EuroTimes Vol. 20 - Issue 7/8 by EUROTIMES

SPECIAL FOCUS PRACTICE MANAGEMENT & DEVELOPMENT RETINA

FLOATERECTOMY – EXPERTS MAKE THEIR CASE FOR AND AGAINST THE PROCEDURE Jul/Aug 2015 | Vol 20 Issue 7/8

EYE ON TECHNOLOGY

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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

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS PRACTICE MANAGEMENT & DEVELOPMENT 4 Cover Story: How

Colour and Print W&G Baird Printers

ophthalmologists can utilise old and new marketing strategies Getting to grips with the business side of running a practice

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.

9 NEWSMAKER

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

INTERVIEW

FEATURES CATARACT & REFRACTIVE 10 Performing MICS with 11

12 14

16 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.

Richard Packard looks at the continuing evolution of capsulotomy techniques

MIGS – compatibility and benefits Expert John Marshall discusses the changing role of lasers through the decades ‘Incisional techniques can provide visual benefits to astigmatism patients’ A more individualised approach to LASIK ablations – greater predictability Leading researchers in refractive surgery look to the future

CORNEA 24 New lens designs

provide good vision in advanced keratoconus 25 Affordability and reproducibility – the keys to success for new surgery 26 CXL for keratoconus: standard and accelerated epi-off prove effective

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GLAUCOMA 29 Implant shows promise

as an alternative to traditional filtering surgery

PAEDIATRIC OPHTHALMOLOGY 41 Gene therapy

RETINA 35 Study confirms efficacy of

dexamethasone implant in macular oedema 36 Floaterectomy – experts make their case for and against the procedure 37 Trial may put neuroprotection to the forefront of diabetic retinopathy treatment 38 The future of AMD and imaging – polarisation sensitivity and adaptive optics

targeting Leber’s congenital amaurosis

REGULARS 42 Ophthalmologica update 44 EBO Diploma update 47 Eye on History 48 Bio-ophthalmology 51 Book Reviews 52 ESASO update 54 Eye on Technology 56 JCRS Highlights 57 Industry News 59 Travel 60 Calendar

P.55 EUROTIMES | JULY/AUGUST 2015

EDITORIAL A WORD FROM PAUL ROSEN BSc, FRCS, FRCOphth, MBA

STIMULATING DEBATE

The ESCRS Practice Management and Development Programme gives ophthalmologists and their teams the chance to develop new business skills

discuss how ophthalmologists can use both traditional forms ur first Practice Management course was held of marketing and also social media to build connections with at the XXVI Congress of the ESCRS in Berlin, their patients. Germany in 2008. A lot has changed in European Rod Solar will present a day-long Masterclass on what ophthalmology in the last seven years, not only motivates patients, what concerns they have, what they look clinically, but also in terms of the political and for in an ophthalmologist, and why they will choose an economic landscape. There is much fresh thinking individual ophthalmologist. Other keynote speakers include coming out of Eastern Europe and we now have a very Ludger Hanneken, Jerome Vryghem, Bojan Pajic, Keith stimulating mix of ideas and debate coming through. Willey, Arthur Cummings, Ed Toland, Lisa Mcloughlin, The principal focus of the ESCRS is clinical education and Nadezda Bilic, David Evans and research, however we cannot ignore the fact that health Mike Malley. services, including ophthalmology, need a strong While surgeons are not We appreciate that many financial base and business discipline particularly in always good business doctors are busy and may not have very challenging times, in order to achieve growth and people, we need the chance to attend all of our deliver for our customers, our patients. to understand how sessions, but I would encourage Our Practice Management and Development their colleagues including Programme has evolved over the years, including businesses work, including practice managers, optometrists, the Practice Development Weekends and now how to recruit your team orthoptists, nurses and other expansion of the programme at the annual meeting. and train and retain them practice staff to take advantage For Barcelona we have introduced new and more of the Practice Management and varied topics and have moderators for each of the Development Programme, as it will offer them a fantastic sessions, which will encourage more direct participation opportunity for a stimulating two days to learn more about the from delegates. business of ophthalmology. We have chosen specific topics that relate to the needs of ophthalmologists, both in private and government healthcare settings. Sessions will include how ophthalmologists can set up their own businesses, how you know when to grow and not to grow these businesses and when to introduce new services. While surgeons are not always good business people, we need to understand how businesses work, including how to recruit your team and train and retain them. We will ask: ‘Who Runs Your Practice? Is it you, it is your practice manager, your clinical administrator, or all three of you together?’ Ethical marketing is a key component for any business, * Paul Rosen is Chairman of the ESCRS Practice Management especially in these challenging economic times, and we will and Development Committee

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Bill Aylward (UK), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), Hiroko Bissen-Miyajima (Japan), John Chang (China), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Vikentia Katsanevaki (Greece), Thomas Kohnen (Germany), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-Jose Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | JULY/AUGUST 2015

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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.

EC-2015-16 03/15

COVER STORY: PRACTICE MANAGEMENT & DEVELOPMENT

THE OLD & THE NEW This yearâ&#x20AC;&#x2122;s ESCRS Practice Management and Development Programme looks at how ophthalmologists can use modern and traditional marketing techniques. Colin Kerr reports

hange is neither good or bad. It simply is. - Don Draper, Mad Men Mad Men, one of the most successful dramas in American television history, is set in an advertising agency in New York City. It tells the story of how the world of advertising changed dramatically in the 1960s and 1970s and how consumer habits helped drive the change. EUROTIMES | JULY/AUGUST 2015

This may seem far removed from the benign world of ophthalmology but there are parallels. Ophthalmology, like advertising, is a business and it has been subject to dramatic changes in the last 20 years. While the majority of ophthalmologists will feel comfortable with the technical and clinical changes that have driven the profession in the last two decades, for many the biggest challenge has been establishing a business model to sustain their practices. In a challenging economic environment it is no longer good enough to be the best

clinician operating in your locality. You have to be able to communicate this message to your patients to make sure that they will book appointments in your clinic, rather than with your colleague down the street or in the adjoining neighbourhood. You can manage your practice successfully with a well-trained and well motivated staff of doctors, nurses and administrators, but if you do not advertise or market the services you provide, you will find it difficult to sustain your practice in the long-term.

COVER STORY: PRACTICE MANAGEMENT & DEVELOPMENT

Rod Solar delivering a presentation

The perception of the quality of your practice is directly related to how (and how prominently) people see you online David Evans PhD a highly skilled doctor or clinic. To elevate your brand in the minds of potential patients, you need to create a strong online presence and make it easy for people to find your website and visit your Facebook page,” he says. Dr Evans agrees that budget can be an issue for some doctors. “You don’t have to spend a lot of money on your website or internet strategy. There are several things you can do to save costs, such as writing the material yourself instead of buying it from a third party. It is important to remember that the quality of the content on your site is critical. It has to be oriented toward what consumers want to learn and not be too technical, while still clearly communicating your unique vision. Other tasks, such as improving your rankings on Google, typically require professional help. And while these costs vary based on several factors, the cost should not be exorbitant.” Some doctors will express concern that it is difficult to evaluate how much new business their websites actually generate, but Dr Evans says the metrics are improving all the time. “You can now use analytical tools that will show you how many people visit your site, how much time they spend there and specifically what articles they are reading.

Now, as marketers, we are shifting a lot of our strategies online. The purchase cycle is also different today compared to what it was in the 1980s Mike Malley

Courtesy of LiveseySolar Practice Builders

DRAMATIC CHANGES This will be one of the key messages at this year's Practice Management and Development Programme at the XXXIII Congress of the ESCRS in Barcelona, Spain. Mike Malley of the Centre for Refractive Marketing, Houston, Texas, recalls the dramatic changes that have occurred since he started working with ophthalmologists 28 years ago. “In the early 1980s, when I started out, we were much like the Mad Men in our use of traditional media: newspapers, radio, television, magazines and billboards. During that era of advertising in the US, medical marketing was brand new and was frowned upon by many in the medical profession. So we worked closely with industry professionals and authorities to help establish appropriate guidelines to allow us to discuss and promote medical products. This was before the internet, before cellphones, before email,” he says. “Now, as marketers, we are shifting a lot of our strategies online. The purchase cycle is also different today compared to what it was in the 1980s. Now, if you are online, it is all about giving people timely information and unique offers. You have to drive inquirers to your website, not necessarily by selling products but by providing unique information that piques the interest of potential patients browsing the web.” According to Malley, while the majority of ophthalmologists have recognised the advantages of the internet and social media, there are some who are very traditional and still have reservations about its effectiveness as a marketing medium. “What doctors have to realise is that when you are online you are not just competing with people in your own area, you are competing with everyone on the internet who is promoting the same services and products that you provide. And once you have directed them to your website, we strongly believe in re-targeting and event tracking to allow us to properly track them and provide ongoing relevant messaging,” he adds. This is a message reinforced by David Evans PhD, CEO of Ceatus Media Group, San Diego, California, who will also be presenting at this year’s ESCRS meeting. “The perception of the quality of your practice is directly related to how (and how prominently) people see you online. You cannot disconnect those two things. A highly visible, quality online presence equals (in the minds of potential patients)

In addition, to gauge the effectiveness of your online strategy, you should view your website as if you were a potential patient, and objectively assess from a consumer’s perspective what your website says about you and your practice online,” adds Dr Evans. Dr Evans says that ophthalmologists must not only know their market, they must also be conscious of the fact that they are competing with other service providers. “We are all buyers when we visit the internet and regardless of the product or service being searched, the process is essentially the same. This means that consumers who visit your site will also visit the websites of other providers in the area in order to make a decision about which procedure they want and who they want to perform their surgery.” The marketing of medicine is regulated in all countries but every territory has its own regulations, and some are less restrictive than others in decreeing what doctors can say about their individual practices. “Your content manager must be cognisant of and sensitive to the regulations applying in your area, but in my opinion, this can easily be managed because it is all about patient education. With proper management, an ophthalmologist can have a very compelling and successful website and online image, without being overly promotional,” says Dr Evans. Is there a bottom line in deciding how much you should spend on your website? “Ultimately, as with all purchases, a website’s cost will depend on many factors including size and features desired. And every web company promises something different,” says Dr Evans. EUROTIMES | JULY/AUGUST 2015

COVER STORY: PRACTICE MANAGEMENT & DEVELOPMENT “There are some basic guidelines that can help determine the appropriate image/size/ cost for an individual website. First, you should review the portfolio of the company you are considering and then talk to a few of their clients. Keep in mind that just because you pay more for your website than one of your colleagues, that does not mean that you will get higher quality. And conversely, just because you are quoted a lower price does not mean that it is better value.” At this time, the need to have an internet presence is well established. However, as with all aspects of an ophthalmologist's practice, it must be done purposefully and professionally to avoid damage to your reputation. “When content is posted on the internet, it is there permanently. If something is placed online that doesn't represent you well, it is often impossible to remove. Research shows that most patients believe what they read online, so it is very important to closely manage, to the greatest extent possible, what appears about you online. You should bear this in mind, especially if you work in a country where patients can post reviews about individual practices,” says Dr Evans.

HANGING ON THE TELEPHONE? One of the highlights of this year’s Practice Management and Development Programme will be a one-day workshop focusing on how ophthalmologists can convert enquiries into procedures which are paid for by the patient. Rod Solar, of Livesey Solar Practice Builders, London, UK, says if ophthalmologists want to attract more private patients they must understand what their patients want. Solar also argues that, while the internet and social media have revolutionised marketing, the most effective tool for converting enquiries into sales is the telephone, invented in the 19th Century. “We have done a lot of study into what people actually talk about on the phone. We have audited over 1,000 phone calls and listened to the recordings, where we have been able to glean aggregate data that reveals the kind of questions patients ask and how they respond to targeted questions such as what type of solution they are looking for. We also evaluate how many people they have seen in the past to help

Rod Solar makes his point

them with their problems, how soon they want to fix a problem and how long they wait until they fix that problem,” says Solar. The mix between new and old marketing platforms is very important, says Solar, but he stresses the primacy of the telephone. “Most conversions will arise from the many website visitors an ophthalmologist might receive. Of the number of patients that actually come in and see you, who are the only people who are actually going to pay an ophthalmologist, 99 per cent of those conversions happen on the telephone. Money exchange rarely occurs online for an ophthalmologist's services. Without the telephone introduction, without the telephone invitation to get someone to walk into you clinic, payment does not materialise and transactions do not happen.” Solar says that social media is very important to stimulate word of mouth and to give patients a platform on which to communicate, but appointments do not tend to arise via email. “The internet and social media are hugely valuable but the phone conversation is still the most important medium to convert enquiries into visits,” he adds.

PLAN CAREFULLY Solar also agrees with Mike Malley and David Evans that ophthalmologists need to have a clear vision of what they want to

Courtesy of LiveseySolar Practice Buildersr

achieve when they market their practices. In the old days, he says, ophthalmologists would ask him: 'Should I have a website?' “Now we are getting a lot more people who have tried setting up their own websites and who feel somewhat disillusioned with the experience. They may have gone to a marketing specialist with expertise in fastmoving consumer goods or selling cars or electronics. The techniques these marketers use may not work for ophthalmologists. Another complaint is that they have spent a lot of money without satisfactory financial return,” says Solar. That is why it is important for ophthalmologists to have a plan before they decide which marketing tools they use, says Solar. “As an ophthalmologist,” he says, “you need someone in your practice who understands statistics and how to experiment so you can find out what works best.”

BACK TO THE FUTURE Every good marketing story has a beginning, middle and an end, but the ophthalmologists who will be ahead of the marketing curve, says Mike Malley, are those who are already looking to the future. The future, he says, will be driven by the generation known as The Millennials, the generation born between the early 1980s and the early 2000s. “The Millennials are the first group of individuals whose parents had refractive surgery,” says Malley. “All of a sudden we have a group of people who are not afraid of refractive surgery, they just don’t fully understand why their parents are wearing reading glasses, they don’t understand presbyopia. The presbyopic market is wide open online. If ophthalmologists are not online promoting the benefits of presbyopic vision correction, they are falling behind.” We’re going to sit at our desks and keep typing while the walls fall down around us because we’re creative – the least important, most important thing there is. - Don Draper, Mad Men Mike Malley: mike@refractivemarketing.com David Evans: devans@ceatus.com Rod Solar: rod@liveseysolar.com

Marketing Competition The first annual ESCRS Practice Management and Development Marketing Case Study Competition in 2014 was won by Bilić Vision in Zagreb, Croatia. It best captured the spirit of the competition – use of the marketing ideas that are shared during the Practice Management and Development workshops and applied by an ophthalmologist and her/his team. This year, the judges will look for similar traits in the winning entry – a marketing programme which has clearly been developed by an ophthalmologist(s) with the support of the internal team, within a specified budget, which provides a measurable return on investment. The competition will be judged by Paul Rosen, Chairman of the ESCRS Practice Management and Development Committee, and marketing expert Kris Morrill. The deadline for submitting an entry for this year’s competition is Friday, 7 August 2015. For further details visit: www.escrs.org

EUROTIMES | JULY/AUGUST 2015

Kris Morrill

ESCRS

Practice Management

& Development

12 .00 – 12.45 Who Runs your Practice? Presenters: Arthur Cummings, Ed Toland, Lisa Mcloughlin IRELAND Moderator: Keith Willey UK

6–7 September 2015 Barcelona, Spain

12.45 – 14.10 Break

Programme

14.15 – 14.40

Sunday 6 September

Marketing your Practice Presenter: Nadezda Bilic CROATIA Moderator: Kris Morrill FRANCE

09.15 – 09.40 Starting a Practice

14.40

Presenter: Ludger Hanneken ANDORRA Moderator: Kris Morrill FRANCE

Announcement of 2015 Marketing Prize Presenter: Paul Rosen UK

14.45 – 15.40 The Power of Internet Marketing

09.45 – 10.40

Presenter: David Evans USA Moderator: Rod Solar UK

To Grow or Not to Grow? Presenters: Jerome Vryghem BELGIUM, Bojan Pajic SWITZERLAND Moderator: Kris Morrill FRANCE

