EuroTimes Vol. 21 - Issue 3

SPECIAL FOCUS CATARACT & REFRACTIVE LASER GLAUCOMA

AB EXTERNO DEVICE: SCHLEMM’S CANAL EXPANDER SHOWING PROMISE

RETINA

March 2016 | Vol 21 Issue 3

STEM CELL THERAPY IS OPENING UP EXCITING THERAPEUTIC POSSIBILITIES

CAPSULOTOMY

EVOLUTION 1747 1850 1917 1950 1957 c.1958

1967 1970 1978 1982 1984 2008 2015

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor.

Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor.

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

ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CATARACT & REFRACTIVE LASER 4 Cover Story: The

evolution of capsulotomy – and new alternatives entering the clinical research pipeline

9 Merits of FLACS: ESCRS

case-control study results

10 Laser vision correction proving popular with ophthalmologists themselves

12 The challenge of treating intumescent white cataracts

FEATURES CATARACT & REFRACTIVE 14 Achieving better

IOL outcomes with intraoperative aberrometry

GLAUCOMA 18 Expert surgical

technique can help minimise problem of long-term increased IOP

19 New Schlemm’s canal

expander showing promise in cataract patients with glaucoma

P.28

RETINA 21 Positive results for

vitrectomy in macular hole repair surgery

22 Cause of macular

atrophy in eyes receiving anti-VEGF injections for AMD still not clear

23 ‘Stem cell therapy

myopia – the benefits of a low concentration

26 Optimising prognosis for

REGULARS 28 Travel 29 Industry News

15 ‘The importance of

31 Ophthalmologica Update

testing glare disability in patients is increasing’

33 ESCRS News 34 JCRS Highlights

CORNEA

35 ESASO Update

16 ‘Endothelial

36 Calendar

17 CXL effective in

halting progression of post-LASIK ectasia, finds study

25 Atropine treatment for

children with retinopathy of prematurity

opening up exciting new therapeutic possibilities in degenerative eye diseases’

keratoplasty offers significant safety and visual advantages over penetrating keratoplasty’

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.

PAEDIATRIC OPHTHALMOLOGY

EuroTimes & JCRS

P.5

1996–2016

EUROTIMES | MARCH 2016

2

EDITORIAL A WORD FROM RICHARD PACKARD MD, FRCS, FRCOphth

NEW TECHNOLOGIES There have been extraordinary changes in cataract surgery over the years

I

n July of this year it will be 46 years since I started my This really where capsule matters stood until the late first post as a junior doctor in ophthalmology. What noughties when a new technology emerged for parts of the extraordinary changes there have been in our specialty cataract procedure, the femtosecond laser. As has been stated in that time and not least in cataract surgery. elsewhere, Zoltan Nagy was the pioneer here who showed My first experience in 1970 was, as stated elsewhere in how perfectly round, consistently sized capsulotomies could this edition, to see a Graefe knife used to open be produced. The femtosecond the eye. My own first cataract removal in 1972 was an laser could also make incisions ... for the first time I intracapsular extraction with no implant. At the end of and break up the nucleus all under 1978 I saw phacoemulsification and lens implantation optical coherence tomography or became very aware that as I joined Eric Arnott at Charing Cross Hospital in similar control. Although there the capsule needed to London. This changed my life in ophthalmology. was considerable initial excitement be opened to remove the Also for the first time I became very aware that the associated with femtosecond lasernucleus from the eye. capsule needed to be opened to remove the nucleus assisted cataract surgery (FLACS) from the eye. When I did my first phaco in January this has somewhat waned.

When I did my first phaco 1979 I used the “Christmas tree” technique. That was Cost has been a major issue in January 1979 I used the the easy part; getting the nucleus to prolapse into the and also there has as yet been “Christmas tree” technique anterior chamber for emulsification was the most no refractive outcome advantage challenging. Very soon after this Eric and I started to demonstrated. There was significant use the “can opener” capsulotomy which gave better access agreement among FLACS users, however, that the most to the nucleus and allowed posterior chamber or at least iris important function of the laser was to create the capsulotomy. plane phaco.

So was it going to be possible to do this by other means?

As reported in the cover story, there are two new technologies which aim to do this. One, CAPSULaser, has the advantage of STANDING OVATION small size - it bolts on to the operating microscope. The other In 1986 at a meeting in Bordeaux, having performed my live is a handheld thermal device, Zepto, which is applied to the surgery as had Charlie Kelman, we were sitting together in capsule to create the capsulotomy. There are now intraocular the audience when Jürgen Greite from Munich performed lenses out there, Oculentis FEMTIS and Morcher ND, to the Neuhann style capsulorhexis most beautifully. Not only take advantage of these developments. Time will tell whether were Charlie and I stunned, the whole audience was silenced outcomes will improve. until he finished. Then there was a standing ovation. This was going to change the way that phaco was performed but it did not happen overnight.

Phacoemulsification was not the mainstream procedure for most surgeons in 1986 and it was not really so for another decade. By the time EuroTimes was born 20 years ago, most surgeons were performing phacoemulsification. They may have been using a variety of techniques to break up the nucleus, but all used capsulorhexis, creating the capsular opening either with a needle or specially designed forceps like those of Peter Utrata.

Richard Packard is a member of the ESCRS Education Committee

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

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

EUROTIMES | MARCH 2016

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4

COVER STORY: CATARACT & REFRACTIVE LASER

CAPSULOTOMY EVOLUTION EuroTimes reviews the evolution of capsulotomy, femtosecond laser capsulotomy and new alternatives entering the pipeline. Sean Henahan reports

1747

Jacques Daviel (1696-1762) pioneers the idea of removing the cataract from the eye, by opening the capsule and expressing the nucleus

1850

Albrecht von Graefe (1828-1870) refines extracapsular technique, using a forceps to lacerate the capsule

1917

Ignacio Barraquer (1984-1965) develops an intracapsular approach without a capsulotomy, using suction to remove the lens

1950

Sir Harold Ridley (1906-2001), implants the first IOL via an extracapsular approach using Hess’s forceps to perform the capsulotomy

1957

Joaquin Barraquer develops the enzymatic zonulolysis technique that simplifies intracapsular extraction

c.1958

EUROTIMES | MARCH 2016

Cornelius Binkhorst (1912-1995) develops the iris clip lens and works to develop IOLs that would fixate in the capsular bag, removing the need for pupil involvement. Experiments with different shapes of capsule opening

1967

Charles Kelman (1930-2004) introduces phacoemulsification and the “Christmas tree” capsulotomy using a hooked cystitome

1970

Early phaco pioneer Richard Kratz (1920-2015) says he believs the posterior chamber approach is safer, devising the can opener capsulotomy, and the iris plane phaco technique

1978

Calvin Fercho begins using continuous tear circular capsulotomy

1982

Daniele Aron Rosa invents YAG laser, original for PC capsulotomy, tries it for anterior capsulotomy

1984

Howard Gimbel, Kimiya Shimizu, Thomas Neuhann refine continuous curvilinear capsulorhexis (CCC)

2008

Zoltan Nagy uses femtosecond laser to create precise circular capsulotomy

2015

First clinical trial with CAPSULaser. CE mark for Zepto

COVER STORY: CATARACT & REFRACTIVE LASER

Courtesy of Richard Packard MD, FRCS, FRCOphth

T

Daviel technique for extracapsular surgery by expressing the lens nucleus through a capsular tear

THE FEMTOSECOND REVOLUTION Zoltan Nagy MD, Head of the Department of Ophthalmology, Semmelweis University, Budapest, Hungary, generated huge enthusiasm and some controversy in 2008 when he reported his first results with femtosecond laser-assisted cataract surgery (FLACS). Here at last was a system that could produce precise circular capsulotomies every time.

Since its debut, the femtosecond laser approach has demonstrated many advantages including higher safety, higher predictability, less phaco energy, shortened treatment time, better results with premium lenses, and significant help in complicated cases like traumatic cataracts, loose zonules, and white and tumescent cataracts, and also in paediatric cataracts, according to Dr Nagy.

“When I heard first about the femtosecond laser for cataract treatment I felt the same excitement as with the excimer laser. I knew that it would be an important part of the future of ophthalmology. The experimental phase of the first femtolaser treatment justified my assumptions. The future is here with the femtolaser,” Dr Nagy told EuroTimes.

FLACS. For example, published studies comparing FLACS and conventional surgery show few discernible differences from the patient’s point of view in terms of visual outcome, notes Dr Packard.

There are also reports of higher rates of certain complications with FLACS, particularly anterior capsular tears (RG Abell, Ophthalmology, 2014, Volume 121, Issue 1, Pages 17–24). Scanning electron microscopy (SEM) of femtolaser capsulotomy edges revealed ‘postage stamp’ type perforations, irregular margins, aberrant pulses and anterior capsule tags.

This has been proposed as a mechanism

Courtesy of Richard Packard MD, FRCS, FRCOphth

idea of using a continuous tear circular capsulotomy, dubbing it continuous curvilinear capsulorhexis (CCC).

As a consequence of the development of the CCC, IOLs could be placed reliably and securely in the capsular bag. This required the development of new phaco techniques including chip and flip, divide and conquer, nucleofractis, phaco chop and prechop. New enhancements for making the CCC also appeared, such as a capsular ring placed in the eye created by MarieJosé Tassignon in Belgium.

Albrecht von Graefe and his cataract knife for ab interno incision Courtesy of Marie-José Tassignon MD, PhD, FEBO

he capsulotomy has often been considered the most difficult component of extracapsular cataract surgery, the last step in a young cataract surgeon’s training. A well-centred and stable capsulotomy is more important than ever with the advent of multifocal and toric specialty intraocular lenses (IOLs). Recent years have seen dramatic changes in how this procedure is performed, along with marked improvements in safety and accuracy.

The femtosecond laser approach in particular is said to simplify creation of the capsulotomy, possibly improving outcomes for some premium lens procedures.

However, not everyone is convinced that the femtosecond laser results are better, or that the results justify the considerable cost of the equipment.

“A high-quality capsulotomy provides the foundation for the whole of modern cataract surgery. What we’re all looking for is a reliable and stable effective lens position with a low incidence of posterior capsular opacity and minimum side effects.

Proper capsulotomy size and shape are crucial to achieving these goals,” Pavel Stodulka MD, PhD, Gemini Eye Clinics, Czech Republic, told EuroTimes.

In his recent Binkhorst Medal Lecture at the XXXIII Congress of the ESCRS in Barcelona, Richard Packard MD, FRCS, FRCOphth, Senior Consultant Surgeon at Prince Charles Eye Unit, Windsor, UK, described the evolution of capsulotomy from the 18th Century origins to the present.

French surgeon Jacques Daviel first demonstrated the technique of extracapsular cataract surgery in 1747. One hundred year later, Albrecht von Graefe refined the extracapsular approach, using a forceps to lacerate the capsule. Subsequent innovators have attempted to improve on the capsulotomy, increasing the accuracy of the key surgical step, while reducing operative complications.

The 20th Century saw a revolution in cataract surgery in general, and the capsulotomy step in particular. Sir Harold Ridley, who implanted the first IOL in 1950, used forceps to perform the capsulotomy. Cornelius Binkhorst developed the iris clip lens and worked to develop IOLs that would fixate in the capsular bag. He experimented with many different shapes of capsule opening.

The introduction of phacoemulsification

by Charles Kelman in the 1960s was another major revolution in cataract surgery, with associated changes in capsulotomy technique. Dr Kelman introduced the “Christmas tree” capsulotomy, so called because of its shape. Dr Richard Kratz advocated a circular serrated edge capsulotomy that became known as the can opener technique. Finally, Calvin Fercho, followed

by Howard Gimbel, Kimiya Shimizu and Thomas Neuhann, introduced the

5

FEMTO CAVEATS However, recently published research suggests there are still caveats about

Capsulorhexis being performed with Tassignon ring in place on the lens surface to assist in sizing and circularity

EUROTIMES | MARCH 2016

COVER STORY: CATARACT & REFRACTIVE LASER for the capsular tears. SEM of manual capsulotomy edges were much smoother by comparison.

“That was both surprising and puzzling at first. Since that time the leading theories based on the SEM findings suggest that, due to subtle saccadic eye movement, some of the laser shots are actually misaligned and create aberrant microperforations.

Theoretically, these eccentric perforations might predispose some areas of capsule edge to tearing if too much manipulation or force occurred,” said David F Chang MD, Clinical Professor of Ophthalmology at the University of California, San Francisco, USA, and former president of the ASCRS. Dr Nagy told EuroTimes that a good femtosecond capsulotomy requires a complete understanding of all of the features of the laser. “You need to have perfect patient interface centration, use a low energy level and have perfect optical coherence tomography (OCT) measurements. To avoid anterior tears the surgeon should respect that femtolaser cataract surgery is different from manual phacoemulsification. You have to follow the contour line of femtolaser pretreatment for capsulotomy. If these criteria are fulfilled, the capsulotomy will be perfect,” he said.

