both RGC survival and optic nerve regeneration in glaucoma patients. CNTF is a member of the IL6 cytokine category. It is released by retinal glial cells. Laboratory research has shown that CNTF promotes RGC survival, protects RGCs from degeneration, and promotes optic nerve regeneration. Two open-label safety studies enrolled 11 patients with primary open-angle glaucoma. Patients received CNTF delivered via a proprietary approach known as encapsulated cell therapy (NT-501, Neurotech). The

Courtesy of Gupta et al, BJO 2009

COVER STORY: GLAUCOMA

Structural degeneration of the lateral geniculate nucleus has been shown in patients using MRI

implant is a small immunologically neutral capsule designed to release a steady stream of CNTF. The 1.0 x 3.0mm implant contains RPE cells primed to produce CNTF. All patients completed the study with no serious adverse events related to treatment. There are also a number of promising animal studies in which implanted RGCs showed evidence of growing both dendrites into the retina and axons along the retinal nerve fibre layer and across the optic chiasm. This suggests that it may be possible to transplant RGCs even in the very late stages of glaucoma, he said.

RESEARCH HITS A WALL However, there is a sense that glaucoma research has a hit a wall, with quite a lot of promising animal studies but little movement towards early clinical studies in humans. Dr Goldberg told EuroTimes that the main obstacle to success is the reticence to move such approaches into early phase trials for human testing. But he said this reticence is beginning to melt away as more confidence is gained in the ability to design clinical trials for neuroprotection and neuroenhancement.

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Examples are coming from growth factors and stem cell trials that are just beginning to enter human testing Jeffrey Goldberg MD EUROTIMES | JUNE 2015

“Examples are coming from growth factors and stem cell trials that are just beginning to enter human testing. From here forward it is an empiric question: will the treatments that work so well in animal models of human diseases, like glaucoma or optic nerve stroke, prove their worth in humans with these diseases? The only way we will answer that question is to do the actual trials,” he said. Gene therapy is another area of active investigation, and is a good example of this situation where promising in vivo research awaits the next step into human trials. Animal studies have shown the basic feasibility of introducing genes to the back of the eye that can inhibit apoptosis and encourage neurotrophic factors to preserve RGCs. Another approach is the development of therapeutic constructs that target the cytoskeleton of the trabecular meshwork. Yet another avenue of gene therapy in the pipeline involves using non-viral gene replacement therapy delivered in DNA nanoparticles. “Gene therapy holds the ultimate promise to eliminate glaucoma-induced visual disability across a spectrum of possibilities: pre-disease onset detection, treatment targeted at basic cellular dysfunction (whether in the outflow pathways or in the retina/optic nerve head), optimal use of individualised pharmacological neuroprotection and/or IOP reduction, and even neural regeneration and/or repopulation,” commented Ivan Goldberg MD, Director of Eye Associates in Sydney, and Head of the Glaucoma Unit at the Sydney Eye Hospital, Australia. Hidenobu Tanihara: tanihara@pearl.ocn.ne.jp Jeffrey Goldberg: jlgoldberg@glaucoma.ucsd.edu Neeru Gupta: GuptaN@smh.ca Ivan Goldberg: eyegoldberg@gmail.com

Friday 4 September

ESCRS

Glaucoma Day 2015

Registration Open Alcon Satellite Meeting Lunchtime Sponsored by

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SPECIAL FOCUS: GLAUCOMA

The device is inserted into Schlemm’s canal lumen Closure of superficial scleral and conjunctival flaps A second instrument, Hoskin corneal forceps, is used to free the device from the microprobe

The device mounted on microprobe before insertion The device is in the lumen of Schlemm’s canal Canalography to identify patent collector channels

REFRACTORY PRIMARY OPEN-ANGLE GLAUCOMA Novel intracanalicular device shows promise for IOPlowering in challenging cases. Cheryl Guttman Krader reports

egment dilation of Schlemm’s canal using a novel stainless steel spiral expander appears safe and effective for reducing intraocular pressure (IOP) and medication use in patients with medication-refractory primary open-angle glaucoma, reported Galina Dushina MD at the XXXII Congress of the ESCRS in London. The intracanalicular device is patented in Russia and was designed and developed by a group of inventors at the ophthalmic unit of Skhodnya Hospital and Department of Ophthalmology, Medical Institute, Peoples’ Friendship University of Russia: Kumar Vinod MD, PhD, Frolov Mikhail MD, PhD, Dr Dushina and Bozhok Elena MD. It is made of 0.05-mm thick, medical grade soft vanadium stainless steel wire that is wound around a 0.2mm stainless EUROTIMES | JUNE 2015

steel microprobe to create a spiral having the same curvature as Schlemm’s canal. Dr Dushina presented one-year outcomes from 12 eyes with preoperative IOP above 21mmHg on maximum IOPlowering medication. In two patients who had end-stage glaucoma, the surgery was performed to salvage the eye, and five patients underwent concomitant cataract surgery. Mean IOP was 25.1mmHg preoperatively, 11.2mmHg at one month postoperatively, and 13.4mmHg at 12 months, a 46 per cent reduction from baseline. The surgery was judged a complete success (IOP reduction >25% or ≤18mmHg without medication) in five eyes, and the remaining seven eyes met criteria for partial success (same IOP thresholds with medication use). Mean daily medication use decreased from 2.4

preoperatively to 1.1 at 12 months. Of the seven patients on medication, three were using a single drop, one was on two drops, and three were on three medications. “There is early rehabilitation with this surgery, and we have not seen any serious complications or inflammation at the insertion site. Now, randomised controlled studies with longer follow-up and larger patient populations are required to confirm the efficacy and safety of this technique,” said Dr Dushina, Department of Ophthalmology, Peoples’ Friendship University of Russia, Moscow.

WATERTIGHT CLOSURE The ab externo surgery involves exposure of a 3.0mm area of Schlemm’s canal with a technique similar to that used for deep sclerectomy but without creating

SPECIAL FOCUS: GLAUCOMA

a window in Descemet’s membrane. After first dilating a 5 to 6.0mm segment of unexposed Schlemm’s canal with a cohesive viscoelastic and microprobes with diameters 0.2 to 0.3mm, the expander device is mounted on a microprobe for insertion. Watertight closure of the deep and superficial scleral flaps and conjunctival flap is verified at the end of the procedure. “Insertion of the device into the canal is the only new element of this viscocanalostomy surgery, and it was easily done except in one patient who had previous glaucoma surgery,” Dr Dushina observed. However, microperforation of the trabecular meshwork at unexposed sites of Schlemm’s canal occurred intraoperatively in three eyes due to insufficient dilation of the canal. In the latter cases, one end of

Courtesy of Kumar Vinod MD, PhD

Watertight closure of deep scleral flap

Device is mounted on 0.2mm thick microprobe having curvature as of Schlemm’s canal

the device resided in the anterior chamber angle, but it was not touching any tissue. The only other device-related event occurred postoperatively at a second follow-up visit when pressure during examination with a gonio lens caused the body of the device to dislocate into the

angle. The two ends remained embedded in Schlemm’s canal, and the patient’s IOP was controlled at one year with use of one medication and no evidence of inflammation. Galina Dushina: dushina_galina@mail.ru

There is early rehabilitation with this surgery, and we have not seen any serious complications or inflammation at the insertion site Galina Dushina MD

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EUROTIMES | JUNE 2015

SPECIAL FOCUS: GLAUCOMA

DUAL PROCEDURE Phaco-vicsocanalostomy can produce long-lasting IOP reduction. Roibeard O’hEineachain reports

b externo glaucoma surgery techniques that are designed to improve the outflow of aqueous through Schlemm’s canal can be safely and successfully combined with phacoemulsification in juvenile patients, with good long-term results, Robert Stegmann MD told the XXXII Congress of the ESCRS in London. “What we are really trying to achieve in all these operations is to re-establish the normal outflow of aqueous, which is mainly driven by the engine of the ocular pulse, which is also synchronised with the patient’s respiration and expiration that helps pump it out,” said Dr Stegmann, Professor and Chairman of Ophthalmology at Medical University of South Africa. Dr Stegmann noted that, although he used to perform combined surgeries frequently, he now almost always prefers to perform the procedures separately when possible. There nonetheless remain certain cases where combined surgery is the best option.

You want to keep the anterior hyaloid intact at all costs Robert Stegmann MD

15th International Paediatric Ophthalmology Meeting GIBSON HOTEL, DUBLIN 15th & 16th October 2015 Topics Retina, Strabismus, Amblyopia, Retinoblastoma, Uveitis, Neuro-ophthalmology, Glaucoma

Faculty David Walton – Boston Vernon Long – Leeds John Burke – Sheffield Martin Snead – Cambridge Eibhlin McLoone – Belfast Wefong Siah – London Kais Algawi – Abu Dhabi

David Keegan – Dublin Donal Brosnahan – Dublin Caitriona Kirwan – Dublin John Stokes – Waterford John Murphy – Dublin Gillian O’Mullane - Dublin

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MARFAN’S SYNDROME As an example, he cited a case he had around 20 years ago involving a patient of about 12 years of age with Marfan’s Syndrome who had a subluxed lens and a pressure of 41.0mmHg and a cup/disc ratio of 0.8 in that eye. The zonule was detached in places from both the equatorial and anterior capsule, as commonly occurs in Marfan’s Syndrome. To begin the procedure he first performed a temporal frown incision in the sclera. As the anterior hyaloid was still intact, Dr Stegmann took special care to maintain its integrity. He injected high viscosity sodium hyaluronate to take the stress off the zonule and the anterior capsule, which allowed entry into the anterior chamber in the safest possible way with no damage to the vitreous face. “You want to keep the anterior hyaloid intact at all costs. I consider it to be one of the most important structures of the human eye and not something that should be gobbled up at random and indiscriminately by vitrectomy units,” he emphasised. He used a micro-diamond knife to puncture the youthful and therefore highly elastic anterior capsule and injected some high viscosity sodium hyaluronate to begin the separation of the capsule from the soft, almost paediatric cortex. Then, using micro-scissors from Grieshaber, he cut further along the equatorial region to the point where it became safe to dry-aspirate the lens material, once the separation of the cortex from the capsule was complete. “These kind of cases I always favour doing dry aspiration, because otherwise there is a very definite chance you will hydrate the vitreous,” he said. After completing dry aspiration of the cortex and nucleus with a 23-gauge cannula, he very carefully cleaned off the lens epithelial cells with a diamond-studded burr and implanted the lens. He noted that among the cataract patients he has treated over his long career are some who have continued to have crystalclear posterior capsules throughout up to 26 years of followup, provided that meticulous removal of lens epithelial cells is achieved at surgery. To reduce the intraocular pressure (IOP), Dr Stegmann performed a viscocanalostomy, a procedure he had recently introduced. It involves the dissection of a scleral flap 200 microns thick and beneath it the excision of a second scleral flap 250 microns or so thick, depending on the depth required to unroof Schlemm’s canal. Then, using a very fine cannula with a lumen of about 150µ, sodium hyaluronate is injected into either of the newly created ostia to fill a length of 6-8mm of the canal on both sides, followed by watertight closure of the flap. The procedure allows the outflow of aqueous through the opening up of the pores in the trabecular meshwork, resulting in a significant drop in IOP, Dr Stegmann explained. “This is a very successful case, you have a very mobile pupil and a clean bag and the pressure in that eye dropped from 41mmHg to 11mmHg and remained at that level for 13 and a half years, during which he completed his high school, he went to university before the poor young man died of the cardiac complications of Marfan’s Syndrome,” he said. Robert Stegmann: eyeclinic@ul.ac.za

EUROTIMES | JUNE 2015

SPECIAL FOCUS: GLAUCOMA

AVOID PRECONCEPTIONS Conventional wisdom regarding pseudoexfoliative glaucoma is overly pessimistic. Roibeard O’hEineachain reports

