EuroTimes Vol. 21 - Issue 4

SPECIAL FOCUS CORNEA RETINA

ARGON LASER-BASED TECHNIQUE TO TREAT THE UNDERLYING CAUSE OF CRVO April 2016 | Vol 21 Issue 4

HOSPITAL DIARY

CLIMBING HIGHER: THE TRANSITION FROM RESIDENT TO FELLOW

REGENERATION

REVOLUTION

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

CONTENTS

Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

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

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

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

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

ISSN 1393-8983

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CORNEA

4

Cover Story: Ocular surface disorders – major advances in regenerative medicine

8 ‘CXL is safe and effective

for treating keratoconus over the long-term’

10 Culturing corneal

endothelial cells showing great promise

11 CXL-plus: benefits for patients with ectatic disorders

12 Enhancing corneal

thickness during CXL

FEATURES CATARACT & REFRACTIVE 14 Extended-depth-of-focus lens provides spectacle independence

GLAUCOMA

P.40

20 Opening the angle:

phacoemulsification a useful option

21 ‘Advances in SD-OCT

present new paradigm in glaucoma imaging’

RETINA 24 Amsterdam Retina

Debate: vitreolysis vs victrectomy

25 New lens improves near vision and quality of life for AMD patients

27 Argon laser-based

technique to treat the underlying cause of CRVO

PAEDIATRIC OPHTHALMOLOGY 28 Idiopathic amblyopia

– exploring possible link with newborn retinal haemorrhages

15 Accommodative IOL in clinical trials

REGULARS 31 ESCRS News 32 Research 35 ESASO Update 36 JCRS Highlights 37 Practice Management 38 Book Reviews 39 Industry News 40 Hospital Diary 41 Travel 42 Eye on Technology 44 Calendar

16 Non-refractive inlay scores high on safety and efficacy

P.28

18 A new approach to

postoperative IOL adjustment

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.

EuroTimes & JCRS

Included with this issue...

Bayer supplement

1996–2016 EUROTIMES | APRIL 2016

2

EDITORIAL A WORD FROM FRANÇOIS MALECAZE MD, PhD

CORNEAL RESEARCH

EuCornea is going from strength to strength, encouraging research and providing training in an ever-changing field

E

uCornea is a growing and evolving organisation, which main symposia focusing on current hot topics in the area of is expanding its scope while maintaining focus on its corneal disease. The topics will change every year, giving a very original goals. From the society’s inception, we have individual character to each of our congresses. been dedicated to bringing training and education to At this year’s EuCornea congress in Copenhagen, there will young ophthalmologists who wish to become corneal be four main symposium topics, among them the diagnosis specialists, while also providing updates on the latest and treatment of corneal infections, and the joint symposium and most advanced techniques in the treatment of corneal with ESCRS on modern corneal transplantation – a topic disease to more experienced corneal specialists. where there have been many innovations in recent years, from Therefore, at our annual congresses we provide courses, the increasing standardisation and precision of Descemet’s symposia and free paper sessions aimed at all levels of membrane endothelial keratoplasty and deep anterior lamellar expertise. Our meetings include a mix of courses for young keratoplasty, to the use of femtosecond laser in keratoplasty aspiring corneal specialists, courses for experienced procedures and the preparation surgeons who want to learn new techniques, and and use of pre-cut donor tissue.

By bringing together cornea highly specialised symposia with presentations from It is an area where there leading experts in the field. remains much controversy and, specialists from around the Moreover, our free paper sessions provide younger as new techniques are introduced, world, we can combine our ophthalmologists with a means to present their new controversies will inevitably knowledge and experience, own findings and make their own contributions emerge over time. The topic is thus bringing surgical, to corneal research. This represents an important particularly appropriate given source of encouragement and an opportunity to build that the congress will share a medical and technological reputations for these budding corneal specialists, who venue with the XXXIV Congress advances to mainstream are, after all, our future. of the ESCRS. practice more rapidly The benefits of such collaboration between our societies CONSENSUS BUILDING can be further seen in the very Another important role of EuCornea is consensus building. successful Cornea Day sessions at the ESCRS Winter Meetings.

When new treatments and diagnostic techniques are The sessions combine keynote lectures from recognised experts introduced, it takes time to evaluate their utility and safety. By with case reports, which highlight the underlying science of bringing together cornea specialists from around the world, corneal treatments and the very individual nature of each case. we can combine our knowledge and experience, thus bringing surgical, medical and technological advances to mainstream practice more rapidly. The friendships and collaborations that develop through our meetings further consolidate the continued progress of the corneal subspecialty.

Our experience so far suggests that we are achieving our aims, and this can be seen by the ever-growing attendance at our meetings. We are also learning ways of fine-tuning our meetings to enhance their educational potential. For example, we have decided that in our future congresses we will have four François Malecaze is president of EuCornea

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)

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4

COVER STORY: CORNEA

REGENERATION REVOLUTION

Advances in regenerative medicine leading to paradigm shift in treating ocular surface disorders.

Dermot McGrath reports cular surface disorders (OSDs) represent a broad spectrum of conditions ranging from mild dry eye and minor corneal scars to potentially devastating limbal stem cell deficiencies and immune conditions that can cause significant morbidities and corneal blindness. Without effective treatment, OSDs account for up to two million new cases of monocular blindness every year, adding to the existing 39 million cases worldwide.

Treatment options for patients with severe sight-threatening OSD have improved in the past decade, thanks to advances in tissue transplantation techniques and the development of sophisticated artificial corneas. Nevertheless, such approaches are not without significant drawbacks, including graft rejection, longterm immunosuppression, cell loss in the case of allogeneic limbal transplantation, and complications such as glaucoma and infectious endophthalmitis in the case of keratoprostheses.

EUROTIMES | APRIL 2016

To overcome some of these issues and taking their cue from the wider trend towards regenerative medicine, research teams around the world are drawing on major advances in tissue engineering, molecular biology, nanotechnology and biomaterials to try to restore the intricate homeostasis integral to ocular surface health and integrity.

In Europe alone, numerous research programmes are currently under way to find improved methods of accelerating ocular surface healing and reconstruction using techniques such as limbal and mesenchymal stem cell transfer, novel amniotic membrane matrixes, mimetic constructs and decellularised corneas, among others.

“It is a very exciting time to be involved in the field of ocular surface reconstruction and to witness the progress that has been made on so many fronts over the past decade. At least now, we actually have some different options to offer patients with severe OSD and give them a real chance at minimising their visual loss,” said Marie-José Tassignon MD, PhD, FEBO, Professor and Head of the

Department of Ophthalmology, University Hospital Antwerp, Belgium, and one of the lead partners in several EU-funded corneal regeneration projects.

ARREST BLINDNESS Beginning this year, ARREST BLINDNESS (Advanced Regenerative and REStorative Therapies to combat corneal BLINDNESS) is a four-year EU Horizon 2020 project with a budget of €6million bringing together researchers and companies from eight European countries. The goal is to develop innovative, targeted regenerative therapies for the cornea focusing on bioartificial organs, tissueengineered scaffolds and advanced cell and molecular therapies.

ARREST BLINDNESS follows on from the COST Action project of the European NexCR consortium (Network of Excellence in Corneal Regeneration), the aim of which is to develop biodegradable artificial corneas, consisting of bio-matrices seeded with host limbal stem cells.

“I think these are excellent examples of what pan-European collaboration

COVER STORY: CORNEA

AMNIOTIC MEMBRANE While many ocular surface regeneration projects are still in the experimental stage, other improvements to existing methods are already making a tangible difference to patient outcomes in the clinic. Amniotic membrane, for instance, has been employed in corneal surface reconstruction since the mid-1990s, but new applications are showing promise beyond its use as a structural scaffold to promote epithelial wound healing, points out Scheffer Tseng

Courtesy of Marie-José Tassignon MD, PhD, FEBO

can achieve. We have different research institutions focusing on different aspects of the problem, and bringing their expertise to bear in areas such as scaffold development, cell biology, tissue engineering and so forth. There is still a long way to go before the biocornea will be ready for clinical use in humans, but we are making steady progress on all fronts,” Prof Tassignon told EuroTimes.

The Antwerp group is also involved in REGENERATE, another EU project (EuroNanoMed II) focused on exploiting the recent introduction of human recombinant collagen to develop transparent, mechanically stable and peptide-enhanced nano-scaffolds that mimic the corneal collagen alignment observed in normal, healthy corneas.