"All surgeons starting femtolaser cataract surgery should accept that this technology is different in some steps from manual phacoemulsification and needs a different surgical approach.

If the surgeon follows the contour of capsulotomy at the beginning they will not experience any anterior tear. If they allow the intralenticular bubble to leave the eye toward the anterior chamber ("rock & roll technique"), they will never have a posterior capsular problem," he added.

Perhaps the biggest caveat for those considering performing femtosecond laser is the price tag. There is a huge initial cost of investment in the technology, and considerable ongoing costs of servicing the equipment. There is also a cost to the patient of providing the patient interface. While this might be

justifiable for those offering ‘premium’ IOL options, national healthcare systems that are already stretched financially may not be as enthusiastic.

BEYOND FEMTO Two new surgical tools now in development, both originating in California’s Silicon Valley, could offer many of the same benefits of the femtolaser capsulotomy, at a considerable financial discount.

One of these is the CAPSULaser. A target is created within the capsule, by staining it with trypan blue, after which the continuous laser is scanned in a single circular pattern to create a continuous curvilinear capsulotomy. The laser facilitates a molecular phase change that turns type 4 collagen in the capsule into amorphous collagen.

“Amorphous collagen has different properties. It is much more elastic, much tougher than type 4 collagen. Our tests indicate that you can stretch the tissue much more than with a manual capsulorhexis, and probably more than with a femtosecond capsulotomy as well,” said Dr Packard, who is involved in the development of the new system.

The CAPSULaser bolts underneath the microscope. This means that, unlike most lasers which are very large and may require a break in the normal flow of surgery, with patients first of all going to a laser room to have the laser work done and then returning to the operating theatre, this just fits into the normal work pattern, he explained.

The first clinical results with the CAPSULaser were presented by Pavel Stodulka MD at the XXXIII Congress of the ESCRS in Barcelona (see video at: https://youtu.be/dU0VbTHjUCQ).

The CAPSULaser produced complete circular capsulotomies in all 10 eyes, and there were no adverse events. The edge was as smooth as the edge of a manual capsulorhexis, and was quite firm. There were no tears or tags at the edge of the rhexis. The dark blue contour of the stained edge with amorphous collagen

Courtesy of Mynosys

6

Scanning electron microscopy shows that the ZeptoTM capsulotomy edge has a unique morphology characterised by an extremely smooth functional edge (arrow). Detailed analysis revealed that ZeptoTM not only creates a perfectly round, tagfree opening in the capsule, but at the same time also places a microscopic up-turning or eversion at the edge to present a small amount of the capsule underside for maximal edge integrity during surgery

enhances the capsulotomy visibility and is very firm. A video showing capsule strength can be found at: https://www. youtube.com/watch?v=djXlB5fmI6k&f eature=youtu.be. Dr Stodulka also did not encounter any problems with postcapsulotomy miosis, a problem sometimes seen with laser capsulotomies.

At one month postoperatively, 80 per cent of eyes had a visual acuity of 20/20 or better. All IOLs were well centred.

There were no corneal epithelial or stromal issues, no postoperative flare, no iris damage, no capsular fibrosis, no increases in intraocular pressure and no fundus abnormalities.

“My experience with the CAPSULaser capsulotomy is very positive. The latest generation performs capsulotomy in under one second. The strength of the capsulotomy has been demonstrated to be higher compared to any other capsular opening method. I like this approach very much. Because it is more precise than handmade capsulorhexis and still inexpensive compared to femtosecond technology, I believe this is the future of capsulotomy in cataract surgery," Dr Stodulka told EuroTimes.

Courtesy of Mynosys

ZEPTO

The ZeptoTM disposable capsulotomy handpiece attaches to a control console that provides power and suction for capsulotomy (left panel). The handpiece terminates in a soft, clear silicone capsulotomy tip (SC) that houses a circular collapsible superelastic nitonol ring (NCR) to perform the capsulotomy (right panel). A retractable push rod (PR) elongates and narrows the tip profile for insertion through a clear corneal incision

EUROTIMES | MARCH 2016

Dr David F Chang is involved with the development of another investigative technology called precision pulse capsulotomy (Zepto, Mynosys) which, like CAPSULaser would be used in the normal surgical sequence in lieu of capsulotomy forceps.

The Zepto system consists of a disposable handpiece and capsulotomy tip that are powered by a small console.

The tip delivers micropulses of direct current through a circular nitinol ring to produce a precise capsulotomy of a pre-

COVER STORY: CATARACT & REFRACTIVE LASER designed diameter. This instantaneously cleaves the capsule simultaneously around all 360 degrees without any cautery. Nitinol is a shape memory alloy allowing the ring to be compressed for insertion through a clear corneal incision, after which it returns to its original shape inside the anterior chamber that has been filled with OVD. The surgeon apposes the ring to the anterior capsule, and gentle suction is applied through a thin surrounding silicone cover. A central viewing opening in the silicone cover permits capsulotomy centration on the visual axis using patient fixation intraoperatively.

Dr Chang presented early in vivo results of the Zepto system in rabbit eyes at the 2015 annual conference of the American Academy of Ophthalmology in Las Vegas, USA (Chang DF, Mamalis N, Werner L. Precision Pulse Capsulotomy – Preclinical Safety and Performance of a New Capsulotomy Technology. Ophthalmology 2016; 123:255-264). The study indicated that the automated system produced consistent, round anterior capsulotomies with a safety profile equal to that of conventional CCC in the fellow eye, he reported.

“Live postoperative slit lamp evaluations, combined with histologic post-mortem exams, showed no differences in terms of inflammation or endothelial cell loss. Anterior chamber thermocouple measurements showed insignificant temperature change. This is because we are using such a brief, confined application of energy of the order of four milliseconds,” Dr Chang told EuroTimes.

A strain gauge study in paired human cadaver eyes compared the strength of the Zepto capsulotomy with those created by the femtolaser or manual capsulorhexis. The Zepto capsulotomies consistently proved to be strongest of the three (Thompson VM, Berdahl JP, Solano JM, Chang DF. Comparison Of Manual, Femtosecond Laser, And Precision Pulse Capsulotomy Edge Tear In Paired Human Cadaver Eyes. Ophthalmology 2016;123:265-274).

A Miyake Apple video study in paired human cadaver eyes showed no increased zonular stress with Zepto compared to manual capsulotomy (Chang DF et al, Ophthalmology 2016; 123:255-264).

The Zepto device received the CE mark at the end of 2015 for performing anterior lens capsulotomies during cataract surgery. The company is seeking 510k FDA approval for the device in the US, and plans to begin clinical trials this year.

Richard Packard: mail@eyequack.vossnet.co.uk Pavel Stodulka: stodulka@lasik.cz Zoltan Nagy: zoltan.nagy100@gmail.com David F Chang: dceye@earthlink.net Dr Chang is a consultant to Mynosys and AMO

MY FIRST SURGERY RENOWNED SURGEONS REMEMBER THEIR FIRST CATARACT PROCEDURES… Dr David F Chang: “I was attracted to ophthalmology as a third year medical student after watching a 35mm film of Charlie Kelman performing phacoemusification in 1978. I immediately signed up for an ophthalmology rotation at MEEI, and after studying Kelman’s textbook on phaco, eagerly arranged to observe my attending perform a cataract operation. He and his assistant did an ICCE with loupes, and I was totally disheartened – maybe this wasn’t the right specialty after all. My first case as a first year UCSF resident in 1982 was an ICCE. My thumping heart was in my throat as I watched the cryoprobe iceball rapidly expand up to, but not into the cornea or iris.

“After a dozen ICCEs, I progressed to ECCEs with PC IOLs, before finally getting to try phaco – at long last. None of our attendings did phaco, but John Stanley at our VA had the courage to let us try. I broke capsules on my second, fourth and seventh cases and was ready to abandon phaco.

In a conversation I’ll never forget, my senior resident confided that he had also started similarly and it wasn’t until after 12 cases that he felt he understood what to do.

“Thanks to his encouragement, I ended my residency in 1984 setting a programme record of 70 phaco cases. All IOLs were implanted under air, because the new Healon viscoelastic was so expensive, it was reserved for AC IOLs. I must be the rare ophthalmologist who got to perform ICCE, ECCE and phaco as a second year of resident.”

Dr Richard Packard: “My first ophthalmology experience was watching a surgeon use a Graefe knife for cataract surgery, using the left hand for the left eye and the right hand for the right eye. When I began my studies in Moorfields Eye Hospital (London, UK) in 1975 I came under the influence of some remarkable men who really taught me my first skills. I was doing a lot of intracapsular cataract surgeries, and never saw an implant. I saw one extracap while at Moorfields. The capsule broke as the surgeon tried to remove an intumescent cataract with a cryoprobe, and had to convert to an extracap.”

Dr Packard then moved on to Charing Cross Hospital in London. He worked with noted ophthalmic surgeon Eric Arnott, a pioneer in phaco surgery.

“I was dimly aware what he was up to with phaco. Indeed, on the day of my arrival they were doing a phaco course, and putting in IOLs. This was like St Paul’s conversion on the road to Damascus. Suddenly my whole world changed in the most extraordinary way. I learned phaco, and thanks to Eric Arnott, I was able to meet Charlie Kelman, Bob Sinskey, Jan Worst, Cornelius Binkhorst… it was an extraordinary start.”

My first ophthalmology experience was watching a surgeon use a Graefe knife for cataract surgery...

EUROTIMES | MARCH 2016

7

10–14 September

2016

XXXIV Congress of the ESCRS

Scientific Programme, Registration & Hotel Bookings www.escrs.org

/ESCRS

@ESCRSOfficial

ESCRS

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

THE MERITS OF FLACS ESCRS case-control study finds better astigmatism control as only benefit. Cheryl Guttman Krader reports

T

he ESCRS-EUREQUO femtosecond laserassisted cataract surgery (FLACS) study questioned whether femto outperforms conventional phacoemulsification.

According to the results of this case-control study, the answer to that fundamental question is ‘no’, said Peter Barry MD at the XXXIII Congress of the ESCRS in Barcelona, Spain.

Explaining the caveat, Dr Barry noted the importance of considering what the study did and did not measure. The study did measure anticipated surgical difficulty, ocular comorbidity, peri-operative complications, monofocal versus premium intraocular lenses (IOLs), postoperative complications, best corrected visual acuity (BCVA), biometry prediction error, and postoperative cylinder and surgically-induced astigmatism (SIA).

“We did not measure circularity or centration of the capsulorhexis, absolute phacoemulsification energy, the laser platform used, endothelial cell loss, effective lens positioning, or higher order aberrations. These are not unimportant, but there were no comparisons in the database,” explained Dr Barry, St Vincent’s University Hospital and Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

The ESCRS FLACS study included data from 2,814 FLACS cases entered prospectively into the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) database and 4,987 controls entered into EUREQUO in 2014.

These were identified retrospectively and matched for precisely the same preoperative BCVA, age within two years, and scoring the same ‘yes’ or ‘no’ for the EUREQUO fields on ocular comorbidity and anticipated surgical difficulty. All FLACS cases were performed by surgeons who had exceeded a 50-case learning curve and all reported cases were consecutive.

“The I-Ring has significantly simplified performing cataract surgery in patients with non-dilating pupils; its easy insertion and removal make it the ideal tool for optimizing intraoperative pupil size.”

SIGNIFICANT BENEFIT Summarising the results, Dr Barry reported FLACS was associated with a statistically significant benefit for minimising the incidence of postoperative astigmatism of equal or greater than 1.5D (nine per cent vs 18.5 per cent). The results were similar in an analysis excluding cases with a toric IOL, concurrent femtosecond laser refractive surgery, or a history of corneal refractive surgery. In addition, SIA of greater than 0.5D occurred at a significantly lower rate with FLACS compared with phacoemulsification (47 per cent vs 53 per cent).

However, postoperative BCVA was worse after FLACS than in the phacoemulsification group. The proportion of eyes with worse BCVA postoperatively than preoperatively was significantly higher in the FLACS group than in the phacoemulsification group (3.3 per cent vs 1.3 per cent). This is important because the preoperative visual acuities were the same as the result of the matching process. This worse vision was due to postoperative complications, not to previous corneal refractive surgery. The worse BCVA outcomes with FLACS were due to a higher rate of postoperative surgical complications – corneal oedema, early posterior capsular opacification and uveitis requiring treatment.

Femto currently does not outperform phaco, Dr Barry concluded.