UNDIAGNOSED CASES The Thessaloniki Eye Study also showed that the rate of undiagnosed cases was 57.1 per cent in primary open-angle glaucoma patients, compared to 34.9 per cent in patients with pseudoexfoliative glaucoma. Primary open-angle glaucoma patients had three to four times increased risk to be undiagnosed compared to patients with pseudoexfoliative glaucoma after adjusting for potential confounders. The likelihood of glaucoma increased highly

in both pseudoexfoliation and non-pseudoexfoliation subjects for IOP >20mmHg, although the likelihood was approximately three times higher among those with pseudoexfoliation at any IOP above 20mmHg, an indication that pseudoexfoliation glaucoma involves additional contributing factors apart from IOP. However, when all patients treated and untreated were considered, the difference between the mean IOP of the two groups was no longer significant. There were no significant differences between the two groups regarding the cup disk ratio or the visual field AGIS (Advanced Glaucoma Intervention Study) score whether or not they were treated. These findings reflect the fact that less pseudoexfoliative glaucoma cases remain undiagnosed and untreated. He added that, unlike the Blue Mountain Eye Study, in the Thessaloniki Eye Study vascular diseases and their treatment were associated only with primary open-angle glaucoma. The Greek study could show no significant associations between pseudoexfoliation or pseudoexfoliative glaucoma and cardiovascular disease, heart attack, coronary artery bypass or vascular surgery. Therefore the association of pseudoexfoliation or pseudoexfoliative glaucoma with vascular diseases is still under debate and further research is needed to clarify this issue. Fotis Topouzis: ftopouzis@otenet.gr

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Athens Athens

2016

any common preconceptions regarding pseudoexfoliation and pseudoexfoliative glaucoma find little support in the findings of population studies, said Fotis Topouzis MD, Aristotle University Thessaloniki, Greece, at a Glaucoma Day session at the XXXII Congress of the ESCRS in London. He noted that many of these false preconceptions paint a somewhat grimmer clinical picture of pseudoexfoliation than is actually the case, depicting the condition as typically taking an aggressively glaucomatous course, often undiagnosed, with poorly controlled intraocular pressure (IOP) and rapid disease progression. In fact, current evidence indicates that only a minority of pseudoexfoliation patients have glaucoma and that, when pseudoexfoliative glaucoma occurs it is less likely than primary open-angle glaucoma to remain undiagnosed. Although pseudoexfoliative glaucoma is more aggressive with more rapid progression and often poorly controlled at the individual patient level, this is counter-balanced at the population level by the fact that less pseudoexfoliative glaucoma cases remain undiagnosed and untreated, resulting in similar mean visual field defect between pseudoexfoliative and primary open-angle glaucoma cases in the community. In the Thessaloniki Eye Study, the prevalence of all types of openangle glaucoma among those over 60 years of age was 5.5 per cent. The prevalence of primary open-angle glaucoma was 3.8 per cent and the prevalence of pseudoexfoliative glaucoma with 1.7 per cent. Meanwhile, the prevalence of pseudoexfoliation was 11.9 per cent in the Greek population, and among those patients the prevalence of glaucoma was 15.2 per cent. “Despite the high prevalence of pseudoexfoliation in the Greek population, the prevalence of primary open-angle glaucoma appears to be twice that of pseudoexfoliation glaucoma, and 85 per cent of patients with pseudoexfoliation don’t have glaucoma," Dr Topouzis said. Those figures were closely paralleled by the findings of the Blue Mountain Eye study in Australia, where the prevalence of primary open-angle glaucoma among those older than 60 years was only slightly lower ( 3.5 per cent). Although the prevalence of pseudoexfoliation (2.3 per cent) and pseudoexfoliative glaucoma (0.5 per cent) were lower, the prevalence of glaucoma among eyes with pseudoexfoliation was roughly the same (14.2 per cent).

26–28 February

Athens 20TH

ESCRS

Winter Meeting

...85 per cent of patients with pseudoexfoliation don’t have glaucoma Fotis Topouzis MD

In conjunction with the 30TH International Congress of HSIOIRS

www.escrs.org EUROTIMES | JUNE 2015

SPECIAL FOCUS: GLAUCOMA

NEUROPROTECTION Advances in analytics and study design could make new trials feasible.

Howard Larkin reports

n January 2008 glaucoma neuroprotection development suffered a setback. Two large phase III clinical trials of oral memantine failed to reach their primary endpoint of slowing glaucoma progression compared with placebo – even though progression was significantly slower in the higher dose group than in the lower dose group. “Many companies that had been carefully monitoring the emerging activity in glaucoma neuroprotection lost their appetite for what appeared to be a high risk venture, and others that had already made a commitment to develop a neuroprotective drug reallocated their resources from glaucoma into areas they thought might be more productive, including retina,” Robert N Weinreb MD told Glaucoma Day at the 2014 American Academy of Ophthalmology annual meeting in Chicago. But recent advances may make new neuroprotection trials viable, said Dr Weinreb, of University of California, San Diego, US. “With new technologies, new methods of assessment and our better understanding of clinical trials, I wonder whether it’s time to reassess our ability to do these trials.” What went wrong? The failed memantine glaucoma trial involved two parallel arms of 1,100 patients each followed for four years. Although the total cost for these trials has not been made public, it is likely that it was sizeable and a huge risk for any investor. Given memantine’s success in animal models, including monkeys, the failure was especially disappointing, Dr Weinreb said. But animal glaucoma models are difficult to translate to human disease due to differences in anatomy and mechanisms of ganglion cell damage. Differences in design between preclinical and clinical trials include dosing, timing and intervention duration. Subject age and previous treatment with intraocular pressure-lowering agents are also significant differences. Detecting progression and defining study endpoints have been especially problematic, Dr Weinreb noted. Regulatory agencies equate glaucoma progression with achromatic visual field loss. However, visual fields are not sensitive in early disease and are highly Robert N Weinreb MD variable in late disease.

New trials could be feasible with changes that address previous weaknesses

Neuroprotective agents also must be evaluated in glaucoma patients already treated with IOP-lowering drugs, so trials are necessarily longer than required to establish IOP reduction. The lack of endpoint precision combined with slow and uneven disease progress means large numbers of patients must be followed for more than a year to generate meaningful data.

BETTER ENDPOINTS Still, many glaucoma specialists are unwilling to give up on neuroprotection. Many glaucoma patients progress despite lowering their IOP. It is possible that other factors besides IOP contribute to optic nerve injury in glaucoma including ischaemia, failure of trophic support and others. New trials could be feasible with changes that address previous weaknesses, Dr Weinreb said. For example, opening participation to patients other than those with advanced disease would make recruiting easier. Including patients at high risk for progression such as those with disc haemorrhage increases the difficulty of recruitment but would reduce the sample size. Adopting structural as well as functional endpoints might also help. Measures such as retinal nerve fibre layer thickness on OCT are more sensitive for assessing early progression, with changes often appearing long before any measurable vision loss, Dr Weinreb noted. Such testing also does not require pupil dilation and so are less burdensome for patients, enabling quicker data collection and fewer patients lost to follow-up. Better still may be a combined structure and function index for estimating retinal ganglion cell numbers. One such test, the retinal ganglion cell index developed by Felipe Medeiros MD, PhD, has proven more sensitive than visual function, OCT retinal thickness or mean deviation for detecting both early and late glaucoma progression, Dr Weinreb said (Medeiros FA et al. Am J Ophthalmol 2012;154:814-24). Dr Weinreb suggests that it may be possible to design a neuroprotection trial with fewer than 500 patients. “In fact if you look at some of the assumptions and tweak them a bit you can get samples even smaller and durations less than one year,” Dr Weinreb said. He believes a new trial with an appropriate drug and testing parameters has a good chance of succeeding at a reasonable cost. Robert N Weinreb: rweinreb@ucsd.edu

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EUROTIMES | JUNE 2015

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CATARACT & REFRACTIVE

CAPSULAR RUPTURE Rates of PCR range greatly in cases of posterior polar cataract. Leigh Spielberg reports

any cases of capsular rupture could probably be avoided by taking appropriate precautions, said Graham D Barrett MD, of Australia, in a presentation during the Combined Symposium of Cataract & Refractive Societies at the XXXII Congress of the ESCRS in London. “Posterior polar cataract is associated with a very high incidence of posterior capsular rupture (PCR) during cataract surgery. The posterior capsules in eyes with posterior polar cataract are known to have an abnormal adhesion to the polar opacity or a pre-existing weakness of the capsule that predisposes the eye to PCR. It is this, rather than a pre-existing capsular defect, which implies that we can avoid capsular rupture if we take the correct precautions,” he said. Posterior polar cataract is a round discoid opacity of degenerative lens fibres associated with autosomal dominant mutation of the PITX3 gene. This is a transcription factor responsible for a protein involved in lens formation during eye development. “What can we do to decrease the chances of rupture?” asked Dr Barrett. Published rates of PCR in cases of posterior polar cataract range from six per cent to 36 per cent, which represent significant rates even at the low end of this spectrum. “First of all, one should not begin with an initial hydrodissection. This forces fluid into a closed space, which builds up pressure inside the capsule and risks PCR. Instead, a deep hydrodelineation should be performed first, which places far less pressure on the posterior capsule. After hydrodelineation, one can proceed to a gentle, multicentric hydrodissection,” he explained. Inside-out delineation, a technique first described by Dr Abhay R Vasavada in 2004 for the treatment of posterior polar cataract, Graham D Barrett involves fluid injection from the inside of the nucleus to the outside, allowing precise, controlled hydrodelineation and minimal risk to the posterior capsule. Multicentric hydrodissection involves injecting fluid into the capsule at various locations, so as to avoid one single highpressure flow. He referred to a study by IH Fine et al, published in the JCRS in 2003, which describes this technique. Regarding nucleus fragmentation techniques, Dr Barrett prefers a vertical chop, even with a very soft lens. This allows the surgeon to stay away from the posterior capsule during this step. “In most cases, you’ll see that the posterior polar opacity will be removed during the removal of the cortex,” he said. However, if this is not the case, he added: “I don’t recommend aggressive scrubbing of the opacity. This is too risky.” Another point Dr Barrett strongly emphasised was the maintenance of a very stable anterior chamber throughout the procedure. This can be achieved by injecting a viscoelastic device when removing instruments from the eye, in order to prevent the posterior capsule from bulging forward. Graham Barrett: graham.barrett@uwa.edu.au EUROTIMES | JUNE 2015

XXXIII Congress of the ESCRS

Main Symposia Cataract Surgery in Ocular Surface Disease The Ageing Eye: Can We Delay or Reverse the Process? FLACS: What Have We Learned and What Can We Expect? Treating Presbyopia: From Concept to Evidence Late Dislocation of IOLs: Causes and Treatments

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5–9 September 2015 Fira Barcelona Gran Via, Spain North Access, Hall 8

Binkhorst Medal Lecture Richard Packard UK

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XXXIII Congress of the ESCRS 5–9 September

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CATARACT & REFRACTIVE

SURFACE ABLATION Future prospects for surface treatments remain good.

Tired of seeing those unhappy patients?

Roibeard O’hEineachain reports

urface ablation remains an evolving science and may yet keep pace with recent advances in intrastromal techniques, asserted Ioannis Pallikaris MD, University Hospital of Crete, Heraklion, Crete, Greece, at the 19th ESCRS Winter Meeting in Istanbul. Reviewing the history of lasers in corneal refractive surgery, Dr Pallikaris noted that photorefractive keratectomy (PRK) was introduced in the 1980s. Its minimally invasive nature and predictable results initially made it a very attractive option. However, the procedure as originally designed caused postoperative pain and haze and there was regression of effect. That in turn led to the development of LASIK. LASIK involved less pain than conventional PRK and provided faster rehabilitation. But as with PRK, unforeseen complications emerged, in this case corneal ectasia and unpredictable flap-induced aberrations. That in turn led to the development of advanced surface ablation. Dr Pallikaris noted that advanced surface ablation is a term covering a variety of procedures, including standard PRK but with the addition of mitomycin –C to prevent haze, LASEK, which involves the use of epithelial flap loosened by alcohol as a sort of bandage for the stromal surface, and epi-LASIK, where an epikeratome is used instead of alcohol to create an epithelial flap. “In the case of LASEK, the retained epithelial flaps allow for a reduced incidence of haze, and it is better tolerated by patients. With epi-LASIK, the use of the epikeratome provides the benefit of avoiding alcohol toxicity,” Dr Pallikaris said. Advanced surface ablation techniques offer several advantages over conventional PRK, such as an increased quality of vision, a reduction of postoperative pain and minimal corneal haze. In addition, like conventional PRK, they have the advantage of having no risk of flap-related complications, Ioannis Pallikaris ectasia or flap-induced aberrations. Furthermore, surface ablations are a very useful option in deep set eyes with small palpebral aperture. They also have safety advantages for patients with a history of recurrent epithelial erosions, and participants in contact sports. Other indications for surface treatments include eyes with thin corneas, those with preoperative dry eye, epithelial basement membrane dystrophies, or flat or steep corneas. Dr Pallikaris said that one problem that remains with surface ablations is the compensatory smoothing of the ocular surface by the epithelium as it regrows. However, ablation algorithms could be developed to compensate for that, and new masking agents used in the manner of the photoablatable lenticular modulator (PALM) technique may also play an important role in the future of surface ablations. The PALM technique refers to corneal excimer laser phototherapeutic keratectomy through a gel used as a masking agent.