15.45 – 17.00 Website Marketing Bootcamp

10.45 – 11.55

Presenter: Mike Malley USA Moderator: Rod Solar UK

Why Set Up a Business? Presenter: Keith Willey UK Moderator: Paul Rosen UK

Monday 7 September 08.30 – 17.30

BUSINESS

Masterclass: Get More Private Patients by Understanding What they Want

UTILISE BUSINESS

Rod Solar UK Registration €75

INNOVATE UTILISE BUSINESS

LEADERSHIP INNOVATE UTILISE BUSINESS

DEVELOPMENT LEADERSHIP INNOVATE UTILISE BUSINESS

www.escrs.org

SPECIAL FOCUS: PRACTICE MANAGEMENT & DEVELOPMENT

FOLLOW THE NUMBERS Ophthalmologists need a clear vision of how their practices operate. Colin Kerr reports

ollow the numbers. That is the advice of John Pinto to ophthalmologists who want to know the true worth of their practice. Pinto, an ophthalmic practice management consultant from San Diego, California, says one of the biggest challenges facing ophthalmologists and their practice managers is assessing the day-to-day value of what they do in commercial terms. “If I go up to a typical eye care administrator and say: ‘What is your profit margin? What is your average revenue yield per patient visit? What is the surgical density of your practice?’, a few of them will have a ball park answer, but a lot of them will not be able to answer those questions,” says Pinto. “They are most likely to tell me: ‘Oh, we have a very nice practice. We have five doctors and we provide cataract surgery and some glaucoma care and a visiting retina specialist. We take great care of our patients, we get paid very well and my doctor drives a Ferrari’.” These are subjectives, says Pinto, and should be avoided. “It would be like if I asked a doctor: ‘How is your patient?’, and he or she answered: ‘Oh they are lovely. You should see their eyebrows and their blue eyes. I have never seen such azure eyes in my life!’”

v Sa

at D

Athens Athens

2016

26–28 February

Athens 20TH

ESCRS

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

www.escrs.org EUROTIMES | JULY/AUGUST 2015

In a clinical setting, these subjective questions or answers do not work. “You do not ask the patient: ‘Are you left-handed or righthanded?’, during an eye clinic,” he added. Pinto says when asked to describe their practices, ophthalmologists should be able to tell him that they were established in 1975, they have a profit margin of 57 per cent, which is up from 54 per cent the previous year but which is still behind the 60 per cent profit margin of their best-of-class colleagues. “They will also tell me that, in order to drive more efficiency in the practice, they will have to discuss how to do this with their doctors. If ophthalmological businesses are to run well they must operate in the same way as they operate clinically, objectively and diagnostically. “I should be able to go to an administrator and have them tell me what the most adverse 'diagnoses' in the practice are, and have them say: ‘We have insufficient space. We cannot afford to build more rooms so we will have a temporary expansion’,” says Pinto.

CLEAR VISION Arthur Cummings MD, FRCS, Consultant Ophthalmologist at the Wellington Eye Clinic, Dublin, Ireland, agrees with Pinto's assessment. He also argues that if you follow the numbers, you need to have a clear vision of how your practice operates. “If you own your own practice, it is generally assumed that you run it. This is not always the case. It depends what size it is and what it involves. Some ophthalmologists will have busy surgeries, and if they are taking on other responsibilities such as research it is not possible to manage the practice on your own,” he says. “In a busy practice, you need a clinical manager as well as a business manager. Your clinical manager should decide on a dayto-day basis how the clinic operates, what the surgery lists look like and what rooms are used for which professionals on a given day and so on. Besides that, you need someone with a different skill set who looks after the administrative and business side of the practice. That person, as well as overseeing the financial end of the practice, will also be responsible for staff contracts and contracts with research companies for example. “I am the sole owner of our practice and work closely with my business manager and my clinical manager. All three of us understand what the other is doing, but we know for a fact that the person in charge of their own particular area knows more about that area than the rest of us. Everyone knows their roles well, which gives me time to look at clinical issues. Teamwork is vital and I cannot run my practice without a very strong team around me. The best compliment I can get from any patient is: ‘You have an amazing team’,” says Dr Cummings.

I am the sole owner of our practice and work closely with my business manager and my clinical manager Arthur Cummings

John Pinto: pintoinc@aol.com Arthur Cummings: abc@wellingtoneyeclinic.com

NEWSMAKER

UNENDING INNOVATION Richard Packard recounts the history of capsulotomy from its inception in the 18th Century to the present Richard Packard FRCS, Senior Consultant at Prince Charles Eye Unit, Windsor, UK, spoke with EuroTimes contributing editor Roibeard O’hEineachain about the still-continuing evolution of capsulotomy techniques, the theme of his Binkhorst Medal Lecture at the XXXIII Congress of the ESCRS in Barcelona.

’ve been involved with the ESCRS from when it was still the European Intraocular Lens Implant Council (EIIC) and I went to the first meeting under its present name, and have been to every meeting ever since. It is therefore an enormous honour, one of the crowning achievements of one's career, to be asked to give such a prestigious lecture and to receive the medal. So much so, that my children and their sundry spouses will be in attendance to watch the old man strut his stuff. So it's a big deal. Later on this year, the UKISCRS will be giving me a lifetime achievement award. So it's going to be a big year for big lectures for me. The title of my lecture is ‘The Evolution of the Capsulotomy: From Crude Forceps to Precision Laser’. The reason I thought of this title was because I'm involved with a small start-up company called Capsulaser, which has a very interesting laser for doing a capsulotomy in a completely different way from the femtosecond laser. It is a thermal laser and it is a tiny device which fits underneath the microscope, and enables you to have a perfectly precise capsulotomy which is actually stronger than you can achieve either manually or with the femtosecond laser, and at a fraction of the cost of the latter technique. We want to combine it with devices like the Callisto system (Zeiss) or Verion (Alcon), which will enable a perfectly centred capsulorhexis as well as a perfectly sized one. Capsulaser is going into clinical trials with their new capsulotomy laser this year. They've done 1,000 pig eyes and 100 cadaver eyes and the laser will do a perfect capsulotomy in two seconds. It will be something that virtually every cataract surgeon will want to have on their microscope to do the capsulotomy.

I’ve been involved with the ESCRS from when it was still the European Intraocular Lens Implant Council (EIIC)... Richard Packard FRCS

There are also other new devices under development, such as the Zepto device, which is being developed again by a small start-up company, Mynosys, in the US. It is a device that you can push through the wound and it sits on top of the capsule, and in a few nanoseconds it creates a capsulotomy. They haven't done any clinical trials with it yet, they have done pig eyes, but again it's new technology. An awful lot of people are not convinced, as I am not convinced, that femtosecond laser cataract surgery is going to be going anywhere. So far, every study that has been done comparing femtosecond laser with cataract surgery done in the conventional manner has shown no real difference between the two techniques in terms of clinical outcomes. I also thought this would be a good opportunity to review the whole business of capsulotomy use, from Daviel in the 18th Century onwards, and look at the different roles capsulotomy has had over the years, how it has been done, how the shape has changed. Initially, for example, it was just a means of getting the nucleus out of the eye - it still serves that purpose, but over the years it has also been adopted in various ways and in various shapes to secure the stable placement of the intraocular lens (IOL) in the capsular bag. There are also other ways that capsulotomy has been used, such as Tassignon’s bag-in-the-lens IOL and Samuel Masket’s new grooved-optic lens which fits into a perfect capsulotomy. I think the topic of my Binkhorst lecture is particularly appropriate, since it was Binkhorst who brought everyone back to extracapsular surgery. I'll be talking about his two-loop iridocapsular lens and how he thought this would give them greatest stability. What Binkhorst wanted to develop when he moved away from the Ridley lens to the four-loop lens, which was held in the pupil, was to accomplish perfect centration. But since he found that the four-loop lens could be dislocated, he thought that a two-loop lens which had loops in the capsule, but with the optic still in front of the iris, would be a better option. Finally he developed his endocapsular lens, which was called the “moustache” lens, because the haptics looked a bit like Salvador Dali’s moustache. As I will mention in my lecture, I in fact met Cornelius Binkhorst as a senior registrar at Charing Cross. Eric Arnott, who was my mentor there and taught me phacoemulsification in the late 70s, had organised a huge meeting with multiple international surgeons like Binkhorst and Worst and everybody that had a lens named after them. I assisted Binkhorst in a cataract procedure and watched him put in a “moustache” lens. Richard Packard: mail@eyequack.vossnet.co.uk

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CATARACT & REFRACTIVE

MICS MEETS MIGS Micro-incision cataract surgery generally compatible with minimally invasive glaucoma surgery. Roibeard O’hEineachain reports

erforming micro-incision cataract surgery (MICS) with minimally invasive glaucoma surgery (MIGS) combines the benefits of both techniques in terms of refractive stability and intraocular pressure (IOP) reduction, said Boris Malyugin MD, PhD, Fyodorov Eye Microsurgery Complex, Moscow, Russia. “MICS and MIGS is a new trend in combined cataract and glaucoma treatment. The techniques are generally safe and easy to perform. But of course there is a learning curve involved,” Dr Malyugin told the XXXII Congress of the ESCRS in London. MICS refers to procedures using incisions less than 2.0mm in size to remove the lens with coaxial or biaxial instrumentation with the aim of reducing induced astigmatism to a minimum. The term MIGS refers to a range of techniques, generally ab interno in approach and performed under gonioscopic view, which are designed to create new channels for the outflow of aqueous from the anterior chamber into either Schlemm’s canal or the suprachoroidal space, with minimal trauma to the eye and few complications. Most of them are associated with the use of the micro shunts inserted into the Schlemm’s canal (for instance iStent) or suprachoroidal space (CyPass), while the others are aimed on opening the trabecular meshwork (Trabectome). He noted that approximately one out of seven patients undergoing cataract surgery also has glaucoma. Included in their number is a population of patients who are in an early stage of the disease and who maintain good control of their IOP but require many medications to do so. It is those patients for whom the MIGS and MICS combined procedures are best suited. In several published studies, MIGS techniques combined with phacoemulsification have appeared to achieve significantly greater IOP reduction than was achieved with phacoemulsification alone. As a result, patients who have undergone the two procedures require fewer medications postoperatively. Apart from the presence of well-controlled glaucoma, the indications and contraindications for MIGS and MICS combined procedures are broadly similar to those of cataract surgery alone. One important additional requirement is that patients need to be cooperative and able to follow the surgeon’s instructions, since the procedures are generally performed under local anaesthesia. Dr Malyugin noted that the literature is sparse regarding the safety and efficacy of combined MIGS and cataract procedures in pseudoexfoliative patients, as they are generally excluded from the clinical trials involving the MIGS devices. However, one published study showed that pseudoexfoliative glaucoma Boris Malyugin MD

patients who underwent treatment with the Trabectome in conjunction with a phacoemulsification procedure had greater reductions in IOP than did patients with primary open-angle glaucoma who underwent the same two procedures. There is a general consensus that the cataract surgery should be performed before the glaucoma surgery. In addition, clear corneal incisions are preferable so that blood does not go under the gonioscopic lens. Furthermore, the incisions should be placed temporally to make it easier or the patient to turn his head or eye as required for the surgery. The surgical microscope should be tilted at a 30 to 45-degree angle. Dr Malyugin pointed out that eyes with glaucoma represent a special challenge to the cataract surgeon because they are prone to compromised endothelia, small pupils and loose zonules. “In spite of all this, by using proper technique and utilising intracameral mydriatics with viscoadaptive OVDs to stabilise the pupil, decreasing fluidic parameters and manipulating the nucleus in the very centre of the anterior chamber, it is possible to safely perform a MICS procedure even in a patient with pseudoexfoliative syndrome and a relatively small pupil,” Dr Malyugin said.

iop mics reduction migs

MICS and MIGS is a new trend in combined cataract and glaucoma treatment

EUROTIMES | JULY/AUGUST 2015

BIMANUAL METHOD He added that the surgeon should use quick-chop manoeuvres to fragment the nucleus. Irrigation and aspiration is best performed using a bimanual method either with a coaxial handpiece, using the second instrument to expose the equatorial portion of the capsular bag in order to completely evacuate the cortical material or with two biaxial handpieces (one used for irrigation, while the other one for aspiration). If zonular damage should occur during surgery, the placement of a capsular ring can safely repair zonular defects of up to 90 degrees of the capsular bag’s circumference. In eyes with small pupils, pupil expander rings (such as Malyugin Ring) are extremely useful. In cases with small pupils associated with loose zonules, pupil-expanding hooks, specifically double-threaded hooks having elongated working elements help in stabilising the capsular bag and reducing the amount of stress placed on the capsular bag. That, in turn, reduces the risk of anterior capsulorhexis radial tears and the vitreous loss that might follow. Patients undergoing the MIGS/MICS procedures do not require special intraocular lenses (IOLs) or special IOL power calculation formula. However, multifocal IOLs are generally contraindicated in such eyes because of the loss of contrast that will occur with progression of their glaucoma. Cataract surgeons who are unaccustomed to gonioscopic surgery will need to refresh their knowledge of the anterior chamber’s anatomical landmarks before they start performing MIGS procedures. The choice of which MIGS technique to use is another consideration, Dr Malyugin said. Those currently available have a relatively low complication rate and a good safety profile, and decrease patients' dependency on medication. However, they also entail some risk of complications such as hyphema, iridodialysis and iritis. Boris Malyugin: boris.malyugin@gmail.com

CATARACT & REFRACTIVE

LASERS IN SURGERY The transition from fearful weapons to tools of healing.

hough first perceived as potentially blinding anti-personnel weapons, lasers have proved to be valuable instruments that can preserve, enhance and restore vision, said John Marshall PhD, UK, as he looked back on nearly 50 years of involvement with lasers in ophthalmology in his UKISCRS Lifetime Achievement Award lecture, which he delivered at the 2014 UKISCRS Congress in London. He noted that his involvement with lasers in ophthalmology goes back to the early days of lasers themselves. Albert Einstein first postulated the possibility of lasers back in 1917. In 1953 Charles Townes and his team exploited Einstein’s theoretical work to create the first maser, in 1960 Theodore Maiman invented the first working laser, and the first eye accident was reported in 1963. “It was all new, so I was really lucky to be headhunted by the Royal Air Force in 1965 and given a grant to do a PhD. This PhD was divided between the Institute of Aviation Medicine and the Institute of Ophthalmology. The requirement was to investigate laser damage to the retina in order to try to protect aircrew against weapons which at that time did not exist,” said Prof Marshall. His research elucidated the different mechanisms by which lasers can damage tissue. It showed a time dependency in determining the mechanisms of damage. If a laser caused detectable tissue damage using pulse durations of a nanosecond or

Roibeard O’hEineachain reports less then the damage results from electronMeanwhile, LASIK was under stripping and ionisation. development theoretically as a means However, if it took a nanosecond to a of increasing the amount of refractive millisecond the damage results from explosive correction compared with surface ablations. heating and shockwaves. By contrast, when Although it did not achieve that primary pulse durations range from a millisecond to aim, it did reduce pain and eliminated a second the damage was a thermal effect, haze, and as a result has become the and finally, when the pulse duration was predominant form of corneal refractive longer than a second the damage results from surgery performed in some countries today. photochemical effects with short wavelengths More recently, Prof Marshall and his being the most hazardous. associates have developed a new approach, Prof Marshall’s research led to many designated LASIK Xtra, which involves innovations in the use of lasers for retinal locking in the post-ablation stromal shape pathologies and also the use of the lasers with a two-minute collagen crosslinking for corneal refractive surgery. (CXL) procedure. The new His work led to the initial technique has been adopted patents in refractive surgery at many centres around and the development of the world and the results photorefractive keratectomy so far suggest that CXL (PRK). This resulted in the improves the predictability establishment of the first of the LASIK procedure company to manufacture and extends the amount of lasers for commercial use in refractive error it can correct, refractive surgery, and the first up to -19 dioptres. to receive FDA approval in 1995. Finally, he showed a new John Marshall He noted that PRK’s predictability technique of refractive surgery was poor in the early days. However, (PiXL) whereby corrections are refinements in laser technology, particularly achieved by topographically applied increasing spot sizes, greatly reduced the ultraviolet radiation such that the variability in outcomes. The problems that resultant tensional changes in collagen remained included postoperative pain and a fibres address refractive errors in myopia, haze. The solutions for these problems came hyperopia and astigmatism. in the form of the use of pharmacological John Marshall: inhibitors of keratinocyte activity and the eye.marshall@googlemail.com use of topical anaesthesia postoperatively.