Such scaffolds could play a critical role for tissue engineering limbal epithelial stem cell grafts. These are required in cases of limbal stem cell deficiency (LSCD), which cause conjunctival encroachment over the cornea with scarring, corneal neovascularisation and opacification, reduced visual acuity and photophobia.

While the surgical transplantation of large segments of donor-excised limbal tissue is often effective for such cases, the procedure carries a high risk of complications. Small limbal grafts cultured on biological scaffolds such as the amniotic membrane have also been shown to be feasible but are optically deficient, difficult to standardise and carry health risks.

“With REGENERATE the idea is to engrave (micro-pattern) the surface of the human recombinant collagen scaffold to encourage optimal cell growth and adherence. We are currently testing different patterns on different scaffolds in animal models of LSCD, and the data acquired will give us a better understanding of the role that collagen nano-fibre alignment and surface nanopatterning plays in improving implant integration and survival,” she said.

The protocol of University Hospital Antwerp consists of the following steps: 1 - Prelevation of the limbal biopsy at the 12 o’clock position; 2 - Culturing of the biopsy on an amniotic membrane spanned over an interlockable ring; 3 - After two weeks of culture the patients are planned for surgery. The fibrovascular tissue on top of the cornea is removed; 4 - The composite graft consisting of the biopsy with the two weeks culture is transplanned on the debulcked cornea; 5 - After one year of observation, the patient receive a penetrating keratoplasty. The affected eye is not only in better condition but in some cases recovers a certain degree of visual acuity

MD, PhD, Medical Director of the Ocular Surface Center, Miami, Florida, USA. “Recent research strongly suggests that amniotic membrane can be used not just as a surgical graft for reconstruction but also as a temporary biological bandage.

This is changing the way we are treating OSD conditions as simple as dry eye and as serious as chemical burns. It also alters the way we think about this tissue as something which may contain active components that can be released through the membrane to deliver therapy directly onto the cornea or the ocular surface,” he told EuroTimes.

Dr Tseng said that initial trials conducted using the FDA-approved Prokera class II biological bandage device (Bio-Tissue, Inc) have shown encouraging results for moderate to severe dry eye, and other OSDs. “It can be used rather easily in the office without bringing the patient into the operating theatre, and is very useful in treating diseases that require amniotic membrane technology where time is of the essence to prevent serious visionthreatening complications with early intervention,” said Dr Tseng.

I think these are excellent examples of what pan-European collaboration can achieve Marie-José Tassignon MD, PhD, FEBO

5

A primary focus of Dr Tseng’s research over the past decade has been to shed light on the molecular composition of amniotic membrane and specifically the properties that enable it to promote epithelialisation, suppress inflammation, and inhibit scarring and angiogenesis.

“Our research has shown that amniotic membrane contains a very unique matrix.

Biochemically we have succeeded in purifying this novel matrix, called HC-HA/ PTX3, which can be very effective in anti-inflammatory, anti-scarring or antiangiogenic action. Moreover, we have shown that the same matrix component can also maintain stem cell quiescence. This is very important because stem cell function is dictated by quiescence. To maintain tissue integrity, stem cells need to be captured at the quiescent stage and kept that way, and this matrix component is able to achieve that,” he added.

SILKEN PROMISE In animal models, the matrix has already been shown to be effective at preventing corneal allograft rejection and graft versus host disease complications such as severe dry eye.

Going forward, Dr Tseng believes that inflammation needs to be given greater prominence in any strategy seeking to regenerate the ocular surface.

“It really is not that different from the rest of the body. Every disease, be it cancer, dry eye or graft versus host disease, is characterised by prolonged, uncontrolled inflammation. We have perhaps put too much emphasis on EUROTIMES | APRIL 2016

COVER STORY: CORNEA

NEW APPROACHES

Courtesy of Marie-José Tassignon MD, PhD, FEBO

6

Three cases of patients with severe limbal stem cell deficiency: prior to surgery (left column), after application of the composite graft (middle column), and after penetrating keratoplasty performed one year after the initial limbal stem cell transplantation (right column)

We have spent the last 12-18 months optimising our preclinical model and refining our fibroin membranes Damien Harkin PhD

the belief that stem cell failure is at the root of the problem, when we really need to be looking more at the stem cell environment. An environment loaded with chronic inflammation is not conducive to stem cells doing their job properly, so we need to ensure that antiinflammatory therapy is a key part of our arsenal for regenerative medicine,” he said.

While amniotic membrane has become a mainstay of ocular surface regeneration methods, it does have some limitations including poor mechanical strength, semi-transparent appearance, difficulty of handling, and the potential risk of disease transmission. Such issues have prompted researchers to find new biomaterials capable of supporting the growth and differentiation of corneal epithelial cells. These include materials such as fibrin glue, keratin, chitosan hydrogels, thiloated crosslinked hyaluronic acid films (CMHA-S), extracellular matrix (ECM) based scaffolds, siloxane-hydrogel contact lenses, thermo reversible polymers and nanofibre scaffolds.

Another potential material showing promise for corneal reconstruction is silk fibroin, the primary structural protein of Bombyx mori silkworm cocoons.

EUROTIMES | APRIL 2016

“Silk fibroin is particularly well suited for corneal regeneration, as it can be readily purified and fabricated into transparent membranes that support the growth and differentiation of corneal epithelial cells,” said Damien Harkin PhD, an Associate Professor at the Queensland University of Technology, Brisbane, Australia.

Dr Harkin and co-workers at the Queensland Eye Institute are currently investigating the feasibility of using silk fibroin as a vehicle for delivering corneal epithelial cells and corneal stromal cells, primarily with a view to treating LSCD. The group is also looking at using fibroin membranes to implant corneal endothelial cells, but this aspect of the research needs to be developed in conjunction with advances in stem cell differentiation, said Dr Harkin.

“We have spent the last 12-18 months optimising our preclinical model and refining our fibroin membranes. While our model is currently being used to test a different hypothesis relating to our broader interests in corneal stem cells, we plan to examine the safety and feasibility of using fibroin membranes as a vehicle for delivering limbal epithelial cells within the next six-12 months,” he said.

Topical compounds designed to enhance corneal wound healing and cell proliferation also hold great promise for ocular surface regeneration. Cacicol® (Laboratoires Théa), a matrix therapy agent for the management of chronic corneal wound healing, is already commercially available in Europe and has performed well in early clinical trials.

Another topical agent, recombinant human nerve growth factor (rhNGF, Dompé), is currently undergoing phase I/II trials for the treatment of neurotrophic keratitis with results due in the coming months.

Blood-derived products such as platelet rich plasma (PRP) growth factors are also sparking interest from clinicians. Dr Jorge L Alió in Alicante, Spain, has reported a high success rate treating more than 1,000 patients in recent years with autologous PRP for a variety of OSDs. Other groups are exploring the potential of recombinant human growth hormone (rHGH) to promote corneal wound healing by enhancing and stimulating corneal epithelial cell and fibroblast and migration in vitro and in vivo.

One approach currently undergoing trials in animal models has been to formulate CMHA-S (Jade Therapeutics) to deliver rHGH to the ocular surface for persistent corneal epithelial defects (PCEDs).

“HGH could be an effective therapy used in conjunction with other treatments such as antibiotics or steroids to facilitate the healing of ocular wounds and disparities that are persistent,” said Barbara Wirostko MD, Clinical Adjunct Associate Professor in Ophthalmology at the University of Utah, USA, and co-founder of Jade Therapeutics.

If all goes according to plan, Dr Wirostko hopes that rHGH will be ready for clinical studies in human eyes in a few years.

“We have conducted dose ranging studies and we are now optimising a favourable dose formulation. rHGH is extremely sensitive to degradation and as such will not be stable in liquid form for extended time periods. We have been working with formulating rHGH as a dried film formulation using our novel and proprietary biodegradable CMHA-S polymer, a topical innovative polymer formulation. This unique CMHA-S already has extensive global animal data from the veterinary space on its ability to help heal the cornea as well as deliver autologous stem cells clinically, hence making it a very attractive polymer to develop to treat this unmet need in ophthalmology,” she added.

Marie-José Tassignon: marie-Jose.tassignon@uza.be Scheffer Tseng: stseng@ocularsurface.com Barbara Wirostko: barbara.wirostko@jadetherapeutics.com Damien Harkin: d.harkin@qut.edu.au

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SPECIAL FOCUS: CORNEA

CXL LONG-TERM Corneal crosslinking safe and effective for treating keratoconus.