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Ioannis Pallikaris: pallikar@med.uoc.gr EUROTIMES | JUNE 2015

CATARACT & REFRACTIVE

TAILORED PRESBYLASIK Adaptive optics help find optimal asphericity for better visual results. Howard Larkin reports

tilising adaptive optics before surgery can help identify patient-specific presbyLASIK treatment parameters that improve visual outcomes, Pablo Artal PhD told Refractive Surgery Day at the American Academy of Ophthalmology annual meeting in Chicago. PresbyLASIK addresses loss of accommodation by inducing corneal aberrations that increase depth of focus, usually by increasing negative asphericity, said Dr Artal, of Murcia University, Spain. This improves middle and near vision, enabling patients to see objects over a range of distances – but at the cost of reduced distance image quality. It is often used with monovision to further stretch functional vision range. However, it is hard to predict how inducing a particular corneal aberration will affect vision because visual outcomes depend on many variables, he noted. Some of these are purely optical, such as the eye’s total spherical aberration, which may be anywhere from neutral to 0.2 microns. Also, neural responses to different amounts of spherical aberration vary from patient to patient. Therefore, every eye cannot be treated the same. The key to a good visual outcome in presbyLASIK is to find the degree of corneal asphericity that provides adequate near vision without intolerable loss of distance vision, he explained. “PresbyLASIK forces you to have a good compromise between the two factors, depth of focus and visual acuity. If you are able to find a good compromise, you will have a good visual outcome; if not it is going to be a problem,” said Dr Artal.

ADAPTIVE OPTICS Adaptive optics make it possible to test how a patient responds to induced aberrations before surgery, making it possible to determine how specific aberrations affect depth of focus and visual acuity. These findings can then be used to adjust the amount of asphericity induced at LASIK surgery.

Courtesy of Pablo Artal PhD

The adaptive optics device combines an aberrometer which objectively measures the optical properties of the eye, and spatial light modulators which can introduce different aberrations into projected images. The patient’s visual acuity at different distances can then be measured and graphed. Generally, distance visual acuity declines and near acuity increases as negative asphericity increases. The point where the two lines cross is often close to where patients are most comfortable with the compromise, though some will prefer more distance and others more near vision, Dr Artal said. “You can induce different amounts of spherical aberration in a non-invasive way and see how the patient responds,” he added. Dr Artal and colleagues have demonstrated that customising LASIKinduced corneal asphericity based on adaptive optics analysis can improve presbyLASIK visual outcomes. In a study involving 76 patients, the 37 treated with an optimal spherical aberration value as determined preoperatively using

PresbyLASIK forces you to have a good compromise between the two factors, depth of focus and visual acuity Pablo Artal PhD EUROTIMES | JUNE 2015

an adaptive optics instrument (AOneye, Voptica SL) gained a mean 0.93 +/- 0.5 dioptre of pseudo-accommodative capacity, significantly more than the 0.46 +/- 0.42 dioptre gained by those treated with a nonoptimal degree of spherical aberration, and the 0.35 +/- 0.32 gained by controls receiving standard LASIK ablation (P<0.05). The mean spherical aberration induced in the adaptive optics group was -0.18±0.13 microns at a pupil size of 4.5mm. The wide range of spherical adjustments reflects the variability of the optimal correction from patient to patient. All the study patients received distance correction in the dominant eye with a standard LASIK profile, and -0.75 monovision with increased depth of focus profile or standard profile in the non-dominant eye (Leray B et al. Ophthalmology. 2015 Feb;122(2):233-43). Dr Artal has observed similar results inducing asphericity and monovision in the non-dominant eyes of patients implanted with the Light Adjustable Lens (Calhoun Vision). The system uses a special ultraviolet lamp to correct the IOL’s power and optical characteristics after it is implanted, allowing patients to “try out” the adjustments before they are locked in. “It is possible to find a good compromise if you are customising for each patient. The solution is to use adaptive optics,” Dr Artal said. Pablo Artal: pablo@um.es

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CORNEA

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MATRIX REGENERATION New agent shows promise in treatment of corneal melting. Roibeard O’hEineachain reports

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new matrix regenerating therapy preparation, Cacicol20® (Inovanz), appears to restore the structural integrity to corneas severely damaged by autoimmune diseases, said Ewa Mrukwa-Kominek MD, PhD, Department of Ophthalmology, Silesia University of Medicine, Katowice, Poland, at a Cornea Day session of the 19th ESCRS Winter Meeting in Istanbul. “Matrix regenerating therapy contributes to a persistent healing of corneal ulcers. It promotes epithelialization and supports further reconstruction of the corneal stroma. Patients also display significant improvement in corneal thickness and visual acuity. Furthermore, no systemic or local side-effects of treatment were observed,” Prof Mrukwa-Kominek said. She presented a case study involving a 42-year-old man with Sjogren's syndrome and rheumatoid arthritis who had advanced dry eye syndrome which manifested as filamentous keratopathy in his right eye, causing corneal melting and perforation, and necessitating a penetrating keratoplasty procedure. The patient’s left eye also had less advanced corneal melting. “Chronic defects of this type are usually progressive and treatment-resistant. The corneal ulcers they cause can result in significant vision loss from scarring, astigmatism and perforation,” Prof Mrukwa-Kominek said. To avoid the need for a second keratoplasty in his right eye and a first keratoplasty in the left eye, the patient underwent topical treatment with the new matrix regenerating therapeutic agent onceweekly for five weeks.

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The agent consists of large biopolymers that mimic the glycosaminoglycan, heparin sulphate, an important component of cornea’s extracellular matrix. However, unlike Ewa Mrukwa-Kominek heparin sulphate, Cacicol20 is protected from proteolysis and it therefore allows the natural regenerative processes of the cornea to proceed unimpeded. Prof Mrukwa-Kominek noted that throughout the course of treatment the patient had a gradual increase in corneal thickness in his left eye and a gradual decrease in corneal oedema in his right eye. He also had a steady improvement in visual acuity and quality of life. By the end of treatment, corneal thickness had increased from 119 microns to 379 microns in his left eye and had decreased from 1,188 microns to 657 microns in his right eye. Furthermore, visual acuity improved from 0.015 to 0.1 in the right eye, and from 0.2 to 0.3 in the left eye. “Despite the advances of ophthalmology, progressive corneal thinning, which may be secondary to systemic or local eye diseases, is difficult to treat and is often resistant to medication. A new agent that stops the progression of corneal thinning and enhances matrix regeneration appears to be a potentially useful alternative non-invasive therapeutic approach to progressive corneal thinning,” Prof MrukwaKominek concluded. Ewa Mrukwa-Kominek: emrowka@poczta.onet.pl

EUROTIMES | JUNE 2015

CORNEA

DEFINING KERATOCONUS Early diagnosis may improve outcomes, avoid surgery disasters. Roibeard O’hEineachain reports

n improved definition of the different stages of keratoconus will aid in the assessment of candidates for corneal refractive surgery and research into potential treatments for the condition, said Stephen Tuft FRCS, Moorfields Eye Hospital, London UK. “The drive in investigation and research should be towards early diagnosis and better ways of intercepting patients at a stage when treatment and intervention is more appropriate,” Dr Tuft told the 19th ESCRS Winter Meeting in Istanbul. The basic definition of keratoconus is a bilateral asymmetric thinning of the cornea that causes keratometric myopia and irregular astigmatism. Its onset generally occurs when patients are in their teens, but it can occur later. Most patients have a stabilisation of the condition by their late 30s, possibly as a result of the general tendency of the body’s collagen to stiffen with age. Among European populations the prevalence of keratoconus is about one per 1,200 individuals. The prevalence is about four times higher among South Asian populations, with a tendency towards an earlier age of onset and more rapid progression. In developed countries, keratoconus accounts for about one third of patients requiring a corneal graft procedure. There are four main phenotypes of keratoconus. They are apex keratoconus, inferior or slipped cone keratoconus, pellucid marginal degeneration, and keratoglobus. The phenotype tends to be the same in families with the condition and, as the disease progresses, the phenotype does not shift into a different phenotype. The cause of keratoconus appears to be a combination of genetic and environmental factors. Allergy and consequent eye rubbing has a role in some cases, although the exact pathological mechanism whereby this occurs has yet to be elucidated. Genetic studies have identified gene variants that may have a role in the disease, but none that are exclusive to keratoconus patients. Dr Tuft said that when assessing patients for corneal refractive surgery, a surgeon should begin with the assumption that all patients under the age of 40 are keratoconus suspects in the broadest sense. The most reliable way to identify patients in an early stage of the disease is to see if there is a lack of concordance between the area of maximum curvature and the area of maximum elevation, and between the position of the corneal apex and the thinnest point. “Overall, I think that measurements such as topography, refractive error and astigmatism should be combined and used towards developing better algorithms to improve discrimination in the diagnosis of keratoconus,” Dr Tuft added.

The drive in investigation and research should be towards early diagnosis...

Stephen Tuft: s.tuft@ucl.ac.uk

Stephen Tuft FRCS

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CORNEA

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iboflavin/UVA corneal crosslinking (CXL) leads to significant visual improvements in some keratoconus patients, and has saved paediatric patients from needing corneal transplants, the Joint Irish/UKISCRS Refractive Surgery Meeting in Dublin, Ireland heard. David O’Brart MD gave the Dermot Pierce Memorial lecture on CXL indications, techniques and complications, and discussed the results of his own seven to eight year follow-up studies. Dr O’Brart said his results have been extremely encouraging, with stabilisation of keratoconus in all treated eyes, excellent stability over seven to eight years of follow-up with continued improvement in corneal shape and reduction of keratoconus in the vast majority of eyes. Dr O’Brart said CXL in keratoconus continues to show great promise and being able to now offer hope to these patients is “wonderful”. “The improvement in vision in some patients can be quite phenomenal. What you are seeing at eight years is that visually some of these patients have improved by as many as four lines," he told the meeting. “If you have a patient with keratoconus, particularly under 40, and you think the David O’Brart condition is progressing, then perform CXL. It is a relatively cheap procedure and a lot cheaper than performing a corneal transplant down the line. It is going to get more sophisticated and we are learning more about optimising the technique,” Dr O’Brart maintained. Dr O’Brart said while he had gotten very close to achieving comparable riboflavin stromal uptake with an “epithelium-on” iontophoresis technique compared to “epithelium-off CXL”, he stated that “we have not yet discovered how to not damage the epithelium during the procedure”.

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Dr O’Brart also described his positive results of performing CXL on children, maintaining that proactive treatment is vital to halt progression of keratoconus and consequent visual loss. “I now have treated a number of children where in one eye, because of severe disease, I had to undertake corneal transplantation, with the other eye progressing rapidly. After crosslinking of these better eyes, no progression has occurred. It is very likely that these less severely affected eyes would have progressed to such a stage that would require transplantation. CXL has, it appears, saved these eyes thus far from invasive potentially blinding surgery. With the long-term data I have now, I have no qualms about performing CXL on a child,” he told EuroTimes. Concluding, Dr O’Brart said more prospective and comparative studies are needed, particularly on accelerated CXL, and on different epithelium on and off protocols. “That CXL works is not in doubt but there are still many unknowns in CXL," he said. David O’Brart: DavidOBrart@aol.com