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CATARACT & REFRACTIVE

INCISION PRECISION Anti-astigmatic corneal incisions need better predictability. Roibeard O’hEineachain reports

ncisional techniques can provide visual benefits to patients with mild to moderate amounts of astigmatism, and new technologies and improved nomograms for planning and creating the incisions are likely to improve their still suboptimal predictability, reports Thomas Kohnen MD, PhD, FEBO, Goethe University, Frankfurt, Germany. “We have to work on standardising our nomograms and we also have to look at the long-term clinical outcomes. The published data is still a little bit scarce,” he told the XXXII ESCRS Congress in London. The indications for astigmatic cuts in the cornea include natural astigmatism, astigmatism after penetrating keratoplasty, and induced or residual astigmatism after cataract or refractive surgery . The basic principle of incisional techniques is to create cuts that are perpendicular to the steep meridian in order to flatten the cornea on that meridian. In eyes with astigmatism after penetrating keratoplasty, the incisions are performed on the donor tissue no more than 7.0mm from the centre. The aim of these incisions is to reduce astigmatism, refraction can then be fine-tuned with an excimer procedure. Limbal relaxing incisions, on the other hand, are performed on the peripheral cornea, close to the limbus, and are

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generally used for the purpose of fine-tuning the refraction after cataract and refractive procedures. He noted that peer-reviewed studies suggest that limbal relaxing incisions are effective for the treatment of 1.5D to 2.0D of astigmatism and that they should only be performed when the spherical equivalent is within plus or minus 0.5D to 0.75D of plano, because otherwise the patient will have residual myopic error and will not be satisfied, if emmetropia is the goal. “We see a pretty quick recovery and usually excellent optical outcomes with limbal relaxing incisions. It is a safe procedure in cataract procedures with a low rate of complications and rarely any loss of best-corrected visual acuity. I think they are also useful for fine-tuning patients after procedures like PRK or LASIK. For example, if you don’t have enough tissue and you cannot do any further treatment on the cornea,” Prof Kohnen said.

IMPROVING PREDICTABILITY One drawback of incisional techniques is that, although on average they provide reasonably good results, there is actually a lot of variability in outcomes. The residual or induced cylinder following the procedures may result from a number of factors, including incorrect measurement of the astigmatism and/or the incorrect placement of the incisions. Prof Kohnen noted that if the meridian of the anti-astigmatic incision is off by just 10 degrees it will lose 30 per cent of its effect, and if it's off by 30 degrees it will lose all of its effect. If the transversely incised meridian is off by more than 30 degrees, the astigmatism starts to increase. He noted there are also as yet several incompletely understood factors of corneal healing and biomechanics that can effect outcomes. There are now numerous nomograms available for performing incisional astigmatic corrections, Prof Kohnen noted. However, the long-term predictability they afford is unknown because the studies published to date generally have follow-up periods of less than a year. The advent of femtosecond cataract surgery systems with online OCT guidance for placing the incisions may help remove some of the uncertainties from the procedures. He noted that he and his associates have been using the laser and their results so far appear promising. Femtosecond laser-assisted corneal surgery can also be used to create intrastromal peripheral relaxing incisions. He added that Douglas Koch MD and his team have had impressive results in a series of 19 patients who received intrastromal incisions using the Optimedica® femtosecond laser system. “I think that in the future we will see a growing use of femtosecond lasers for performing penetrating and intrastromal keratotomies with better predictability than the manually driven devices,” Prof Kohnen said.

We see a pretty quick recovery and usually excellent optical outcomes with limbal relaxing incisions Thomas Kohnen MD, PhD, FEBO

EUROTIMES | JULY/AUGUST 2015

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CATARACT & REFRACTIVE

PERSONAL EYE MODEL Highly customised ablations the future of refractive laser treatments. Roibeard O’hEineachain reports

more individualised approach to LASIK ablations using a personal virtual eye model for each patient could lead the way to greater predictability in the treatment of refractive errors, said Arthur Cummings MD, FRCS, Dublin, Ireland at the XXXII Congress of the ESCRS in London. There are numerous types of laser ablation profiles available to corneal refractive surgeons today, including wavefront-optimised, wavefront-guided and topography-guided ablations. However, the ablation patterns used in each approach are based on the Gullstrand Eye model, and therefore assume a corneal power of 43D and an axial length of 24mm. “Irrespective of how sophisticated the data is that you’re going to use to drive the treatment, when you enter it into the laser, the laser thinks you are treating Gullstrand’s Eye,” Dr Cummings said. In addition, measurement errors can further reduce the predictability of the procedure. Research shows that subjective refraction measurements are repeatable to within 0.5D only around 90 per cent of the time. A similar proportion of eyes are within 0.5D of target refraction in most published LASIK series.

INDIVIDUAL VIRTUAL EYE MODEL A superior option to using the Gullstrand Eye model would be to base a laser ablation profile on a customised virtual eye model in each patient, he maintained. Such a model would be built from wavefront refraction instead of manifest refraction, the actual OCT-measured axial length, instead of the Gullstrand Eye’s arbitrary 24mm, and topography data with 24,000 data points for the corneal shape instead of the arbitrary 43D for the cornea’s power. Additional measurements would include the refractive effects of the posterior cornea and the anterior and posterior lens surfaces. An additional enhancement would be a further modification in the pattern of the placement of the laser shots to better compensate for the reduction of

their effect as they move more peripherally on the cornea’s surface and hit it more obliquely as the cornea slopes away toward the periphery. The wavefront-optimised treatment, designed by Michael Mrochen PhD, already includes that kind of compensation but is based on the amount of compensation needed with the Gullstrand Eye model. A new treatment algorithm is available in which the mathematical compensation is based on the personal eye model of each patient.

PROMISING RESULTS Dr Cummings noted that results of a multicentre study in which he participated showed that an individualised ray tracing LASIK approach based on the personal virtual eye model he described can provide visual acuity that is as good if not better than that achieved with wavefront-optimised, wavefront-guided or topography-guided approaches, particularly in the higher ranges of myopia. The study involved 127 eyes of 71 patients. Part of the study’s inclusion criteria was myopia of -4.0D or greater or myopic astigmatism between 2.0D and 6.0D. Therefore their refractive errors were higher than average for LASIK patients, he noted. Dr Cummings and his associates performed diagnostic measurements with three devices. They used the Pentacam® (Oculus) or the Wavelight Allegro Oculyser® (Alcon) for topography and pachymetry, the Lenstar® (HaagStreit) or Wavelight OB820 (Alcon) optical biometer for the axial length measurements, and the Wavelight Analyzer® (Alcon) for the wavefront measurements. They performed surgery using femtosecond laser or a microkeratome for flap creation. They used either the Wavelight® 400 Eye-Q or the Wavelight® 500 Concerto excimer laser to perform the ablation using a personalised compensation algorithm for each eye. Despite the high levels of myopia treated, the new treatment’s predictability

...when you enter it into the laser, the laser thinks you are treating Gullstrand’s Eye Arthur Cummings MD, FRCS EUROTIMES | JULY/AUGUST 2015

Having one device that provides all the diagnostic information would in turn provide quicker acquisition of data... was good. At three months follow-up, around 87 per cent of patients were within half a dioptre of emmetropia, and 84 per cent had an uncorrected visual acuity of 20/20 or better. The mean cylinder decreased from -1.06D preoperatively to 0.31D postoperatively. Postoperative uncorrected distance visual acuity was equivalent to or better than the preoperative corrected distance visual acuity in 73 per cent of eyes, and 12 per cent had a postoperative decimal uncorrected visual acuity of 1.6. In addition, corrected visual acuity improved from 0.05 logMAR preoperatively to -0.109 logMAR postoperatively. He added that the results compared favourably with those of FDA trials with wavefront-optimised and wavefront-guided LASIK. For example, the proportion achieving 20/20 among those undergoing correction of -4.0D to -7.0D of myopia was 80 per cent in the FDA Wavelight study with wavefront-optimised ablation, 91.2 per cent in the FDA wavefront-guided study, and 93.7 per cent with the new ray tracing method. Dr Cummings added that further improvements in predictability may in the future come from an integration of the different measurement instruments into one single instrument, itself closely integrated with the laser. “Having one device that provides all the diagnostic information would in turn provide quicker acquisition of data, better registration. It would also be more convenient for our staff, and most importantly more convenient for the patients,” Dr Cummings added. Arthur Cummings: abc@wellingtoneyeclinic.com

FUTURE OF FEMTO

Veterans of cataract and refractive surgery research offer their predictions. Roibeard O’hEineachain reports

ver the past few years, femtosecond lasers have made rapid inroads into both cataract and refractive surgery, with procedures that create intrastromal lenticules that can be extracted for myopic corrections, and increasingly automated technology for performing several of the most difficult manoeuvres of the cataract procedure. In a discussion held at the XXXII Congress of the ESCRS in London, several leading researchers in refractive surgery reflected on the current state of the art in femtosecond laser technology, the improvements still needed, and the ultimate goal at which to aim. “When we adopt new technology we have to continue to do good research to make sure that what we’re doing is not going against us,” said Thomas Kohnen MD, PhD, Goethe University, Frankfurt, Germany, who co-chaired the session

with John Marshall PhD, UCL Institute of Ophthalmology, London, UK. Dr Kohnen noted that small incision lenticule extraction (SMILE) is emerging as an important new contender in the field of corneal refractive surgery. The new technique involves the use of a femtosecond laser to first create a lenticule and then perform the side-cut for its removal. Dan Reinstein MD, MA (Cantab), FRCSC, DABO, FRCOphth, FEBO, London, UK, noted that in his practice the SMILE technique has been living up to its expectations, providing accuracy and efficacy comparable to that of LASIK but with better spherical aberration control and less biomechanical impact. Moreover, the SMILE procedure now accounts for 80 per cent of his myopic treatments. He pointed out that there have been more than 300,000 procedures performed worldwide, with over 40,000 SMILE procedures performed last year alone in China.

When we adopt new technology we have to continue to do good research to make sure that what we’re doing is not going against us Thomas Kohnen MD, PhD EUROTIMES | JULY/AUGUST 2015

The SMILE technique reduces the tensile strength of the cornea less than is the case with LASIK. This is because no flap is created, and therefore the integrity of the anterior stroma lamellae, which is known to possess greater tensile strength than the posterior stroma, is maintained, Dr Reinstein said. It therefore stands to reason that SMILE can be used to correct higher levels of refractive error than is possible with LASIK or PRK. The SMILE technique also has the advantage of cutting through fewer nerve fibres than LASIK, which leads to a lower reduction and faster recovery of corneal sensitivity, and therefore we believe a reduction in dry eye symptoms postoperatively. The VisuMax femtosecond laser is currently the only femtosecond laser being used for intrastromal lenticular surgery. In order for accurate 3D intrastromal cutting, a number of technological hurdles have to be overcome; not only does the femtosecond pulse placement 3D accuracy need to be very high and pulse energy very low, but there has to be minimal tissue distortion of the cornea when optically coupling to the femtosecond laser source. This is achieved by using a curved contact glass and by applying suction to the peripheral cornea (not the conjunctiva/sclera) allowing for immobilisation of the cornea using a very low suction force. In turn, because the eye is immobilised by the contact glass interface centred on

the corneal vertex while the lenticule is being cut, no eye-tracker is necessary, Dr Reinstein pointed out. He added that, for any refractive procedure to gain wide acceptance, the safety aspects must be a foremost consideration. There are many people, including some refractive surgeons, who will not undergo corneal refractive surgery because they fear that they might have a complication that would result in an irreversible loss of vision, he pointed out. “My dream for the field of refractive surgery is that the worst-case scenario possible would be that, after all is said and done, patients’ vision with glasses would always be as good as it was preoperatively. The current situation is that unfortunately we don’t quite yet have that, but we’re working on it based on stromal surface topography guided treatment,” he said. Dr Marshall noted that SMILE was in some ways a compromise. The original concept was to have a procedure that could be performed completely within the stroma. However, that proved too difficult because of the uncontrollable nature of the cavitation that resulted from the plasma the laser generates in the stroma. “Then again, watch this space because there is at least one company, Schwind, that is beginning to use ultraviolet-induced plasmas where the photon concentration is so much less and you get only tiny, tiny plasma formations in the cornea,” Dr Marshall said.

Courtesy of Dan Reinstein MD, MA (Cantab), FRCSC, DABO, FRCOphth, FEBO

CATARACT & REFRACTIVE

Figure 1: SMILE diagram

ROBO-CAT Paul Rosen FRCS, FRCOphth, Oxford Eye Hospital, Oxford, UK, noted that the advent of femtosecond laser-assisted cataract surgery (FLACS) has elicited concern that surgeons in the future will be largely replaced by robots. However, he maintained that surgeons will

always be needed as clinical decision makers. Dr Marshall countered that perhaps the more automated the surgery is, the better. “I always keep in mind accidents. More than 80 per cent of the air accidents of the last 15 years have been due to human error, so I think we have to bear that in mind. We rarely have system errors in ophthalmology and very often it is our inappropriate decisions that cause the problems,” Dr Marshall added. Dr Rosen said he largely concurred, but pointed out that humans will be needed to programme the machines and that the effective use of the technology is bound to require certain skills. Femtosecond laserassisted cataract devices will provide an extension to a surgeon’s skills. “These systems will magnify our skills rather than take them away. It’s a bit like the shift from intra-cap to extra-cap and then to phaco. Currently, the vast majority of our residents would be incapable of doing cataract surgery without a phaco machine. In the future they will need a femto machine. I predict that the advantages will be a more reproducible quality in cataract surgery with fewer complications,” he said. Thomas Kohnen: kohnen@em.uni-frankfurt.de John Marshall: eye.marshall@googlemail.com Dan Reinstein: dzr@londonvisionclinic.com Paul Rosen: paul.rosen@ouh.nhs.uk

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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

Poster Village Moderated Poster Sessions Presented Posters ePoster Terminals

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

Binkhorst Medal Lecture Richard Packard UK

The Evolution of the Capsulotomy: From Crude Forceps to Precision Laser

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XXXIII Congress of the ESCRS 5–9 September

Saturday 5 September

Lunchtime Symposia

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13.00 – 14.00

The Extended Range of Vision IOL – A Proven Concept for Presbyopia Correction E. Marques PORTUGAL The innovative optics of the Extended Range of Vision IOL G. Auffarth GERMANY Large scale clinical results with the Extended Range of Vision IOL M. Pande UK Adopting the Extended Range of Vision IOL into a premium practice Supported by an unrestricted educational grant from

Preserving the Cornea and the Lens for the Future

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Moderator: A. Kanellopoulos GREECE

Heidelberg Engineering Satellite Meeting Sponsored by

Pentacam® Goes IOL World Premiere of the New Pentacam® AXL Moderator: T. Kohnen GERMANY Sponsored by

Ziemer Satellite Meeting Sponsored by

MicroPulse® Laser Therapy for Glaucoma and Retina Sponsored by

Rayner Satellite Meeting Sponsored by

G. Sauder GERMANY Nano laser cataract surgery pearls and facts J. Tanev BULGARIA Endothelial cells - comparison phaco/nano laser

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Swept Source OCT Combined with OCT-Angio and Other Multi Modal Imaging Tools Sponsored by

Saturday 5 September

Sunday 6 September

Lunchtime Symposia

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13.00 – 14.00

Extending Depth-Of-Focus With Small Aperture Technology Moderator: B. Dick GERMANY Sponsored by

The Oculentis Toolbox for Lens Surgery-LENTIS Comfort for Cataract Surgery, LENTIS Mplus Family for Refractive Cataract Surgery, FEMTIS for Laser-Assisted Cataract Surgery Sponsored by

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Complex Cataract Cases - The Simple Truths Moderator: R. Osher USA Speakers: R. Osher USA B. Malyugin RUSSIA

Saturday 5 September Evening Symposium 18.15 Avedro Advanced Cross-Linking Symposium