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Dermot McGrath reports

orneal crosslinking (CXL) has been proven to be a safe and effective means of treating keratoconus over the long-term, Frederik Raiskup MD, PhD, FEBO told delegates attending the 6th EuCornea Congress in Barcelona, Spain.

“I think when we look at the evidence in the scientific literature and consider that it is now over 16 years since the first CXL procedure was performed in human eyes, we are justified in speaking about long-term results for this procedure,” he said.

Discussing the clinical results of epithelialoff CXL, Dr Raiskup, Carus University Hospital, Dresden, Germany, said that a cursory examination of PubMed shows that interest in the procedure shows no sign of diminishing.

“Last year (2014) there were around 850 papers on this topic, whereas today another 250 papers have been added to the list and the trend shows no sign of slowing down,” he said.

While many of these papers were nonrandomised case series or retrospective studies, a number of randomised controlled trials have been conducted in recent years, added Dr Raiskup.

The study by Wittig-Silva et al (Ophthalmology. 2014 Apr;121(4):812-21) for instance recently presented three years’ results of a prospective, randomised controlled trial of 94 eyes, 48 in the control group and 46 in the treatment group.

SUSTAINED IMPROVEMENT “The conclusion at 36 months was that there was a sustained improvement in maximum simulated keratometry values (Kmax), uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) after CXL, whereas eyes in the control group demonstrated further progression of keratoconus,” he said.

The evidence, however, was less clear-cut in a review and metaanalysis by Craig et al (Ocul Surf. 2014 Jul;12(3):202-14), said Dr Raiskup.

Their literature search identified 3,400 records of which 49 were considered for inclusion in the metaanalysis. The majority of the studies (39/49) were graded as very low quality evidence.

While statistically significant improvements were found in all efficacy outcomes at 12 months after the operation, the authors noted that “uncertainty remains about the duration of benefit”.

Another wide-ranging review by Hamada et al for the Cochrane Collaboration (Cochrane Database Syst Frederik Raiskup MD, PhD, FEBO Rev. 2015 Mar 24;3) analysed

The authors concluded that there is reason to believe that this reduction is for a great part caused by the introduction of CXL treatment

EUROTIMES | APRIL 2016

data from 219 eyes drawn from three randomised controlled trials of CXL. The study concluded that the evidence for the use of CXL in the management of keratoconus is limited due to the lack of properly conducted randomised controlled trials.

A more recent study by O’Brart et al (Am J Ophthalmol. 2015 Aug 22. pii: S0002-9394(15)00517-6) reported that improvements in topographic and wavefront parameters evident at one year after CXL continued to improve at five years and were maintained at seven years.

The conclusions of O’Brart’s study were also echoed in the 10-year results published

by Dr Raiskup’s own group in 2015 (Journal of Cataract & Refractive Surgery, Volume 41, Issue 1, 41-46) of 34 eyes of 24 patients which found that CXL was safe and effective in treating progressive keratoconus and achieving long-term stabilisation of the condition.

Good results have also been obtained in paediatric patients, said Dr Raiskup.

“We know these patients are at high risk because of the very fast progression of keratoconus and increased probability of the need for corneal transplant.”

In a study carried out by Caporossi et al (Cornea. 2012 Mar;31(3):227-31), 152 patients with progressive keratoconus aged 18 years or younger (range 10-18 years) demonstrated significant and rapid functional improvement and stable outcomes up to three years after CXL treatment.

The evidence for the efficacy of so-called accelerated CXL, which shortens the illumination time by increasing the illumination intensity and reduces the overall treatment time, was less convincing, said Dr Raiskup.

“This works well in theory, but when we perform these experiments on animal corneas, we see that the biomechanical effect is limited up to the intensity of around 45mW/cm2.

Studies by Hammer et al (Invest Ophthalmol Vis Sci. 2014 May 2;55(5):2881-4) also showed that the biomechanical effect of CXL decreased significantly when high irradiance and shorter irradiation time settings were used,” he said.

OXYGEN CONSUMPTION The Hammer study also identified increased oxygen consumption associated with higher irradiances as a potentially cause of reduced treatment efficiency, said Dr Raiskup. He said that more controlled, randomised studies were needed to properly assess the safety and efficacy of accelerated CXL. Dr Raiskup also noted that a few recent studies have underscored the cost-effectiveness of CXL compared with standard management for the treatment of progressive keratoconus.

He concluded by citing the results of a 2015 study by Sandvik et al (Cornea. 2015 Sep;34(9):991-5), which reported that the frequency of keratoplasty for keratoconus had been more than halved in their department over the last decade.

“The authors concluded that there is reason to believe that this reduction is for a great part caused by the introduction of CXL treatment. I think this confirms what we are seeing ourselves in our own clinic,” he said.

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

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7th EuCornea Congress

OPENHAGEN2016

9–10 September Bella Center, Denmark Scientific Programme, Registration & Hotel Bookings

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www.eucornea.org

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European Society of Cornea and Ocular Surface Disease Specialists

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SPECIAL FOCUS: CORNEA

CULTURING CELLS Industrialising the process necessary to make cell injection therapy a reality.

Howard Larkin reports

W

ith several patients regenerating anatomically perfect corneas and recovering 20/20 vision in an early trial, injecting cultured corneal endothelial cells (CECs) shows great promise for treating Fuchs’ and other corneal endothelial dysfunction. However, many challenges must yet be overcome for the technology to move from the lab to the clinic, Naoki Okumura MD, PhD told the 6th EuCornea Congress in Barcelona, Spain.

Developing CEC injection therapy from concept to the first clinical trial took nearly a decade, said Dr Okumura, of Doshisha University, Kyoto, Japan. Several more years will be required to conduct clinical trials comparing CEC injection to endothelial keratoplasty, and to develop processes for reliably culturing high-quality cells and efficiently distributing them for clinical use.

ROCK INHIBITOR BREAKTHROUGH Early injections of cultured rabbit CECs into rabbit eyes with induced endothelial dysfunction failed to regenerate transparent corneas, Dr Okumura said. Analysis revealed that removing CECs from the culture plate activated a Rho kinase (ROCK) pathway that interfered with their ability to attach to a substrate and enabled anoikis, or programmed cell death induced by separation from the extracellular matrix.

Dr Okumura and colleagues hypothesised that countering this activation with a ROCK inhibitor might allow injected CECs to adhere to Descemet’s membrane.

And sure enough, damaged corneas of rabbit eyes injected with both CECs and the ROCK inhibitor Y-27632 cleared and thinned significantly after 48 hours, with CECs densely adhering, while those injected with CECs only remained as clouded and thick as untreated controls, with very few CECs adhering.

Subsequently, six of six monkeys with induced corneal dysfunction regenerated completely transparent and anatomically normal corneas after injection with cultured monkey CECs and Y-27632. “This was proof of concept,” Dr Okumura said.

Beginning in 2013, Dr Okumura and colleagues injected human CECs and Y-27632 into the anterior chambers of patients with Fuchs’ endothelial dystrophy in an as-yet unpublished clinical trial.

Several of these patients regenerated anatomically normal corneas with vision EUROTIMES | APRIL 2016

returning to 20/20, Dr Okumura reported.

One year after treatment, one patient saw better with the CEC injection-treated eye than his fellow eye, which had received Descemet’s stripping automated endothelial keratoplasty (DSAEK) five years earlier – showing that tissue engineering has the potential not only to relieve donor cornea shortages, but also improve visual outcomes for patients with endothelial diseases.

However, treating patients with CEC injection requires very large quantities of cultured cells. In theory, five passes of seeding and expansion can produce enough cells from a single donor cornea to treat more than 200 patients. In practice this has proven quite difficult, Dr Okumura said.

Early attempts found limited proliferation of human CECs in vitro, and the cells that did develop often transformed into non-functioning fibroblastic phenotypes.

As cells underwent multiple expansion passes, their quality also fell, with many cells in later passes becoming senescent.

This limited their density, ability to create tight intercellular junctions, and their ion pumping capacity, all of which are needed to create an effective epithelial barrier with pump action that prevents corneal oedema.

ROCK inhibitors helped by promoting in vitro cell proliferation and adhesion.

Conditioning support medium with human bone marrow mesenchymal stem cells also promoted cell proliferation.

Coating the culture substrate with Laminin

511-E8 significantly enhanced cell proliferation and promoted rapid growth with high cell density.

Analysis also found that CEC fibroblastic transformation could be interrupted by inhibiting TGF-β receptors. This resulted in culturing hexagonal phenotype cells that expressed normal pumping and intracellular adhesion proteins, Dr Okumura said.