EUROTIMES | JUNE 2015

RETINA

NEW AMD TREATMENTS Complement inhibition opens new pathway to treatment. Cheryl Guttman Krader reports

he first evidence that intravitreal lampalizumab (Genentech/Roche) slows the progression of geographic atrophy appears to support the role of complement inhibition in the treatment of dry agerelated macular degeneration (AMD). This is just the beginning, as lampalizumab and similar agents modulating the complement pathway enter clinical trials, said Zohar Yehoshua MD at the 14th EURETINA Congress in London. “Today we have very good treatments for wet AMD and we can preserve vision, however many patients with AMD still have decreased vision due to the development of geographic atrophy. Ultimately, we would like to prevent AMD-related vision loss and that requires preservation or replacement of the photoreceptors, RPE, and choriocapillaris. Modulation of the immune system through complement inhibition is one of several strategies under investigation for achieving that goal,” said Dr Yehoshua, of Bascom Palmer Eye Institute, University of Miami, Florida, US. Lampalizumab, an antigen binding fragment of a humanised monoclonal antibody against complement factor D (CFD), is a selective inhibitor of the alternative complement pathway. In the Phase II MAHALO trial, 129 patients with bilateral geographic atrophy were randomised to receive lampalizumab 10.0mg or sham monthly or every other month. Results of the primary endpoint analysis that assessed mean change in geographic atrophy area from baseline to month 18 showed a 20.4 per cent treatment benefit for monthly lampalizumab. The benefit was observed by month six and maintained through 18 months. Monthly lampalizumab decreased the rate of geographic atrophy growth by 44 per cent among patients positive for complement factor inhibition (CFI), 57 per cent of the population, and by 54 per cent among those positive for CFI with vision of 20/50 to 20/100 at baseline. Dr Yehoshua cautioned that the results from the biomarker analysis must be considered carefully because of the small sample size. He noted that it is unclear why the better seeing eyes among CFI positive patients might respond better. Looking ahead to the possibility of positive results in the Phase 3 lampalizumab trials, one audience member questioned the ethics of a treatment involving bilateral intravitreal injections in patients with fairly good vision. Other drugs in clinical development are targeting different effector molecules in the complement system. For example, POT-4 (Potentia/Alcon), a C3 inhibitor that inhibits all three major pathways of complement activation, is also administered intravitreally and will be entering into Phase 2 research. Dr Yehoshua also discussed two monoclonal antibodies against C5 – intravitreal LFG316 (Novartis) and intravenous eculizumab (Soliris, Alexion). “There may be an advantage with agents targeting C5 because the proximal complement functions remain intact,” said Dr Yehoshua. Data from the Phase 2 COMPLETE study showed eculizumab did not significantly decrease the growth rate of geographic atrophy. Zohar Yehoshua: zyehoshua@miami.edu EUROTIMES | JUNE 2015

RETINA

AMD BRACHYTHERAPY Minimally invasive radiation delivery may improve outcomes and cut risk. Howard Larkin reports anti-VEGF injections beyond two initial injections mandated by the protocol. While the sample is small, the results are consistent with reduced anti-VEGF injection need observed in trials of epimacular and beam radiation treatments, where patients with classic lesions and early proliferative disease responded best.

Courtesy of Salutaris Medical Devices

EPISCLERAL ADVANTAGES

The Salutaris SMD-1 episcleral brachytherapy device

ollowing a promising phase I/II safety trial, a minimally invasive episcleral brachytherapy device for treating neovascular agerelated macular degeneration (AMD) has completed a complementary observational study, said Laurence J Marsteller MD, CEO of Salutaris Medical Devices, who previewed results at the Ophthalmology Futures Europe Forum 2014 in London. The new study used imaging technologies to evaluate the distance from the device’s radiation source to target lesions, potentially improving efficacy by precisely calculating radiation doses. Ionizing radiation therapy is widely used outside ophthalmology for its antiangiogenic as well as anti-inflammatory and anti-fibrotic effects, often with antiVEGF compounds, Dr Marsteller noted. Early results with Salutaris’ SMD-1 episcleral brachytherapy device as well as large trials of epimacular brachytherapy and beam radiation suggest radiation may also be useful for treating wet AMD. “The mechanism of action goes beyond anti-VEGF and may reduce the treatment burden (of frequent intraocular injections). For many patients it could be ‘one and done’,” Dr Marsteller said. EUROTIMES | JUNE 2015

PRECISION DOSING Brachytherapy irradiates tissues by placing a radioisotope seed near the target. The SMD-1 device uses Beta radiation from a strontium-90 source because it has a very short range, falling off more than 90 per cent between 1.0mm and 4.0mm from the source, greatly reducing radiation to non-target tissues, Dr Marsteller said. The SMD-1 device consists of a curved cannula with a fibre-optic light at the tip. The surgeon inserts it through a small conjunctival incision into the sub-Tenon’s space, and uses a handheld indirect ophthalmoscope to place the lighted tip directly behind the target lesion. Using a plunger, a seed of strontium-90 is advanced from a shielded vault on the device handle to the tip, and held there until a prescribed radiation dose is delivered, usually for about five minutes. At no time does the probe penetrate the globe. In the earlier phase I/II trial conducted at the University of Arizona, Tucson, US, three out of the four treatment-naïve patients and one of the two chronically treated wet AMD patients improved their best corrected visual acuity levels two years after SMD-1 treatment (range: +4 to +25 ETDRS letters), Dr Marsteller said. In addition, two treatment-naïve patients did not require any further PRN

The minimally invasive episcleral procedure takes about 15 minutes and can be done in an outpatient clinic with no capital or continuing operating costs, Dr Marsteller said. Patient discomfort is minimal and only about half required a single stitch to close the conjunctival incision. “It is an elegantly simple surgical device,” he said. The SMD device is unlike the epimacular probe that requires vitrectomy, with related endophthalmitis and cataract risk. Furthermore, the epimacular probe is inserted anteriorly, exposing the retina to more radiation than does the SMD-1’s posterior placement, Dr Marsteller noted. Trial data also suggest the epimacular probe is difficult to hold steady, possibly resulting in unreliable dosing and uneven results, while the episcleral probe is inherently stable. Still, the extremely short range of Beta radiation requires extremely precise placement and timing. The second SalutarisMD study, conducted at Moorfields Eye Hospital in London, used ultrasound to measure the total distance from sclera to choroid to retina, and optical coherence tomography to determine the distance from lesion apex to retina. In future interventional trials, combining this data will allow calculation of the precise dwell time to deliver a therapeutic dose of 24Gy to the entire lesion while holding retina surface exposure to less than 18Gy, which is within safety limits, Dr Marsteller said. “This ensures consistent, accurate dosing individualised to each patient and independent of the operator. We believe the advantage of consistent radiation dosimetry and individualised targeting will improve patient outcomes,” Dr Marsteller added. To contact Laurence Marsteller, email Joanne Vitali of Salutaris Medical Devices: jvitali@salutarismd.com

NICE 15th EURETINA Congress

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

11 Main Sessions 24 International Society Symposia 21 Free Paper Sessions 48 Instructional Courses 5 Surgical Skills Courses EURETINA Lecture Keynote Speaker: Alain Gaudric FRANCE The Broad Range of Cystoid Maculopathies

Kreissig Lecture Keynote Speaker: Bill Aylward UK A Logical Approach to Retinal Detachment

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EURETINA

Thursday 17 September

Friday 18 September

Lunchtime Symposia

13.00 – 14.00

Allergan Satellite Meeting

Novartis Satellite Meeting

Topcon Satellite Meeting

Sponsored by

Novartis Satellite Meeting

Geographic Atrophy: The Next Frontier in AMD

Optos Satellite Meeting

Sponsored by

J-F. Korobelnik FRANCE Welcome and introduction

Friday 18 September Morning Symposium 10.00 – 11.00 Alcon Satellite Meeting Sponsored by

Sponsored by

Moderator: J-F. Korobelnik FRANCE

F. Holz GERMANY Geographic atrophy: leading with the science N. Bressler USA Geographic atrophy: from the science to the clinic E. Souied FRANCE Geographic atrophy: what now for patients? J-F. Korobelnik FRANCE Q&A Sponsored by

A New Wave in Vitreoretinal Surgery Technology Moderator: R. Tadayoni FRANCE P. Stanga UK New innovations in vitrectomy F. Fayyad JORDAN Complex cases using the Stellaris® PC Next Generation Trends in vitreoretinal surgery – interactive Q&A session with the experts Sponsored by

Alimera Satellite Meeting Sponsored by

Oertli Satellite Meeting Sponsored by

15 EURETINA TH

CONGRESS

NICE Friday 18 September

Saturday 19 September

Evening Symposium

Morning Symposia

Lunchtime Symposia

18.00

10.00 â&#x20AC;&#x201C; 11.00

13.00 â&#x20AC;&#x201C; 14.00

Bringing Nutritional Prevention into Clinical Practice

Alcon Satellite Meeting

Novartis Satellite Meeting

Sponsored by

Moderator: J. Seddon USA C. Delcourt FRANCE, F. Bandello ITALY S.T.A.R.S.: a score to identify patients at risk of AMD

Allergan Satellite Meeting

Nidek Satellite Meeting

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T. Aslam UK How to efficiently advise AMD patients in nutrition

Oraya Therapy for Wet AMD, Real World Clinical Outcomes

DORC Satellite Meeting

Sponsored by

Moderator: T. Jackson UK

J. Seddon USA Nutrition & visual function

F. Zimmermann SWITZERLAND Stereotactic radiotherapy for wet AMD using microcollimated low-voltage X-ray: mechanisms and synergy with anti-VEGF M. Ranjbar UK Integration of Oraya Therapy as a second line therapy: experience in Germany K. Hatz SWITZERLAND Stereotactic Radiotherapy for treatment of wet AMD in a treat-and-extend regime first year outcomes C. Brand UK Stereotactic Radiotherapy for the treatment naive patient with neo-vascular age related macular degeneration Sponsored by

Sponsored by

Second Sight Satellite Meeting Sponsored by

Quantel Satellite Meeting Sponsored by

EURETINA is delighted to announce the 4th Retina Race Date: Saturday 19 September (Registration opens at 6.30am)

Location: Promenade des Anglais, Nice Registration Fee: Ð30 in aid of Orbis N.B. Please note that according to French Law all race participants must submit a medical certificate dated from less than one year before the Race-Day signed by a doctor with the mandatory mention: “Mr/ Mrs X is conditioned to participate in the running competition” (French Law Buffet, March 1999) YOU WILL NOT BE PERMITTED TO PARTICIPATE IN THE RACE WITHOUT SUBMITTING THIS CERTIFICATE WITH YOUR REGISTRATION

OCULAR

7TH ICOI CONFERENCE The International Conference on Ocular Infections 2015 will be held from 3–4 September in Barcelona, Spain. Colin Kerr reports

he International Conference on Ocular Infections (ICOI) represents “the Olympics” of ocular infectious diseases, says Prof Terrence O’Brien MD. Prof O’Brien, professor of ophthalmology and Charlotte Breyer Rodgers Distinguished Chair at the Bascom Palmer Eye Institute, Miami, Florida, US is serving as ICOI meeting chairman. The meeting immediately precedes the XXXIII Congress of the ESCRS which opens on 5 September. The ICOI, which formally convenes every four years, expects this year’s meeting to attract its largest attendance to date. “The conference agenda provides broad material of practical interest to general and subspecialty ophthalmologists,” said Prof O’Brien. “We hope to expand participation from delegates in related disciplines such as bioinformatics, biostatistics, epidemiology, microbiology, molecular biology, pharmacology, drug delivery and systemic infection, to diversify and enrich the discussions on ocular infections,” he said. Among the keynote speakers for the meeting are Prof John Dart, Dr José Güell, Dr Peter Barry, Dr Prashant Garg, Prof Yoshitsugu Inoue, Prof Elmer Tu, Prof Francis Mah, Prof Joseph Frucht-Pery, Prof Farhad Hafezi, Prof David Granet, Prof Thomas Liesegang and Prof Eduardo Alfonso.

The programme for the meeting is being developed by an international expert scientific advisory board with the support of national and regional organising groups, said Prof O’Brien. Prof O’Brien said they hope to deliver a diverse scientific programme, with significant contributions from faculty experts outside of ophthalmology in related areas of infectious diseases and microbiology. “In this way I believe participants can truly learn new concepts and think of innovative ways to apply them for the ultimate benefit of those suffering from ocular infections.” The meeting will discuss topics including Prevention and Management of Endophthalmitis with Eye Surgeries, New Perspectives on Antimicrobial Resistance in Ophthalmology, Advances in Ocular Microbiology Laboratory Techniques and Newer Anti-infective Agents. “The ICOI 2015 programme offers the greatest diversity to date with a multinational, multidisciplinary, comprehensive educational exchange. The participants shall depart with practical pearls to immediately apply in clinical and surgical settings, to both protect and treat patients with eye infections. It will help to fill the current gaps of knowledge and bring advances to the care of patients suffering from ocular infectious diseases,” he said. * For more information visit: www.ocularinfections.com Terrence O'Brien: tpob3333@hotmail.com Janine Koeries: JKoeries@paragong.com

The 7th International Conference on Ocular Infections 3 - 4 September 2015 Barcelona, Spain

EYE

Save the date

CONTACT

STUDIO INTERVIEWS with leading ophthalmologists EXCLUSIVE TO EUROTIMES!