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IC Route the New Standard Route for Cataract Surgery Moderator: B. Cochener FRANCE

Retinal Rejuvenation Therapy (2RT), and Laser Vitreolysis Moderator: M.J. Tassignon BELGIUM Speakers: J. Marshall UK K. Brasse GERMANY H. Kaymak GERMANY J. Conrath CANADA Sponsored by

Astigmatism Management – New Surgical Solutions for a Most Common Problem O. Findl AUSTRIA A new IOL to treat astigmatism and presbyopia B. Dick GERMANY Intraoperative correction of astigmatism with a laser cataract surgery suite M. Shafik EGYPT High definition wavefront guided laser correction of astigmatism Supported by an unrestricted educational grant from

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XXXIII Congress of the ESCRS 5–9 September

Sunday 6 September

Lunchtime Symposia

Boxed Lunch Included

13.00 – 14.00

Tomorrow´s Vision Today - Rethinking Established Conventions in Refractive Laser Surgery

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Moderator: W. Sekundo GERMANY W. Sekundo GERMANY SMILE: current status of the technique and long-term results G. Carp UK The MEL 90: state of the art presbyopia correction with PRESBYOND and therapeutic refractive surgery S. Ganesh INDIA SMILE: my preferred refractive procedure for myopic spherocylindrical corrections and the results L. Trinh FRANCE Comparison of dry eye syndrome after SMILE and LASIK K. R. Pradhan NEPAL Preliminary report: SMILE for hyperopia Sponsored by

Phaco Forward: Surgical Experience of New Phaco Technologies Introduction R. Bellucci ITALY EVA: a new paradigm in phaco fluidics S. Srinivasan UK No compromises: sub 1.8mm cataract surgery J. van Calster BELGIUM My case experience: pseudoexfoliation, floppy iris and other complex cataract cases TBC Anterior staining: why purity matters Questions & Answers Sponsored by

Omega-3 fatty acids: Current and futureSunday treatments for ocular surface diseases

6 September

Moderator: S. Barabino ITALY

Lunchtime Symposia

M. Rolando ITALY Boxed Lunch Included Ocular surface diseases: the – 14.00 alteration13.00 of a system

Video Symposium on Premium Procedures Moderator: S. Daya UK J. Fernández SPAIN Advancing femtosecond laser cataract surgery techniques with the Zero Phaco Handpiece P. Stodulka CZECH REPUBLIC Combining the VICTUS® femtosecond laser and a new premium IOL J. Alvarez de Toledo SPAIN Therapeutic applications with the VICTUS® Femtosecond Laser Platform R. Ang PHILIPPINES Presbyopic LASIK Solutions with the TECHNOLAS® TENEO™ 317 and SUPRACOR® Sponsored by

Sunday 6 September

Monday 7 September

Evening Symposium

Lunchtime Symposia

18.00

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13.00 – 14.00

Essential Fatty Acids: Current and Future Treatments for Ocular Surface Diseases

FineVision 4 Years Follow-Up: The Secrets to Guarantee Patient Satisfaction and Practice Performance

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Moderator: S. Barabino ITALY

Monday 7 September Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 The Complete Portfolio to Suit All Your Patient Profiles

M. Rolando ITALY Ocular surface diseases: the alteration of a system E. Messmer GERMANY Essential fatty acids therapies for dry eye: what is hype and what is real? P. Aragona ITALY Topical treatment with Omega-3 fatty acids: clinical results Conclusion, Questions & Answers Sponsored by

Moderator: A. Denoyer FRANCE E. Ligabue ITALY The enVista® Toric IOL - clinical outcomes and surgical pearls C. Leydolt AUSTRIA Clinical study on a yellow, preloaded, hydrophobic IOL E. Mertens BELGIUM Premium procedures - VICTUS® femtosecond laser and a new premium IOL S. Morselli ITALY The MICS INCISE® IOL – evaluation of the optical quality A. Toso ITALY Two year PCO outcomes with the MICS INCISE® IOL Sponsored by

VSY Biotechnology Tri-ED Satellite Meeting P. Stodulka CZECH REPUBLIC Reviol Tri-ED first clinical experience J. Blanckaert BELGIUM Tri-ED: Trifocal IOL with EDOF combination initial outcomes

Moderator: L. Álvarez-Rementería

SPAIN

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CORNEA

PROGRESS IN LENS DESIGN New lens designs provide good vision in advanced keratoconus. Roibeard O’hEineachain reports

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dvances in the design of contact lenses are reducing the need for corneal grafts in keratoconus patients, according to Ebru Toker MD, Marmara University Medical School, Istanbul, Turkey. “The contact lens management of keratoconus is challenging and it demands greater expertise compared to standard contact lens fitting. But we are lucky to have many designs and materials for our patients, and with the appropriate selection and application of these lenses, we can restore vision in most of these patients without the need for surgery,” Dr Toker told the 19th ESCRS Winter Meeting in Istanbul. Rigid gas permeable lenses provide excellent vision to patients with mild forms of keratoconus. They rest on the cornea and are fitted in alignment with the cornea. Because of their rigidity they provide optimal centration and mask corneal irregularities. However, as the cone advances, a conventional rigid gaspermeable lens will become unstable with frequent dislodgement, resulting in epithelial disruption and progressive scarring of the cornea. But there remain several contact lens Ebru Toker options for even the more advanced cases. For example, there are specialty RGP contact lenses with complex designs that can be selected based to the shape and the position of the cone. In addition, for patients in whom rigid gas-permeable lenses cause discomfort there are now custom piggyback lens systems, consisting of a soft lens with a circular recessed depression in the centre within which is fitted the rigid lens. There are also new soft lens designs with a thick central optical zone that mimic the behaviour of a rigid lens and can therefore mask some mild to moderate corneal irregular astigmatism.

BONDED For patients with advanced keratoconus or in cases where the other lenses don’t work, there are also hybrid lenses consisting of a rigid RGP centre with apical clearance that is covalently bonded with a hydrogel skirt that extends from the limbus out to the sclera. Finally, for really hard-to-fit eyes, there are the new scleral lenses. With diameters ranging from 15mm to 24mm, the lenses are supported exclusively by the sclera and completely avoid the cornea and the limbus. They are therefore much more comfortable than a rigid corneal lens. Dr Toker cited a retrospective study showing that, in eyes with stage 4 keratoconus, those implanted with the new lenses had significantly better visual acuity than those who underwent keratoplasty. “It seems that these new scleral lenses with sophisticated designs will reduce the need for keratoplasty for advanced keratoconus,” she added. Ebru Toker: dretoker@gmail.com

EUROTIMES | JULY/AUGUST 2015

CORNEA

LAMELLAR SURGERY Keys to success for new techniques. Priscilla Lynch reports

Tired of seeing those unhappy patients?

he key to success in any type of new ophthalmic surgery is affordability as well as reproducibility and standardisation of the required technique, Massimo Busin MD told the Joint Irish/UKISCRS Refractive Surgery Meeting in Dublin, Ireland. Dr Busin, Head of Ophthalmology, Villa Igea Hospital, Forli, Italy, gave the Tom Casey Memorial Lecture on corneal surgery, describing in detail the development of various corneal procedures including penetrating keratoplasty (PK), Descemet’s stripping automated endothelial keratoplasty (DSAEK), Descemet’s membrane endothelial keratoplasty (DMEK), the latest move to ultra-thin DSAEK (UT-DSAEK) as well as the increasing use of femtosecond laser. “For solid advancement in any type of surgery, you must develop something that is affordable for every surgeon. If you have something that is only applicable by an elite group of surgeons I don’t think it will ever become popular and make it through. My efforts were always devoted to trying to develop ways to perform difficult things in an easy way,” he told EuroTimes. During the course of his lecture, Dr Busin strongly advocated the use of UT-DSAEK, praising its ability to provide the best form of DSAEK, resulting in good visual outcomes, faster healing and lower immunologic rejection risk, as shown by his own studies. Dr Busin described how he originally carried out UT-DSAEK graft preparation using the ‘double pass’ method but, with the new linear microkeratomes that cut at a uniform depth, now uses a ‘single pass’ technique. “Most of the time now I’m performing UT-DSAEK, which I developed, though DMEK can also be performed with good success rates these days, especially if you try to standardise it like I did. However, I think the jury is still out about which one is superior to the other,” he said. While UT-DSAEK is still a relatively new procedure, Dr Busin said it is increasing in use, particularly due to the increased availability of donor tissue and its pre-surgery preparation from eye banks. “The problem with thinner tissue concerns mainly manipulation during surgery, but the more experience the surgeons gain, the more requests there are for thinner tissue and that is the trend all over the world,” he told EuroTimes. Discussing corneal dissection, he said femtosecond laser is expensive but precise, but does not cut through opacities. In terms of anterior lamellar grafts Dr Busin believes pneumatic dissection does not have rivals against other procedures. Massimo Busin: mbusin@yahoo.com

For solid advancement in any type of surgery, you must develop something that is affordable for every surgeon

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Massimo Busin MD EUROTIMES | JULY/AUGUST 2015

CORNEA

CXL FOR KERATOCONUS At one year, standard and accelerated epi-off was more effective. Howard Larkin reports

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ne year after treatment, both standard and accelerated corneal crosslinking (CXL) protocols applied in eyes with corneal epithelium removed were more effective in treating keratoconus than accelerated CXL applied with the corneal epithelium intact, Minoru Tomita MD, PhD, Tokyo, Japan, told the 2014 American Academy of Ophthalmology annual meeting in Chicago. Both standard and accelerated epi-off approaches reduced mean keratometry values, indicating corneal flattening, while accelerated epi-on did not. In addition to stabilising keratoconus progression, OCT imaging showed clear CXL demarcation lines more than 300 microns deep in the stroma for both epi-off techniques, compared with diffuse and transient crosslinking effects seen in the transepithelial or epi-on group. Results of this one-year randomised prospective study suggest that the accelerated epi-on approach promotes crosslinking only in the anterior stroma, which may limit its effectiveness as a keratoconus treatment, Dr Tomita said.

OBSERVATIONS Dr Tomita’s study involved 45 eyes of 23 patients with moderate keratoconus randomly assigned to receive standard CXL with epithelium off and 30 minutes exposure to 3.0mW/ cm2 ultraviolet A, or accelerated CXL with epithelium off or on and two minutes 45 seconds exposure to 45.0mW/cm2 UVA. Patients were aged 21 to 39 years, showed evidence of keratoconus progression, had central cornea thickness of 400 microns or more, endothelial counts of 2,000 cells/cm2, and had no other ocular, corneal, immune system or other diseases that might complicate observations. The 18 standard CXL cases were treated with a CCL-VARIO (PESCHKE Meditrade) device after 30 minutes pre-soaking with VibeX (Avedro) 0.1 per cent riboflavin solution with dextran. The 27 accelerated CXL cases were treated with the KXL (Avedro) device, with 14 epi-off pre-soaked for 10 minutes with VibeX Rapid (Avedro) 0.1 per cent riboflavin, and 13 epion pre-soaked for 10 minutes with ParaCel (Avedro) 0.25 per cent riboflavin, which includes HPMC and BAC to facilitate epithelial penetration. One year after treatment the standard CXL group had statistically significant reductions in both mean and maximum keratometry values, while the accelerated epi-off group saw a significant reduction in mean K but not maximum K, and the accelerated epi-on group showed no changes. The standard group recorded a small but significant reduction in mean corrected distance visual acuity, to -0.09 +/-0.11 logMAR from -0.12 +/-0.09 preoperatively, while both accelerated groups saw improved uncorrected visual acuity. “Standard CXL and accelerated CXL are considered as effective treatments for keratoconus, whereas the efficacy of transepithelial accelerated CXL is limited to only anterior corneal stroma, indicating it is less effective compared to standard and accelerated CXL,” Dr Tomita concluded. Minoru Tomita: tomita@eyecanmedical.com

EUROTIMES | JULY/AUGUST 2015

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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 Friday 4 September 16.00 – 17.00 (At the Opening Ceremony) Cicatrising Conjunctivitis Update: Translating Research into Effective Therapies John Dart UK

Friday 4 September 13.00 – 14.00

Chiesi Satellite Meeting Sponsored by

Dompé Satellite Meeting Sponsored by

Saturday 5 September 13.00 – 14.00

Linking Inflammation to Dry Eye Disease (DED) Moderator: C. Baudouin FRANCE C. Baudouin FRANCE Chronic inflammatory response in DED pathogenesis M. Rolando ITALY Treatment oriented diagnostic assessment of dry eyes J. Duran de la Colina SPAIN New treatment alternatives in dry eye associated with ocular surface damage

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GLAUCOMA

Novel stent harnesses benefit of subconjuntival drainage pathway. Cheryl Guttman Krader reports

E E R IP F R EA RSH EES 3 Y BE AIN EM TR M OR F

FILTRATION SURGERY

Become an ESCRS Member

n investigational soft collagen implant (XEN Gel Stent, AqueSys) designed to optimise aqueous drainage to the subconjunctival space is showing promise as a safe and effective minimally invasive alternative to traditional filtering surgery, according to preliminary data from ongoing studies presented at the XXXII Congress of the ESCRS in London. Inga Kersten-Gomez MD, Head of the Glaucoma Department at University Eye Hospital Bochum, Germany, described the stent and reported results from up to 36 months of follow-up for 23 eyes enrolled at a single-centre study at their University Eye Hospital. She explained that the novel device uses the most effective mechanism for achieving sustained lowering of IOP – the subconjunctival drainage pathway. However, the subconjunctival space remains non-dissected as the device is implanted via an ab-interno technique, either in a standalone procedure or combined with cataract surgery. In addition, it features some unique material and design characteristics that may enhance safety and efficacy early and over the longer term. The implant is made of porcine gelatin crosslinked with glutaraldehyde, which is a non-resorbable material with an extensive track record for medical use. “The softness and flexibility of the implant material allow the implant to conform to the ocular tissue and for reduced forces between the implant and ocular tissue. These features should reduce risks for erosion and migration,” said Dr Kersten-Gomez.

AQUEOUS OUTFLOW Measuring 6.0mm in length with a 45-micron lumen, the cylindrical implant’s dimensions are optimised to maintain a standardised rate of aqueous outflow while avoiding hypotony. Herbert Reitsamer MD, an investigator in a multicentre European study in which the implant is placed with preinjection of a low dose mitomycin-C, demonstrated the surgery in a video presentation. “The collagen gelatin stent is preloaded into an IOL-like injector. The implantation procedure is rather simple, and because it is conjunctiva-sparing, it leaves open the opportunity for alternative surgical intervention in the future,” he said. “The bleb that develops after the collagen gelatin stent procedure is deep in the intra-Tenon’s tissue. Due to the thickness of the tissue above the bleb, it is not irritating like the trabeculectomy bleb, and has a low risk of infection,” said Dr Reitsamer, Professor and Director of the Glaucoma Service at SALK/Paracelsus University of Salzburg, Austria. Preliminary data from the single-centre study in Germany and the multicentre European trial show IOP reductions of about 30 per cent to 40 per cent at one year after surgery. Dr Kersten-Gomez reported that the patients enrolled at the Bochum Eye Hospital had a mean preoperative IOP of 21mmHg on one or more medications. It was reduced to 15.4mmHg at 12 months, and was even lower at 24.