Peter Barry: peterbarryfrcs@eircom.net

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EUROTIMES | MARCH 2016

9

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

OBJECTIVE ANALYSIS Refractive surgeons practise what they preach.

Dermot McGrath reports

O

phthalmologists who perform refractive surgery are nearly four times more likely to undergo laser vision correction than the general population, according to a study presented at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“Our study indicates that almost 62 per cent of refractive surgeons who are candidates for laser vision correction have had a procedure, and more than 90 per cent recommend laser vision correction to their immediate family members,” said Jason P Brinton MD, an ophthalmologist in private practice in St Louis, Missouri, USA. (Kezirian GM, Parkhurst GD, Brinton JP, Norden RA. Prevalence of laser vision correction in ophthalmologists who perform refractive surgery. J Cataract Refract Surg.

2015 Sep;41(9):1826-32. doi: 10.1016/j. jcrs.2015.10.027) Discussing the rationale behind such a study, Dr Brinton said it was prompted by a desire to bring some objective analysis to an issue that interests a lot of patients.

“We are often asked by patients if, as ophthalmologists, we have had laser vision correction on our own eyes. Among some patients there is a suspicion that doctors are more likely to wear glasses or contact lenses and do not have laser vision correction themselves. One ophthalmologist featured on a national television programme last year even stated that LASIK was one procedure that ophthalmologists do not want to have,” he said.

With this in mind, Dr Brinton and co-workers set out to determine the prevalence of laser corneal refractive surgery among ophthalmologists who perform these procedures, and assess the willingness of these physicians to recommend laser vision correction to immediate family members.

Their prospective randomised questionnaire of 22 questions was sent by email to 250 ophthalmologists, randomly selected from a database of 2,441 ophthalmologists known to have performed laser vision correction at some point in the past decade.

Courtesy of Guy M Kezirian MD

10

Figure 1: Age distribution of the 232 surgeons who responded and were qualified to participate in the survey

SURVEY RESULTS Responses were received from 248 (99.2 per cent) of the 250 queried ophthalmologists, of whom 232 (92.8 per cent) met the protocol criteria of currently working as refractive surgeons.

Interestingly, the prevalence of preexisting refractive errors was significantly higher among ophthalmologists performing refractive surgery than in the general population, said Dr Brinton.

Of the 232 ophthalmologists eligible for the study, 161 (69.4 per cent) reported that they had refractive errors potentially amenable to treatment with laser vision correction, not including presbyopia.

Of the 161 ophthalmologists with treatable refractive errors, 54 (33.5 per cent) reported they were not candidates for laser vision correction for a variety of reasons, and 107 (66.5 per cent) reported they were candidates for laser vision correction.

Of the laser vision correction candidates, 62.6 per cent reported that they had a laser vision correction procedure in their own eyes. Of the overall 232 subjects, more than 90 per cent recommend laser vision

We are often asked by patients if, as ophthalmologists, we have had laser vision correction on our own eyes Jason P Brinton MD EUROTIMES | MARCH 2016

Figure 2 : Distribution of 107 surgeons with refractive errors who were candidates or likely candidates for corneal laser vision correction (LVC). Nearly two-thirds (62.6 per cent) reported they had undergone a laser vision correction procedure. This compares to an overall penetration of LVC of 13.1 per cent in the USA in 2013 (p < 0.01, Chi Test), indicating that ophthalmologists who perform refractive surgery are far more likely to undergo refractive surgery than the general population

correction for adult members of their immediate family.

Dr Brinton noted that the high rates of participation in the survey indicate that surgeons are willing to disclose their personal experiences with refractive surgery.

“Future studies should be conducted to evaluate acceptance of refractive procedures across ophthalmologists generally, and to compare these rates against age- and income-matched controls from the general population,” he said.

Jason P Brinton: jpbrinton@gmail.com

FOUR EVENTS ONE VENUE Bella Center, Denmark

XXXIV Congress of the ESCRS

16th EURETINA Congress

7th EuCornea Congress

WSPOS Paediatric Subspecialty Day

10–14 September www.escrs.org

8–11 September www.euretina.org

9–10 September www.eucornea.org

9 September www.wspos.org

12

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

WHITE CATARACTS The treatment of intumescent white cataracts has always been challenging for the surgeon.

Dermot McGrath reports

U

sing a femtosecond laser may offer a safer means of removing intumescent white cataracts compared to traditional manual phacoemulsification, according to a study presented at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“Despite some controversy relating to the high costs of buying and running a femtosecond laser, the device finds its place in difficult cases such as white intumescent cataracts. The greatest advantage of its use is enhanced safety during the capsulotomy step, with a much lower risk for anterior capsule run-out. This minimises the potential risk for further intraoperative complications and eventually for poorer long-term stability and centration of the intraocular lens,” said Ozana Moraru MD. Nevertheless, the technology is not perfect by any means, added Dr Moraru, with ongoing improvements required to further reduce the risk of complications associated with femtosecond laser-assisted cataract surgery (FLACS).

Dr Moraru, Medical Director of Oculus Private Eye Clinic, Bucharest, Romania, defined an intumescent white cataract as a completely white lens with a liquefied and under-pressure cortex, no fundus visibility, an anterior chamber depth of less than 2.5mm and a specific A-scan pattern.

“These cases have always been challenging for the surgeon. For anterior capsulotomy and continuous curvilinear capsulorhexis (CCC) there is a high risk for EUROTIMES | MARCH 2016

single or multiple run-out and irregularities as well as the dreaded ‘Argentinian flag’ sign. There are also associated issues such as flat anterior chamber with little room for manoeuvre, hard brown nucleus underneath, small pupil and high intraocular pressure,” she said.

STUDY RESULTS Dr Moraru’s study included 56 eyes of 56 patients aged 42 to 75 operated between March 2014 and March 2015. All eyes were classified as having white, intumescent

cataracts with shallow anterior chamber.

Manual surgery was performed on 38 eyes, and the remaining 18 patients were treated using FLACS. Primary outcome measures included total surgical time, the difficulty of each surgical step and intraoperative complications.

Surgery was generally more difficult in the manual phaco group, said Dr Moraru.

“The CCC was more difficult. We always needed to stain the capsule, and sometimes the capsulorhexis was not well centred, or was irregular, or interrupted with a high risk of run-out,” she said.

FemtoLaser treatment with LenSx - image after docking on white intumescent cataract. Note the extremely flat anterior chamber

SPECIAL FOCUS: CATARACT & REFRACTIVE LASER

FASTER AND SAFER Summing up, Dr Moraru said that the main benefit of the FLACS technique in white intumescent cataracts is the anterior capsulotomy step, which is faster and safer than manual creation. For nucleus division, emulsification and fragment removal there was no difference between the two approaches. Although most of the complications in this series were minor, the risk of potential serious complication

CCC double run-out

after a CCC run-out should not be underestimated, she said.

“In our series, the difference between the two techniques for white cataract removal was not significant statistically due to the surgeons’ extensive experience in dealing with intumescent white cataracts in recent years. This explains the low rate of complications in standard phaco in these cases, but would probably be higher for surgeons less accustomed to dealing with such complex cases,” she said.

Ozana Moraru: ozana@eye.ro

Courtesy of Ozana Moraru MD

By contrast, the capsulorhexes created by the femtosecond laser were regular and well centred and staining was not always needed. Overall, it was easier, quicker and safer with the femtosecond laser, she said.

Complications in the study were all due to the CCC, said Dr Moraru, with seven adverse events in the standard phaco group: three partial rhexis run-outs, three Argentinian flag signs, and one run-out to the periphery. In the femto laser group, two eyes recorded incomplete CCCs that were completed manually. Total surgical time was an average of 12.53 minutes for the standard group and 14.61 minutes for the femtosecond group.

“This was mainly due to the docking time of the femtosecond laser, which was prolonged because of difficult fixation.

There is a slight learning curve with this in order to do it properly,” she said.

13

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14

CATARACT & REFRACTIVE

Glaucoma Day 2016 ESCRS

Friday 9 September

Immediately preceding the XXXIV Congress of the ESCRS 10–14 September

Scientific Programme organised by

www.escrs.org

BETTER IOL OUTCOMES Achieving better IOL outcomes with intraoperative aberrometry.

Leigh Spielberg MD reports

M

‘

y surgeon had to do two surgeries to get it right,’ is not something you want your patients to think after they’ve undergone a second procedure to correct residual refractive error, said Robert Cionni MD, Salt Lake City, USA, in a presentation on the Optiwave Refractive Analysis (ORA) System® from Alcon.

Speaking to delegates at the XXXIII Congress of the ESCRS in Barcelona, Spain, Dr Cionni discussed the high expectations that now frequently accompany cataract surgery outcomes, the challenges to obtaining good refractive results, and what can be done to improve them.

His answer is intraoperative aberrometry, which he says can be used to improve refractive outcomes in a variety of refractive cataract cases including monofocal, multifocal and toric intraocular lenses (IOLs) as well as post-corneal refractive surgery cases.

“Not getting it right the first time leads to extra post-op chair time, as well as time and expense to enhance the outcome. And even if an enhancement improves the results, the patients might start losing faith in you since you didn’t get it right the first time,” he said.

The ORA System provides intraoperative guidance to determine cylinder power and axis based on aphakic refraction, not corneal K-values. After the toric lens has been placed, intraoperative pseudophakic Robert Cionni refraction can help guide the refining of the lens orientation during the procedure. Lastly, the ORA System provides guidance for the placement of arcuate incisions and limbal relaxing incisions.

Dr Cionni reviewed the results extracted from AnalyzOR, the ORA database, as well as the results of a prospective, randomised, contralateral design toric IOL study.

INTENDED TARGET “In a large study of more than 2,500 eyes, the mean absolute value of the prediction error (MAVPE) using the ORA System was better, at 0.28D +/- 0.23D, than with pre-op data alone, which resulted in a MAPVE of 0.33D +/- 0.28D. The ORA System led to a final refraction within 0.5D of the intended target in 85 per cent of eyes, as opposed to 78 per cent using only pre-op data.”

The difference was even more pronounced when comparing results in post myopic LASIK eyes. Here, using ORA led to results within 0.5D in 67 per cent, compared to 46-50 per cent using conventional preoperative methods, said Dr Cionni.

“My own personal results in post myopic LASIK eyes show a 75 per cent success rate (within 0.5D) using the ORA and a 66 per cent rate using pre-op data,” he added.

“We’re getting better and better at hitting the refractive target, and intraoperative aberrometry represents a means to refine the process,” concluded Dr Cionni.

Robert Cionni: rcionni@theeyeinstitute.com EUROTIMES | MARCH 2016

CATARACT & REFRACTIVE

DEVELOPING GLARE TESTS Better measures needed for dysphotopsias.

Dermot McGrath reports

T

he importance of testing glare disability in patients is increasing as surgical technology and patient expectations advance, Oliver Stachs PhD told delegates attending a Clinical Research Symposium on Dysphotopsia at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“Clinicians and researchers need to understand the principles behind halo and glare measurement in order to be able to use available measures,” he said.

Prof Stachs, University of Rostock, Germany, noted that simply defining glare and halos is fraught with difficulty, as the terms have many different meanings to different people.

“When a patient states that they have problems with glare or halo, there are many distinct visual effects that they may be describing. In order to address the problem we first need to find exact definitions for glare and halo, identify methods for objective quantification and define baseline values. My personal opinion as a physicist is that it is difficult to give exact definitions for halo and glare due to the overlap between neural and intraocular light scattering effects,” he said.

Endoject TM for DMEK

NEURAL COMPONENT The standard example of glare disability is caused by oncoming headlights, said Prof Stachs, with two main reasons for the discomfort: firstly, the neural component related to the period of light adaptation required by the photoreceptors; and secondly, the reduction of contrast in the retinal image.

Dysphotopsia – defined as the introduction of unwanted patterns on to the retina after intraocular lens implantation – takes two main forms: positive and negative, said Prof Stachs.

Approaches to quantifying glare include subjective methods such as score charts or patient questionnaires, or objective methods using any one of a number of devices currently available such as the halometer, glaremeter, stray light meter, brightness acuity tester, Berkeley glare test and straylight meter.

While there is a wide range of commercial devices on the market purporting to objectively measure dysphotopsias, the lack of agreed standards and definitions makes it difficult to assess their efficacy, said Prof Stachs.

Going forward, Prof Stachs said there was a need for some universally agreed method to quantify halos and glare.

“Successful glare tests that are cheap, accessible, valid and reliable are required,” he added.

Oliver Stachs: oliver.stachs@ uni-rostock.de

Clinicians and researchers need to understand the principles behind halo and glare measurement...