Laser Technology: What Do We Have? What Do We Want? Oliver Findl interviews John Marshall and Michael Mrochen Available at www.eurotimes.org/eyecontact and the EuroTimes App

www.ocularinfections.com Paragon Group

Congress Secretariat: Paragon Group 18 Avenue Louis-Casai | 1209 Geneva | Switzerland Tel: +41 22 5330 948 Email: secretariat@ocularinfections.com

EUROTIMES | JUNE 2015

World Society of Paediatric Ophthalmology and Strabismus

/WSPOS @WSPOS

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

Keynote Lectures Non-Strabismus Keynote Lecture Alex Levin USA

Friday 4 September 12.15 – 13.15

Strabismus Keynote Lecture Lionel Kowal AUSTRALIA

Clarity Satellite Meeting Sponsored by

Saturday 5 September 12.45 – 13.45

Kanski Medal

Paediatric Management of Ocular Surface and Lids

Helen A. Mintz-Hittner USA

Moderator: D. Brémond-Gignac FRANCE D. Brémond-Gignac FRANCE Good use of mydriatics in paediatrics E. Silva PORTUGAL Azyter phase III results

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E. Knop GERMANY Embryological development of the meibomian gland & meibomian gland disorders in children Sponsored by

Sunday 6 September 12.30 – 13.30

Kids by Safilo Satellite Meeting Sponsored by

Expertise Resides ALL Around the World

MEETING REPORT

SOURDILLE HONOURED

American Society of Cataract and Refractive Surgery meets in San Diego. Howard Larkin reports

n 1974, Philippe Sourdille MD, Nantes, France, organised the first symposium on phacoemulsification cataract surgery in France, with phaco inventor Charles D Kelman MD demonstrating the technique. He later introduced in-the-bag intraocular lens (IOL) placement in Europe with the Nantes technique. For his tireless efforts promoting intraocular implant surgery in Europe and advancing IOL design, Prof Sourdille was recognised with the Honoured Guest Award at the 2015 American Society of Cataract and Refractive Surgery Symposium in San Diego, US. Addressing the opening session, Prof Sourdille acknowledged the challenges of new technology such as femtosecond lasers, and the impact on surgical skills, but warned against going backwards. “We know the answer is international exchange and teamwork,” he said. On receiving the ASCRS honour, Dr Sourdille said: “I can summarise my thoughts in one single French word, and this word is 'Merci'.” Also honoured was Marcelo Ventura MD, Rio de Janeiro, Brazil. Dr Ventura is co-founder and CEO of the Altino Ventura Foundation, a non-profit organisation that has performed more than 220,000 eye surgeries, provided care for over seven million patients, and trained more than 229 residents, 128 Brazilian fellows and 28 international fellows.

Incoming ASCRS President Robert J Cionni presents Philippe Sourdille with the ASCRS Honoured Guest award in recognition of his contributions to advancing intraocular implant surgery worldwide

SUCCESSFUL YEAR Outgoing President Richard A Lewis MD, Sacramento, California, US, reviewed several ASCRS successes. These include removal of a punitive Medicare payment cap that threatened a 21 per cent pay cut this year. ASCRS also bolstered overseas missions as well as domestic efforts to provide cataract surgery for uninsured US residents, and free LASIK for injured military veterans.

Dr Lewis also emphasised outreach to young ophthalmologists, many of whom forego private practice in favour of large groups affiliated with managed care organisations (MCOs). Incoming ASCRS President Robert J Cionni MD, Salt Lake City, US, emphasised international collaboration. “With current US government barriers, new technologies are frequently seen first in other countries, thus our involvement with similar societies across the globe is imperative,” he said.

EUROTIMES

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EUROTIMES | JUNE 2015

6th EuCornea Congress

BARCELONA 4–5 September 2015 Fira Barcelona Gran Via, Spain North Access, Hall 8

2 Days. 4 Symposia.

8 Focus Sessions.

4 Courses. 6 Free Paper Sessions.

EuCornea Medal Lecture

Saturday 5 September

Friday 4 September

13.00 – 14.00

16.00 – 17.00 (At the Opening Ceremony) Cicatrising Conjunctivitis Update: Translating Research into Effective Therapies John Dart UK

Linking Inflammation to Dry Eye Disease (DED) Moderator: C. Baudouin FRANCE C. Baudouin FRANCE Chronic inflammatory response in DED pathogenesis M. Rolando ITALY Diagnosis of dry eye patients: future perspectives J. Duran de la Colina SPAIN New treatment alternatives in dry eye associated with ocular surface damage Sponsored by

Dompé Satellite Meeting Sponsored by

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ESCRS

Board

Election 2015

Nominated Candidates Please note that only European full members of the ESCRS are entitled to vote in the Board election. Voting opens on 25 May and closes on 15 August. Members will receive a ballot paper in the post by 25 May. ESCRS Board elections are held every two years. Board members serve for a term of four years and can be re-elected for one additional four year term. Board members must have been a full member of the ESCRS for at least the last three consecutive years and in order to stand for election candidates must be nominated by ďŹ ve other full members of the Society. There are ďŹ ve positions open on the Board in this election and the names of the new Board members will be announced at the Annual General Meeting of the ESCRS which will take place during the Annual Congress in Barcelona in September.

European Society of Cataract & Refractive Surgeons

ESCRS BOARD ELECTION 2015

Michael Amon Austria

have been chairman of the Academic Teaching Hospital St. John Vienna since 2008. In 2009 I was awarded a professorship by the Medical University Vienna. I was Austrian delegate for EBO and UEMS, board member and congress president of DGII, and president of the Viennese Ophthalmological Society. I am currently head of the Austrian Committee of Cataract Surgery and board member of the Austrian Society of Ophthalmology. In a citation analysis in 2008 I was cited as 5th influential author in Europe and 20th worldwide. I am member of several journal editorial boards and of the IIIC, and have invented intraocular implants and instruments. With the introduction of the term ‘uveal and capsular biocompatibility’ I underlined my main scientific interest in IOLs and cataract surgery in compromised eyes. I have performed over 20,000 intraocular procedures, including pediatric cataract, posterior segment-, glaucoma- and corneal surgery. I have given symposia lectures, chaired sessions, organised instructional courses, presented for iLearn and performed live surgery for the ESCRS since 1993. Since 2012 I have been a member of the Education Committee. I seek to increase transparancy of European medical activities, intensify interactive education and assist in enhancing globally the leading scientific role of the ESCRS.

A. John Kanellopoulos Greece

ince 1997, I have been practicing initially part time and then full time after 2001 in Europe, specifically Athens, Greece as a clinical anterior segment ophthalmologist. I am proud to live in Europe and raise my children as Europeans. I became a member of the ESCRS in 1997 and have remained active and have learned enormously through the multiple scientific endeavors of the Society. I have been strongly involved in clinical research in the fields of CXL, keratoconus, and topographic-guided excimer treatments. The ESCRS has given me the opportunity to actively participate in every annual meeting and most winter meetings since. I have contributed to over 50 didactic courses as an instructor, and over 150 original paper/poster presentations, resulting in dozens of original scientific published papers and book chapters (please refer to my online CV at www.laservision.gr for more detailed information). Should your valuable vote enable me to become a Board member, representing Greece, I will strive to further contribute to the educational activities of the Society, the education of younger colleagues and the propagation of the Society’s valuable mission.

NOMINATED CANDIDATES

Charles Claoué UK

t is an honour and a privilege to have been nominated to stand for election to the ESCRS Board. Following undergraduate training at the University of Cambridge, my ophthalmic training was at Southampton, Bristol, St. Thomas’ and then Moorﬁelds before moving to Queen’s Hospital, now the busiest multi-speciality hospital in London. I have been secretary of both the British Society for Refractive Surgeons, and the United Kingdom and Ireland Society of Cataract and Refractive Surgeons. I co-founded the International Society for Bilateral Cataract Surgeons and am a member of the International Intraocular Implant Club. I am an active anterior segment surgeon with a cataract and refractive practice, and an active corneal transplant surgeon. I am one of the UK pioneers of DMEK. I have a long-term interest in education and would like to use my energy to promote this via ESCRS. I strongly believe that we Europeans have the ability to move forward together and continue to provide outstanding advances in our chosen speciality. I have supported ESCRS for over 20 years and would welcome the opportunity to represent you on the Board; thank you for your support.

Vikentia Katsanevaki

José L. Güell Spain

have been an active member of the ESCRS for more than 14 years. After being elected to the Board in 2003, I assumed the position of secretary of the Society in 2004 and served in this role until 2009. During the period 2007–2009 I was heavily involved with the educational and academic activities of the ESCRS. In 2009 I became president elect, before serving a two year term as president in 2010 and 2011. I continue to have a central role in the activities of the Society as a Board member and member of the Programme Committee. I am director of the Cornea and Refractive Surgery Unit at the “Instituto de Microcirugia Ocular de Barcelona”, and scientiﬁc coordinator and professor of the cornea module, ESASO, European School for Advanced Studies in Ophthalmology. I was president of EuCornea from 2012–2014 and still belong to the Board where we closely work with the ESCRS in our education activities. I have recently been elected IMO Foundation president. If elected to the Board, I hope to continue to build the teaching and organisational tasks of the Society and to expand the ESCRS’ role in providing superior educational programmes.

Boris Malyugin Russia

Greece

graduated from the Medical School of the University of Crete (1988–1994) and completed a clinical fellowship in refractive surgery (1995–1998), residency (1999–2003) and my PhD thesis (2003) at the University of Crete, Greece. I completed a surgical cornea fellowship at Moorfields Eye Hospital (2006–2007) and I currently practice refractive surgery in Athens, Greece. I worked as a committee member for the ESCRS Young Ophthalmologists Programme and am currently a member of the Programme Committee and Poster Judges Panel. I have served as representative of the ISRS (1999–2008) and chaired the International Council for two years (2012–2014). I participate in the editorial board of EuroTimes and Ocular Surgery News (European Edition) and I review for the Journal of Refractive Surgery. I am a recipient of the Achievement Award (AAO 2007) and the Founder’s Award (ISRS 2014). I would be very keen to be further involved with the ESCRS, where I already feel at home. I think that committee members graduating to the Board have a lot to offer the Society. I consider my previous experience qualifies me to become a worthy new member of the Board, to which I can also bring fresh ideas.

ver the last number of years it has been a great pleasure for me to serve the ESCRS as a Board, Programme Committee and Publications Committee member. Currently I am professor of ophthalmology at the S. Fyodorov Eye Microsurgery Complex in Moscow, Russia. If I have the chance to be re-elected to the ESCRS Board, I will continue doing my best to strengthen the relationships between the European ophthalmological community and eye care professionals from the eastern part of the Eurasian continent, to stimulate the exchange of new ideas and technologies, develop joint educational and research projects, and spread the spirit of integrity.

ESCRS BOARD ELECTION 2015

Ewa Mrukwa-Kominek

NOMINATED CANDIDATES

Milind Pande UK

Sunil Shah UK

Poland

s a professor of ophthalmology (MD, PhD) I am head of the Department of Ophthalmology of the Silesian University of Medicine, Katowice, Poland. I am also chair of the Department of Ophthalmology for Adults (the largest in Poland) and head of the Corneal and Refractive Unit in the University Center of Ophthalmology and Oncology where I was previously medical director. I am a member of the Polish Society of Ophthalmology (board member since 2010, president of the Cataract and Refractive Surgery section, vice-president of the Corneal and Ocular Surface Diseases section). I am an ESCRS co-opted Board member (since 2014), member of the Education Committee and on the faculty of the ESCRS Academy. I am a member of the Editorial Advisory Board of Cataract & Refractive Surgery Today Europe. I am author or co-author of 175 published scientiﬁc papers and have given more than 500 presentations at international and Polish congresses. If elected to the Board, I would like to organize a future ESCRS Winter Meeting in Poland. I intend to participate in the training of European residents and organise ESCRS programmes in Poland. Furthermore I am keen on expanding the Society’s educational services.