Centrifuging cultured cells has also proven an effective way to remove senescent cells, which have a lower density. Higher cell density has proven to be an important predictor of better clinical outcomes in animal models, he added.

Incorporating these features has produced a CEC culturing protocol sufficient for research. “We are now routinely culturing human CECs for clinical trial use,” Dr Okumura said.

But many steps remain before cultured human CECs become clinically available.

“We do understand the long and winding road waiting for us. But we have to move forward to commercialisation and industrialisation, because we believe that to provide the cultured cells by eye banks or companies is the only way to make this therapy a real therapy that helps patients,” added Dr Okumura.

References available on request Naoki Okumura: nokumura@koto.kpu-m.ac.jp

SPECIAL FOCUS: CORNEA

CROSSLINKING CXL-plus benefits patients with ectatic disorders.

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Dermot McGrath reports

orneal crosslinking (CXL) can safely and effectively be combined with a variety of adjuvant procedures such as intracorneal ring or phakic intraocular lens (IOL) implantation in order to stabilise the cornea and simultaneously deliver good functional vision in selected patients, George Kymionis MD, PhD told delegates attending the 6th EuCornea Congress in Barcelona, Spain.

“Adjuvant-combined procedures, whether Intacs, phakic refractive lenses or ablative procedures, maximise the effect and the benefits of simple CXL. The surgeon can customise the technique according to the patient’s preoperative data as there is no single rule that can be applied to every patient,” he said.

Dr Kymionis said that, while CXL has proven to be an excellent procedure in terms of halting the progression of keratoconic and ectatic corneas, some patients remain dissatisfied after treatment because of poor functional vision.

He cited the example of one of his first patients treated for progressive keratoconus in 2006. Before treatment, her uncorrected visual acuity (UCVA) was 20/100 and she was contact lens- and spectacle-intolerant. She also had a corneal thickness of around 490 microns. Three years after CXL, the topography maps showed that the keratoconus had stabilised or even slightly improved.

“While this made the doctor happy, the patient was still very unhappy as she had both poor UCVA and poor best spectaclecorrected visual acuity (BSCVA), and she was still not able to wear contact lenses or glasses,” said Dr Kymionis, Department of Ophthalmology, Medical School, National and Kapodistrian University of Athens, Greece.

BETTER FUNCTIONAL VISION This scenario, where the patient has been effectively “cured” but remains unhappy because of poor quality of vision, prompted Dr Kymionis to experiment with adjuvant refractive treatments that might provide better functional vision for these patients.

Potential combined treatments with CXL, which Dr Kymionis has termed “CXL-plus”, include intrastromal corneal ring segment implantation, photorefractive keratectomy (PRK), transepithelial phototherapeutic keratectomy (PTK), phakic IOL implantation, and multiple combined procedures. CXL treatment in

combination with intracorneal ring segment implantation can be an effective treatment, said Dr Kymionis, as the synergic influence of the two procedures can partially reverse the progressive irregular astigmatism and result in favourable outcomes for the patient. The ring segments are placed first, followed by CXL treatment.

Another option to implant a toric intraocular contact lens also worked quite well, but was not effective for treating irregular astigmatism, he said.

Topography-guided PRK followed

by CXL has also delivered good results, said Dr Kymionis. Several studies have shown that keratoconic patients treated with simultaneous topography-guided PRK followed by CXL showed significant improvement in best corrected visual acuity, UCVA and keratometric values. In a longterm study of simultaneous topographyguided PRK followed by CXL in a series of keratoconic patients recently published by Dr Kymionis, all patients showed marked improvement of corneal irregularity and visual acuity over the follow-up period.

In a comparative case series of 38 eyes, Dr Kymionis and co-workers showed that epithelial removal using transepithelial PTK during CXL (Cretan protocol) resulted in better visual and refractive outcomes compared with mechanical epithelial debridement.

Because some uncertainty remains as to the optimal strategies for each patient, a decision tree can be usefully employed to ensure optimal patient management, said Dr Kymionis.

After diagnosis of keratoconus, patients with deep scar, very thin corneas, and low visual acuity with rigid gas permeable (RGP) contact lenses are probably likely candidates for deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PKP).

If none of these criteria are present and the keratoconus is progressive, then patients with acceptable visual acuity and good contact lens tolerance can undergo CXL. Poor visual acuity and contact lens intolerance means that CXL-plus may be considered. Likewise, CXL-plus may be an option in cases of no progression with poor visual acuity, said Dr Kymionis.

Summing up, Dr Kymionis said that combined treatments seem to be the way to optimise the result of CXL treatment for keratoconus, although further studies with longer follow-up are needed to confirm the promising results of this approach.

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George Kymionis: kymionis@med.uoc.gr EUROTIMES | APRIL 2016

11

SPECIAL FOCUS: CORNEA

Diagram showing steps of technique in a cross section view. A - Femtosecond laser separates the lenticule of myopic patient. B - Lenticule being extracted through small incision.

C - Lenticule placed on deepithelialised surface, the lenticule’s thickest portion (1) being placed over thinnest part of cone (2)

CORNEAL THICKNESS SMILE-CXL combination safe and effective ectasia treatment.

Dermot McGrath reports

U

sing a refractive stromal lenticule offers a safe, effective and viable means of enhancing corneal thickness during corneal crosslinking (CXL) in patients with kerectasia and thin corneas, according to Hemlata Gupta MD. “While longer follow-up is needed to ascertain progression of disease and possible scar formation, our study showed that myopic lenticule-assisted CXL seems to be a safe and effective technique to perform CXL in thin and ultra-thin corneas that would not otherwise be amenable to CXL,” she told delegates attending the XXXIII Congress of the ESCRS in Barcelona, Spain.

Dr Gupta, Centre for Sight, New Delhi, India, noted that while CXL is the only treatment modality currently available which halts disease progression in keratoconus, the standard Dresden protocol requires a corneal thickness of at least 400 microns after epithelial removal to safely crosslink the cornea.

“The problem is that many patients with advanced progressive ectasia often have thinner corneas, a situation which is not helped by the fact that referral of the disease is usually late in developing countries like India,” she said.

She explained that ReLEx (refractive lenticule extraction) and SMILE (small incision lenticule extraction) is a femtosecond laser technique which involves creation of a refractive lenticule with femtosecond laser (VisuMax, Carl Zeiss Meditec) and its removal through a small incision. Using this technique, a stromal lenticule is placed and spread over the host cornea following epithelial debridement, so the thickest area of the lenticule corresponds to the thinnest area of the cone. The remaining collagen crosslinking procedure is then carried out in a routine manner.

EUROTIMES | APRIL 2016

Dr Gupta’s study included seven patients affected by progressive kerectasia with thinnest pachymetry values ranging from 360 microns to 397 microns. The epithelium was debrided and a stromal lenticule 6.0mm in diameter and thickness of 110 to 120 microns was placed so that the centre of the lenticule corresponded to the apex of the cone. All patients underwent complete ophthalmological examination, including endothelial cell density measurements and Pentacam before CXL and at one, six and 12 months thereafter.

No intraoperative or postoperative complications were noted and best

corrected visual acuity with contact lens fitting of 6/9 or more was achieved in all cases. Corneal stability was demonstrated on topography at 12 months follow-up and specular microscopy revealed no significant endothelial cell loss.

“This technique increases the corneal thickness in the most physiological way and seems to a safe, effective and viable alternative to enhance corneal thickness during CXL for these patients,” she concluded.

Hemlata Gupta: hemlatagupta@rediffmail.com

Courtesy of Centre For Sight, New Delhi, India

12

Preoperative Pentacam of left eye of a 17-year-old patient with thinnest pachymetry 374 microns

10–14 September

2016

XXXIV Congress of the ESCRS

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

/ESCRS

@ESCRSOfficial

ESCRS

14

CATARACT & REFRACTIVE

BENEFITS OF LENS

E

Extended-depth-of-focus lens provides spectacle independence at many distances. Howard Larkin reports

arly results of a large multicentre trial suggest that a new extended-range-of-vision intraocular lens (Symfony, AMO) provides good functional vision and spectacle independence across a wide range of distances for most patients, with better intermediate vision than many competing bifocal multifocal IOLs, Béatrice Cochener MD, PhD told the XXXIII Congress of the ESCRS in Barcelona, Spain.