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15

CORNEA

EK ECLIPSING PK Mid-term graft survival similar, DMEK better for endothelial cell density and rejection rate. Howard Larkin reports

E

ndothelial keratoplasty (EK), particularly Descemet’s membrane EK (DMEK), offers significant safety and visual advantages over penetrating keratoplasty (PK), with similar three- to five-year graft survival rates at large centres, and superior five-year endothelial cell density preservation, according to a review by the Cornea Research Foundation of America, Indianapolis, USA. Results from several long-term studies also show that EK graft failure rates are higher early in the surgical learning curve, and prompt replacement of failed grafts improves visual outcomes, Marianne O Price PhD, MBA told the 6th EuCornea Congress in Barcelona, Spain.

The biggest risk factor for late EK failure is prior glaucoma surgery, while the lower rejection risk of DMEK permits reduced steroid use, which in turn reduces the risk of intraocular pressure (IOP) spikes after surgery, added Dr Price, Executive Director, Cornea Research Foundation of America.

Registry reports show EK volume exceeded PK in the USA since 2012, while in the UK more than three-quarters of Fuchs endothelial dystrophy and 70 per cent of pseudophakic corneal oedema cases were treated with EK in 2013 – not surprising given the safety advantage of a smaller incision, and quicker and better visual recovery that EK offers, Dr Price said.

UK registry data also show more failures of EK at two years for both Fuchs and corneal oedema, and failure rates are much higher for surgeons with 15 or fewer EK procedures (Greenrod et al. Am J Ophthalmol 2014; 158;957-66).

A similar EK learning curve was observed at Dr Price’s large referral centre, with six out of the first 100 Descemet’s stripping EK (DSEK) cases failed but only one of the second 100 (Price and Price. J Cataract Refract Surg 2006;32:411-8), and seven of the first 75 DMEK cases failed but only two of the second 75 (Guerra, Price et al. Ophthalmology 2011;118:2368-73).

RE-OPERATE DMEK FAILURES EARLY Replacing a failed DMEK graft promptly results in visual outcomes equal to primary DMEK surgery, Dr Price said (Price et al. Ophthalmology 2015;122:1639-44). If the graft doesn’t clear after a procedure involving surgical trauma, it should be replaced promptly. After routine surgery, wait one month because sometimes it can EUROTIMES | MARCH 2016

Courtesy of the Cornea Research Foundation of America

16

Chronic endothelial cell loss occurs at a faster rate after PK than after EK, resulting in superior five-year endothelial cell density preservation with DMEK or DSEK. DMEK and DSEK data are from consecutive case series performed at Price Vision Group, Indianapolis, USA, and PK data is from the Cornea Donor Study (Cornea Donor Study Investigator Group, Ophthalmology 2008;115:627-632)

take several weeks for a successful DMEK graft to clear, she advised.

Quickly replacing failed grafts minimises oedema and pain, as well as anterior stromal changes or scarring that can degrade outcomes, Dr Price added. After successful clearing, the five-year survival rates for DMEK, DSEK and PK for Fuchs are similar at Dr Price’s centre, running at about 95 per cent.

Similarly, the Singapore National Eye Centre reports three-year graft survival for Descemet’s stripping automated EK (DSAEK) at 87 per cent and PK at 85 per cent (Ang et al. Ophthalmology 2012;119:2239-44). The somewhat lower surivval rate is likely due to more complications in a population with 70 per cent corneal oedema, Dr Price noted.

LONG-TERM FAILURE RISKS At five years, only 59 per cent of DSEK grafts survived in patients with a prior trabeculectomy and just 25 per cent in patients with a prior shunt, compared with 90 per cent for medically managed glaucoma patients and 96 per cent for patients with no prior glaucoma, Dr Price said (Anshu et al.

Ophthalmology 2012;119:1982-7).

The differences may be due to increased plasma proteins found in the aqueous of eyes with glaucoma shunts, suggesting a breach in the blood-aqueous barrier, Dr Price said. Increased oxidative, apoptotic and inflammatory proteins may

accelerate endothelial cell damage. Protein concentrations are up to 10 times higher in eyes with tubes and five times higher in eyes with Express shunts or trabs than control eyes without glaucoma surgery (Rosenfeld et al. Mol Vision 2015;21:911-8).

But that does not mean glaucoma surgery should be avoided, Dr Price said.

Rather, set realistic expectations. Her centre counsels patients that glaucoma surgery is important because the optic nerve can’t be replaced, and while a corneal transplant may fail sooner because of a glaucoma procedure, the graft can be replaced. After the initial cell loss associated with the surgical procedure, PK eyes lose endothelial cell density at a higher rate than EK eyes so that five years out, EK eyes have higher mean endothelial cell density, Dr Price noted (Price et al. Ophthalmology 2011;118:725-9.

Ophthalmology 2013;120:246-51).

PK also has higher incidence of rejection episodes, with 18 per cent at two years vs 12 per cent for DSEK and less than one per cent for DMEK at a centre with similar patient demographics for all three procedures, Dr Price said (Anshu et al.

Ophthalmology 2012;119:636-40). The rejection rate may be related to the number of layers transplanted, she said. DMEK has such a low rejection rate it allows reduced steroid strength after surgery, she said.

Marianne O Price: marianneprice@cornea.org

CORNEA

SAFE AND EFFECTIVE CXL effective in halting progression of post-LASIK ectasia.

Dermot McGrath reports

C

orneal crosslinking (CXL) seems to offer a safe and effective means of stabilising or partially reversing the progression of LASIK-induced keratectasia with minimal complications, according to a study presented at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“Our study with up to three years follow-up showed that CXL stopped the progression of post-LASIK ectasia in 88 per cent of cases in the first year, 96 per cent in the second year, and 100 per cent of cases in the third year. Best corrected visual acuity (BCVA) improved by one line or more in over half of patients, and less than nine per cent recorded a loss of two lines of BCVA,” said Denise Wajnsztajn MD. Post-LASIK ectasia is a rare complication of refractive surgery, said Dr Wajnsztajn, resulting in progressive central or inferior

corneal steepening, thinning of the corneal stroma and loss of visual acuity after LASIK. While the exact incidence of the disease is unknown, surveys by J Bradley Randleman MD have put the number at one in every 2,500 cases with older screening technology and one in 5,000 or less with appropriate screening.

“Although CXL is the only method capable of stopping or delaying the progression of post-LASIK ectasia, there is limited data on the long-term effect of the procedure to prevent further deterioration,” she said.

Dr Wajnsztajn presented a retrospective review of 36 eyes of 29 patients with a mean age of 34 years who underwent CXL for postLASIK ectasia between August 2007 and July 2015. All CXL procedures were carried out using the standard Dresden protocol with regular or hypotonic riboflavin.

The results showed good stability in terms of corneal topography (Kmax)

Best corrected visual acuity (BCVA) improved by one line or more in over half of patients...

C

Denise Wajnsztajn MD

after 12 months, 24 months and three years, said Dr Wajnsztajn. The Kmax outcomes showed improvement (decrease of one or more dioptres) at 12 months in 59 per cent, stability in 29 per cent and deterioration (increase of one or more diopters) in 12 per cent of patients.

The figures for 24 months showed improvement in 62.5 per cent, stability in 33 per cent and deterioration in four per cent. This trend continued at 36 months, with 65 per cent showing improvement, 35 per cent remaining stable and a decline in none, she said.

The BCVA outcomes were also encouraging, said Dr Wajnsztajn, with an improvement at 36 months in 59 per cent of patients, stability in 29 per cent and a decline in 12 per cent. There was no loss of more than two lines of BCVA throughout the study period.

Adverse events included six patients with early ocular surface complications: sterile infiltrates in two eyes (contact lens-related), mild diffuse lamellar keratitis (DLK) in one eye, and peripheral ingrowths of less than 1mm in three eyes.

Corneal haze was also present in five eyes but there was no associated loss of BCVA, she said.

Denise Wajnsztajn: denisewaj@gmail.com

7th EuCornea Congress

OPENHAGEN2016

9–10 September Bella Center, Denmark

Abstract Submission Deadline 15 March 2016

Corn

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Eu

a

a

Eu

www.eucornea.org

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European Society of Cornea and Ocular Surface Disease Specialists

EUROTIMES | MARCH 2016

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18

GLAUCOMA

PREPARATION IS KEY Phacoemulsification after filtration surgery may increase IOP and may alter bleb morphology. Roibeard O’hEineachain reports

P

hacoemulsification in patients who have undergone previous filtration surgery can cause long-lasting increases in intraocular pressure (IOP), but expert surgical technique can help minimise that effect, said Carlo E Traverso MD, PhD at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“Glaucoma specialists are qualified for difficult phacoemulsification surgery, and glaucoma patients with cataracts can often be very challenging. Modern small-incision phacoemulsification has greatly improved our management of these difficult cases, although specific skills are still required,” said Prof Traverso, University of Genoa, Italy.

He noted that filtration surgery unquestionably increases the likelihood of patients developing cataracts in the short to medium term. Phacoemulsification often reduces IOP to normal levels in virgin eyes with angle-closure glaucoma and also tends to lower IOP slightly but significantly in unoperated eyes with primary open-angle glaucoma (POAG). Several studies showed that phacoemulsification in patients who have undergone previous filtration surgery results in a small increase of average IOP, which can be significant in some individuals.

“This is one of the problems with cataract surgery in these patients, the long-term increase of IOP in patients that have been stable after filtration surgery,” Prof Traverso said.

ELEVATED IOP AND DEFLATED BLEBS As an example, he cited a fairly recent retrospective controlled study which showed that, in 50 POAG patients who underwent cataract surgery after having undergone a successful trabeculectomy, there was a significantly greater increase in IOP throughout 18 months of follow-up than there was in 72 POAG patients who underwent trabeculectomy alone. Both groups underwent trabeculectomy a mean of 20 months prior to the study period (Salaga-Pylak et al, BMC Opthalmol 2013;13:17).

He noted that among those who underwent phacoemulsification after having previously undergone trabeculectomy, the mean IOP was 13.2mmHg at 18 months followup, compared to 11.6mmHg prior to the cataract procedure. Among those who underwent trabeculectomy alone, mean IOP remained stable throughout the study period, increasing only slightly from 11.0mmHg, preoperatively, to 11.5mmHg at 18 months.

Carlo E Traverso MD, PhD

To younger and less experienced colleagues I suggest not to venture into this type of surgery unless you feel your training and experience are adequate...

EUROTIMES | MARCH 2016

Furthermore, there was an increase in IOP in 70 per cent of those in the phacoemulsification group, compared to only 36 per cent of those in the trabeculectomy alone group. IOP remained stable in 49 per cent of patients who underwent trabeculectomy alone, compared to 12 per cent of those who underwent subsequent phacoemulsification.

In addition, IOP increased by more than 2.0mmHg in half of the patients in the phacoemulsification group, compared to only a sixth of those in the trabeculectomy alone group.

Conversely, IOP decreased by more than 2.0mmHg in slightly over a third of those in the trabeculectomy alone group, compared to only a ninth of those who underwent phacoemulsification afterwards.

The study’s authors noted that patients in the phacoemulsification group had statistically significant reductions in the surface area and height of their blebs following the cataract procedure, whereas the blebs of those who underwent trabeculectomy alone had no statistically significant changes in surface area or height.

Prof Traverso suggested that it is likely that the inflammation resulting from cataract surgery plays a role in the increase in IOP and changes in bleb morphology that occur after the procedure in eyes with previous trabeculectomies. He pointed out that the functionality of a bleb depends almost exclusively on the integrity of the sclerostomy and on the efficiency of subconjunctival diffusion of fluid, both of which may be impaired by inflammation.

SURGICAL PEARLS When performing phacoemulsification after filtration surgery it is important to remember that such patients are not routine cases, but can be difficult and challenging and frequently require very complex and specific technique.

“To younger and less experienced colleagues I suggest not to venture into this type of surgery unless you feel your training and experience are adequate, and perhaps refer the case to a more experienced surgeon, or do it together with such a colleague,” Prof Traverso said.

He added that preparation is the key to a successful outcome in unusual cases, and all the tools that might be needed to deal with the expected and unexpected difficulties that one might encounter should be made available and planned for.

Such tools include iris hooks or pupillary expansion rings, for eyes with poor mydriasis and/or floppy iris, and capsular tension rings or segments, for eyes with weakened zonules. He added that trypan blue is often useful for optimal visualisation when performing the capsulorhexis in such cases.

Prof Traverso noted that the IOP of the patient undergoing the procedure should be brought to normal or below normal levels at the time of surgery. Mannitol is better than Diamox for that purpose. In addition, gentle globe compression should be used to avoid further damage to the optic nerve. The choice of anaesthesia used – local, peribulbar or sub-Tenon’s – should be based on what the surgeon finds most appropriate for a particular case.