Dimitrios Siganos Greece

imitrios Siganos is a medical and masters (Ophth.) graduate of Cairo University. Lecturer, then assistant professor at University of Crete, Greece. In 1999 founded and is scientific director of “VLEMMA” eye centre in Athens. An international leader in anterior segment research and clinical work. Besides pioneering work in LASIK and PRK, he was among the first to use the “express valve” in glaucoma (2000), introduced clear lensectomy in hyperopia (1991), been using premium IOLs since 2001 (Crystalens, multifocals, toric IOLs) and implanting and teaching ICLs (STAAR) since 1993. First worldwide to publish on Ferrara rings and early CXL user. At the spearhead of the first clinical trials and publications on the Pascal tonometer. Clinical advisor in refractive and cataract surgery in many centres in Europe and the Middle East. Original references, reviews in medical journals, book chapters and hundreds of presentations at conferences (AAO, the ESCRS, etc.). Co-editor with Ioannis Pallikaris of the reference book “LASIK”. Run courses in America, Europe and the Middle East (also speaks Arabic). Was member of the Refractive Committee and founding advisory board of EuroTimes. Mission if elected: to promote relationship between all ESCRS members and advocate highest and uniform eye patient care level.

ur Society is about education, communication and friendship. These values guide my personal and professional life. I am medical director of the Vision Surgery & Research Centre in East Yorkshire, UK, member of the International Intraocular Implant Club and founding member of the laser eye surgery committee of the Royal College of Ophthalmologists. I am a past president of the United Kingdom and Ireland Society of Cataract and Refractive Surgeons. I founded the State of the Art Refractive and Cataract Surgery Symposium in Hull in 1999. Now in its ﬁfteenth year, I take great pride in personally designing, directing and delivering this meeting, which attracts an international faculty and is free to attend for over 250 delegates every year. I have been actively involved with ESCRS since 1993 and have presented many courses and papers, taught surgical skills training courses, and performed live surgery a number of times. My research areas are IOLs, presbyopia and functional vision assessment. If elected to the Board, I would work to bring ESCRS closer to its members, extend its educational activities worldwide and help raise public awareness of our specialty. It would be an honour to serve on the Board of our wonderful Society.

Emrullah Tasindi Turkey

orn in 1957, I was educated at Hacettepe University Medical Faculty, where I also completed my residency by 1984. I worked for and became an associate professor of ophthalmology at GATA Haydarpaşa Military University Hospital in 1991. The very same year, I opened one of the first private eye hospitals in Turkey, Veni Vidi, where I also performed the first excimer laser surgery in the country. My areas of expertise include cataract and refractive surgery, corneal surgery, ocular surface diseases and glaucoma. The Turkish Ophthalmology Society (TOS) Cataract and Refractive Surgery Division appointed me as the Turkish coopted Board member for ESCRS between the years 2005–2009. As the current treasurer of TOS and expresident of TOS Cataract and Refractive Surgery Division, I have continuous access to over 4,000 eye surgeons across Turkey whose scientific activities and experiences I believe would be a great contribution to ESCRS. Moreover, as an established educator, opinion leader and trainer on anterior segment surgeries for over 20 years, I aim to enhance and contribute to ESCRS training programmes between nations. I promise to bring my innovative and idealist personality to ensure growth, collaboration and creation at ESCRS.

y training was in England, culminating with a fellowship with Harminder Dua. I subsequently joined the department in Birmingham where I am now corneal lead physician with an interest in lamellar and paediatric corneal surgery. I was subsequently made a visiting/honorary professor at Aston and Ulster University. My academic career has focused on anterior eye but has been quite wide reaching with some seminal work in biomechanics, cornea, premium IOLs and more recently presbyopia (106 peer reviewed articles, seven chapters). I was president of the British Society for Refractive Surgery, and have served on the Royal College of Ophthalmologists refractive sub-committee and run the online Masters in Refractive and Cataract Surgery. I am an advisor to NICE, BSI, MHRA and the ISO standards committee. Last year, I was honoured to be voted one of the top 100 most inﬂuential ophthalmologists in the world. I am a frequent contributor to the ESCRS and feel that it has solidiﬁed its role as the premier meeting worldwide for cataract and refractive surgery. If elected, my intent would be to grow the Society further and to ensure that the Society meets the requirements for all of its members from whichever member country they originate.

David Teenan UK

y name is David Teenan and I am a candidate for election to the ESCRS Board. This is an important ballot and I wanted to set out why I hope you will consider me a candidate worthy of your vote. We are all aware how diﬃcult the past few years have been for refractive surgery. I believe the ESCRS can help build public conﬁdence in these life-changing procedures through an increased focus on the continuing education and training of surgeons, and by demonstrating our commitment to clinical excellence and patient care. These are areas I have a great deal of experience in and would wish to work with you, the ESCRS members, on. I have dedicated my career to ophthalmology and latterly refractive surgery. Following a successful career in the NHS as a consultant with a special interest in cornea and external diseases, I decided to pursue my interest in refractive surgery and have completed over 32,000 refractive procedures. I am now medical director of Optical Express, giving me oversight of a group of surgeons that, collectively, performs more refractive surgeries than any other group in the UK. I hope you will consider entrusting me with one of your votes.

GET TO THE SOURCE Become an ASCRS member to receive the latest clinical advances, research, and information on issues affecting your practice. • Annual meetings, clinical reports, web seminars, and online daily discussions • Surgical videos, symposia, and paper sessions in the ASCRS MediaCenter • Post-refractive IOL and Barrett Toric Calculators, Toric Results Analyzer, and more online tools • Journal of Cataract & Refractive Surgery, Ophthalmology Business magazine, and EyeWorld News magazine

START YOUR MEMBERSHIP TODAY.

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RESIDENT’S DIARY

NO SUPERVISION

Thrill – and a bit of fear – as residency takes step towards independent practice. Leigh Spielberg reports

“

Courtesy of Eoin Coveney

he cataract In an act of desperation, I sent team convened a WhatsApp text to the whole last week and group: “If anyone has an overreviewed Leigh busy clinic with calm & friendly Spielberg’s cataract patients they’d like me to application,” take off their hands, call me! It’s a read the email, “and it was win-win situation for you & me!” determined that he may perform My phone started ringing unsupervised cataract surgery in off the hook. Chang, Michelle the Rotterdam Eye Hospital.” and Angela, three incredibly There were no exclamation enthusiastic and helpful young points in the email, but I read residents, sent me one patient it as though its contents were after the other. Within no time, a front-page news. Unsupervised dozen patients had appointments cataract surgery! From with me. beginning to end! I couldn’t Despite my trainee status, they believe it. What a rush. were generally enthusiastic to be But what now? The operated on by me. Maybe the Rotterdam Eye Hospital has fact that they were “referred” to a huge department dedicated me for their operation by my solely to cataract surgery, colleagues lent me some stature in performing approximately the eyes of the patients. However, 7,000 phacos per year. But this made it all deceptively easy it isn’t designed to channel and somewhat dangerous. I tried eligible patients to residents to keep in mind what I had been with surgery privileges. We advised, to only schedule the have to do it ourselves. I was simplest cases. in the middle of an intense Dr Manzulli, a cataract specialist, vitreoretinal surgery rotation, was my advisor during this process. and I rarely saw patients “I just screened a perfect patient, with uncomplicated cataract. but her pupil was too small, so I How would I ever fill my referred her to you instead,” I said ...I rarely saw patients with surgical schedule? to him one afternoon. uncomplicated cataract. How would The advice I received from “Velle, juste pute ina soma iris several surgeons was: “Do hookse anda no problem!” he I ever fill my surgical schedule? yourself a favour and make it all replied, his Italian accent making as easy as possible. Only select it all sound so simple. I had some the simplest cases for your first solo surgeries.” Logical enough, experience placing iris hooks, but that was a few standard but finding these patients was tricky. deviations outside of my comfort zone. His synthesis of nearI scheduled myself into the cataract clinic on my postcomical enthusiasm and complete confidence in my skills was very call days off. Eligible patients would appear by the dozens, I comforting. But I suspected that he was overestimating me, which thought, and I’d be on my way. Not exactly. The most difficult was both flattering and unnerving. post-trauma, uveitic, highly myopic and surgical mishap eyes populate our cataract clinic, referred by other subspecialties PERFECT GUIDANCE and general ophthalmologists. Nevertheless, his guidance was perfect. Before long, I had all my I needed a new plan. I paid a visit to the surgical planning operating schedules filled with patients. I had selected each patient’s department, through which all patients’ dossiers passed, and lens power, and double-checked all the details. But as the date of my explained my situation. Maybe they could contact me when first procedures neared, my heart occasionally skipped a beat and standard cases were booked into the OR. seemed to jump into my throat. What had I gotten myself into? “Should we only call you if we have nun-nuns?” asked Jolien, I would be sitting in the driver’s seat with no real back-up. a planner. An uncomplicated phaco is like cruising down the highway on “Sorry, but did you say nun-nuns?” I asked. a clear day, all smooth riding and sunny skies. But what if an iris “Yes, nun-nuns,” she replied. “Patients with neither ocular nor decided to take an extraocular detour? I hadn’t had any significant systemic risk factors. Both boxes are checked as ‘none’ on the complications, which gave me the feeling that I wasn’t prepared to surgical request document. We call them none/nones.” solve them if they occurred. “Um, yes, that would be great, thanks,” I replied, as I gave her I didn’t sleep well the night before the first session. I dreamt that my phone number. all my patients were scattered at random throughout the hospital, This didn’t work out too well either. Most doctors seemed to and I had to locate them while all the building’s toilets overflowed. want to keep these uncomplicated cases for their own surgical It was pure chaos and I hadn’t yet begun. programs. As it turned out, the best way to get referrals was to ask my fellow residents who don’t yet operate independently. To be continued… EUROTIMES | JUNE 2015

OUTLOOK ON INDUSTRY

RAYNER REFOCUS

New leadership seeks surgeon partners to develop the next generation of IOLs. Howard Larkin reports

he world’s first and oldest manufacturer of intraocular lenses (IOLs) will now focus exclusively on developing and marketing high-tech IOLs. After selling its 104 retail optical stores, Rayner Group Limited has strengthened its research, added surgical training and trebled its IOL manufacturing capacity – moves its new leaders say will transform it into a world IOL market leader. “We aspire to be a global pure play IOL business,” says Tim Clover, who has stepped up from a non-exec board role to become Joint CEO and New Projects Director earlier this year, with former CFO The Ridley Innovation Centre Darren Millington. “There is no intention to bolt on equipment product lines or get supporting the vision of creating a market into other areas of ophthalmology. We see leading IOL manufacturer. an opportunity for a global organisation Internally, Rayner are developing a focused entirely on IOLs that will invest all hydrophobic acrylic platform to complement its resources and R&D in that one area,” its extensive line of hydrophilic acrylic he added. offerings, including in-the-bag and sulcusSurgeons will play a leading role in the fixated designs. New multifocal designs are transformation, Clover says. Rayner’s new in the works to add to the firm’s existing headquarters and state-of-the-art production aspheric monofocal, toric and multifocal facility in Worthing, West Sussex, UK, models, Clover says. includes expanded wetlab and All will be built to the exacting training suites. “We look quality standards for which forward to welcoming Rayner are known. “I’ve been surgeons to learn the astonished by the enormous latest techniques.” lengths our quality assurance It is even named team goes to, ensuring that the Ridley Innovation every lens is perfect and will Centre in honour of give a predictable outcome. the firm’s most famous At Rayner, the quality of collaboration with Sir manufacturing certainly Harold Ridley, inventor stands out,” Clover added. of the IOL. Tim Clover Clover, whose job is to lead Rayner also hope to build Rayner’s strategic expansion while surgeon collaboration by expanding Millington advances operations, also plans its direct distribution operations beyond the to roll up some of the smaller IOL firms UK, Germany and the US. Having its own developing innovative products. “There are representatives work directly with surgeons a lot of tier-two players all spending large in many countries and in many types of amounts of money on similar R&D, and practices will not only engage physicians arguably none has the market presence with the firm’s existing products, it will alone to make a global impact. There is help Rayner develop and refine new IOL clearly an opportunity for two or more of concepts, Clover says. “We want to work these to come together,” he says. with surgeons in every country and every Clover says he is currently investigating subspecialty rather than heavily engaging several acquisition prospects and expects to with just one or two.” conclude one or more in the next year.