She reviewed the results of 229 patients bilaterally implanted with the Tecnis Symfony lens and followed them for four to six months after surgery. The sample includes 60 patients targeting micro-monovision. Overall, the ongoing study involves 481 patients treated at 42 European centres, said Dr Cochener, who is an active research consultant for the Abbott-sponsored trial.

Nearly 95 per cent of patients reported never or only occasionally needing spectacles for distance vision, while 93 per cent reported spectacle independence for intermediate and 75 per cent for near, said Dr Cochener, Professor and Chairman of the Department of Ophthalmology at Brest University Hospital, France.

Postoperative mean uncorrected visual acuity was decimal 0.95 for distance, 0.79 intermediate and 0.7 near. A subset of patients targeted for micro-monovision, or -0.25 to -0.75 dioptre in the non-dominant eye, had slightly worse mean uncorrected distance vision at 0.92, but better intermediate at 0.85 and near at 0.8.

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ELONGATED FOCUS Compared with a similar aspheric monofocal lens, the Symfony lens’ diffractive echelette optic elongates its focal point by about 1.0D, improving visual acuity continuously across the entire defocus curve, Dr Cochener explained. Combined with the eye’s approximately 0.5D of natural pseudoaccommodation, this yields binocular functional vision over about 2.5D of defocus – which translates to 20/40 or better from 40cm to infinity. Micromonovision can further extend this range.

The arrangement eliminates the intermediate distance defocus dip typically seen with multifocal designs, which split incoming light into two or three discrete focal points. However, it also weakens near vision performance compared with most multifocal lenses.

The functional advantage of targeting micro-monovision with the Symfony lens is reflected in lower near vision spectacle use. Nearly 25 per cent of all patients said they needed glasses for near vision half the time or frequently, compared with less than 17 per cent of the micro-monovision subgroup, Dr Cochener reported.

Micro-monovision was associated with a gain of about one line of vision. The micro-monovision subgroup also ended up slightly more myopic than all patients, with a post-op mean spherical equivalent of -0.55 +/- 0.52 compared with -0.36 +/- 1.27.

The Symfony optic also corrects for chromatic aberration, reducing image blur resulting from the approximately two-dioptre difference in refraction between the shortest and longest visible wavelengths. This improves modulation transfer function, in turn improving contrast sensitivity, which is comparable to a monofocal lens and superior to most multifocal designs.

Photic phenomena were also less common with the Symfony IOL than typically observed with conventional multifocals. Most often reported were halos at 10 per cent of all patients, with 6.1 per cent moderate and 3.9 per cent severe. Moderate and severe glare was reported by 3.3 and 2.2 per cent respectively; starbursts by 1.3 and 0.4 per cent; and “other” by 2.4 and 0.2 per cent. The micromonovision subgroup reported halo and “other” slightly more often and glare slightly less often.

Patients were also very satisfied, Dr Cochener said. On a zero to 10 point scale with 10 best, mean satisfaction with distance vision was 8.92, intermediate 8.83 and near 7.9 for all patients. At a mean 8.57, micro-monovision patients were slightly more satisfied with near vision, but slightly less satisfied with distance at 8.33.

Overall satisfaction of surgeon performance was also high, with a mean of 8.76 for mini-monovision and 8.89 for all patients. Nearly 95 per cent of all patients would recommend Symfony to friends or family, while 96 per cent would choose the same lens again.

Nearly 95 per cent of patients reported never or only occasionally needing spectacles for distance vision,..

Béatrice Cochener MD, PhD

EUROTIMES | APRIL 2016

Béatrice Cochener: beatrice.cochener@ ophtalmologie-chu29.fr

CATARACT & REFRACTIVE

IOL STUDY RESULTS Fluid-filled hydrophobic acrylic accommodative IOL in clinical trials. Leigh Spielberg MD reports

C

an we create an intraocular lens (IOL) that replicates this mechanism?” asked Jorge L Alió MD, PhD as an animated video of a crystalline lens cycled through the shape transformation of accommodation and relaxation. “Are accommodative IOLs possible?”

Dr Alió presented the results of a prospective study of the accommodative response of an accommodative IOL, the Akkolens Lumina, to delegates at the XXXIII Congress of the ESCRS in Barcelona, Spain. The study included 82 eyes of 58 patients with ages ranging from 43 to 85 years. Fifty-nine eyes were implanted with the Akkolens, while 23 eyes were implanted with the monofocal AcrySof SA60AT IOL. “The Akkolens Lumina was designed based on the Alvarez principle, in which a two-element varifocal lens changes its focal power by a sliding shift of optical elements in the plane perpendicular to the optical axis,” explained Dr Alió, of Vissum Ophthalmologic Institute, Alicante, Spain.

In this case, the sliding shift is caused by muscular contractions of accommodation.

Before he discussed the results of the study, Dr Alió outlined several conditions for a new accommodative IOL. First, it must operate independently of the capsular bag. Outcomes must be tested by optometrical standards for near (40cm) and intermediate (70cm) vision. Accommodation should be measured by both subjective and objective tests. Further, pseudoaccommodation should be identified, and outcomes must be proven in large, long-term, multicentre studies.

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BASIC APPROACHES Historically, accommodating IOLs have known three basic approaches. These include a change in axial position of an IOL with single or dual optic; a change in refractive index or power; and a change in the shape or curvature of the lens, which would occur via capsular bag elasticity, via the zonulo-capsular diaphragm or via changes in vitreous-capsular pressure, he explained.

Distance and near visual acuities, defocus curve, and the objective accommodation with the Grand Seiko WAM-5500 autorefractometer were measured. The follow-up was 12 months.

The results demonstrated statistically significant better near visual acuities for the Jorge L Alió Akkolens in uncorrected near visual acuity and corrected distance near visual acuity (p<0.01). A statistically significant difference was also observed between groups for defocus levels between -4.50 and -0.50D (p<0.01) with better values for the Akkolens.

Both depth of focus and WAM accommodative stimuli of -2.00D, -2.50D, -3.00D and -4.00D were significantly better in eyes that had received the Akkolens.

“The Akkolens Lumina accommodative IOL demonstrated an accommodative response and a depth of focus greater than the monofocal control group,” said Dr Alió.

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Jorge L Alió: jlalio@vissum.com EUROTIMES | APRIL 2016

15

16

CATARACT & REFRACTIVE

CORNEAL INLAYS

T

Non-refractive inlay that modifies corneal asphericity scores high on safety and efficacy. Roibeard O’hEineachain reports

he Raindrop Near Vision Inlay (ReVision Optics) appears to fulfil all the requirements of an ideal corneal implant for the correction of presbyopia, said Patrick Versace MD, who is in private practice in Sydney, Australia.

“The Raindrop inlay is now our preferred treatment for the emmetropic presbyope. It has minimal impact on uncorrected distance visual acuity and provides excellent spectacle independence,” Dr Versace told the XXXIII Congress of the ESCRS in Barcelona, Spain.

He noted that their preference is based on their experience with 60 consecutive presbyopic patients who underwent implantation of one of three different types of corneal inlays in their non-dominant eye at their centre over a period of six years.

The first inlay they used was the KAMRA inlay (AcuFocus), which they implanted in 47 patients as part of an FDA trial. The 3.8mm diameter implant is opaque except for a 1.6mm aperture which increases the depth-of-focus through the pinhole effect.

The next inlay Dr Versace and his associates tried – and the one they have settled on for the time being – was the Raindrop Near Vision Inlay (ReVision Optics). The clear hydrophilic hydrogel inlay is designed to provide a broad depth-offocus by reshaping the anterior corneal shape while also inducing a small myopic shift. The implant is best suited for emmetropes and those with a small amount of hyperopia.

Among the five patients implanted with the inlays at his centre, all achieved an uncorrected binocular visual acuity of 6/6 or better for distance and a monocular near visual acuity of N5 or better in their treated eye at one month. “At present, the Raindrop ticks the boxes for me. It has good functional near vision, you preserve binocular function and distance vision is minimally affected. There are also very few photopic symptoms and the cornea seems to tolerate it well,” said Dr Versace.

Dr Versace and his associates found that, in general, patients achieved good gains in near visual acuity without any significant loss of distance visual acuity. However, 30 per cent of eyes had a hyperopic shift greater than one dioptre over the first postoperative year and 10 (21 per cent) of the inlays were removed as a result.

NEAR FOCUS Dr Versace and his associates also implanted a small series of the Presbia Flexivue Microlens™ (Presbia). The corneal inlay is 3.2mm in diameter and has a central 0.51mm hole within 1.6mm nonrefractive zone.