Free to members Reduced registration fees for Barcelona Annual Congress 2015 ESCRS iLearn Online interactive courses ESCRS On Demand Online library of presentations from ESCRS Congresses Subscription to Journal of Cataract & Refractive Surgery EUREQUO Registry of Quality Outcomes

visit www.escrs.org today

Inga Kersten-Gomez: inga.kersten-gomez@kk-bochum.de Herbert Reitsamer: ha.reitsamer@gmail.com EUROTIMES | JULY/AUGUST 2015

NICE 15th EURETINA Congress

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

11 Main Sessions 24 International Society Symposia 24 Free Paper Sessions 47 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

www.euretina.org

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@EURETINA

EURETINA

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

Thursday 17 September

Friday 18 September

Lunchtime Symposia

Morning Symposia

Lunchtime Symposia

13.00 – 14.00

10.00 – 11.00

13.00 – 14.00

Allergan Satellite Meeting

Alcon Satellite Meeting

Novartis Satellite Meeting

Sponsored by

Novartis Satellite Meeting

RVO: More Than Meets the Eye

Geographic Atrophy: The Next Frontier in AMD

Moderator: C. Creuzot-Garcher FRANCE

Moderator: J-F. Korobelnik FRANCE

Sponsored by

J-F. Korobelnik FRANCE Welcome and introduction 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 Questions & Answers Sponsored by

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15 EURETINA TH

CONGRESS

NICE Friday 18 September

Friday 18 September

Saturday 19 September

Lunchtime Symposia

Morning Symposia

13.00 – 14.00

10.00 – 11.00

DME: Every Letter Matters, Every Day

From Clinical Trials to Clinical Practice; The Benefit of Sustained Therapy in the Management of DMO

Moderator: I. Pearce UK Sponsored by

Moderator: J. Cunha-Vaz PORTUGAL

A New Wave in Vitreoretinal Surgery Technology

Speakers: U. Chakravarthy UK P. Massin FRANCE F. Goñi SPAIN C. Bailey UK J. Cunha-Vaz PORTUGAL

Moderator: R. Tadayoni FRANCE

Conclusion, Questions & Answers

P. Stanga UK New innovations in vitrectomy

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F. Fayyad JORDAN Complex cases using the Stellaris® PC next generation TBC Trends in vitreoretinal surgery – interactive Q&A session with the experts Sponsored by

Optos Satellite Meeting Sponsored by

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Oraya Therapy for Wet AMD, Real World Clinical Outcomes Moderator: T. Jackson UK

Friday 18 September Evening Symposium 18.00 Bringing Nutritional Prevention into Clinical Practice Moderator: J. Seddon USA C. Delcourt FRANCE, F. Bandello ITALY S.T.A.R.S.: a score to identify patients at risk of AMD J. Seddon USA Nutrition & visual function T. Aslam UK How to efficiently advise AMD patients in nutrition Sponsored by

Alcon Satellite Meeting

F. Zimmermann SWITZERLAND Stereotactic radiotherapy for wet AMD using microcollimated low-voltage X-ray: mechanisms and synergy with anti-VEGF M. Ranjbar GERMANY 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

15 EURETINA TH

CONGRESS

NICE Saturday 19 September

Saturday 19 September

Lunchtime Symposia

13.00 – 14.00

Rising to the Challenge: How Technology Advances Benefit Complex Vitrectomy Surgery

Second Sight Satellite Meeting Sponsored by

Moderator: P. Stalmans BELGIUM Z. Koshy UK Is 27G a realistic option for complex cases? P-O. Barale FRANCE Two dimensional cutting: a new tool for delicate surgery T. McCannel USA Tumor taps: technology enhancements in treatment of complex retinal pathologies A. Mohr GERMANY Overcoming the odds: EVA performance for challenging cases Questions and Answers

Taking a Clear View: Efficacy and Durability of EYLEA in Wet AMD Moderator: J.-F. Korobelnik FRANCE Sponsored by

577nm MicroPulse® Laser Therapy - Benefits in Macular Edema Pathologies Moderator: V. Chong UK S. Fauser GERMANY Introduction to MicroPulse® laser therapy V. Chong UK MicroPulse® recommended treatment guidelines G. Staurenghi ITALY Why consider the yellow 577nm wavelength? S. Fauser GERMANY, E. Ozmert TURKEY MicroPulse® for central serous chorioretinopathy

Novartis Satellite Meeting Sponsored by

V. Chong UK MicroPulse® for diabetic macular edema Sponsored by

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RETINA

OZURDEX TRIALS French study confirms efficacy of dexamethasone implant in macular oedema. Dermot McGrath reports

atients with macular oedema due to retinal vein occlusion who received the slowrelease intravitreal dexamethasone implant Ozurdex (Allergan) showed significant improvements in best corrected visual acuity (BCVA), reported French researchers at the 14th EURETINA Congress in London. “This observational, multicentre French study in patients with macular oedema after retinal vein occlusion replicates what we have seen before in the clinical trials of Ozurdex in terms of efficacy and safety. BCVA increased significantly during follow-up and seemed to be strongly correlated with the time since onset of macular oedema and whether the patient had already received treatment,” said Jean-Francois Korobelnik MD, FEBO. Dr Korobelnik, of University Hospital Bordeaux, France, noted that the effects of treatment were most marked in treatmentnaïve patients. As with the phase III trials, the most commonly encountered adverse events were ocular hypertension and cataract. Dexamethasone is the first agent to be approved and validated for the treatment of macular oedema related to retinal vein occlusion, said Dr Korobelnik. In November 2010 the French National Authority for Health (Haute Autorité de Santé) requested a study to monitor the outcomes of patients treated with that

implant. As a result, the LOUVRE protocol was validated by an independent scientific committee and was conducted after the authorities approved it in 2011. The aim of the study was to assess the prescribing patterns, efficacy and safety of dexamethasone intravitreal implant when used in the French clinical setting for the treatment of macular oedema due to retinal vein occlusion. Dr Korobelnik presented the six-month interim data from the 24-month study carried out at 48 centres in France, 75 per cent of them private and 25 per cent public. Eligible patients were treatment-naïve or could have received previous treatment of any type. Treatment with dexamethasone intravitreal implant was at the physician’s discretion, based on responses to a screening questionnaire completed by the patient. Of 520 patients that initially enrolled for the study, 383 patients were treated, and 276 were evaluated at six months.

PRIMARY ENDPOINT Assessments were conducted at baseline and grouped around week six, and months four, six, 12, 18 and 24 of the study, and included a follow-up questionnaire completed by the physician. The primary endpoint was the change in best-corrected visual acuity from baseline to month six. Secondary endpoints included change in BCVA from baseline and the proportion

ESCRS

Practice Management

& Development

BUSINESS

6–7 September 2015

ESCRS Practice Management and Development Marketing Case Study Competition

UTILISE BUSINESS

Winner of a €1,000 bursary will be announced during the XXXIII Congress of the ESCRS in Barcelona

INNOVATE UTILISE BUSINESS

Jean-Francois Korobelnik: jean-francois.korobelnik@chu-bordeaux.fr

CALLING ALL MARKETING GURUS!

Barcelona, Spain

of patients with an increase of more than 15 letters of vision from baseline, as well as adverse event reports at each follow-up assessment. Branch retinal vein occlusion (BRVO) was diagnosed in 55 per cent and central retinal vein occlusion (CRVO) in 45 per cent of patients. The mean patient age was 70 years, and around 45 per cent of patients were treatment-naïve. The mean time for macular oedema onset was 11 months and the mean BCVA was 47 letters at baseline. At six months, 47 per cent of patients received one injection, 51 per cent received two injections, and six patients received three injections, according to Dr Korobelnik. Turning to the results, Dr Korobelnik said that the mean change in BCVA from baseline at six months differed according to the time of onset of macular oedema. “The improvement in BCVA was greater in patients with recent-onset macular oedema than in those diagnosed more than three months previously. The gain was almost 12 letters for those with recent-onset oedema compared to just two letters for those with oedema over three months.” The most common treatment-related adverse events were ocular hypertension in 26 per cent of patients and some degree of cataract in nine per cent of the eyes.

To enter email colin@eurotimes.org

LEADERSHIP INNOVATE UTILISE BUSINESS

Submission Deadline Friday 7 August 2015 DEVELOPMENT LEADERSHIP INNOVATE UTILISE BUSINESS

Further details at www.escrs.org

EUROTIMES | JULY/AUGUST 2015

RETINA

FLOATERECTOMY DEBATE Amsterdam Retina Debate generates lively discussion.

Leigh Spielberg reports

loaterectomy in an otherwise healthy eye remains a highly controversial topic in vitreoretinal surgery. What is considered by some surgeons to be a legitimate medical procedure that improves patients’ quality of life, is for others simply a cosmetic procedure with high risks of serious complications. It was within this context that Thomas Wolfensberger MD, of Jules Gonin Eye Hospital, Lausanne, Switzerland and Alistair Laidlaw MD, of the London Eye Clinic, battled it out in the Amsterdam Retina Debate at the 14th EURETINA Congress in London. Dr Wolfensberger made the case for floaterectomy while Dr Laidlaw argued against the procedure. “Many of these patients with vitreous floaters are desperate, pleading for help. We as vitreoretinal surgeons can provide the only floater treatment that has actually been proven to work,” stated Dr Wolfensberger. He reviewed the published evidence in support of floaterectomy, pointing out the high levels of patient satisfaction and low incidence of complications. “An overwhelming majority of patients who are treated view the operation as very successful, both in terms of improvement of visual symptoms and the limited peri- and postoperative pain,” he added. In the spirit of a classic British debate tinged with humour, Dr Wolfensberger then outlined in increasing order of importance “The top five reasons why I do floaterectomies”. Reason No 5: “Patients with floaters suffer more than you will ever know, unless you have floaters yourself.” Reason No 4: “Decades of surgical experience have honed the technique of floaterectomy.” Reason No 3: “Risk is part of life! Its evaluation is a very personal matter. The absence of floaters may mean a new life for some patients.” Reason No 2: “An overwhelming majority of patients, up to 95 per cent, view the operation as very successful.” And finally, the No 1 reason to do floaterectomies: “Apart from enucleation, floaterectomy is the only surgical procedure in ophthalmology that has a guaranteed 100 per cent anatomical success rate.” This facetious Thomas Wolfensberger MD comment was greeted

An overwhelming majority of patients who are treated view the operation as very successful

EUROTIMES | JULY/AUGUST 2015

with muffled murmuring and chuckling throughout the crowded auditorium. “Of course, if you want to avoid all risks, then you shouldn’t operate,” concluded Dr Wolfensberger.

NUANCED APPROACH Dr Laidlaw began on the offensive: “My opponent’s Reason No 1 is simply not true. Nothing in medicine is 100 per cent.” He then took a more nuanced approach. “I realise that this side of the argument is nearly unwinnable, so I decided to change my tactic. I will argue that floaterectomy is rarely justified,” he said. “Floaterectomy is undoubtedly effective if uncomplicated, but I believe the risks to be underestimated. The studies often fail to consider the longterm complications, which can include RD in up to 10 per cent at five years postoperatively. Even with this underestimation, less than 10 per cent of patients complaining of floaters elect to undergo surgery.” Dr Laidlaw emphasised the proper selection of eyes to operate, in particular regarding the status of the posterior vitreous. The treatment is particularly suited in cases of syneretic clumping, as opposed to posterior vitreous detachment-related floaters (PVD). The symptoms in patients with a PVD will usually remit spontaneously. “Of course, you always have to exclude uveitis as a potential cause of the floaters and screen for retinal pathology,” he said. Dr Laidlaw also warned against the potential large discrepancy between patients’ symptoms and the intraocular signs. “Somatization is not infrequent. Anxiety depressive disorder is common within this patient population, so look out for patients in whom the vitreous changes are not as marked as their symptoms. “When I suspect it, I refer to a psychiatrist as the primary pathology can be psychological, not vitreal. When I see a patient with recent onset floaters I assess for serious pathology, reassure them, and provided all is well, advise them that help is at hand if required. I then discharge them.” Pointing to his own data, he explained: “A PVD is present in 75 per cent of patients that I see with floaters and about one in 20 of them will eventually want surgery . The other 25 per cent of patients have syneretic floaters, and about one in three of them will want an operation. I only operate after a very extensive discussion of the risks.” The debate ended in a perfect draw, with each debater earning exactly 50 per cent of the votes cast by the audience. Thomas J Wolfensberger: thomas.wolfensberger@fa2.ch Alistair Laidlaw: a.laidlaw@thelondonclinic.co.uk

RETINA

DIABETIC RETINOPATHY Trial may put neuroprotection to the forefront of DR treatment. Dermot McGrath reports

he results from a clinical trial currently under way in 11 different European clinical centres have the potential to profoundly alter the therapeutic management of diabetic retinopathy in the near future, according to a report at the 14th EURETINA Congress in London. The therapeutic strategy of the European Consortium for the Early Treatment of Diabetic Retinopathy (EUROCONDOR) project is based on neuroprotection to prevent or arrest retinal neurodegeneration in the early stages of the disease, explained Rafael Simó MD, chairman of the project and Head of the Diabetes and Metabolism Research Unit, Val d’Hebrón Research Institute, Barcelona, Spain. “It is a prospective and randomised study in 450 type 2 diabetic patients of two neuroprotective agents, somatostatin and brimonidine, administered topically through eye drops,” said Dr Simó. There is growing evidence to suggest that retinal neurodegeneration plays an important role in the onset of diabetic retinopathy which participates in the development of microvascular abnormalities, said Dr Simó. The phase II and III EUROCONDOR clinical trial will assess whether therapeutic strategies based on neuroprotection are effective not only in preventing or arresting retinal neurodegeneration, but also in preventing the development and progression of the early stages of diabetic retinopathy, he said. Focusing on the growing evidence of neurodegeneration as an early event in the pathogenesis of diabetic retinopathy, Dr Simó referred to a study published by his research group in 2007, which showed the high rate of apoptosis and reactive gliosis in diabetic eyes compared to non-diabetic controls. More recently, Dr Simó's group has demonstrated that there is an imbalance between proapoptotic and survival signalling in the early stages of diabetic retinopathy. “This imbalance in proapoptotic signalling promotes neuron death in diabetic patients. There is a lot of evidence demonstrating that neurodegeneration measured either by multifocal electroretinorgram or spectral domain OCT exists in the absence of microvascular impairment when we perform an ophthalmoscopic examination,” said Dr Simó. Dr Simó said that the next step was to determine whether these abnormalities participate in microvascular disease. Dr Simó said that the EUROCONDOR study design includes three groups of 150 patients: group A who receive placebo eye drops twice daily; group B who receive brimonidine tartrate eye drops (0.2 per cent) twice daily; and group C who receive somatostatin eye drops (one per cent) twice daily. Measurements taken include mfERG, frequency domain OCT, digital fundus photography and visual field assessments. The recruitment period for the EUROCONDOR trial ended in October 2013, with the final results expected in January 2016. One of the early results of the baseline data showed that, as expected, diabetic patients present an increase of implicit time abnormalities on multifocal electroretinogram (mfERG) readings. Rafael Simó: rafael.simo@vhir.org EUROTIMES | JULY/AUGUST 2015

RETINA

THE FUTURE OF AMD AND IMAGING Polarisation sensitivity and adaptive optics enhance SD-OCT capabilities. Cheryl Guttman Krader reports ualitative and quantitative information obtained with multimodal spectral domainoptical coherence tomography (SD-OCT) imaging technology is providing new opportunities for determining the pathophysiological mechanisms of age-related macular degeneration (AMD) and for predicting disease progression. Speaking at the 14th EURETINA Congress in London, Ursula SchmidtErfurth MD, Professor and Head, Department of Ophthalmology, Medical University of Vienna, Austria, described the advantages of incorporating polarisation sensitivity (PS) and adaptive optics (AO) into SD-OCT and the use of these advanced imaging technologies for identifying and measuring pathological changes in AMD, including features of the retinal pigment epithelium (RPE), drusen, geographic atrophy and photoreceptor disease. Interest in enhanced imaging of the RPE relates to the fact that it is considered the key structure in AMD pathology, said Dr Schmidt-Erfurth. “If we look early to the disease process, we see the retina still looks perfect, but there is already extensive change in the RPE. So, both compartments are important, and there may be a time sequence of events when disease is forming,” she explained.