Carlo E Traverso: mc8620@mclink.it

GLAUCOMA

19

SCE in SC six months after operation

Courtesy of Kumar Vinod MD, PhD

Schlemm’s canal exposure without dissecting a window in Descemet’s membrane

A schematic representation of the device

NEW AB EXTERNO DEVICE New Schlemm’s canal expander showing promise in cataract patients with glaucoma. Roibeard O’hEineachain reports

T

he ab externo implantation of a new Schlemm’s canal expanding device, the Kumar SCE-2, combined with a standard cataract procedure has a good safety profile and can produce dramatic reductions in intraocular pressure (IOP) in patients with cataracts and glaucoma, according to the results of a study presented by Galina Dushina MD at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“The combined surgery resulted in significant reductions in IOP and the use of hypotensive medication from baseline without any major complications,” said Dr Dushina, Department of Ophthalmology, Peoples’ Friendship University of Russia Medical Institute, Moscow.

The uncontrolled non-randomised interventional case series involved 19 eyes of 19 patients with cataracts and open-angle glaucoma who underwent the combined procedure. The patients had a mean age of 73.3 years, all had an IOP greater than 21mmHg on maximal anti-glaucoma medication, and all had a follow-up of more than 18 months following implantation of the Schlemm's canal expander.

The World Glaucoma Association’s criteria for complete success – a decrease in IOP greater than 20 per cent or IOP of 18mmHg or less without medication – was achieved in seven (47 per cent) of 15 patients at six months and in four (33 per cent) of 12 patients at 12 months. Partial success – the same IOP reductions but

with the use of anti-glaucoma medications – was achieved in 40 per cent of patients at six months and 50 per cent of patients at 12 months.

In addition, mean IOP was decreased by 41.1 per cent from a preoperative value of 23.1mmHg to 11.8mmHg at six months (p = .0000007), and by 45.4 per cent from a preoperative value of 23.6mmHg to 12.5mmHg at 12 months (p = .000001).

Furthermore, the mean number of IOPlowering medications patients used fell from 2.6 preoperatively to 0.7 at six months (p = .0000001) and 1.1 at 12 months (p = .0008).

The Kumar SCE-2 consists of a coil of 0.04mm-thick medical grade stainless steel wire, 2.5mm to 3.0mm in length with an inner lumen diameter of 0.12mm, and a curvature like that of Schlemm’s canal.

The SCE-2 is the second generation of the Kumar SCE and was developed by Kumar Vinod MD, PhD, Mikhail Frolov MD, PhD, Dr Dushina and Elena Bozhok MD. The Peoples' Friendship University of Russia Medical Institute, Moscow holds the patent for the device.

THREE-STAGE PROCEDURE Dr Dushina and her associates performed the combined glaucoma and cataract procedure in three stages. The first stage is similar to deep sclerectomy, with the creation of scleral flaps and the unroofing of 3.0mm of Schlemm’s canal, although without the creation of a Descemet’s window. The second step is the

phacoemulsification of the cataract and the implantation of the intraocular lens.

The final stage involves the viscodilation of a 5.0mm to 6.0mm segment of Schlemm’s canal with a cohesive ophthalmic viscosurgical device, followed by the insertion of the canal expanding device, mounted on a specially designed and similarly curved 0.2mm-diameter stainless steel microprobe into the ostia of Schlemm’s canal. Once the scleral expanding device is in place, the probe is removed, leaving the Schlemm’s canal expander behind.

The procedure is concluded with the watertight closure and suturing of the scleral and conjunctival flaps.

Intraoperative complications included five cases of microperforation due to inadequate viscodilation of Schlemm’s canal and one case of posterior capsule rupture (five per cent). Postoperatively, two cases (10 per cent) required YAG laser trabeculopuncture to control IOP. There were no cases of hypotony, endophthalmitis or shallow anterior chamber. In addition, there was not a single case of inflammation at the insertion site.

“We found that the implant was easy to implant and that patients had a rapid rehabilitation. Randomised controlled and comparative studies with longer follow-up and larger groups are required in order to confirm the efficacy of the technique,” Dr Dushina concluded.

Galina Dushina: dushina_galina@mail.ru EUROTIMES | MARCH 2016

8â&#x20AC;&#x201C;11 September 2016

COPENHAGEN 16th EURETINA Congress

Bella Center, Denmark

Abstract Submission Deadline 15 March 2016

www.euretina.org

RETINA

MACULAR HOLE REPAIR Positive results for vitrectomy in macular hole repair surgery.

Priscilla Lynch reports

P

ars plana vitrectomy (PPV) for macular hole repair is a highly effective procedure with optimal results occurring in patients with smaller holes and good preoperative visual acuity, a study presented at the 2015 Irish College of Ophthalmologists annual conference in Westport concluded.

Hadia Paryani MB.BCh.BAO.BA, a basic specialist trainee at the Royal Victoria Eye and Ear Hospital (RVEEH), Dublin, Ireland, presented the results of a study that evaluated the functional and anatomical outcomes of 25-gauge PPV for macular hole repair over a two-year period (2012-2014) in a single Irish centre under a single surgeon, Mr Dara Kilmartin, Consultant Ophthalmic Surgeon at RVEEH. All procedures included internal limiting membrane peeling with the vital retinal membrane stain, Brilliant Blue G and postoperative posturing as standard protocol. The average follow-up was 12 months. Forty-seven patients underwent 25-gauge PPV for the treatment of macular hole repair over the two-year study period. The average age of diagnosis was 71.8 years.

Preoperatively, the majority of these eyes had a significant cataract, and about 30 per cent were pseudophakic.

The majority of patients presented with a stage 2 macular hole. There were three cases of bilateral macular holes, while 22 cases underwent simultaneous cataract extraction and intraocular lens (IOL) implantation, Dr Paryani reported.

CLOSURE RATE The macular hole closure rate at the postoperative visit was, in line with similar international studies, 78 per cent, with two further cases demonstrating hole closure at the three- and six-month follow-up visits, bringing the total hole closure rate to 80 per cent. Hole closure was maintained at 12 months of follow-up in all cases. Dr Paryani noted the macular hole closure rate was inversely proportional to hole size at presentation. â&#x20AC;&#x153;Most of the stage 2 and stage 3 holes closed, however only three out of the eight stage 4 holes closed postoperatively,â&#x20AC;? she said.

Overall, there was a clinically significant 0.25 improvement in visual acuity according Hadia Paryani to the LogMAR scale over three months, which increased to 0.35 at one year. This was as a result of subsequent phacoemulsification and IOL implantation surgery as well as YAG capsulotomy in a number of cases.

Some 19 per cent of patients had increased intraocular pressure postoperatively, while eight per cent developed significant cataracts at three to six months. Retinal detachments occurred in four per cent of cases, which were subsequently repaired.

Summarising the study findings, Dr Paryani said shorter duration of symptoms, hole stage and better preoperative visual acuity were associated with both anatomical success and regaining visual acuity of LogMAR 0.38 (6/15 postoperatively).

Hadia Paryani: paryanih@tcd.ie EUROTIMES | MARCH 2016

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RETINA

MACULAR MYSTERY Cause of macular atrophy in eyes receiving anti-VEGF injections for AMD still not clear. Roibeard O’hEineachain reports

A

post-hoc analysis of patients in the HARBOR study indicates that the development of macular atrophy in patients receiving intravitreal ranibizumab for neovascular age-related macular degeneration (AMD) does not appear to be influenced by the dosage regimen they receive and that the intravitreal agent continues to provide benefits in those who develop the condition, said Frank G Holz MD, University of Bonn, Germany, at the 15th EURETINA Congress in Nice, France.

Dr Holz noted that researchers have reported the development of macular atrophy among patients participating in several of the large clinical trials evaluating anti-vascular endothelial growth factor (anti-VEGF) agents in the treatment of neovascular AMD. There are several possible explanations for this phenomenon, he said. Geographic atrophy may be a natural progression of macular degeneration, and neovascularisation may accelerate that progression through some sort of micro-mechanical stress on the retinal tissues. Alternatively, anti-VEGF treatment may interfere with the physiology of the eye.

To investigate the matter further, Dr Holz and his associates retrospectively analysed the findings from the phase III HARBOR study. The multicentre, double-masked, randomised controlled clinical trial involved 1,095 patients with neovascular AMD who received either 0.5mg or 2.0mg intravitreal ranibizumab, administered monthly or as needed (PRN) over a two-year period.

aegean

summer school in Visual Optics

The HARBOR study investigators assessed the presence of macular atrophy based on fluorescein angiograms and colour fundus photographs. They defined the condition as the presence of well-defined areas of depigmentation, with increased choroidal vessel visibility with diameters of 250µm or more that corresponded to flat areas of well-demarcated staining on fluorescein angiography.

They included all atrophy immediately within, adjacent to and nonadjacent to choroidal neovascular lesions, but excluded atrophy associated with retinal pigment epithelium tears.

In their retrospective analysis, Dr Holz and his associates found that 11.2 per cent of eyes had macular atrophy at baseline and an additional 29 per cent had developed the condition by month 24 of the study. By that time, the mean best visual acuity gains from baseline among those with and without macular atrophy at baseline were 6.7 letters and 9.7 letters, respectively.

RISK FACTORS The risk factors they identified for the development of macular atrophy included the presence of intraretinal cysts at baseline, which had a hazard ratio of 2.45, and the presence of macular atrophy at baseline, which had a hazard ratio of 2.02. Counter-intuitively, the presence of baseline subretinal fluid was associated with a lower incidence of macular atrophy, he said. Furthermore, at 24 months only 8.1 per cent of eyes with current subretinal fluid had macular atrophy, compared to 32.9 per cent of eyes without subretinal fluid.

Their findings did not seem to indicate that there was any dosedependent effect of ranibizumab on the development of macular atrophy. For example, the condition did not occur any more frequently among those receiving the 2.0mg dosage than it did among those receiving the 0.5mg dosage, with a hazard ratio of 1.09.

And although there was a trend towards a higher incidence of macular atrophy occurring among those receiving a monthly regimen compared to those receiving a PRN regimen, greater frequency of injection in the study’s PRN arms did not significantly increase the incidence of macular atrophy. That is, among those receiving one to six PRN injections the macular atrophy incidence was 24 per cent in the 0.5mg group and 42 per cent in the 2.0mg group, and among those receiving more than 18 PRN injections the incidence was 21 per cent in the 0.5mg group and 19 per cent in the 2.0mg group.

Dr Holz noted that the weaknesses of their study included its retrospective nature and the lack of a control group. He also pointed out that visual outcomes tend to be worse in non-treated eyes and that macular atrophy is the default outcome in AMD. “Based on existing data, macular atrophy development does not appear to outweigh the benefits of ranibizumab therapy in neovascular AMD.”

Based on existing data, macular atrophy development does not appear to outweigh the benefits of ranibizumab therapy in neovascular AMD Frank G Holz MD

EUROTIMES | MARCH 2016

Frank G Holz: Frank.Holz@ukb.uni-bonn.de

RETINA

NEW POSSIBILITIES Slow but steady progress in retinal cell transplantation for AMD. Dermot McGrath reports

S

tem cell therapy is opening up exciting new therapeutic possibilities in degenerative eye diseases such as advanced age-related macular degeneration (AMD), Susanne Binder MD told delegates attending the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria.

“Today we have increasing solutions for better cell sources, their adhesion and basal lamina construction. However, progress for successful human retinal transplantation is constant but comes only in small steps. We still need better timing of intervention and case selection in order to demonstrate that transplanted cells are well tolerated, in which case we may be able to use them much earlier in the course of the disease,” she said.

The rationale for using cell transplantation in AMD, a disease with dysfunctional retinal pigment epithelium (RPE), is well founded, explained Dr Binder.

“Human retinal transplantation followed a lot of experimental research showing that transplanted RPE cells have the potential to rescue photoreceptors. RPE is incapable of self-renewal and is considered to be the initial site for events leading to AMD. Furthermore, it is easily accessible as a visible pigmented monolayer,” she said.

The molecular mechanisms for nonneovascular AMD are not fully defined, with several distinct pathways probably leading to oxidative stress culminating in RPE dysfunction and death, said Dr Binder.

TREATMENT STRATEGY Dr Binder identified three major types of treatment strategy: firstly, preventing RPE dysfunction or death, which would necessitate early intervention; secondly, providing support to stressed RPE to maintain its function for an extended period; and thirdly, replacing diseased RPE with a new healthy RPE layer.

In the early 1990s many experiments focused on RPE replacement and it was shown that extrafoveal RPE can provide foveal function with retinal translocation.

Foetal and adult RPE were tested as potential cell sources, but these cells

degenerated easily upon implantation and the sources were limited, said Dr Binder.