Surrounding that is a refractive annulus designed to provide a gradation of near focus from +1.5D to +3.5D. In the eight patients who underwent implantation of the Flexivue inlay, functional near vision was good. However, several patients lost lines of corrected distance visual acuity in the operated eye and three implants were explanted as a result.

Patrick Versace: patrick.versace@bigpond.com

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29 th International Congress of GerMan OphthalMIC SurGeOnS June 09 th - 11th, 2016 · nürnbergConvention Center, nCC Ost

Main topics ➤ award ceremonies and honorary lectures ➤ Cataract surgery ➤ Glaucoma surgery ➤ Corneal surgery ➤ DOC – ISrS/aaO-Symposium

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Video live Surgery Friday, June 10th Saturday, June 11th (3D) Scientific posters/e-posters

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You are invited to visit a comprehensive industry exhibition with exhibits and information on medical equipment and pharmaceuticals. The exhibition will take place in Hall 7a during the congress.

EUROTIMES | APRIL 2016

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

CATARACT & REFRACTIVE

Patient interface of the in-vivo system (left) In-vivo system set-up (below)

Courtesy of Perfect Lens LLC

18

LASER TO MODIFY IOL New system for postoperative IOL refraction adjustment.

Roibeard O’hEineachain reports

C

alifornia-based company Perfect Lens has developed a new approach to the postoperative adjustment of an intraocular lens (IOL) that involves using a femtosecond laser to change the refractive index of the lens material, said Josef Bille PhD, Professor of Physics at University of Heidelberg, Germany, and Perfect Lens LLC’s Vice President, at the XXXIII Congress of the ESCRS in Barcelona, Spain.

Dr Bille noted that the process, called refractive index shaping, causes a change of the hydrophilicity within the lens, which in turn causes a negative refractive index change in the targeted region of the lens. In this way, it is possible to create a lens within a lens with range of possible optical properties, including asphericity and toricity, which can be finely adjusted postoperatively within the patient’s eye.

Dr Bille noted that they have used the system for a new phase wrapping process, whereby they create a custom Fresnellike lens in a 50μm-thick layer within a standard acrylic hydrophobic IOL (EC1Y, Zeiss). In experiments with their current prototype they have been able to induce changes of up to five dioptres in a predictable fashion with minimal change to the IOL’s modular transfer.

The Perfect Lens system includes an infrared femtosecond laser (Mai Tai HP, Spectra-Physics) and an acousto-optic modulator (Gooch and Housego) to provide pattern shaping and modulate the EUROTIMES | APRIL 2016

laser energy of the beam. The system also includes a 2D scan system (Newson), ultraprecise 3D linear motor set-up and a high numerical aperture microscope and a Nimo 0815 (Perfect Lens) wavefront analyser to measure spherical aberration, modular transfer function and dioptric power.

CUSTOM ASPHERICITY Through this process they have been able to induce spherical aberration changes from -0.27μm to +0.28μm in a standard IOL. The internal lens-shaping process takes only five seconds, reported Ruth Sahler MSc, Perfect Lens LLC Vice President and COO. Visualisation of the in-vivo treatment.

RIS shaping inside the implanted IOL

She added that, although the experiments were carried out in a laboratory setting, the lens modifications were performed in a manner which complies with applicable laser safety regulations. She and her associates are now in the process of developing an interface for use in humans, and animal trials are likely to start soon.

“Our goal is to use the hydrophilicity based refractive index shaping technology to create customised, premium IOLs and to improve the outcome of patients after cataract surgery,” Ms Sahler said.

Josef Bille: josef.bille@urz.uni-heidelberg.de Ruth Sahler: rsahler@perfectlens.com

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20

GLAUCOMA

OPENING THE ANGLE

P

Phacoemulsification a useful option when peripheral iridotomy and medication fail. Roibeard O’hEineachain reports

eripheral iridotomy and phacoemulsification are effective in opening the angle and lowering intraocular pressure (IOP) in patients with angle closure and angle-closure glaucoma, but questions remain regarding precisely when to employ either technique, said Augusto Azuara-Blanco MD, Queen’s University Belfast, UK, at a Glaucoma Day session at the XXXIII Congress of the ESCRS in Barcelona, Spain.

He noted that primary angle-closure glaucoma tends to be greatly underdiagnosed. Current estimates are that it occurs overall in about 0.4 per cent of people over the age of 40 and in 0.94 per cent of those over 70 years of age. However, research has not established what percentage of eyes with primary angle closure will go on to develop an elevated IOP or glaucomatous damage.

“Compared with open-angle glaucoma, there are very few trials concerning angle closure and angle-closure glaucoma so we have less direction about what to do,” said Prof Azuara-Blanco.

TREATMENT GUIDELINES Since primary angle closure suspects have a very low risk of visual loss, their recommended treatment is laser peripheral iridotomy.

The question of whether peripheral iridotomy can prevent angleclosure glaucoma in eyes with narrow angles in the long-term remains a topic of research, he said.

He noted that early reports from the Zhongshan Angle Closure Prevention (ZAP) trial indicate that the procedure is safe in primary angle closure suspects, causing only a temporary IOP elevation in around ten per cent of patients. However, the reports also indicate that the opening of the angle achieved through the procedure diminishes over time.

When angle closure progresses to angle-closure glaucoma, the European Glaucoma Society’s Guidelines recommend peripheral iridotomy and topical medication. However, the guidelines leave the options open regarding patients with an inadequate response to iridotomy and medication.

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Prof Azuara-Blanco recommended using trabeculectomy if the iridotomy opens the angle but leaves IOP uncontrolled.

In eyes where the angle remains closed but IOP is controlled, he recommended monitoring the condition. When the angle remains closed and IOP remains uncontrolled, he recommended phacoemulsification in mild cases and phacotrabeculectomy in more severe cases.

He noted that the rationale behind lens extraction for primary angle-closure glaucoma is based on the phacomorphic pathogenesis of the disease. Lens growth, which is age-related, leads to increased pupillary block which in turn leads to angle closure. Patients who undergo lens extraction for primary angle-closure glaucoma also have a much wider open angle after cataract surgery than they do after laser iridotomy.

Studies indicate that phacoemulsification and trabeculectomy achieve similar reductions in IOP in eyes with angle-closure glaucoma. And although those undergoing trabeculectomy require fewer medications, they also have more complications than those who undergo phacoemulsification. Moreover, around a third of patients undergoing trabeculectomy go on onto develop cataracts as a result.

A study that is now under way, the EAGLE study, asks the question of whether primary lens extraction in primary angle closure and primary angle-closure glaucoma is effective and safe as well as cost-effective. Prof Azuara-Blanco said that he expects to present results from the study at the 12th European Glaucoma Society Congress in Prague in June.

DIFFICULT CASES There are many special considerations to keep in mind when performing phacoemulsification in eyes of patients with primary angle-closure glaucoma. For example, biometry is less predictable in hyperopic eyes than in emmetropic or myopic eyes, and the inaccuracy increases with the degree of hyperopia. However, the refractive outcome achieved in the first eye can be used to adjust the intraocular lens choice in the second eye.

Some of the surgical difficulties involved in eyes with angle-closure glaucoma include shallow anterior chamber, positive posterior pressure, poor pupil dilation and goniosynechiae.

Furthermore, those with previous acute attacks are prone to weak zonules and compromised epitheliums.

Prof Azuara-Blanco recommended using a cohesive viscoelastic or else a spatula under gonioscopic view when performing a goniosynechialysis. He added that clear corneal incisions rather than limbal incisions should be used to avoid iris prolapse.

Compared with open-angle glaucoma, there are very few trials concerning angle closure and angleclosure glaucoma so we have less direction about what to do Augusto Azuara-Blanco MD

Augusto Azuara-Blanco: a.azuara-blanco @qub.ac.uk

GLAUCOMA

OPTIC DISC MARGIN Advances in SD-OCT present new paradigm in glaucoma imaging.

Roibeard O’hEineachain reports

U

sing a clinician-defined disc margin to assess neuroretinal rim should be abandoned in favour of using Bruch’s membrane openingminimum rim width (BMO-MRW) measurements performed with spectraldomain optical coherence tomography (SD-OCT), said Nick Strouthidis MBBS, MD, PhD, FRCS, FRCOphth, FRANZCO at a Glaucoma Day session at the XXXIII Congress of the ESCRS in Barcelona.