SCRAMBLING PROPERTY Polarisation-sensitive optical coherence tomography (PS-OCT) uses the intrinsic polarisation scrambling property of the RPE to selectively distinguish it from other retinal structures. Unlike SD-OCT, PS-OCT can identify the RPE cells and not just differentiate the RPE. In addition, because the depolarising appearance of the RPE is caused by intracellular melanincontaining organelles – melanosomes, melanolipofuscin and melanolysosomes

– PS-OCT provides information on RPE biology that can help in understanding the pathophysiology of AMD. Discussing the use of PS-OCT for studying specific pathological features of AMD, Dr Schmidt-Erfurth reviewed its application for imaging and quantification of drusen. Although drusen can be imaged with SD-OCT and quantified using a manual segmentation technique, PS-OCT allows for an automated segmentation algorithm. A study comparing the manual SD-OCT and automated PS-OCT techniques using data from patients with early AMD validated the automated PS-OCT analysis as a reliable and time-saving tool for measuring drusen size and volume. “We can now use the PS-OCT drusen segmentation algorithm with multiple raster B scans, which show the contour of the RPE, to generate a three-dimensional drusen map that corresponds tightly with the clinical picture of the drusen on colour fundus photography. However, PS-OCT is objective, more precise, able to detect small drusen and gives reliable measurements, so that when it is repeated we can determine progression over time,” Dr Schmidt-Erfurth said. Taking advantage of that capability to study the long-term natural history of drusen development, Dr Schmidt-Erfurth and colleagues performed an integrated analysis of data from three years of followup in 56 eyes. The results showed that drusen volume increased linearly over time, and the researchers calculated a doubling time. Looking at the temporal changes in drusen volume in individual patients showed a sudden, precipitous regression of drusen volume occurred just before the development of choroidal neovascularization or geographic atrophy. Noting that different types of drusen differ in their impact on RPE integrity, Dr Schmidt-Erfurth noted that research with PS-OCT indicates that the qualitative

...PS-OCT is objective, more precise, able to detect small drusen and gives reliable measurements... Ursula Schmidt-Erfurth MD EUROTIMES | JULY/AUGUST 2015

information it provides about drusen morphology may also have relevance for determining disease progression. “Our findings suggest that PS-OCT holds promise as a prognostic tool for identifying risk for progression to advanced AMD. We believe this method, which relies on quantitative data sets, is a much more precise prognostic indicator than genetic risk calculation and gives insight into the mechanisms of RPE pathology,” said Dr Schmidt-Erfurth.

GEOGRAPHIC ATROPHY IMAGING Dr Schmidt-Erfurth explained that depending on the segmentation algorithm used, the PS-OCT en-face images can also be used to depict borders of geographic atrophy. Another comparison study demonstrated the reproducibility of an automated PS-OCT segmentation algorithm for quantifying areas of geographic atrophy and showed that the results correlated with those obtained using fundus autofluorescence (FAF). “FAF has been the gold standard modality for visualisation and quantification of geographic atrophy, but it gives a twodimensional map. PS-OCT gives 3D topography and a very nice histological relief of the cellular changes,” she said. In addition, Dr Schmidt-Erfurth noted that PS-OCT provides comprehensive, detailed information on all layers of the ocular fundus in eyes with geographic atrophy with a single three-dimensional data set. “PS-OCT can provide integrated multimodal information comparable to that obtained using FAF, IR and standard SD-OCT performed separately,” she said. Discussing imaging and quantification of photoreceptor disease, Dr Schmidt-Erfurth said that visualisation of foveal rods and cones becomes possible by combining AO with SD-OCT as the technique offers resolution of 1.5 x 5 microns. “This is the imaging of the future, and it is important because we need to understand which parts of the photoreceptors are damaged first in order to understand the pathophysiological sequence of AMD progression,” she said. Ursula Schmidt-Erfurth: ursula.schmidt-erfurth@meduniwien.ac.at

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World Society of Paediatric Ophthalmology and Strabismus

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

NAI – The Mock Trial

Keynote Lectures Non-Strabismus Keynote Lecture Alex Levin USA

For the first time, WSPOS presents ‘NAI -The Mock Trial’ with Alex Levin USA and Gill Adams UK

Joint Symposia Strabismus Keynote Lecture

• European Society of Cataract and Refractive Surgeons/WSPOS Symposium

Lionel Kowal AUSTRALIA

• International Conference on Ocular Infections/WSPOS Symposium

Kanski Medal

WSPOS Inaugural Video Awards

Helen A. Mintz-Hittner USA

The “Oscars” of PO&S

www.wspos.org Expertise Resides ALL Around the World

PAEDIATRIC OPHTHALMOLOGY

MIXED RESULTS Friday 4 September 12.15 – 13.15

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Saturday 5 September 12.45 – 13.45

Paediatric Management of Ocular Surface and Lids Moderator: D. Brémond-Gignac

FRANCE

D. Brémond-Gignac FRANCE Good use of mydriatics in paediatrics E. Silva PORTUGAL Azyter phase III results E. Knop GERMANY Embryological development of the meibomian gland & meibomian gland disorders in children Sponsored by

Sunday 6 September 12.30 – 13.30

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LCA-RPE65 study shows promise and limits at 36 months. Howard Larkin reports

ene therapy targeting Leber’s congenital amaurosis LCA2 can improve rod function, retinal sensitivity and dark navigation. However, at three-year followup the magnitude of functional improvement was highly variable and the duration of maximum impact limited, apparently by progressive degeneration, James W Bainbridge MA, PhD, FRCOphth told the World Congress of Paediatric Ophthalmology and Strabismus in London. The results suggest that while the treatment does incorporate a gene into retinal pigment epithelium cells that expresses RPE65, which is needed for regenerating visual pigment in photoreceptor cells, the amount delivered using the current therapy is insufficient for sustained benefit. LCA2 results from a defect in a single gene that disrupts production of RPE65, leading to progressive loss of dark adaptation and outer retina degeneration. Since rod photoreceptors are entirely dependent on RPE65 for visual pigment recycling, infants with LCA2 have poor rod function from birth. Cones have an alternative regeneration source, so cone function is initially preserved, but is lost to progressive structural degeneration through the first three decades of life. Why degeneration occurs is unknown, though it may result from accumulation of retinyl esters due to interruption of the visual cycle, Dr Bainbridge said. LCA2 is an attractive gene therapy target because it presents the possibility of restarting the visual cycle by supplying the normal gene, improving retinal function. Improved function also occurs quickly, making it a more practical endpoint than preventing degeneration, which may take years to demonstrate, Dr Bainbridge noted. In mouse and dog models, delivering the RPE65 gene using a recombinant adeno-associated virus vector improved retinal function markedly as measured by electroretinography, Dr Bainbridge said. When delivered early enough it also protected against structural degeneration. Twelve patients participated in a Phase I/II open-label dose escalation trial. Each

patient received a subretinal injection in their poorer-seeing eye of the human RPE65 gene controlled by an RPE65 promoter targeting retinal pigment epithelium cells. The rAAV2 vector was the same used in the animal models. For safety reasons the first three patients were older, ranging in age from 17 to 23 years. Patients as young as six years were subsequently included. The first four patients received a dose of 1 x 1x1011 particles, with subsequent subjects receiving 1x1012, a 10-fold dose elevation. “We were very pleased to see that even subjects with the lower dose and relatively advanced degeneration could benefit with improved retinal sensitivity on microperimetry,” Dr Bainbridge said.

The response was also good among some younger children and at the higher dose. However, improvement was also highly variable. “We saw lower magnitude effect, or in some cases no discernible impact on microperimetry in some of the younger subjects in whom we might have expected a more robust response,” he added. Patients also performed much better on dark-adapted perimetry with progressive improvement after as much as four hours. While this demonstrates efficacy, persistently delayed dark-adaptation suggests that the provision of RPE65 is suboptimal, Dr Bainbridge said. Durability of maximum impact was also limited. James Bainbridge: j.bainbridge@ucl.ac.uk * See also: Page 48

We saw... in some cases no discernible impact on microperimetry in some of the younger subjects... James Bainbridge MA, PhD, FRCOphth EUROTIMES | JULY/AUGUST 2015

OPHTHALMOLOGICA protectalon_eurotimes_july_august.pdf

15/06/15

12:05

OPHTHALMOLOGICA VOL: 233 ISSUE: 3/4 MONTH: MARCH/APRIL 2015

AMD – A CARDIOVASCULAR RISK INDICATOR One out of three patients with exudative AMD with no history of coronary artery disease or stroke could nonetheless be at a high risk of acute atherothrombotic events, a new study suggests. Among 259 patients with exudative AMD evaluated, 28.2 per cent had a mean intima-media thickness of 1.0mm or greater and 8.9 per cent had severe carotid artery stenosis, 16.6 per cent had severe atherosclerosis with a plaque score greater than 10, 5.4 per cent had peripheral arterial disease, and 32 per cent had chronic kidney disease. Risk factors identified for abnormal carotid artery thickening were diabetes mellitus and AMD affecting eyes bilaterally, risk factors identified for CKD were age and body mass index. H Taniguchi et al, "Evaluation of Carotid Atherosclerosis, Peripheral Arterial Disease, and Chronic Kidney Disease in Patients with Exudative Age-Related Macular Degeneration without Coronary Artery Disease or Stroke", Ophthalmologica 2015; Volume 233, Issue 3-4 (DOI:10.1159/000371716). C

CHOROID GRAFTS SHOW SOME EFFICACY

Epithelium choroid grafts and anti-VEGF therapy can both provide visual improvements in eyes with exudative AMD, but with both treatments some patients will continue to lose vision postoperatively, according to the findings of a prospective randomised intervention study involving 20 patients. At a followup of one year, the mean change in visual acuity in the graft group was 15 ETDRS letters lower than it was preoperatively, and two patients had a gain of 10 or more lines. In the anti-VEGF group, there was a mean loss of eight ETDRS letters, but no patients had a gain of more than 10 letters. EJT Van Zeeburg et al, “Prospective, Randomized Intervention Study Comparing Retinal Pigment Epithelium-Choroid Graft Surgery and Anti-VEGF Therapy in Patients with Exudative Age-Related Macular Degeneration”, Ophthalmologica 2015; Volume 233, Issue 3-4 (DOI:10.1159/000380829).

CMY

SWITCHING TO AFLIBERCEPT BRINGS ANATOMIC IMPROVEMENTS The findings of a retrospective study indicate that aflibercept treatment can preserve the vision of AMD patients with poor responses to other anti-VEGF compounds, while also extending the interval between injections. The study involved 85 eyes of 69 patients who were either refractory to bevacizumab or were currently receiving ranibizumab. One year after switching to aflibercept there was an insignificant mean decrease of two letters in patients’ mean visual acuity and 90.6 per cent of eyes showed anatomic improvement with a reduction of fluid on OCT and a significant improvement in central retinal thickness. Moreover, the mean number of injections per month fell significantly after switching to the newer agent. J Pinheiro-Costa et al, “Switch to Aflibercept in the Treatment of Neovscular AMD: One-Year Results in Clinical Practice”, Ophthalmologica 2015; Volume 233, Issue 3-4 (DOI:10.1159/000381221).

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

EUROTIMES | JULY/AUGUST 2015

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EUROPEAN BOARD OF OPHTHALMOLOGY

MARIE-JOSÉ TASSIGNON AWARDED PETER EUSTACE MEDAL

Courtesy of Laboratoires Théa

Peter Ringens, president of the EBO, addresses delegates in Paris

SETTING STANDARDS Testing time as EBO exam candidates converge on Paris. Dermot McGrath reports

ver 550 candidates from over 28 European countries converged on Paris to take part in the 2015 European Board of Ophthalmology Diploma (EBOD) examination. “It has been another hugely successful examination and we thank all the candidates who came to Paris to sit this exam in record numbers this year,” said Prof Peter J Ringens MD, PhD, FEBO, President of the European Board of Ophthalmology. Prof Ringens paid special thanks to the French Society of Ophthalmology (SFO), which hosts the exam every year in conjunction with its annual meeting, and also Laboratoires Théa, which has generously supported the EBOD exam since its inception. Held every year in Paris, the EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices. The EBOD examination’s focus is also on harmonisation of ophthalmology training across Europe and is Brussels’ standard. Addressing the assembled audience, Jean-Francois Korobelnik, President of the SFO, said that the society was honoured to host the exams every year. “It is a more challenging situation every year because more candidates want EUROTIMES | JULY/AUGUST 2015

to attend, but this surely means that the EBOD is a very valuable diploma and one that is recognised across Europe,” he said. This year, for the first time, the exam also included a special subspecialty examination in glaucoma. Carlo Traverso, President of the European Glaucoma Society, which co-organised the EBO subspecialty exam, said that his society was gratified to be the first subspecialty to feature in the EBO exam. “Subspecialty examinations are tricky because they are not recognised very easily and therefore our experiment required quite an effort, but I think it has been a very successful debut,” said Prof Traverso. Congratulating the candidates on their achievement, Prof Christina Grupcheva, Chair of the EBO Education Committee, said that the examination was more than a simple test of knowledge. “This is more than an exam, this is a way of harmonising education all over Europe, setting standards for knowledge and also standards for taking care of our patients,” she said. This year, Katrin Franziska Fasler from Switzerland received the Alan Ridgway Award for best MCQs result, while the award for Best Overall EBOD outcome went jointly to Odysseas Georgiadis from Greece and Mehmet Mocan from Turkey. Peter Ringens: p.ringens@mumc.nl

Prof Marie-José Tassignon MD, PhD, FEBO, was honoured at the EBO Diploma Award Ceremony as the recipient of the Peter Eustace Medal for her contribution to ophthalmic education in Europe. “I cannot think of anyone else better placed in 2015 to receive this award in recognition of her outstanding career and contribution to ophthalmic education in Europe and worldwide,” said Peter Ringens MD, PhD, FEBO, President of the EBO. “Marie-José has achieved so much in her career that it is hard to list all of her accomplishments in the short time available,” added Prof Ringens. He noted that Prof Tassignon, current Professor and Head of Ophthalmology at the University Hospital in Antwerp, Belgium, is a member of numerous international societies, and has served as president of EBO and the ESCRS. She has supervised over 40 postgraduate educational courses and developed numerous educational programmes for students, residents and postgraduates. She has published over 250 peer-reviewed scientific papers and serves on the editorial board of a number of prestigious journals. She is the recipient of numerous awards in recognition of her services to ophthalmology, including the American Academy of Ophthalmology’s Achievement Award in 2007 and the ESCRS Binkhorst Medal Lecture in 2011.

Courtesy of Laboratoires Théa

Marie-José Tassignon accepts her medal from Peter Ringens

Prof Tassignon said that she was very honoured and proud to have been appointed as the recipient of the prestigious Peter Eustace Medal. “The vision of the EU in the 1990s was to harmonise education, practice and knowledge in Europe. This was a very ambitious and challenging goal and it took many years before the process started. Now, however, the EBO grows stronger each year in terms of expertise and quality,” she said. Prof Tassignon paid tribute to the candidates who had come to Paris to sit the EBO exams and said that they represented the future of the profession. “The candidates here are the organisers of the future, and will prove once again that scientists are more likely than politicians to realise the dream of a harmonised Europe,” she said.

EUROPEAN BOARD OF OPHTHALMOLOGY

A POSITIVE ATMOSPHERE Mehmet Cem Mocan, Turkey, joint overall winner, EBO Diploma Exams 2015

Mehmet Cem Mocan

My main motivation for taking the exam was to determine whether my basic/clinical scientific level of ophthalmology was on a par with the standards set by the European Board of Ophthalmology. I also wanted to take this exam to show the members of the EBO the motivation of a Turkish candidate

to integrate with the European ophthalmological community. Every test is a stressful experience. For this exam, I tried to prepare in the best way I could by covering all areas of ophthalmology, reading current developments and also reviewing topics in basic science related to ophthalmology. However, it never ends and there is always more to learn, more to review.

It was great to see the next generation of European ophthalmologists celebrate each other during the awards ceremony. I will always vividly remember the positive atmosphere created by the organisers and the candidates. I should also emphasise that the C B examiners were very friendly and clear in their questions. I recommend this board examination to all residents and specialists.

Courtes yo fL

AN INTERNATIONALLY RECOGNISED DIPLOMA ora ab

s Th é a toire

Odysseas Georgiadis

Odysseas Georgiadis, Greece, joint overall winner, EBO Diploma Exams 2015 My main motivation was to obtain an internationally recognised diploma, which I hope will be the first step in continuing my clinical and surgical training in a European country. I found the examinations adequately fair and the whole process quite interesting. The

overall experience was really positive. The opportunity to interact and exchange ideas with ophthalmologists from all over Europe and with different backgrounds was stimulating and motivating. The exam environment was friendly, and taking into consideration the very high success rate of the candidates, the whole atmosphere was warm and

C cheerful. I willBalways remember these two days as an important step in my career. Concerning my future career plans, I intend to continue my training in ophthalmology by applying for a position in a distinguished hospital abroad. I would like to focus on a clinical and surgical subspecialty, so as to master my knowledge and evolve B C my practice.