BUILD AND BUY

Selling its optical shops not only helps Rayner focus on IOLs, it frees cash for developing new products internally and acquiring other innovative IOL makers, Clover says. The firm has no debt and its ambitious private owners are committed to EUROTIMES | JUNE 2015

MARKET OPPORTUNITY As the baby boom generation ages into its 60s and 70s over the next decade, Clover sees big opportunities for advanced IOLs, particularly for presbyopia-correcting lenses. While presbyopia-correcting lenses have

underperformed expectations in recent years, Clover believes that will change. Reimbursement is one reason. More and more countries are allowing patients to pay extra for premium technology such as multifocal IOLs and femtosecond laser-assisted surgery. Baby boomers “are interested in exercising choice, and if a superior technology is €1,000 per eye many will pay it”, Clover says. His experience with co-payments in private hospitals suggests 30 per cent to 60 per cent of patients will spend more for a premium device. Better lens technology is another reason. As presbyopia-correcting lenses improve, more people will want them, Clover says. He points to consumer insights from Optegra, a private ophthalmic clinic chain he built, which found no one really prefers to wear spectacles. “One day this may come to define our generation; that we walked around with bits of wire and glass hanging off our faces. IOL technology is getting better and better every year and I could definitely see a point some time in the future when spectacles are obsolete,” he says. Rayner’s strategy is to advance a range of promising technologies, Clover says. “We are in an accelerating development curve in terms of technology. We are seeing accommodating lenses, extended depth of focus, quad focus – I don’t think it has played itself out. That is why R&D will be increasingly important over the next five to 10 years.” Clover says Rayner’s vision is to lead the pack. “To be successful you will need to be a leader. We are looking to invigorate the market with a steady stream of new development,” he added. Tim Clover: timclover@rayner.com

How many of your cataract patients could benefit from the T-flex® Aspheric Toric IOL?

34.8% of cataract patients present ≥ 1.0 D corneal astigmatism1

rayner.com • Proven rotational stability2 • Excellent centration • Anti-Vaulting Haptic Technology® for excellent fixation within the capsular bag3 • Extensive range of sphere and cylinder powers

1. Ferrer-Blasco T, Monlés-Micó R, Peixoto-de-Matos SC, González-Meijome JM, Cerviño A J Cataract Refract Surg 2009 Jan;35(1): 70-510 1016/j.jcr 2008.09.027 2. Alberdi R et al. J Refract Surg 2012; 28(10); 696-700. 3. Claoué C. Clinical and Surgical Ophthalmology 2008; 26(6): 198-200.

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BOOK REVIEWS

MASSIVE PROGRESS There are many books about how to manipulate the cornea, particularly in the context of refractive surgery. There are also many books that cover the entire spectrum of corneal disease. What is less common is a book that comprehensively covers non-refractive corneal surgery itself. PUBLICATION Mastering Corneal Surgery: MASTERING CORNEAL SURGERY: RECENT Recent Advances and Current ADVANCES AND CURRENT TECHNIQUES Techniques (Slack Incorporated), AUTHORS by Amar Agarwal and Thomas AMAR AGARWAL AND THOMAS JOHN John, does just that. The 300-page text-dense PUBLISHED BY SLACK INCORPORATED handbook describes, in great detail and with uninterrupted prose, exactly how to perform each step of the many surgical procedures performed by corneal specialists in 2015. “For several decades, advancements and our approach to corneal surgery would be best characterised as incremental and evolutionary. Remarkably, over the past decade, improvements in surgical techniques and patient outcomes have accelerated on a trajectory that is nothing short of revolutionary,” reads the foreword. Divided into four sections – “Keratoplasty”, “Keratoprosthesis & Ocular Surface Disorders”, “Corneal Surgery Related to Cataract Surgery” and “Miscellaneous” – the book is not for the faint of heart. It moves from old standbys like penetrating and endothelial keratoplasty to more advanced techniques like the Boston keratoprosthesis, amniotic membrane transplantation, modified osteo-odonto-keratoprosthesis, and the use of plateletrich plasma in corneal surgery. The text is accompanied by high-quality photographs of surgery and materials, as well as several useful flow charts to help guide the clinician to the correct choice of procedure. This book is ideal for corneal surgery fellows and ambitious residents, as well as early-career corneal specialists looking to expand their surgical repertoire.

BOOK

REVIEWS

State-of-the-Art Coating provides outstanding Benefits to enable safe and effective Injection of Premium IOLS. enables an incision size as small as subMICS 1.5 mm • no additive transfer • no lens scratches • no splitting cartridges • for hydrophilic and hydrophobic IOLs •

DOWN TO EARTH More down to earth is Cataract Surgery: Introduction and Preparation (Slack Incorporated), by Lucio Buratto, Stephen F Brint and Laura Sacchi. This relatively straightforward book moves logically from one surgical concept, “Hardness of the Nucleus”, or surgical step, “Capsulorhexis”, to the next. Particularly useful for the beginner is the chapter on viscoelastics, which illuminates the differences by means of explanation and overview tables, and the chapter on the prevention of endophthalmitis which concentrates all the relevant information into six pages. The illustrations are excellent, especially the computergenerated images of each surgical step, particularly those describing incisions and hydrodissection. The book is appropriate for medical students during their ophthalmology rotations, residents who would like to be well prepared for their surgical training, and recently graduated ophthalmologists who might need a review of the basics. LEIGH SPIELBERG Books Editor

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EUROTIMES | JUNE 2015

ESASO

ESASO RETINA ACADEMY Registration is open for the 15th ESASO Retina Academy to be held in Barcelona

www.esaso.org

he 15th ESASO Retina Academy takes place in Barcelona, Spain, from 22-24 October 2015 at the prestigious Palau de Congressos de Catalunya, winner of the National Architecture Prize in 2001 and ideally suited for innovative presentation and discussion formats. A world-class faculty will address hot topics and for the first time the ESASO Retina Academy will introduce a Live Surgery Session directly from the prestigious IMO (Instituto de Microcirugía Ocular) in Barcelona. More than 35 retinal specialists will provide cuttingedge scientific information, the use of new techniques and equipment, and up-to-date clinical guidelines on the treatment of dry and wet AMD, macular oedema and retinal non-perfusion due to diabetic retinopathy or venous occlusion, macular pathology of vitreous adhesion and macular holes, and vitreoretinal surgery, among others. The ESASO Retina Academy sessions include the Lectio Magistralis keynote lectures, plenary presentations and debates between experts. Over the years ESASO has developed and implemented some novel formats to optimise the learning experience. Among these are the ESASO MasterClasses, which are limited to small groups to allow direct exchange with global experts, as well as the “Retinamour” interactive clinical case study discussions. Delegates may also submit case studies for inclusion in the interactive Retinamour sessions. The selected delegates will be invited to present their cases and discuss their clinical experiences with an international panel of renowned ophthalmologists. The Case Studies submission deadline is 22 August 2015. The presenters of the best abstracts will be invited to discuss their studies in a rapid-fire presentation. All accepted abstracts will be presented as posters and published in the Ophthalmic Research, a scientifically rated journal. The abstract submission deadline is 23 June 2015. Young ophthalmologists from the host country will compete for the “Young Ophthalmologist Award”. The winners will be invited to attend the 16th ESASO Retina Academy in Estoril, Portugal, on 22-25 June 2016 as special guests of the scientific committee. Applicants for the Young Ophthalmologist Award must be resident in Spain and under 40 years of age on 1 December 2015. The XOVA Excellence in Ophthalmology Awards programme is sponsored by Novartis Corporation and supports outstanding humanitarian initiatives in the field of eye care, for developing countries. The awards will be announced at the meeting, with the winners presenting their projects. Another highlight is the graduation ceremony, honouring the students who successfully completed the ESASO fellowship programme and the ESASO graduation scheme. The congress president Francesco Bandello notes: “Don’t miss this opportunity to advance your insights in evidencebased science and real-life case experience.” * http://www.esaso.org/15th-esaso-retina-academy-2015 Francesco Bandello: bandello.francesco@hsr.it

EUROTIMES | JUNE 2015

JCRS

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 5 MONTH: MAY 2015

CROSSLINKING AND STRAYLIGHT Despite promising clinical results, corneal crosslinking (CXL) frequently causes a reduction in visual acuity during the initial postoperative phase. Looking into potential factors for this, a retrospective cohort study evaluated the change in backwarddirected and forward-directed corneal straylight in eyes after CXL and its correlation with corrected distance visual acuity (CDVA) and changes in corneal topography. Crosslinking-induced stromal changes resulted in an increase in densitometry, especially in the anterior stroma of the central (0.0 to 2.0mm) zone. These changes correlated with an increase in retinal straylight but not with the postoperative CDVA values. Although post-CXL corneal transparency remained altered for at least 12 months, this transparency change did not seem to affect high-contrast visual acuity. No correlation was found between corneal straylight and retinal straylight and CDVA. This study also provides evidence that a more pronounced transparency loss in the central anterior layer seems to be associated with a more pronounced reduction in maximum K readings. N Pircher, JCRS, “Changes in straylight and densitometry values after corneal collagen crosslinking”, In Press, May 2015.

STROMAL LENTICULES FOR KERATOCONUS Tailored stromal expansion for performing CXL in thin and ultrathin corneas, by adding a myopic lenticule to the ectatic corneal surface following epithelial debridement, represents a potential new approach to treating keratoconus. The stromal lenticule is placed and spread over the host cornea following epithelial debridement so the thickest area of the 6.2mm diameter lenticule corresponds to the thinnest area of the cone. The remaining collagen crosslinking procedure is carried out in a routine manner. Early results indicate the approach is safe and effective. M Sachdev et al, JCRS, “Tailored stromal expansion with a refractive lenticule for crosslinking the ultrathin cornea”, In Press, May 2015.

CORNEAL ECTASIA AND SMILE Corneal ectasia has not been reported after small-incision lenticule extraction (SMILE)- until now. Researchers describe a case of a 19-year-old patient with forme fruste keratoconus who developed ectasia six months after SMILE. Ectasia was diagnosed based on anterior and posterior surface keratometry of 38.4/39.5 dioptres (D) and −6.3/−6.8D, respectively, in the right eye and 38.6/40.8D and −7.1/−6.6D, respectively, in the left eye. The keratometry increased gradually and the corneal thickness decreased after surgery, and these trends continued during the 13-month follow-up. This finding suggests a need to apply the same regulations used for LASIK to SMILE. This includes stricter regulation of patient recruitment before the procedure and postoperative follow-up. Y Wang et al, JCRS, “Corneal ectasia 6.5 months after small-incision lenticule extraction”, In Press, May 2015.

THOMAS KOHNEN European editor of JCRS

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EUROTIMES | JUNE 2015

REVIEW

STOP AND CHOP

Everything you ever wanted to know about stop and chop. Dr Soosan Jacob reports

top and chop is a technique of nuclear division started by Paul Koch and is very useful for beginner phaco surgeons. Stop and chop beautifully describes the essence of the technique - the surgeon begins with one technique (divide and conquer), stops after one groove and then continues with another technique (phaco chop). The stop and chop can be very effectively used as a launch pad for transitioning to direct chop techniques once the surgeon is comfortable with the standard divide and conquer technique.

Image A: A groove is sculpted in the centre of the nucleus

B: Once adequately deep, the posterior plate is cracked to divide the nucleus into two

C: The hemisection is rotated inferiorly and the nucleus is chopped into two quadrants, each of which is then emulsified

D: The other section is also similarly chopped and emulsified

CRACKING

Alternatively, the cracking may also be performed using a pre-chopper such as the Akahoshi pre-chopper. Once the nucleus is separated into hemisections, it is time to stop and chop.

TECHNIQUE The technique starts with a good capsulorhexis, hydrodissection, hydrodelineation and nuclear rotation. Clear corneal incisions may be kept at 60 degrees to each other to enable easy cracking of the nucleus.

SCULPTING Once nuclear rotation is verified, a longitudinal groove is sculpted in the nucleus. Moderate flow, low vacuum and continuous ultrasound power based on nuclear density is used. A combination of down-slope sculpting followed by up-slope sculpting is performed to follow the curve of the posterior capsule and to avoid accidental damage to the posterior capsule. This technique of sculpting allows the groove to be deeper in the centre than in the periphery. The groove is made about one and a half phaco tips wide to allow access to the depth of the groove. It is also made about three phaco tips deep which leaves a thin posterior plate that can be cracked easily. The nucleus is rotated 180 degrees to allow the groove to be deepened equally on both sides. EUROTIMES | JUNE 2015

The nucleus is then divided into two hemisections by cracking. The phaco tip and the second instrument are inserted into the depth of the groove and the posterior plate is cracked in half. Cracking can be accomplished as conventional cracking (both hands move towards ipsilateral sides to separate the nucleus) or by cross-cracking (both hands push towards contralateral sides).

CHOPPING The hemisections are rotated 90 degrees so that the two halves lie at six and 12 o clock. The settings are then changed to high vacuum, high flow rate and pulse or

REVIEW hyper-pulse phaco mode. The hemisection is embedded at mid-depth and chopped into two or more pieces. Each piece is then impaled, brought into the AC and emulsified. The other hemi-section is then rotated inferiorly, chopped and emulsified in a similar manner. The number of pieces each hemisection is chopped into depends on the density and size of the nucleus. For moderately dense nuclei and when a good hydrodelineation has given a welldefined endonucleus, four quadrants are generally enough. Very dense cataracts may however be divided into more pieces. If desired, all the chopping may be completed first followed by piece removal. This is followed eventually by epinucleus removal, cortex aspiration and intraocular lens implantation. Chopping may be done either via a horizontal or vertical chopping technique.