“The disc margin defines the outermost limit of the neuroretinal rim. Accurate, reproducible measurement of its location is essential for the quantification of changes in the optic nerve head in glaucoma. However, the disc margin as defined by the clinician does not correspond to any consistent anatomical landmark and therefore is essentially a meaningless theoretical construct. Therefore, quantifying change based on the clinician’s definition of the disc margin is error-prone,” said Dr Strouthidis, Moorfields Eye Hospital, London, UK. When using optic disc stereophotographs, clinicians define the disc margin as the inner aspect of Elschnig’s ring, a white reflective ring internal to the termination of the retinal pigment epithelium. However, studies show that different clinicians viewing the same stereophotograph will invariably mark its location differently.

Moreover, studies involving optic disc stereophotographs co-localised with SD-OCT-based delineations of the neuroretinal rim’s dimensions have failed to identify a consistent anatomical basis for the disc margin as defined by clinicians. The outer limit of the disc’s neural tissue as defined

by SD-OCT is the innermost edge of Bruch’s Nick Strouthidis membrane, the BMO, which may be invisible by ophthalmoscopy or in stereophotographs. It represents the narrowest aperture through which the neural tissue passes and is easily and reliably imaged using SD-OCT. The advent of SD-OCT represents a true turning point in the imaging of the optic nerve head, Dr Strouthidis noted. Timedomain OCT had poor neuroretinal rim penetration. SD-OCT is faster and has better penetration and is therefore is much more capable of imaging the finer neuroretinal tissue structures.

He added that to provide a precise and consistent demarcation of the neuroretinal rim, it should be defined as being where the distance is shortest between the BMO and the internal limiting membrane, that is, the BMO-MRW. The BMO-MRW parameter is potentially better for phenotyping glaucoma suspects than OCT peripapillary retinal nerve fibre layer thickness or Heidelberg retinal tomography (HRT Heidelberg Engineering) Moorfields regression analysis.

It is the first optic disc parameter to change in the primate model of glaucoma. BMO-MRW measurements are now included in the optic nerve head parameters of Heidelberg Engineering’s Glaucoma Module Premium Edition (GMPE) for the Spectralis.

Nick Strouthidis: nick.strouthidis@moorfields.nhs.uk Declaration of Interest: Nick Strouthidis received lecture fees and travel expenses from Heidelberg Engineering

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24

RETINA

VITREOLYSIS VIABILITY? Does the procedure work well enough for routine use?

Roibeard O’hEineachain reports

T

he question of whether enzymatic vitreolysis with ocriplasmin (Jetrea®, ThromboGenics) has sufficient merit to compensate for its lower success rate compared with vitrectomy in the treatment of vitreomacular traction (VMT) and macular holes was the topic of an Amsterdam Retina Debate held at the 15th EURETINA Congress in Nice, France.

First up was Tim Jackson PhD, FRCOphth, of King’s College London, UK, who said that the MIVI-TRUST Trials provided very robust evidence for the agent’s efficacy compared to placebo and that in the right patients its efficacy is acceptable.

MIVI-TRUST was a combined analysis of two randomised, double-masked placebocontrolled phase III trials involving 652 patients with symptomatic VMT and macular holes up to 400µm in diameter. It showed that VMT was resolved in 26.7 per cent of those receiving a single intravitreal injection of ocriplasmin, compared to 10.1 per cent of the controls. In addition, the rate of macular hole closure was 41 per cent in the active treatment group, compared to 11 per cent in the controls.

BETTER RESULTS IN SELECT PATIENTS Furthermore, a subgroup analysis showed that in patients without epiretinal membranes the rate of VMT resolution reached 35 per cent. In addition, in those with macular holes smaller than 250µm the closure rate was nearly 60 per cent.

Regarding complications, retinal tears and retinal detachment (RD) occurred in only 2.2 per cent, and there were a range of other less serious complications, such as new or worsening macular hole in 6.7 per cent. There were also some unexpected complications, such as dyschromatopsia in 1.6 per cent and electroretinographic changes in 0.1 per cent.

He pointed out that in a more recent post-marketing surveillance study involving over 4,000 patients (Hahn et al, Retina 2015;35: 1128-1134), the rates of all complications were only a fraction of those seen in the MIVI-TRUST Trials.

Looking at vitrectomy, Dr Jackson noted that a meta-analysis of the literature involving VMT patients showed that the visual gains with vitrectomy were fairly modest and the rate of RD was 5.6 per cent, with postoperative visual acuity ranging from 6/28 to 6/16 (Jackson et EUROTIMES | APRIL 2016

al, Retina 2013; 33:2012-2017). Other major complications included epiretinal membranes in 7.2 per cent and cystoid macular oedema in 3.1 per cent. In addition, nearly two-thirds of phakic eyes developed cataracts within one year.

Furthermore, a recently published Cochrane review of vitrectomy in macular hole patients showed that they gained only 1.5 lines of visual acuity and the hole closure rate was 76 per cent. In addition, there was a five per cent incidence of RD, and one in 250 patients developed endophthalmitis after the surgery.

Dr Jackson suggested that ocriplasmin may find niche uses, for example, in patients who refuse vitrectomy and those with milder symptoms. He added that the science of chemical vitrectomy continues to evolve.

OCRIPLASMIN UNRELIABLE Taking up the cudgel against enzymatic vitreolysis as a treatment for vitreomacular adhesion and macular holes, was Grazia Pertile MD, Sacro Cuore Hospital, Negrar, Italy. She said that, for a high proportion of patients, undergoing enzymatic vitreolysis was akin to buying a ticket for a cable car that only made it up the hill half the time.

“The effectiveness of vitrectomy is much higher than for ocriplasmin, so if you have a vitreomacular adhesion and you are rational kind of person you would probably choose a small gauge vitrectomy,” she said. She added that modern small-gauge technology has

greatly improved the success rates of vitrectomy, and pointed out that the macular hole treatment failures in the MIVITRUST Trials all subsequently underwent vitrectomy with a success rate of 80 per cent. Vitrectomy is also safer than it used to be, she said. For example, in a study reviewing the outcome of vitrectomy for VMT, the incidence of endophthalmitis was only 0.03 on average.

Regarding RD, a review of a subset of the same patients who underwent 23-gauge vitrectomy showed that the RD occurred in only 0.2 per cent of patients.

In contrast, with ocriplasmin there have been numerous reports in the literature of strange unexpected complications including retinal breaks, transient but severe visual loss, transient electroretino graphic changes and toxicity to the outer retina.

Many of the transient complications most likely result from the proteolytic effect of ocriplasmin on Müller glia cells.

The cells can fortunately regenerate, which explains the gradual, time-dependent nature of the visual disturbances.

However, it still compares unfavourably to vitrectomy in that respect, she said, adding: “If you want to take off the plastic film from the slice of cheese, would you pour some chemicals on it to melt it, even though they tell you that it may cause you stomach-ache for a couple of weeks? Probably not.”

Tim Jackson: t.jackson1@nhs.net Grazia Pertile: grazia.pertile@sacrocuore.it

The MIVI-TRUST Trials provided very robust evidence for the agent’s efficacy compared to placebo...

Tim Jackson PhD, FRCOphth

RETINA

MULTIFOCAL IOL AND AMD New lens improves near vision and quality of life for AMD patients.

Sean Henahan reports

A

new multifocal intraocular lens (IOL) could provide a new way to help patients with macular disease maintain daily functioning with less dependence on low vision aids, reported Gerd Auffarth MD, University of Heidelberg Eye Clinic, Germany, at the 2015 American Society of Cataract and Refractive Surgery Symposium in San Diego, USA. Dr Auffarth reported his very early experience with the LENTIS Mplus High Add IOL in eight age-related macular degeneration (AMD) patients being treated for cataract. The lens is an aspheric multifocal IOL with a biconvex optic that includes a sector-shaped near addition. Its overall length is 11.0mm, with a 6.0mm optic. With a 8.00D near addition, this IOL has the potential to be very useful in patients with AMD because it translates to 6.00D of near correction on the spectacle plane, providing 1.5 times magnifying power, he explained.

The eight patients were all more than 60 years old with wet AMD. All had stable disease and most had received multiple courses of anti-VEGF therapy. The patients had cataracts and received the IOL in one eye only. The CE approved lens is implanted with standard techniques in the capsular bag.

SIGNIFICANT IMPROVEMENTS The early experience was very positive, with all patients showing significant improvements in functional activities such as cooking, handwriting and reading. Patients were able to reduce or eliminate their reliance on low vision loupes. In addition, perhaps because of the nature of the retinal disease, patients reported no problems whatsoever with glare or halos. “Before surgery these patients needed 15x magnification or 20x magnification using cumbersome low vision aids. At 12 months the same patients could read newspapers and perform the daily activities that allowed them to live independently without low vision aids,” said Dr Auffarth.