A GOOD MOTIVATION Thøger Svahn, Denmark, joint second place overall award, EBO Diploma Exams 2015

Thøger Svahn

My main motivation to take the exam was to put a little bit of pressure on myself to cover the full ophthalmology curriculum. We do not have a mandatory examination at the end of residency in Denmark, and I wanted to make sure that I could reach the requisite standards in all topics.

All examinations in Denmark are either oral or require essay-style written answers, so this was the first multiple-question examination of my life. Of course that made me a little nervous, as I had no idea what the level was and I found some of the questions fairly difficult. I just hoped that a sufficient proportion of the candidates had the same difficulties that I did. Overall, the exam was indeed a

A USEFUL REFERENCE David Bragason, Iceland, joint third place overall award, EBO Diploma Exams 2015

David Bragason

My programme director recommended that I take the exam. Given our small population in Iceland, with only three to four ophthalmology residents in total, it is important to see how we do compared to candidates from major centres in Europe. It also serves as a useful reference for future employers.

Overall, the experience was quite enjoyable despite the inevitable examination stress. It was fun to discuss clinical cases with examiners from different countries in the viva voce and the MCQ exam was also fair. However, A I found that the MCQ examination could include a greater number of questions, which would allow for a more even coverage of the subject matter.

positive experience. I think it was well organised and fair. I would recommend other potential candidates to B take the EBO exam.C If you are studying regularly, then the exam is a good way to prove your knowledge. Likewise, if you are not studying all the time, the exam can be a good way to motivate yourself. My future plan is to pursue my career in ophthalmology, specialising in glaucoma care.

It was a memorable experience to spend a few days in the beautiful city of Paris and meet colleagues from all over Europe. It was an important milestone in our training and overall a very positive experience. After residencyBI would like to doC a fellowship abroad, combining clinical work with research. Fields that currently interest me the most include medical retina, uveitis and neuro-ophthalmology.

EUROTIMES | JULY/AUGUST 2015

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EYE ON HISTORY

THE SPANISH INFLUENCE Ignacio Barraquer, Hermenegildo Arruga and Ramón Castroviejo were innovators in ophthalmology. Andrzej Grzybowski and Francisco J Ascaso report

gnacio Barraquer (18841965), who was born in Barcelona, is best remembered for his idea of extracting the cataract by applying a vacuum or suction cup (1917) with much less damage than other techniques employed at that time. He also designed the necessary instruments, built up the sucking cup and the vacuum-producing mechanical device producing adjustable vacuum to facilitate the extraction of the crystalline lens, and proved the effectiveness of the procedure. It was named by its author "Phacoérysis" (from the Greek “Phakos”, meaning lens; and "Erysis", meaning drawing), and the device was called “Erysiphake” and described as follows: "The sucking cup is a smart clip that fits the physical conditions of the lens. In this way, removal is easier, effective and safe. The cup adheres to the most fragile crystalline lens without breaking them, as it has a greater adherence surface." As Barraquer said, the idea was the result of observation of his aquarium, while watching how a leech apprehended a pebble from the bottom: "If I could catch the human eye lens in the same way that a leech moving it picks up a pebble and moves it along the aquarium without moving any water, the pneumatic suction produced by the sucking cup would break the fibres of the zonule - ligament by which the lens remains fixed - and this way I could gently draw out the cataract with minimal trauma." The invention brought him international recognition. Barraquer also influenced numerous original techniques (eg dacryocystorhinostomy, sclerotomy, reconstruction of the orbital cavity, strabismus surgery, and sclera-iridectomy) and developed many surgical instruments (eg sclerotome, forceps for iridectomy, keratoplasty instruments).

Ignacio Barraquer

Hermenegildo Arruga

Hermenegildo Arruga (1886-1972) was also born in Barcelona. He was a versatile Spanish ophthalmologist who designed numerous surgical instruments and introduced significant improvements in ophthalmic surgical techniques. Thus, he was among the first ophthalmologists to advocate the intracapsular cataract extraction. Furthermore, he refined several surgical procedures such as dacryocystorhinostomy, corneal transplantation, evisceroenucleation and pterygium excision. Above all, Arruga was fascinated with retinal detachment surgery. He perfected Gonin’s operation and contributed significantly to retinal detachment surgery. Later, in 1935, he adopted the injection of air at the end of surgery. Since the introduction (by Schepens et al in 1957) of encircling circumferential buckles into the surgery of retinal detachment, Arruga simplified the equatorial cerclage, pioneering the technique with a simple procedure using a suture such as nylon, silk or supramid to encircle the equator of the eye (1958). Arruga’s string operation could be used with success as the primary procedure in the treatment of many cases of retinal detachment. Ramón Castroviejo (1904-1987) was born in Logroño and studied medicine at the Central University of Madrid. Although he visited the university eye clinics where keratoplasty was already a fact, such as Madrid, Paris, Vienna, Berlin and Prague, he developed most of his professional career in the United States. Castroviejo remained in America for almost half a century, occupying different

Ramón Castroviejo

posts as consultant and surgeon in various institutions in Chicago, Minnesota and especially New York. His private eye hospital in Manhattan became the centre of an international referral practice. Castroviejo combined his research and clinical practice with an active academic life, creating a fellowship programme for training ophthalmic surgeons. Although most of his attention, both in experimental and clinical surgery, was devoted to corneal transplantation (the use of keratoplasty for keratoconus was introduced by Castroviejo, who operated his first case in 1936), he also emphasised many other types of ocular surgery. After returning to Spain, he founded the Instituto Castroviejo and the Spanish Eye Bank in Madrid. The impact of Castroviejo’s innovation was profound, applying his creativity and adaptation to new developments. He once said: “What humans cannot do directly by themselves, they can do indirectly with the help of an instrument or a machine invented by them." Thus, he designed nearly 200 prototypes of instruments, including a new method of cataract extraction by suction,a cryoextractor. * Andrzej Grzybowski MD, PhD, MBA is Chairman at the Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland; Francisco J Ascaso MD, PhD is Chairman of the Medical & Surgical Retina Unit, Department of Ophthalmology, Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain EUROTIMES | JULY/AUGUST 2015

BIO-OPHTHALMOLOGY

GENE THERAPY If gene therapy has taught us anything, it is patience.

ecent reports on the long-term follow-up of a small number of patients treated with RPE65 replacement gene therapy suggest that the effects may be transient in nature. The clinical trial research reports, published on 3 May 2015 by Jacobson et al (doi: 10.1056/NEJMoa1412965) at the Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania, US, and Bainbridge et al (doi:10.1056/NEJMoa1414221) at the Institute of Ophthalmology, University College London, had focused on the treatment of Leberâ&#x20AC;&#x2122;s congenital amaurosis (LCA), a group of early-onset inherited retinal dystrophies. The formal publication of the longterm follow-up results should not come as a surprise, however, especially given the numerous reports at conferences and in blogs, including previous journal publications, on diminished retinal sensitivities in a number of the LCAtreated patients. LCA is one of the most clinically severe retinal degenerations, on occasion causing near total blindness in infancy. While the disorder may result from mutations in any one of 19 different genes, a large proportion of the research to date has focused on the retinal pigment epithelium-65 gene (RPE65), responsible for up to 10 per cent of recessive LCA cases.

INTENSE RESEARCH The disorder has been the subject of intense medical research over the last 15 years, and in 2008 three independent EUROTIMES | JULY/AUGUST 2015

Gearoid Tuohy reports clinical trials successfully delivered a gene encoding RPE-65 into the retina of patients with the disease. In healthy individuals the RPE-65 gene makes a critically important protein involved in the biochemical visual transduction cascade. When RPE-65 is missing this key component of visual transduction is lost, causing photoreceptor cells in the retina to progressively degenerate over time. In each clinical trial, patients received a single subretinal administration of an AAV vector containing the RPE-65 gene followed by detailed and regular patient monitoring in follow-up clinical visits. In the six-year follow-up from Jacobson and colleagues in the US, researchers reported on three patients. The first patient had a visual response at six months with enhanced visual sensitivity increasing until year three, where sensitivity reached its maximal peak and then diminished. The second patient also had a visual response at six months, with sensitivity peaking between years one and three and diminishing thereafter. Finally, in patient number three, an increase of three log units was recorded in visual sensitivity, peaking one year after treatment, followed by a decline in visual sensitivity. Similar data was presented by the UK-led study which reported results on 12 participants, four of whom received a lower dose of 1X1011 AAV vector genomes, while eight individuals received a higher dose of 1X1012. Improvements in retinal sensitivity were seen in six participants for a period of up to three years, peaking at six to 12 months after

treatment and then, similar to the US data, declining visual sensitivity in subsequent years.

PERSPECTIVE REQUIRED In summarising the long-term follow-up data, Bainbridge and colleagues described the efficacy outcomes as largely descriptive in nature, noting improvements in darkadapted perimetry and micro-perimetry in approximately half the patients assessed. Despite the disappointment, a healthy dose of perspective is required, most especially in recognising that: 1) The studies cover a very small number of patients 2) A suggestive dose response effect may be apparent from some of the UK data, which may be built upon in future studies 3) Considerable improvements have been made in manufacturing, vector biology, formulation, dosing and transgene expression since the original single injection administrations were made in 2008 4) Early results from other clinical studies support a continued level of visual sensitivity in LCA patients 5) A transient treatment effect over no effect is clearly desirable (and not unfamiliar for most other medical treatments). While it is imperative that the field is guided by the science, it is equally critical that context and history are not absented from our assessment and that analysis of follow-up studies should clearly acknowledge that small incremental steps, in the long run, can readily match or exceed dramatic leaps. If gene therapy has taught us anything, it is patience.

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BOOK REVIEWS

HANDS AND EYES Ophthalmology trainees learn the vast majority of their clinical skills by observation of their mentors and repetition of what they have seen. It is essentially impossible to perform cataract surgery after having only read about it, and without having seen how it is done. Experiential, on-the-job PUBLICATION learning is a natural approach OPHTHALMIC DOPS AND OSATS: to developing expertise, but THE HANDBOOK FOR it is not very efficient on its WORK-BASED ASSESSMENTS own, as trainees are often AUTHORS unprepared for what they see. SAM EVANS AND PATRICK WATTS The combination of reading PUBLISHED BY RADCLIFFE PUBLISHING preparation and hands-on experience is far more efficient. This is the premise of the 135-page Ophthalmic DOPS and OSATS: The Handbook for Work-Based Assessments, by Sam Evans and Patrick Watts (Radcliffe). It is intended, as mentioned in the foreword, to “provide the trainee and trainer with lucid explanations of workplace competency requirements”, of which The Royal College of Ophthalmologists has 179. The handbook is divided into five sections, which seem to move chronologically through a trainee’s learning process. “Clinical Assessment” covers basic topics like applanation tonometry and slit lamp examination. “Patient Investigation” describes more specialised exam techniques, including ocular electrophysiology (ERG, VEP and EOG) and biometry. “Practical Skills” and “Surgical Skills” describe the skills, like anterior-chamber paracentesis and biopsy of ocular tissues that every ophthalmology resident wants to be able to perform, but often never get the opportunity to do. About 45 skills are described, including the aim, equipment list required, step-by-step procedure and potential complications. This book is most useful as a learning tool for ophthalmology trainees, but can also be used by trainers as a reference guide.

BOOK

REVIEWS

FS LASER TECHNIQUES Femtosecond Laser-Assisted Cataract Surgery: Facts and Results, edited by Zoltán Z Nagy (Slack Incorporated), is a highly specialised manual for the transfer of knowledge and skills regarding the use of femtosecond laser techniques. In the introduction, Dr Nagy states that he writes for “those just starting” and for “those who are already advanced and skilled femtolaser users”. I agree. As suggested by the title, this book is full of evidence in terms of data, figures and postoperative results, based both on the authors’ experience (Section I: Original Chapters) and on peer-reviewed, published papers on femtolaser cataract surgery (Section II: Classic Papers). The sections complement each other; whereas the original chapters are instructive and provide clinical know-how, the classic papers, a selection of the most interesting and relevant published articles on the topic, support the rest of the book and provide scientific support. LEIGH SPIELBERG Books Editor

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

EUROTIMES | JULY/AUGUST 2015

ESASO

2015 RETINA ACADEMY ESASO to host meeting with cutting-edge scientific content

t’s again time for another ESASO Retina Academy, and the organisers have announced the finalised schedule and scientific programme, which is now available on the ESASO website. The event will take place in Barcelona, Spain, from 22-24 October 2015. CME accreditation has been requested. This year’s ESASO Retina Academy is the 15th meeting in a series of advanced study conferences that gather worldrenowned faculty with aspiring young ophthalmologists. ESASO Academies are memorable because of their cuttingedge scientific and practical content, and because of their creative session types and collegial spirit. Innovative highlights for 2015 are a Live Surgery session on 22 October, and ESASO style round-table discussions. Leading ophthalmologists will present and share the latest scientific insights and technical achievements in the understanding, diagnosis and treatment of retina diseases. The agenda will focus 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, vitreoretinal surgery, among others. Rupert Bourne (UK), the first of two prestigious Lectio Magistralis speakers, will deliver a keynote on “Intravitreous Injections and Intraocular Pressure”. Rupert Bourne is Consultant Ophthalmic Surgeon at Huntingdon Glaucoma Diagnostic & Research Centre and Moorfields Eye Hospital, Professor of Ophthalmology at Anglia Ruskin University and Honorary Consultant Ophthalmic Surgeon at Addenbrooke’s Hospital. The second Lectio Magistralis will be presented by Anat Loewenstein (Israel) on “Challenges for Women in Ophthalmology”. Anat Loewenstein is Professor of Ophthalmology and Deputy Dean of the Medical School at the Sackler Faculty of Medicine, Tel Aviv University, and Chairman of the Department of Ophthalmology, Tel Aviv Sourasky Medical Centre.

ESASO EXPERIENCE

www.esaso.org

The ESASO experience is characterised by a creative and productive mix of presentation formats that support fruitful interaction and help foster the learning achievement. The advanced three-day programme will include MasterClasses for small groups, rapid-fire discussions, ESASO-style debates and the well-appreciated “Retinamour” case study session as successfully introduced last year. The level and ambience of ESASO Academies is reflected in feedback from earlier events. A faculty member says about the last meeting: “Besides the scientific success, another great value achieved was the nice and friendly atmosphere around all of us. It was a real personal pleasure being part of it.” Another member adds: “I loved the new formats of the ‘controversies’ as they are lively and gentle.” Feedback on earlier conferences has generally ranged from very positive to enthusiastic, both from faculty and delegates. * www.esaso.org/15th-esaso-retina-academy-2015

EUROTIMES | JULY/AUGUST 2015

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THE CATARACT REFRACTIVE SUITE BY ALCON

EYE ON TECHNOLOGY

VHF ULTRASOUND Important information can be obtained by using very high-frequency digital ultrasound. Dr Soosan Jacob reports maging and measurement of internal corneal and posterior chamber (PC) anatomy is the next frontier for better understanding of the cornea, both before and after refractive procedures as well as for optimising cataract and phakic intraocular lens (IOL) surgery. Very high-frequency (VHF) digital ultrasound can obtain unique biometry measurements of both the cornea and anterior segment to provide a wide range of applications.

VHF DIGITAL ULTRASOUND The Artemis (ArcScan Inc., Morrison, Colorado, US) uses a broadband 15-60MHz digital ultrasound scanning probe used with the patient sitting with the eye immersed in a soft rimmed eyecup filled with warm sterile normal saline (33°C). The transducer sweeps in an arc approximately following the contour of anterior or posterior segment structures of interest. Three-dimensional scan sets are also possible. The tear-film is not incorporated into measurements, unlike current epithelium mapping optical coherence tomography (OCT) systems. Captured data is then digitally processed. Digital signal processing localises interfaces such as Bowman's layer, LASIK flap etc to 0.87µm. Captured data is interpolated between meridional scans to produce pachymetry maps with high repeatability for epithelium (0.58µm), stroma (1.78µm), cornea (1.68µm), flap (1.68µm) and residual stromal bed (2.27µm). Posterior segment is measured using software for anterior segment scans.