Further research using delivery methods such as sheets and suspensions of RPE and photoreceptors brought mixed results, said Dr Binder.

“Overall we found out the hard way that sources of autologous transplants are quite limited and that multiple complications may result from surgery of sheets using RPE. We also discovered that autologous cells from the periphery share the same genetic defect if they are being moved to the centre,” she said.

PHOTORECEPTOR REGENERATION Despite these problems, some patients did show visual acuity improvement with evidence of photoreceptor regeneration. The challenge now was to refine the techniques and find a more abundant cell source to create a feasible treatment, said Dr Binder.

“It was always my conviction that retinal transplantation should be a procedure which is atraumatic, easy to perform and with minimal risk of complications," she said.

Potential new sources for robust RPE cells include several distinct stem cell categories: omnipotent, embryonic, pluripotent, multipotent, mesenchymal and adult stem cells. In ophthalmology, embryonic stem cells and induced pluripotent stem cells (iPSCs) are the two groups most used in clinical studies and seem to offer the most promise, said Dr Binder.

“Many technical and regulatory breakthroughs have made stem cell therapies for AMD more plausible. We can now derive RPE cells from embryonic stem cells, we have seen advances in the use of iPSCs to replace photoreceptor loss, and conducted clinical trials using stem cell derived RPE in retinal degenerative disease showing short-term safety,” she said.

Embryonic stem cells offer several advantages, said Dr Binder: large scale expansion is possible, they are pathogen free, well characterised and have a high degree of similarity to in situ RPE by genetic testing. They are also reproducible, with no embryo destruction, and stem cell plasticity can optimise their ability to attach on aged or diseased Bruch’s membrane and reduce rejection. Their main disadvantages include the ethical consideration of using human embryonic stem cells and the fact that long-term immunosuppression will probably be required.

Induced pluripotent stem cells, by contrast, carry no risk of immune rejection, said Dr Binder.

“For AMD, human iPSCs have been differentiated into RPE and it has been shown that they have the full range of morphologic and functional properties characteristic of RPE cells in vitro and in vivo. The disadvantage is that affected patients are old and probably carry the same genetic abnormalities,” she said.

Other interesting lines of research include stem-cell derived photoreceptor cells, which have shown early promise in RPE rescue in animal models, and also a technique using genetic non-viral in vitro RPE modificationplasmids to overexpress pigmentepithelium-derived factor (PEDF).

PEDF is thought to be not only an effective neurogenic and neuroprotective agent but also a potent inhibitor of neovascularisation, said Dr Binder.

A multicentre trial in eight European centres has recently commenced to assess the viability of replacing degenerated RPE cells with genetically modified PEDFproducing cells.

Susanne Binder: susanne.binder@wienkav.at

Many technical and regulatory breakthroughs have made stem cell therapies for AMD more plausible Susanne Binder MD EUROTIMES | MARCH 2016

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NEW ORLEANS

MAY 6–10

ONE FOCUS. ONE VISION. THE LARGEST U.S. MEETING DEDICATED EXCLUSIVELY TO THE NEEDS OF THE ANTERIOR SEGMENT SPECIALIST. THE LEADING PRACTICE MANAGEMENT PROGRAM IN OPHTHALMOLOGY.

“Best symposium to acquire and share up-to-date information on the latest developments in the field of anterior segment surgery” TOP REASONS TO ATTEND • Roundtables and private consultations with experts (No extra fees) • Innovative lectures, case studies, and interactive panels • Exclusive programming for Young Eye Surgeons (YES) • Networking events and lounges • 34th ASCRS Film Festival reception and awards ceremony • Exhibit Hall entry for three days to meet more than 300 ophthalmic industry exhibitors • Crossover access for ASCRS and ASOA programs: • 1,300 sessions and post-meeting resources—films, posters, symposia, and papers

REGISTER TODAY TIER II DEADLINE—THURSDAY, APRIL 21

AnnualMeeting.ascrs.org

ADDITIONAL PROGRAMS T&N TECH TALKS (NEW EDUCATIONAL FORUM FOR TECHNICIANS & NURSES) ASOA WORKSHOPS ASCRS GLAUCOMA DAY CORNEA DAY

TECHNICIANS & NURSES PROGRAM MAY 7–9, 2016

PAEDIATRIC OPHTHALMOLOGY

TREATMENT FOR MYOPIA Low concentration of atropine emerges as potential game changer.

A

Cheryl Guttman Krader reports

lthough atropine is regarded as an effective and acceptable treatment for controlling myopia progression in various Asian countries, it is not a mainstream strategy in the Western world. A change may be coming, however, considering findings from recent research.

Speaking at the 3rd World Congress of Paediatric Ophthalmology and Strabismus in Barcelona, Spain, Ian Flitcroft MD presented evidence demonstrating the benefits of treatment with a low concentration of atropine, 0.01 per cent, suggesting its potential acceptance for use in a European patient population.

“Reports of atropine use for the treatment of myopia date back to the 19th century, and there is a good evidence base for its efficacy,” said Dr Flitcroft, consultant ophthalmologist, Children’s University Hospital, Dublin, Ireland.

“The most extensive experience is with atropine one per cent.

However, results of a trial conducted in Singapore showing atropine 0.01 per cent slowed myopia progression and minimised side effects, will change the way we treat myopia. Certainly, a study is needed in Europe, but 200 years late is better than never,” he added.

The investigation in Singapore, known as the Atropine for the Treatment of Myopia 2 trial (ATOM2) (Ophthalmology, February 2016; 123(2), 391–399), was a double-masked study that randomised 400 myopic children to treatment with atropine 0.01 per cent, 0.1 per cent, or 0.5 per cent. Treatment was stopped after two years, the children were followed for one year off treatment, and then atropine 0.01 per cent was restarted for another two years in any child whose myopia progressed ≥0.5D.

cent to 0.02 per cent is currently routinely offered in Singapore.

Questions about its acceptability and efficacy in a European paediatric population relate to the fact that, compared with their Asian counterparts, European myopes are older and have less pigmented eyes.

“Older children are more opinionated and have poorer accommodation, and perhaps side effects of atropine may be greater in eyes with less pigmented irides,” Dr Flitcroft explained.

Results of the Dublin SHIELD study, however, are encouraging (BJO 2016, in press). In this pilot trial designed to evaluate the efficacy, safety and acceptability of atropine treatment in a European population, significant changes were seen after five days of use in pupil size and pupillary response. However, near visual acuity and reading speed were unchanged, and importantly, investigation of quality of life impact based on patient ratings of difficulty performing 14 daily activities showed atropine use had minimal if any adverse effect.

Data from 16 patients showed that half experienced a one-step change in performance of a single task, from ‘no limitation’ to ‘a little’, while four patients reported a one-step change in two tasks.

“All symptoms related to atropine disappeared within the first two days of usage. And, when asked if they would use this treatment if it worked to reduce myopia progression, all of the participants answered ‘yes’,” Dr Flitcroft said.

Ian Flitcroft: ian@flitcroft.com

LESS REBOUND After the first two years when comparing the atropine treatment groups to historical placebo-treated controls from ATOM1, the progression of myopia was slowed by 75 per cent in the group using atropine 0.5 per cent, 70 per cent for those assigned to atropine 0.1 per cent, and 60 per cent for children using atropine 0.01 per cent.

Not only was the lowest concentration of atropine nearly as effective in reducing myopia progression as the higher concentrations, but it had minimal effect on accommodation and was associated with less rebound during the year after treatment cessation.

“Cycloplegia and acceleration of myopia progression after stopping treatment are the two major concerns with atropine as a treatment for myopia.

Atropine 0.01 per cent seems not to cause those issues,” Dr Flitcroft said.

“Compared with atropine one per cent, atropine 0.01 per cent is also associated with less glare, pupil dilation and allergy, and with minimal impact on accommodation, there is no need for bifocal or varifocal glasses.”

Dr Flitcroft noted that atropine one per cent has been extensively used as a treatment for myopia in Taiwan for more than 20 years, and atropine 0.01 per Ian Flitcroft MD

Reports of atropine use for the treatment of myopia date back to the 19th century, and there is a good evidence base for its efficacy

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EUROTIMES | MARCH 2016

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PAEDIATRIC OPHTHALMOLOGY

ROP: OPTIMISING PROGNOSIS

Focus turns to understanding recurrence after anti-VEGF therapy. Cheryl Guttman Krader reports

I

ntravitreal monotherapy with bevacizumab (Avastin, Roche) has significantly improved outcomes for children with retinopathy of prematurity (ROP). Careful monitoring for recurrence is important, however, because of the potential for unfavourable outcomes with late reactivation of ROP, said Helen Mintz-Hittner MD. Delivering the inaugural Kanski Medal Lecture at the 3rd World Congress of Pediatric Ophthalmology and Strabismus in Barcelona, Spain, Dr Mintz-Hittner reviewed the benefits and risks of bevacizumab monotherapy for ROP. In addition, she reviewed findings from analyses conducted to characterise post-bevacizumab recurrences, and outlined a tentative follow-up schedule targeting better clinical management for the treated infants.

“Treatment of ROP with bevacizumab makes children more functional, especially those with zone I disease, but it also alters the natural history of ROP. We know that outcomes can be adversely affected by recurrence, but we have not known when, where or how to look for recurrence,” said Dr Mintz-Hittner, Alfred W Lasher III Professor of Ophthalmology and Visual Science, John P and Kathrine G McGovern Medical School at Houston, USA.

BENEFITS AND RISKS OF BEVACIZUMAB The benefits of anti-vascular endothelial growth factor (anti-VEGF) treatment versus conventional laser therapy (CLT) include better visual field, less myopia (especially high myopia), and better optical coherence tomography (OCT) appearance of the macula corresponding to better

visual acuity. Destruction of the peripheral retina with CLT accounts for the difference in visual field, but also for the reduced risk of myopia since growth factors released from the peripheral retina are responsible for the normal development of the anterior segment.

Discussing safety, Dr Mintz-Hittner said that the systemic toxicity of intravitreal Avastin is still an open question, since there has not been a trial large enough to adequately assess this issue. While the Bevacizumab Eliminates the Angiogenic Threat for ROP (BEAT-ROP) trial was not powered to evaluate the safety of intravitreal bevacizumab, the initial publication raised some concerns about systemic risks as it reported two deaths in the CLT group versus five deaths among bevacizumab-treated infants with followup to 54 weeks’ adjusted age (N Engl J Med. 2011;364(7):603-615). During continued follow-up, however, there was just one additional death in the bevacizumab group while the total number of deaths in the CLT group reached seven (JAMA Ophthalmol. 2014;132(11):1327-1333).

Dr. Mintz-Hittner acknowledged local adverse events can occur with bevacizumab injection, including infection or trauma to the lens or retina. However, the risk can be mitigated with attention to proper injection technique. She added that children treated with both bevacizumab and laser are at risk for all of the adverse consequences associated with laser treatment, including visual field loss, high myopia, and more frequent ROP recurrence.

“The risk of these events is especially high in children treated in zone I, and the risk occurs because the drug leaks out of the defects created by the laser,” she said.

MONITORING FOR RECURRENCE This patient had stage 3+ ROP and required injections of bevacizumab for initial and recurrent disease treatment.

Left: Photograph just prior to first injection for stage 3+ ROP (35.1 weeks AA). Right: Fluorescein angiogram just prior to second injection for recurrent ROP at two sites (52.7 weeks AA) (arrows)

EUROTIMES | MARCH 2016

Dr Mintz-Hittner conducted analyses to understand the incidence, risk factors, risk period, and anatomic characteristics of ROP recurrence after bevacizumab

monotherapy, using data collected from March 2008 to December 2014. The children included initially had Type 1 ROP in zone I or zone II posterior as stage 3+ ROP or aggressive posterior ROP (APROP), and were followed to at least 65 weeks adjusted age. Mean follow-up for the analysed cohort was to 132 weeks.

A total of 471 eyes of 241 infants were eligible for the analyses that found recurrence, defined as return of both intravitreal neovascularisation and plus disease, developed in 20 infants (eight per cent) and 34 eyes (seven per cent).

Taking into account data on mean time of first treatment and the mean time to recurrence, Dr Mintz-Hittner suggested the period between 45 to 55 weeks adjusted age represents the window during which more vigilant follow-up with examinations every one or two weeks is needed.

Based on characterisation of the recurrence pattern after the first bevacizumab injection, Dr Mintz-Hittner proposed this more frequent examination schedule is particularly needed if the advancing edge grows slowly, reaching just one to three disc diameters beyond the site of the first injection. According to findings of a multivariate analysis conducted to determine risk factors for recurrence, she said it is also recommended if the infant had APROP (vs stage 3+), an extended hospital stay, and/or a low birth weight.