ADVANTAGES OF STOP AND CHOP PHACOEMULSIFICATION The creation of a groove before chopping is the main difference between stop and chop and the phaco chop as described by Nagahara. This longitudinal sculpting creates space for nuclear manipulation, unlike direct chop techniques where the pieces are closely wedged together like a jigsaw puzzle and are sometimes difficult to bring out of the capsular bag.

As compared to divide and conquer, the use of the chopper in the subsequent steps helps to decrease the use of phaco power that is used for sculpting, decreases phaco time and energy, as well as consequent endothelial damage. Manual chopping techniques break the nucleus into smaller pieces without the use of phaco power, thereby decreasing the need for ultrasound energy required for emulsification. Once the hard posterior plate of the nucleus is cracked, it becomes easier to subsequently chop it into smaller pieces as the sides of the groove are now available for an adequate purchase on the nucleus.

COMPLICATIONS Care should be taken during sculpting to adjust the phaco power used according to the density of the nucleus. Grooving is difficult in a soft cataract. With inadequate power in a hard cataract, the nucleus may be pushed forward rather than being sculpted which can result in zonular stress. Grooving should be taken beyond the edges of the capsulorhexis only in deeper passes to avoid accidental damage to the capsular rim. The groove should not be carried excessively into the periphery to avoid damage to the capsular bag. For the same reason, the curved contour of the bag should be followed during sculpting. Too thick a posterior plate may not get cracked. Posterior pressure should be

* Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at dr_soosanj@hotmail.com

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CALLING ALL MARKETING GURUS!

ESCRS

Practice Management

& Development 6–7 September 2015 Barcelona, Spain

avoided during the crack to avoid zonular dialysis and nucleus drop. The instruments should instead separate the hemisections with a horizontal and slightly upwards directed force. While chopping, the chopper should avoid tearing the anterior capsular rim accidentally. With soft cataracts, the chopper may end up cheesewiring the nuclear hemisection instead of effectively separating it into quadrants. With hard cataracts, chopping may still be difficult for beginner surgeons. To conclude, stop and chop nucleofractis is an effective technique and every phaco surgeon needs to have an adequate knowledge of all these basic techniques.

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EUROTIMES | JUNE 2015

INDUSTRY NEWS

Ophthalmic Imaging:

from Theory to current Practice Organization : Michel Puech

INDUSTRY

New congress in Paris

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Geuder is expanding its portfolio with Brilliant Peel Dual Dye. “The new dual dye stains much more intensely and features a selective and in contrast clearly differentiable staining of internal limiting membrane (ILM), epiretinal membranes (ERM) and vitreous remnants,” said a company spokeswoman. “The new dye solution stands out due to an even faster sinking and a maximum contact area with the tissue. Brilliant Peel Dual Dye contains no preservatives, has a physiological osmolarity, is non-toxic and convinces with an exceptional safety profile and easiest aspiration,” she added. www.geuder.de

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EUROTIMES | JUNE 2015

AP-93X266mm-150305.indd 1

06/03/2015 11:39

PEELING FORCEPS

OCT CAMERA

Moria has announced a new range of highprecision reusable peeling forceps for smallgauge vitrectomies. “The company has designed and developed a complete range of high-quality reusable forceps to peel retinal membranes,” said a spokeswoman. “Available in 23 and 25G, the forceps are designed with handles of composite material (a high techpolymer) and active parts of surgical stainless steel. Each forceps is supplied with a protector tip and a cleaning cannula,” added the spokeswoman. www.moria-surgical.com

Haag-Streit Surgical’s intraoperative-OCT camera has received 510(k) clearance from the US Food and Drug Administration (FDA). “We are very pleased with the success of the iOCT® camera in Europe and eagerly await the launch of the system on the US markets,” said Dr Eva Lankenau from OPMedT, developer and manufacturer. “Since the market launch with numerous surgeons four years ago, the iOCT® camera has proved to be in great demand. In particular, the physicians appreciate the high resolution of the iOCT® scans and the synchronous picture-inpicture superimposition,” she said. www.haag-streit.com

INDUSTRY NEWS

NEWS IN BRIEF FDA APPROVAL The US FDA has approved the AcuFocus KAMRA corneal inlay, which uses a small-aperture concept to increase depth of focus in presbyopic patients. The approval makes the device available for the first time in the US market, though it has been available in Europe for several years. In development for 15 years at a total cost of $160million, the KAMRA device submitted to the FDA is the sixth version. AcuFocus chairman and CEO Jim Mazzo said that, in addition to opening access to the vast US market, the rigour of the FDA approval process is a boost. “This really validates the smallaperture approach to presbyopia treatment," said Mr Mazzo. www.acufocus.com

COMPANY APPOINTMENTS Contamac Ltd have announced the appointment of John McGregor to chairman, and Robert McGregor to be his successor as managing director. “It is a real privilege and honour to take over the role of managing director from my father. He has been an outstanding mentor who leads with the right ethics and business philosophies. I am committed to ensuring that Contamac retains its position as a world leader,” said Robert McGregor said. www.contamac.com

OCT TECHNOLOGY Heidelberg Engineering has announced “significant improvements” to the SPECTRALIS® OCT2 Module. “The OCT2 Module brings the next generation OCT technology to the SPECTRALIS diagnostic imaging platform. It combines a high scan rate with Heidelberg Engineering’s proprietary TruTrack Active Eye Tracking, to provide unmatched image quality and significantly improved acquisition speed,” said a company spokeswoman. “Since its debut at the 2014 American Academy of Ophthalmology in Chicago, the OCT2 Module is an option for all new SPECTRALIS models,” she said. “In addition, a large number of SPECTRALIS devices in use, depending on their technical specifications, can be upgraded with the OCT2 Module. Introduced with an already high scan rate of 70,000 Hz, Heidelberg Engineering was able to achieve another significant improvement in the acquisition speed,” said the spokeswoman. www.heidelbergengineering.com

NEW MICROPERIMETER Nidek has launched the MP-3 Microperimeter. “The MP-3 measures local retinal sensitivity for functional assessment of the retina,” said a company spokewoman. “The results can be displayed over a color fundus image, correlating retinal anatomy to retinal function. For enhanced clinical assessment, the MP-3 now includes a wider range of stimulus intensity, from 0 to 34dB, compared to the MP-1. The MP-3 measures perimetric threshold values, even for normal eyes. A maximum stimulus luminance of 10,000asb allows evaluation of low-sensitivity,” she said. www.nidek-intl.com

EUROTIMES | JUNE 2015

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TO NOTE...

BARCELONA

ID: REQUESTED WITH CREDIT CARD ELECTRIC SUPPLY: 220 VOLTS; 2 PIN WALL SOCKETS SEA TEMPERATURE IN SEPTEMBER: 24°C THE CITY’S SHOPPING GEMS Unique to Barcelona, the shop Coses de Casa is in a picturesque 19th Century building on the lovely Plaza de Sant Josep Oriol in the Barri Gotic. As its name explains, the shop sells a wide variety of “things for the house” – towels, aprons, quilts, cushion covers, many in Catalan fabrics. But if things for the house are not on your shopping or gift list, there’s also a good range of travel accessories and soft toys for children. Plus the shop is worth a visit for its clever displays, like tempting two- and three-layer cakes, all made of towels. For details visit: cosesdecasa.com. Open: Monday-Saturday from 10.00 to 14.00 and from 16.30 to 20.00. If your shopping list includes some wooden postcards, a bamboo bike and a bowl made of a carved coconut, head straight to Home on Earth. There, you’ll find these and a host of other unusual gifts for adults, children and the house – all made in direct collaboration with the artisans involved. The first Home on Earth shop opened in 2010 in the Raval; a second opened in the Gothic quarter in 2014. Both stock an eclectic range of high-design, sustainable products and organic foods. Find them at C/ Hospital 76 and C/Boqueria 14 respectively. For details telephone: +34 (0) 933 158 558, or visit: www.homeonearth.com. Open: MondayThursday from 09.30 to 21.00, on Friday and Saturday from 09.30 to 21.30, and on Sunday from 10.00 to 20.30. Vintage shopping combines the pleasure of treasure hunting with a walk in the city. If you’re near Barcelona’s Contemporary Art Museum, stroll down Carrer de La Riera Baixa, a pedestrian street lined with shops selling vintage clothing, leather bags, jewellery and the like. On a Saturday afternoon the street transforms into a street market; local residents as well as shops set up tables of knick-knacks. Or if you are serious about vintage, know what you want and are willing to pay for it, call in at one of the two Holala! vintage shops. They are located at Cl de Taller 47 and at Cl. Valldonzella 6. For details visit: www.holala-ibiza.com. Open: Monday-Saturday from 11.00 to 21.00.

QUICK OR QUIRKY

Shopping in Barcelona features choice for both busy delegates and lingering tourists. Maryalicia Post reports Barcelona boasts 35,000 shops and a fivekilometre shopping route from the Ramblas up to Avenue Diagonal. If that’s a few thousand shops and a few kilometres too many, here are three one-stop suggestions: Las Arenas, a mall in an historic bullfight arena near Plaça Espanya, opened in 2011. The complex includes 115 shops, a variety of restaurants, a 12-screen multiplex cinema and the “Museum of Rock”, where you’ll find Elton John’s golden bathtub among other oddities. The Moorish style bullring accommodated 16,000 bullfight enthusiasts when it opened in 1900 but even before bullfighting was banned in Catalonia in 2012, there was little local enthusiasm for the sport. The last bullfight took place here in 1977, after which the building lay empty. Eventually, plans were made to turn the arena into a shopping and entertainment facility; the architectural firm of Richard Rogers undertook the transformation. The red brick facade was raised one level and a theatre and concert space fitted under a domed cupola. There’s a panoramic vista from the “skywalk” on the roof terrace. Free access via the interior escalators or take the exterior lift for a small fee. For details visit: www.arenasdebarcelona.com. Open: Monday-Saturday from 10.00 to 22.00; restaurants open Monday-Thursday from 10.00 to 00.30, and on Fridays, Saturdays and Sundays from 10.00 to 03.00. Conveniently located next to the Conference Centre, GranVia 2 could save you a shopping trip to town. This huge mall opened in 2002, featuring a “classical” design, with Roman and Greek references. It’s punctuated with obelisks, and sections of the ceiling mimic Rome’s Pantheon. There are over 180 shops, from Aire to Zara. Have a meal at one of 24 cafes and

restaurants and follow that with a visit to the 15-screen cinema. For details visit: www.granvia2.com. Open: MondaySaturday from 10.00 to 22.00. Before malls, there were department stores. Barcelona’s biggest and best is the Plaça de Catalunya branch of El Corte Inglés (the name translates as “English Cut”). There’s a multilingual information centre just inside the main entrance; if you plan much shopping, this is where you can pick up a Carta de Compras – a booklet of stickers. One will be affixed to each purchase you make, then you collect and pay for them all at one time in the second basement. This is useful if you are coming from outside the EU as you can pay taxfree. There’s a small charge for the service. A nice view of Plaça de Catalunya comes free with your coffee or lunch on the roof terrace. For details visit: www. elcorteingles.es. Open: Monday-Saturday from 10.00 to 22.00.

Home on Earth

EUROTIMES | JUNE 2015

CALENDAR

JULY

Vitreoretinal Disorders 3–4 July Siena, Italy www.ble-group.com

LAST CALL

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

SEPTEMBER

International Conference on Ocular Infections (ICOI)

JUNE 2015

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

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

6th EuCornea Congress

SOE 2015 Congress

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

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

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

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

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

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

Siena

SEPTEMBER

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

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

OCTOBER

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

26–28 February Athens, Greece www.escrs.org

NOVEMBER

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

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

XXXIII Congress of the ESCRS

6th EuCornea Congress

5–9 September www.escrs.org

4–5 September www.eucornea.org

WSPOS

FOUR EVENTS

North Access, Hall 8

FEBRUARY

20th ESCRS Winter Meeting

NEW ENTRY AAO 2015

Maculart Meeting

Fira Barcelona Gran Via, Spain

23 January Rotterdam, The Netherlands www.euretina.org

5–9 October Naples, Italy www.echography.com

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

ONE VENUE

JANUARY 2016

NEW ENTRY 6th EURETINA Winter Meeting

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AUGUST

28th APACRS Annual Meeting

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

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