KERATOCONUS SCREENING Studies have shown that epithelial thickness profile changes in keratoconic EUROTIMES | JULY/AUGUST 2015

eyes to a “doughnut pattern”, characterised by epithelial thinning over the cone surrounded by an annulus of epithelial thickening. Corneal epithelial thickness profile may be useful in early keratoconus screening owing to the ability to map epithelial thickness to the nearest micron. Dr Dan Z Reinstein, who developed the original VHF digital ultrasound technology with co-workers at Cornell University in the early 1990s, and later the Artemis device for which he holds a proprietary interest and several related patents, says: “The epithelial doughnut pattern masks the extent of any stromal surface cone on topographic anterior elevation bestfit sphere (BFS) and curvature maps and can in some cases completely mask small degrees of stromal front surface ectasia. “Anterior surface topography might thus miss the diagnosis and especially when posterior surface elevation mapping is also equivocal, early keratoconus may be missed. Not all posterior elevation BFS changes are due to keratoconus. Therefore, a diagnostic tool to confirm or exclude a diagnosis of keratoconus in eyes with eccentric posterior elevation BFS is needed. In the absence of epithelial doughnut pattern, underlying stromal surface cone can be excluded as cause of suspect inferior steepening or suspect eccentric posterior elevation. Epithelial thickness mapping thus allows patients to be deemed suitable for corneal refractive surgery who otherwise would have been denied treatment by topography or tomography alone. “The converse may also occur. For example, the figure shows apparently normal front surface topography (Figure A), but epithelial thickness profile shows localised region of epithelial thinning (Figure B) coincident with posterior surface apex elevation (Figure C). This indicated presence of early keratoconus where epithelium was able to compensate fully for

the stromal cone, resulting in an apparently normal front surface corneal topography.”

EPITHELIAL COMPENSATION Compensatory epithelial thickness changes also have a significant impact in irregular astigmatism. The epithelium effectively acts as a low pass filter for both local and global changes in stromal surface curvature so that it becomes thinner over relative peaks and thicker over relative troughs in stroma. Dr Reinstein explains: “This is summarised by my Law of Epithelial Compensation for irregular astigmatism: ‘irregular astigmatism results in irregular epithelium’. “Therefore, if a patient presents with stable irregular astigmatism, by definition epithelium has reached maximum compensatory function. Front corneal surface topography and aberrometry have been the mainstay of diagnostic testing in complicated LASIK. However, neither understanding of optical defect or front surface shape of cornea will necessarily provide a diagnosis for cause of underlying problem and this may lead to sub-optimal treatment planning.”

IMPROVING PHAKIC IOL SIZING A major advantage of ultrasound over optical (OCT, Scheimpflug) techniques is the ability to image the whole PC through iris. Optical instruments cannot image PC because optical path is blocked by iris pigment epithelium. “As PC phakic IOLs gain in popularity, accurate PC biometry becomes increasingly important. Traditionally, IOL sizing is chosen using a formula based on horizontal white-to-white (W-to-W) diameter, which assumes a correlation exists between W-to-W and PC dimensions – sulcus-to-sulcus (S-to-S) diameter in particular.

Courtesy of Dan Reinstein MD, MA (Cantab), FRCSC, DABO, FRCOphth, FEBO

EYE ON TECHNOLOGY

Early keratoconus with epithelial compensation - Figure A: Eye with apparently normal front surface topography; Figure B: Epithelial thickness profile on Artemis scanning shows a localised region of epithelial thinning; Figure C: Epithelial changes are coincident with a posterior surface apex elevation

“However, multiple studies using ultrasound biomicroscopy have demonstrated that nil to very weak correlation exists, and therefore lens sizing inaccuracies are not uncommon enough. “Given that the vast majority of IOL complications are related to lens sizing error (oversized lens can cause angle closure or iris chafing and pigment dispersion; an undersized lens can cause cataract or damage to zonules with dislocation of IOL), it seems that using direct S-to-S measurement is the correct way forwards for improving PC phakic IOL safety. Indeed, a number of surgeons are now doing this with very impressive results,” says Dr Reinstein.

FUTURE POTENTIAL

SUMMARY

An outstanding source of error in calculating IOL power in cataract surgery, particularly after previous refractive surgery, is predicting the effective lens position (ELP). Because of inability to image the crystalline lens outside the pupillary boundary, it is almost impossible to predict the ELP accurately enough with current optical technology. Newer developments will also measure position and volume of crystalline lens, thus allowing better predictability of ELP and hence improved refractive predictability for cataract surgery.

In summary, a huge amount of important information can be obtained by the ability to visualise and measure internal corneal layers and anterior segment structures using VHF digital ultrasound, which cannot otherwise be appreciated by optical or external measurements alone. It is possibly time that this type of technology becomes more widespread among anterior segment and refractive surgeons. * Dr Soosan Jacob is Director and Chief - Dr Agarwal’s Refractive and Cornea Foundation, at Dr Agarwal’s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com

EUROTIMES | JULY/AUGUST 2015

JCRS

XXXIII Congress of the ESCRS, Barcelona, Spain

JCRS Symposium Controversies in Cataract and Refractive Surgery Sunday, September 6, 2015 14.00–16.00

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 6 MONTH: JUNE 2015

IOL GLISTENINGS AND VISUAL QUALITY The effect of glistenings, fluid-filled microvacuoles that form within some hydrophobic IOLs, on visual function is controversial. US researchers report a retrospective cohort study looking at the effects of glistenings on light scatter and visual function. The study of 79 pseudophakic patients stratified two groups, those with glistenings of 6 µm to 25 µm in diameter, and those with larger glistenings. Glistening size correlated with light scatter. They found significant correlations between IOL age and glistening size, as well as IOL age and contrast visual acuity with glare. They also call for larger clinical studies to further examine the effects of glistening size and area on visual function parameters. BS Henriksen et al., JCRS, “IOL glistening size and visual quality”, in press, June 2015.

POST-OP ENDOPHTHALMITIS PROPHYLAXIS

Chairpersons:

T. Kohnen GERMANY (European Editor) S. Srinivasan UK (European Associate Editor) Pharmacological treatment of inflammation after cataract surgery E. Donnenfeld USA – Intraoperative steroid administration R. Nuijts THE NETHERLANDS – Topical nonsteroidals or steroidals

Intraocular lenses: Which optical principle is best? D. Gatinel FRANCE – Bifocality or trifocality G. Barrett AUSTRALIA – Extended depth of focus

Surgical correction of presbyopia: Which will be the treatment of choice in the future? A. Dexl AUSTRIA – Cornea: excimer, implants G. Auffarth GERMANY – Lens: various IOLs

The use of intracameral antibiotic injection prophylaxis is catching on the US, a 2014 online survey of the American Society of Cataract and Refractive Surgery members indicates. Nearly half of respondents already used or planned to adopt this measure. Many of those using this approach continue to have concerns about the lack of a commercially available antibiotic approved in the US for intracameral injection. The majority used topical perioperative antibiotic prophylaxis, and gatifloxacin and moxifloxacin were still the most popular agents. However, there was a trend toward declining use of fourth-generation fluoroquinolones and a greater use of topical ofloxacin and ciprofloxacin. D Chang et al., JCRS, “Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey”, in press, June 2015.

INTRASTROMAL CORNEAL RING SEGMENTS AND KERATOCONUS PROGRESSION Intrastromal corneal ring segments (ICRS) are one treatment option for keratoconus patients. In the short term they induce a geometric change in the central curvature to improve the visual acuity and reduce the refractive error and the mean keratometry. In addition, the corneal remodelling improves the optical quality of the cornea and reduces the potential for optical aberrations. Spanish investigators followed 15 keratoconus patients for five years following ICRS implantation. All were 30 years or younger at the time of surgery, with confirmed progressive disease. At six months patients showed significant improvement in uncorrected and corrected distance visual acuities and all refractive measurements, and the mean keratometry was reduced by 4.48 dioptres. However, at five years these values worsened, with mean K values regressing to 3.36 dioptres. A VegaEstrada et al., JCRS, “Keratoconus progression after intrastromal corneal ring segment implantation in young patients: Five-year follow-up”, in press, June 2015.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | JULY/AUGUST 2015

INDUSTRY NEWS

Length matters! INDUSTRY

NEWS

60TH ANNIVERSARY Oertli is celebrating its 60th anniversary this year. The company was founded in 1955 by Heinz A Oertli in St Gallen, Switzerland, and today employs 130 employees in its headquarters in Berneck. Since the acquisition of Oertli by Andreas Bosshard in 1992 the company has remained in family ownership, and since 2010 has been run by his sons Christoph Bosshard (CEO) and Thomas Bosshard (Head of Marketing & Sales). “What we are harvesting today is the result of many years of consistent work, and above all, our ability to correctly anticipate new challenges in the market and align our company to them in a goal-oriented way,” said Christoph Bosshard on the occasion of the anniversary. www.oertli-instruments.com

WAVEFRONT DIAGNOSTIC ABERROMETRY Abbott has received FDA approval for the iDesign Advanced Wavescan Studio system for use in LASIK procedures. “This first of its kind, wavefront diagnostic aberrometry is able to detect imperfections in the eye that result in poor vision with highdefinition scanning technology,” said a company spokeswoman. Abbott say the precise scan captures five different optical measurements, enabling the surgeon to provide a more customised LASIK treatment specifically tailored to the patient’s eye. www.abbottmedical optics.com

LASER CATARACT A.R.C. Laser have set up more than 10 reference sites in Europe, which the company says are performing remarkable volumes of laser cataract surgeries every day. “Surgeons prefer to use the laser technique because of the sterile and single-use hand pieces. They allow a full disposable surgery and significantly reduce the risk of infections. To date more than 2,000 patients have had the benefit of this gentle laser treatment,” said a company spokeswoman. “The modern Nano Laser System attaches to every existing phaco (I/A) machine with only a very little effort. This simple set-up will extend your existing phaco machine to a Full Laser Cataract System.” www.arclaser.com

That goes for the OCULUS novelty of the year too. Capture the object accurately – calculate its length precisely – and SNAP! The chameleon fascinates us with its surprisingly swift, high-precision hunting technique. What do you think this chameleon would say if you asked it whether length matters ? And what does all of this have to do with our latest product highlight ? Find out at www.length-matters.de The latest OCULUS technology, a world premiere – something exceptional awaits you at the ESCRS 2015

www.oculus.de

EUROTIMES | JULY/AUGUST 2015

NEW ORLEANS

MAY 6–10

HOUSING NOW AVAILABLE BOOK EARLY TO STAY AT YOUR PREFERRED HOTEL.

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

AnnualMeeting.ascrs.org

TRAVEL

Tapas with a view

Barcelona

TO NOTE...

BARCELONA

PAY BAR BILL WHEN YOU’RE READY TO LEAVE ROUND UP BILL TO NEAREST EURO TIP IN TOP RESTAURANTS: FIVE TO 10 PER CENT TASTING BY SIDECAR If you have a taste for tapas, you might try an interesting sightseeing concept: a tour by sidecar that includes gastronomic stops at a bodega serving tapas, a family-run tavern serving pintxos (tidbits speared to a piece of bread with a toothpick), a stop for cava, and dinner in one of Barcelona’s top restaurants. The private guide picks you up at your hotel. Between food destinations, the sidecar tour covers all the basic Barcelona sights. The all-inclusive cost is €290, whether for one or two persons. For details visit: www.foodieandtours. com/barcelona/sidecar-tour-tapas-session

PEDESTRIAN TAPAS For tapas on foot, take a guided walking tour around the Poble-Sec area with a culinary expert. You start at a traditional bodega with a variety of cheeses and locally produced vermouth before heading to other bodegas, such as the historic Quimet y Quimet, now run by the fourth generation of the same family. Rounding out the three-hour tour there’s a stop at a final taverna and then a visit to a Basque bar serving seasonal tapas. Along the way you learn the history of “pica pica” (picar in Catalan means to eat small portions of different foods). The tour is organised by Context Travel for the “culturally curious”. Book for an individual party or enjoy as part of a group. For details visit: http://www.contexttravel.com/ city/barcelona/walking-tour-details/pica-pica-inpoble-sec-tapas-walk

FULL MEAL DEAL If your idea of dinner is a full meal rather than a progression of small plates, consider an evening at the 7 Portes Restaurant. Seafood, rice and meat dishes feature, along with fine wine. Paella is a favourite dish in Barcelona (though it comes from Valencia) and the 7 Portes kitchen offers five varieties including vegetarian. The guest book at this 175-year-old restaurant at Passeig Isabel II (near the Columbus column) has been signed by a cross-section of illustrious visitors, including Spanish royalty, Placido Domingo, Mikhail Gorbachev and Woody Allen, while its walls are decorated with artwork by famous clients. Open: Daily from 1pm to 1am. For details visit: www.7portes.com

LIVING LA VIDA TAPAS

Pre-dinner bites are something of a gastronomic art form in Barcelona. Maryalicia Post reports Dinner hour in Barcelona is one of the latest in Europe. Many restaurants don’t open until 8.30pm, with dinner served between 9pm and midnight. However, that doesn’t mean you need go hungry in the early evening. From about 4pm simply join the crowds shouldering into friendly tapas bars – or relaxing on a terrace – to enjoy a drink and a succession of “pica pica”. These inventive bite-sized offerings are a cross between a snack and an appetiser. In the end, you may skip dinner. Here are some suggestions:

TAPAS WITH A VIEW The terrace of the restaurant on the roof of the Museu d'Historia de Catalunya is an oasis in the sky, called Restaurant 1881. Go for tapas and a glass or two of cava while you admire the views over Barceloneta and out to sea. Sunset can be spectacular. Enter via the museum (even when the museum is closed) and take the lift to the fourth floor. If you are tempted to linger for dinner, it is served from 8pm to midnight. The specialities are steaks and seafood. Museu d’Història de Catalunya – Plaça de Pau Vila, 3; Telephone: +34 932210050. Terrace open from 1pm to 1am most days and until 3am on Friday and Saturday.

for places two months hence. Two other possibilities: 80 seats are made available at the door at midnight, or call a central booking phone number to discover a last-minute reservation. For a map and contact for lastminute bookings visit: elbarriadria.com

TAPAS WITH ATMOSPHERE In the heart of La Boqueria, Barcelona’s oldest and Spain’s biggest market, you’ll find El Quim, where a team of chefs in a tiny kitchen produce tempting dishes while you watch. Expect to wait for a stool at the bar, as there are no tables. It’s easy to order, just tick off your choices on a menu card. El Quim, Stalls 584-585 and 606-609 at Boqueria Market, Ramblas 91. Open: Tuesday-Thursday, 7am-4pm most days and until 5pm on Friday and Saturday. For details visit: www.elquimdelaboqueria.com

TAPAS WITH ATTITUDE Since the closing of el Bulli, which was five times voted the world’s best restaurant, Albert and Ferran Adria have undertaken a two-man revitalisation of an entire neighbourhood of Barcelona, opening or preparing to open five differently themed restaurants in the old Parallel theatre district. The main attraction is Tickets, where a circus vibe is the setting for the Adria brothers’ orchestration of the tapas ritual. Booking for Tickets is online and opens at midnight

La Boqueria market

EUROTIMES | JULY/AUGUST 2015

CALENDAR

SEPTEMBER

NOVEMBER

NEW ENTRY 95th SOI National Congress

International Conference on Ocular Infections (ICOI)

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

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

↙

ESCRS Glaucoma Day

LAST CALL

JULY 2015

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

AUGUST

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

JANUARY 2016

4 September Barcelona, Spain www.escrs.org

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

6th EuCornea Congress

SEPTEMBER

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

15th EURETINA Congress

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

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

↙

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

FEBRUARY

20th ESCRS Winter Meeting 26–28 February Athens, Greece www.escrs.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 5–9 October Naples, Italy www.echography.com

NOVEMBER

AAO 2015

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

XXXIII Congress of the ESCRS

6th EuCornea Congress

5–9 September www.escrs.org

4–5 September www.eucornea.org

WSPOS

FOUR EVENTS

ONE VENUE Fira Barcelona Gran Via, Spain North Access, Hall 8

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

Berlin

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