“Before and after this critical period, examinations can be performed less frequently, every two to three weeks, and especially if the advancing edge advanced many disc diameters after the first bevacizumab treatment,” said Dr Mintz-Hittner.

She noted that most infants treated with bevacizumab demonstrate progression of retinal vessels rapidly toward the ora

27

Courtesy of Helen Mintz-Hittner MD

PAEDIATRIC OPHTHALMOLOGY

This patient had APROP and required injections of bevacizumab for initial and recurrent disease. Left: Photograph just prior to first injection for APROP (34.0 weeks AA). Right: Fluorescein angiogram just prior to second injection for recurrent ROP at a single site (48.9 weeks AA) (arrows)

Treatment of ROP with bevacizumab makes children more functional, especially those with zone I disease...

Helen Mintz-Hittner MD serrata by about 44 weeks adjusted age.

She proposed that when that occurs and the infant has none of the three risk factors for recurrence, the follow-up examinations can be suspended at 55 weeks.

However, if the progression of retinal vessels was very slow and the infant had

APROP initially, she advised continuing the examinations to look for recurrence until retinal vascularisation is complete or up to 65 weeks adjusted age.

Helen Mintz-Hittner: helen.a.mintz-hittner@uth.tmc.edu

Dr Helen Mintz-Hittner discusses the treatment of infants with retinopathy of prematurity in a new Eye Contact video interview at: www.eurotimes.org/eyecontact

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TRAVEL

Copenhagen Opera House

COPENHAGEN

3

TO NOTE...

COPENHAGEN

SEPTEMBER TEMPERATURE AVERAGE: 10-14°C CURRENCY: Danish Krone INTERNATIONAL AIRPORT: Copenhagen Airport, Kastrup Nearby Ørestad merits a visit for exciting architecture and design. Ørestad, a new city between Copenhagen Airport and downtown Copenhagen, is a sampler of innovative architecture.

AC Hotel Bella Sky Copenhagen, in the Bella Center, is Copenhagen’s own leaning tower. In fact, the hotel is a pair of leaning towers; the two towers incline 15 degrees (the leaning tower in Pisa leans at an angle of 3.97 degrees). Specially trained fitters installed the facade by abseiling down the building. The towers cant away from each other, ensuring that most of the 812 rooms have a view of the Amager Nature Reserve and Copenhagen’s rooftops. Corner rooms provide the most spectacular views, from which the view extends down and out. The hotel’s Skybar, open to the public, is another great vantage point.

The architects were 3XN. For details visit: marriott.com Tallet 8 (House 8) by BIG Architects is outstanding - they describe the project as a “three-dimensional neighbourhood rather than an architectural object”. Built in two loops, like the figure 8, the building’s lower level is made up of office space and a cafe/restaurant with an outdoor terrace and pastoral views. Upper floors offer a variety of residential living spaces. Tallet 8’s design features include a cycle path leading from the ground up to the 10th floor and sloping green roofs designed to echo the green fields surrounding the development. Tallet 8 is 10 minutes from the Bella Center by Metro to Vestamager.

VM Mountain is another BIG project in Ørestad.

Completed in 2008, it was voted the World’s Best Residential Building at the World Architecture Fair of 2009. Eighty individual apartments are set out in staggered levels over 11 floors, giving each a stunning view of the coastline. Every apartment has a roof garden maintained by an automatic sprinkling system. Even the parking area is worth a look. Northern and western facades of the parking garage depict a 3,000m2 photorealistic mural of Himalayan peaks. VM Mountain is a 12-minute walk from the Bella Center.

EUROTIMES | MARCH 2016

ON THE WATERFRONT

Delegates to the ESCRS Congress in Copenhagen can view impressive buildings. Maryalicia Post reports Copenhagen is, by design, a low-rise city where verdigris domes and church spires still dominate the skyline. Since 2007, tall buildings have been restricted by law to the fringes of the Danish capital.

Meanwhile, the modestly proportioned modern buildings that have been built in the city centre add the sparkle of glass and reflections of sea and sky to the panorama.

Three of the most important of these new structures are on the waterfront - viewing them is a highlight of a boat ride on the harbour. Canal Tours Copenhagen is one option. For details visit: www.stromma.dk.

Departures from Gammel Strand. Travel is free with a Copenhagen Card.

The Operaen, Copenhagen’s new opera house, is directly opposite Amalienborg Palace on Holmen Island. It was an expensive gift to the Danish people from the head of the Maersk shipping line, whose headquarters also has an unobstructed view of the building. The opera house opened in 2005 to high drama when its architect, Henning Larsen, dismissed the design as “a compromise that failed” (the donor insisted on horizontal metal strings across the bubble-like face; the architect had designed an all-glass facade). The 24-karat gold leaf ceiling of the auditorium also came in for criticism, but its all-important acoustics are agreed to be the best. To judge for yourself, book a ticket online at: www. kglteater.dk/en. The website services the opera house at Holmen, the old opera house (“Old Stage”) at Kongen’s Nytrov, and the Royal Playhouse. Click “What’s on” for productions and guided tours.

The Royal Playhouse, surrounded by a floating oak deck “sidewalk”, is an appropriately theatrical structure by Lundgaard & Tegnetsue Architects. Open both to the city and to the harbour, it

combines expanses of copper scales, rustic brick and glass walls – to dramatic effect.

The foyer and restaurant benefit from the expansive harbour views while its three theatres (with 650, 250 and 100 seats, respectively) are, in contrast, intimate spaces echoing the aesthetics of Italian Renaissance theatres. A backstage tour takes 75 minutes.

For details, again visit: www.kglteater.dk/en The Black Diamond, the spectacular extension to the Royal Library by architects Schmidt Hammer Lassen, juts out over the canal. Its polished black granite exterior mirrors the water traffic. The interior boasts a huge ceiling fresco and canal views. The permanent exhibition, Treasures in The Royal Library, currently includes a Gutenberg bible, philosopher Søren Kierkegaard’s notes, and Hans Christian Andersen’s diary along with a selection of valuable artefacts from 1400 years of Denmark’s heritage. The exhibition is updated periodically as the library’s astounding collection is literally inexhaustible. Entry is free and guided tours are available. Open Monday to Saturday.

For details check the library’s website: www.kb.dk

The Black Diamond

INDUSTRY NEWS

NEWS IN BRIEF BETTER OPTICS Katena Products has announced the acquisition of Sensor Medical Technology (SMT).

SMT specialises in the development and manufacture of high-quality single-use and reusable diagnostic and therapeutic lenses used by ophthalmologists and optometrists in the USA and globally.

“The acquisition of SMT is an important addition to Katena’s product portfolio. SMT disposable and reusable lenses represent an improvement to current clinical practice, as it relates to consistently better optics, while eliminating the chance of disease transmission,” said Bill Friedberg, CEO of Katena Products. www.katena.com

IT SOLUTION

INDUSTRY

NEWS

FDA CLEARANCE The new OCULUS Pentacam® AXL has received the 510(k) clearance of the US Food and Drug Administration (FDA).

“The Pentacam® AXL represents the systematic further development of the successful and time-proven Pentacam® HR. The intuitive and network-compatible intraocular lens (IOL) calculation software offers solutions to nearly every challenge,” said a company spokeswoman.

“Standard formulas, such as formulas for treated corneas, for toric IOLs, and ray-tracing formulas, are already integrated. The calculation of toric IOLs is based on the total corneal refractive power (TCRP), thus taking the influence of the posterior corneal surface into account.

A comprehensive IOL database with IOL constants for the Pentacam® AXL is also integrated,” she added. www.pentacam.com

Topcon has acquired 50.1 per cent of the shares of ifa systems AG. Ifa develops, markets, and provides consulting services for health IT solutions in the eye care field, and sells electronic medical record systems connectable to various types of ophthalmic examination devices.

“By acquiring more than half of the outstanding common shares and majority rights, Topcon will integrate ifa’s health IT solution into its eye care business unit and accelerate its growth strategy,” said a spokesman.

“With the rapid aging of the world’s population as well as explosive population growth, operational efficiency in eye care clinical practice and financial efficiency are key requirements for today’s ophthalmic practice,” he added. www.topcon.co.jp/en www.ifasystems.com

DIGITAL MEDICAL SCOPE

NEW RECORD AT USER MEETING There was a new record participation at the SCHWIND User Meeting, said a company spokeswoman.

“Two-hundred and thirty users from 40 different countries came together from 21-24 January in Singapore to hear professional lectures and to exchange their experiences with SCHWIND technologies,” said the spokeswoman.

The SCHWIND User Meeting takes place on a different continent every year and the choice of Singapore as this year’s event location was SCHWIND eye-tech-solutions’ answer to the ever-growing number of participants and the high demand for SCHWIND technologies in Asia. www.eye-tech-solutions.com

Nidek has launched the Digital Medical Scope VersaCam™ α.

“The VersaCam, α versatile and portable fundus imaging unit, provides high-quality images with simple functionality,” said a company spokesman.

“The lightweight and compact design allow easy portability from room to room or centre to centre, enhancing patient convenience. This portable unit with intuitive user functionality means fundus screenings can be performed virtually anywhere regardless of whether the patient is sitting or supine,” added the spokesman. www.nidek-intl.com/product/ ophthaloptom/diagnostic/dia_ retina/ds-20f.html

EUROTIMES | MARCH 2016

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New Orleans 2016 Save the Date

Friday, May 6 – Monday, May 9, 2016 Make the most of your time at the ASCRS•ASOA Symposium & Congress and attend our EyeWorld multi-supported CME, independent education, and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

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

Registration opens January 2016 These non-CME, ASCRS-authorized educational programs will provide timely and important information on: • Options and considerations in the use of premium IOLs • Advances in technologies, techniques, and outcomes in laser vision correction surgery • An interactive discussion on the applications of femtosecond and excimer lasers for ophthalmic surgery

EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products, procedures, and applications of existing products. Included among the topics discussed in these sessions are: • • • • • • •

Live surgery New developments in surgical instrumentation Growing the overall size of the premium IOL market Considerations in the selection of a premium IOL New developments in laser vision correction Advanced IOL technology Discussion of technological advances and breakthroughs in cataract surgery • Update on crosslinking • Advances in diagnostics and imaging equipment

www.EyeWorld.org

Topics are subject to change.

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 235 ISSUE: 2

MS INCREASES CHOROIDAL THICKNESS The findings of a new study indicate that decreased choroidal thickness occurs in multiple sclerosis (MS) patients whether or not they have a history of optic neuritis (ON). The observational comparative study involved 68 eyes of 34 MS patients and 60 eyes of 30 healthy subjects who underwent enhanced depth imaging-optical coherence tomography (EDI-OCT). They found that mean subfoveal choroidal thickness was reduced significantly in MS patients (310.71μm) versus healthy controls (364.85μm) (p < 0.001), as was the choroidal thickness at six other measurement points. The study’s authors suggest that their findings provide evidence that vascular dysregulation may play a role in the pathophysiology of the disease. E Esen et al, “Evaluation of Choroidal Vascular Changes in Patients with Multiple Sclerosis Using Enhanced Depth Imaging Optical Coherence Tomography”, Ophthalmologica 2016; Volume 235, Issue 2.

Nd:YAG Laser Q-LAS 2016

REDUCING RISK OF HIGH MYOPIA IN CHILDREN Spending more time outdoors may reduce a child’s risk of high axial myopia, according to findings from the Shandong Children Eye Study. The population study involves 6,364 children aged 4-18 years, from an eastern Chinese province where the prevalence of high axial myopia is over 10 per cent. A multivariate analysis showed that independent risk factors for high axial myopia included more time spent indoors reading/ writing (p < 0.001) and less time spent outdoors (p = 0.005).

Other risk factors included having a parent with high myopia, (p < 0.001), residing in an urban area (p < 0.001), longer corneal curvature radius (p < 0.001) and higher intraocular pressure (p = 0.008). TL Lu et al, “Associated Factors in Children: The Shandong Children Eye Study”, Ophthalmologica 2016; Volume 235, Issue 2.

SEVERE DIABETIC RETINOPATHY Diabetic users of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs), may be at a significantly higher risk for sight-threatening diabetic retinopathy (STDR) than are users of β-blockers, a new study suggests. The study involved hypertensive Type 2 diabetic patients aged 20-100 identified from the Longitudinal Health Insurance Database (LHID) 2005. Using Cox proportional hazard models, their analysis indicated that the use beta-blockers posed the lowest risk of STDR, followed by CCBs, followed by ACEIs and ARBs. Lin J et al, “Antihypertensive Drugs and Diabetic Retinopathy in Patients with Type 2 Diabetes”, Ophthalmologica 2016; Volume 235, Issue 2.

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www.arclaser.com info@arclaser.com SEBASTIAN WOLF Editor of Ophthalmologica

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

The peer-reviewed journal of EURETINA

EUROTIMES | MARCH 2016

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Save the Date!

Saturday, May 7, 2016 7:00 AM – 9:30 AM 2016 ASCRS•ASOA

Symposium & Congress

Ernest N. Morial Convention Center S C H E DU L E AT A G L A N C E OCULUS Inc.

The Oculus Pentacam for Cataract Surgery and IOL Calculations Registration: 7:00 – 7:30 AM Program: 7:30 – 9:30 AM

Epsilon USA

Capsular/Cataract Complications: A Video Based Symposium Registration: 8:00 – 8:30 AM Program: 8:30 – 9:30 AM

More to come ...

www.eyeworld.org CME credit is not available for Corporate Mornings programs.

ESCRS NEWS

Kabagore Spring nearing completion after upgrading. Note the clean concrete area, run-off and raised area for clothes washing.

The long pipe allows for collection of the clean water while the concrete sets, reducing risk of damage before finalisation and so lengthening the life of the facility

33

Visitec® FLACS Cannula

ESCRS

NEWS Innovative tip

SUPPORTING OXFAM

design allows multiple

During 2015, ESCRS continued its partnership with Oxfam to bring safe drinking water, proper sanitation facilities and public health information to communities in need.

Thanks to ESCRS, 35,606 vulnerable people will benefit from an integrated community project focusing on water, sanitation, hygiene and protection in North Kivu, Democratic Republic of the Congo. They are drawn from the Nyanga, Hunde, Hutu and Tutsi communities, and include families returning home following a 20-year conflict between rebels and government forces that forced them to flee and live in refugee camps.

There was a prevalence of unprotected water sources in the region and increased demand on the limited existing water and sanitation infrastructure. Poor access to latrine and sanitation facilities, coupled with a lack of information about the importance of good hygiene, led to unnecessary illnesses and deaths from diseases such as cholera and diarrhoea.

Investment by ESCRS has helped combat the spread of these waterborne diseases along with water-washed diseases that affect the eyes, such as trachoma and conjunctivitis.

functions to be performed.

1.

Opening all femto incisions (side-port, phaco & LRIs)

2. 25G cannula for injections of OVD and /or other solutions

3. Check capsulotomy has

iLEARN TASK LIST Mentors and trainers have a love of teaching and a passion for sharing new ideas. There are few, if any, who love the administrative side of searching out educational activities, assigning them to their residents and checking that they actually do them. ESCRS iLearn has a solution.

Trainers looking for useful educational

activities for their residents can find a range of highquality interactive and assessed courses on ESCRS iLearn, covering visual optics, cataract, refractive and cornea.

The new Task List will also allow trainers to identify and organise a list of courses they want their residents to take over time.

Deadlines can be applied and email reminders sent, so the trainer doesn’t have to check up on what is due and when.

Task lists can be saved, so if you want each set of residents to take a similar set of activities, there is no need to rebuild a new list – just assign the list to your new group of residents.

To start using the Task List, email the ESCRS eLearning team at: elearning@escrs.org

been released

Designed to improve: • Surgical efficiency • Clinical performance • Patient safety

Call your local sales rep or BVI customer service in the UK at +44.1865.601256.

Visit us at www.beaver-visitec.com

Beaver-Visitec International, Sales Limited 85c Park Drive, Milton Park, Abingdon, Oxfordshire, OX14 4RY, UK US patent # 8,900,136. Additional US and international patents pending.

BVI, BVI Logo and all other trademarks are property of Beaver-Visitec International (BVI) ©2016 BVI

BVI_FLACS_3.67 x 10.48_02.08.16.indd 1

EUROTIMES | MARCH 2016

2/8/16 4:08 PM

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JCRS

JCRS SYMPOSIUM

Monday, May 9, 2016, 1:00 to 2:30 PM Room 243, Ernest Morial Convention Center

Controversies in Anterior Segment Surgery Chairpersons: Nick Mamalis, MD, USA (U.S. EDITOR) William J. Dupps Jr, MD, PhD, USA (ASSOCIATE EDITOR) 1:00 Complications in Femtosecond Laser–Assisted Cataract Surgery Compared with Manual Phacoemulsification ESCRS FLACS Study Update Results Peter J. Barry, MD, IRELAND Better Femtosecond Results Shachar Tauber, MD, USA 1:20 Discussion 1:30 Topographic-Guided Ablation in LASIK Why You Use Topography-Guided Treatments for All LASIK Cases Doyle Stulting, MD, PhD, USA Why You Don’t Use Topography-Guided Treatments for Irregular Eyes Simon P. Holland, MB, FRCSC, CANADA 1:50 Discussion 2:00 Corneal Crosslinking: When Do You Treat Keratoconus?

Safety and Efficacy Peter S. Hersh, MD, USA Adolescence Ronald N. Gaster, MD, USA 2:20 Discussion 2:30 End of Session

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 12 MONTH: DECEMBER 2015

DRY EYE AFTER PRK, LASIK Dry eye symptoms are perhaps the most common complaint from patients undergoing refractive laser surgery. Researchers at Walter Reed Medical Centre in the USA conducted a prospective, nonrandomised clinical study looking at the incidence and predictive factors of chronic dry eye using a set of dry-eye criteria in 143 patients undergoing photorefractive keratectomy (PRK) or LASIK. Evaluations included Schirmer scores, corneal sensitivity, ocular surface staining, surface regularity index and responses to dry-eye questionnaires. After LASIK, significant changes were observed in tear break-up time, corneal sensitivity, ocular surface staining, and responses to questionnaire. By one year after surgery, five per cent of PRK patients and 0.8 per cent of LASIK participants developed chronic dry eye. Significant changes were observed in the LASIK group in tear break-up time, corneal sensitivity, ocular surface staining and responses to the questionnaire. A statistical analysis indicated that lower Schirmer score before surgery significantly influenced the development of chronic dry eye after PRK. Among LASIK patients, lower preoperative Schirmer score or higher ocular surface staining score significantly influenced the occurrence of chronic dry eye. KS Bower et al, JCRS, “Chronic dry eye in photorefractive keratectomy and laser in situ keratomileusis: manifestations, incidence, and predictive factors”, Volume 41, Issue 12, 2624-34.

CUSTOM SELECTION OF CUSTOM LENSES Determining the optimum amount of spherical aberration in intraocular lenses (IOLs) to maximise optical quality in eyes that have undergone previous hyperopic corneal surgery poses a significant challenge for the surgeon. US researchers conducted a simulation study of aspheric IOL implantation in 106 eyes of 80 patients. The range of optimum IOL spherical aberration that produces the best optical image varied widely. With 0.00D, -0.50D, and +0.50D defocus, respectively, the ranges of 25th to 75th percentiles of the optimum IOL spherical aberration were -0.12 to +0.20μm, +0.10 to +0.42μm, and -0.35 to -0.03μm for a 6.0mm pupil, and -0.14 to +0.26μm, +0.41 to +0.86μm, and -0.74 to -0.24μm for a 4.0mm pupil. The amount of optimum IOL spherical aberration could be predicted on the basis of other higher-order aberrations of the cornea with multiple correlation coefficients up to 0.98. The researchers comment that as more options of aspherical IOL selection become available in the market, clinical studies should be conducted to validate the approach of custom selection of optimum IOL spherical aberration, based on total corneal higher-order aberrations. The study results also suggest the need for clinical studies to evaluate quality of vision in these pseudophakic eyes, with the ultimate goal of developing methods to address residual aberrations postoperatively. L Wang et al, JCRS, “Custom selection of aspheric intraocular lens in eyes with previous hyperopic corneal surgery”, Volume 41, Issue 12, 2652-2663.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | MARCH 2016

ESASO

FELLOWSHIP PROGRAMME ESASO is offering exciting postgraduate fellowships in renowned institutions

N

ow is the time to apply for one of the esteemed ESASO fellowships for aspiring young ophthalmologists who have participated in ESASO modules. Open to the most talented doctors and researchers in the field, these competitive stipends offer unique opportunities to gain experience at first-class medical, research and industrial institutions worldwide, learn from the best and boost an international career as a future leader in the area of eye care.

Our one-year scholarships are funded with up to €40,000 and stand out as maybe the most attractive offer in ESASO’s advanced postgraduate educational programme, together with a two-year industrial training and a range of four-week fellowships of different kinds.

The successful candidates will develop their skills in an individually chosen subspecialty such as anterior segment surgery, glaucoma, medical and surgical retina, oculoplastic and research, at a suitably selected foremost teaching hospital, university or industrial institution. Each fellow will be personally tutored by an internationally leading expert and his or her team.

APPLICATION DEADLINE The application deadline is 18 April 2016. Selected applicants will be invited to an interview in Lugano, Switzerland in June 2016. Following the interviews, the final selection of the successful candidates will be made.

The start of a one-year fellowship is usually around October but this can be negotiated in specific cases.

Last but not least, we expect not only professional brilliance from our fellows, but also a supporting and caring disposition for other people. In accordance with our motto “ESASO: a vision of collaboration”, we count on our successful candidates to give back to our community and to the patients, during and after their fellowship period.

For further information and application forms visit: www.esaso.org/fellowships

TESTIMONIAL ALQAHTANI ABDULLAH, SAUDI ARABIA I am 36 years old and I am currently working at King Saud University and King Abdulaziz Medical City as a consultant in surgical retina and ocular oncology. I did five modules of the ESASO School, and was attracted to the specialty of Vitreo-Retinal Surgery. This progressed to be my next future dream, so I applied for the ESASO Fellowship. I chose Saint-Augustinus Hospital in Antwerp.

During my fellowship with Dr Carl Claes and his excellent team, I learned a lot from him, from dealing with the high exposure work to admiring the perfection in the most difficult cases.

www.esaso.org

EUROTIMES | MARCH 2016

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CALENDAR

APRIL

NEW OCT and OCT-Angiography

2 April Paris, France www.vuexplorer.fr/en/formations/52

LAST CALL

MARCH 2016

1st International Meeting Update on Optic Nerve Degeneration: a European Network 18–19 March Milan, Italy www.jaka.it

4–8 May Manama, Bahrain www.meaco.org

Frankfurt Retina Meeting 19–20 March Mainz, Germany www.eckardt-frankfurt.de

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

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

CFSR (Club Francophone des Spécialistes de la Rétine) 8 May Paris, France www.cfsr-retine.com

18–21 May Milan, Italy www.congressisoi.com

31 March–3 April Warsaw, Poland www.comtecmed.com/cophy/2016

19–22 June Prague, Czech Republic www.eugs.org

23–24 September Toulouse, France www.joi-asso.fr

OCTOBER

AAO 2016

15–18 October Chicago, USA www.aao.org

NOVEMBER

NEW IMO – Trends in Glaucoma: Surgical & Medical Meeting 18–19 November Barcelona, Spain www.imo.es/glaucoma2016

29 September–2 October Berlin, Germany http://dog2016.dog-kongress.de

JULY

46th ECLSO Congress (European Contact Lens Society of Ophthalmologists)

1–3 July Crete, Greece www.ivo.gr/en/aegean-cornea/ meeting.html

30 September–1 October Paris, France www.eclso.eu

XXXth Meeting of the Club Jules Gonin 6–9 July Bordeaux, France www.clubjulesgonin.com

OCTOBER

29th APACRS Annual Meeting

CONTACT

12th JOI (Journées d’Ophtalmologie Interactives)

NEW 114th DOG Congress

Aegean Cornea 2016

EYE

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

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

JUNE

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

XXXIV Congress of the ESCRS

42nd Annual EPOS Meeting

12th EGS Congress

7th World Congress on Controversies in Ophthalmology

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

7th EuCornea Congress

ASCRS 2016

14th SOI International Congress

NEW

SEPTEMBER

16th EURETINA Congress

↙

↙

MAY

Middle East Africa Council of Ophthalmology (MEACO) XIII International Congress

The European Association for Vision and Eye Research (EVER) Congress 2016 5–8 October Nice, France www.ever.be

Paris

STUDIO INTERVIEWS with leading ophthalmologists EXCLUSIVE TO EUROTIMES! LATE IOL DISLOCATION

Dr Peter Barry interviews Prof David Spalton Available at www.eurotimes.org/eyecontact and the EuroTimes App

To us, one great achievement is just the start of the next.

At WaveLight, we’re proud to make innovative products designed to help you achieve excellent results. But like you, we’ll never stop working to deliver more. Which is why we’re continually adding new innovations and new possibilities to the WaveLight ® Refractive Portfolio. This dedication to engineering excellence is backed by a commitment to education, service and support — all designed to help take your performance even higher.

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WaveLight® EX500 Excimer Laser

3 reasons to start Nano-Laser Cataract-Surgery.

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