One patient, a 68-year-old woman, presented with a central macular scar in one eye and AMD in the other.

Before receiving the IOL she required 15x magnification in order to read. She received a 20.5D lens. At 12 months her distance vision improved from 0.1 decimal to 0.3, but her near visual acuity improved to 0.4, good enough to read a newspaper. “We don’t expect to see much improvement in distance because of the nature of the lens and the disease. But the near visual acuity improvement is quite a big thing for this patient,” he added.

Gerd Auffarth: gerd.auffarth@ med.uni-heidelberg.de

Before surgery these patients needed 15x magnification or 20x magnification using cumbersome low vision aids Gerd Auffarth MD

EUROTIMES | APRIL 2016

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8–11 September 2016

COPENHAGEN 16th EURETINA Congress

Bella Center, Denmark

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

/EURETINA

@EURETINA

EURETINA

RETINA

CRVO: LASER ANASTOMOSIS The rationale for L-CRA stems from the limitations of anti-VEGF treatments. Dermot McGrath reports

A

n argon laser-based technique appears to effectively treat the underlying cause of central retinal vein occlusion (CRVO), which is an obstruction to venous outflow and may lead to vision gains in a significant number of patients, Ian McAllister MBBS, FRANZCO told delegates attending the 15th EURETINA Congress in Nice, France.

The laser chorioretinal anastomosis (L-CRA) works to bypass the occluded central retinal vein by creating an anastomosis between a retinal vein and the choroidal venous circulation, and provides an alternative route for the obstructed venous blood to exit the retinal circulation.

The rationale for L-CRA stems from the limitations of antiVEGF treatments, which essentially treat only the component of the CRVO-induced macular oedema caused by upregulated cytokines and not the underlying cause, said Dr McAllister, of Australia.

Studies have shown that raised venous pressure in occluded retinal veins can be up to 24 times the normal pressure and is a component of the macular oedema in CRVO, he explained.

Ian McAllister “Given that we know that venous pressure is a significant but as yet unaddressed component of the macular oedema in CRVO, what can we do about it? It really has been the elephant in the room for too long,” he said.

Since L-CRA usually takes four to six weeks to become apparent, anti-VEGF agents should be deferred for at least one month prior to attempt and one month post attempt, said Dr McAllister.

“I would advise following up at monthly intervals for at least the first six months. Retinal ischaemia from any closure of the distal segment of the vein should be treated with segmental panretinal photocoagulation (PRP). Retinochoroidal neovascularisation from the L-CRA site can be easily controlled with anti-VEGF agents and PRP to any peripheral ischaemia,” he added.

The efficacy of L-CRA has already been demonstrated in the randomised Central Retinal Vein Bypass Study, said Dr McAllister. Some 113 patients who had between three and 12-months onset of non-ischaemic CRVO were randomised to laser-induced chorioretinal venous anastomosis or sham treatment.

With a follow-up of 18 months, a successful L-CRA was created in 76.4 per cent of patients in the treatment group, and treated eyes that developed an L-CRA achieved an 11.7-letter mean improvement from baseline over the control group in that same period.

More recent studies looking at L-CRA treatment in combination with anti-VEGF agents also show promise as a means of producing better and more stable visual acuity with less reliance on continued intravitreal injections, concluded Dr McAllister.

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27

PAEDIATRIC OPHTHALMOLOGY

IDIOPATHIC AMBLYOPIA Researchers explore possible link with newborn retinal haemorrhages.

Cheryl Guttman Krader reports

Courtesy of Darius M Moshfeghi MD

28

A

Asymmetric bilateral birth haemorrhages with intraretinal, subretinal, white-centred and peripapillary flame haemorrhages (left and right eyes) in a term otherwise healthy infant

pproximately one-third of cases of amblyopia are deemed idiopathic. Now, using data collected in the Newborn Eye Screen Test (NEST) study, researchers are investigating whether retinal haemorrhage at birth may be an etiologic factor explaining at least some of those cases.

Under way at Stanford University, California, USA, NEST is a prospective cohort study that is evaluating universal newborn screening with wide-angle digital photography. At the 2015 annual meeting of the Association for Research in Vision and Ophthalmology in Denver, USA, Natalia Callaway MD, MS presented findings on the prevalence, characteristics, and potential risk factors for retinal haemorrhage at birth from data collected during the first year of NEST. The analyses showed that retinal haemorrhages were common overall, being identified in >10 per cent of screened infants (n=202 at 12 months). The lesions were almost always present in multiple areas of the retina, and most often involved the macula and optic nerve while generally sparing the fovea.

Multivariable statistical analyses found that the odds of having a retinal haemorrhage were significantly higher among infants delivered vaginally compared to their counterparts born by Caesarean section. Self-identified Hispanic/Latino ethnicity appeared protective, reported Dr Callaway.

“Previous papers report that the majority of retinal haemorrhages present at birth resolve within four weeks. Haemorrhages that persist may be an amblyogenic factor by encroaching on the visual axis during the critical period of vision development,” she said.

LONGITUDINAL FOLLOW-UP “Our investigation is the first prospective study of retinal haemorrhages at birth conducted in the United States that includes a diverse population and evaluates not only the prevalence of retinal haemorrhage, but also its characteristics. We will now be categorising haemorrhage severity in our cohort and we look forward to presenting the data on vision outcomes from longitudinal follow-up,” she added.

In NEST, screening is offered to all infants who do not receive retinopathy of prematurity screening. The images are taken by a trained neonatal intensive care unit nurse and interpreted by a paediatric vitreoretinal specialist.

Approximately one in four parents approached about the NEST study gave consent for participation. There were no significant differences between the enrolled infants and those whose families declined with respect to gender, birth weight, delivery method, or ethnicity.

Dr Callaway suggested that vaginal delivery might increase the risk of retinal haemorrhage by causing a rapid increase in intracranial pressure that affects retinal artery and retinal venous flow. A future analysis will investigate duration of the active phase of delivery as a risk factor.

Natalia Callaway: nfijalk1@gmail.com Darius M Moshfeghi MD, Director of Ophthalmic Telemedicine, Byers Eye Institute, Stanford University School of Medicine: dariusm@stanford.edu

World Society of Paediatric Opthalmology and Strabismus Preceding the XXXIV Congress of the ESCRS

ber

m pte

e 9S EUROTIMES | APRIL 2016

2

016

10 – 14 September 2016

Bella Center, Copenhagen, Denmark

www.wspos.org

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 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

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.

ESCRS NEWS

ESCRS president David Spalton (left) with HSIOIRS president Spyros Georgaras at the Winter Meeting Welcome Ceremony in Athens

NEWS IN BRIEF CATARACT POSTER WINNER

ESCRS

NEWS

WINTER MEETING SETS A RECORD More than 2,200 delegates from 74 countries attended the 20th ESCRS Winter Meeting in Athens, Greece, a record attendance for any Winter Meeting.

At the Welcome Ceremony, ESCRS president David Spalton said the society was very pleased to return to Athens after successful meetings in 1999 and 2007, and to once again join colleagues from the Hellenic Society of Intraocular Implant and Refractive Surgery (HSIOIRS) for this important event.

“Greece is a special place for doctors because it is where the science of medicine first started over 2,500 years ago. Hippocrates (about 400BC), the father of medicine, based his practice on observation and scientific reasoning, leading him to be able to make a prognosis. His ethics of ‘first do no harm’ are still with us and underlie modern medicine,” said Prof Spalton.

The welcome from the local hosts was delivered by Spyros Georgaras, president of HSIOIRS. “For this meeting, we are proud to achieve such a large number of Greek papers, which defines the Greek tone of this event. Since the founding of our society 30 years ago, we have been working side-by-side with all the ESCRS board, more as close friends than colleagues,” said Prof Georgaras.

“We are very familiar with these ties, and we do not forget that ESCRS has been sending distinguished speakers to our conferences, as well as scientific and organisational material, enhancing the quality of our meetings and contributing to the training of Greek ophthalmologists,” added Prof Georgaras.

JOSÉ GÜELL AWARDED FYODOROV MEDAL

Dr José Güell delivering the HSIOIRS Fyodorov Lecture

Prof Pandelis Papadopoulos presented the HSIOIRS Fyodorov Award to Dr José Güell at the Winter Meeting, which was held in conjunction with the 30th International Congress of the HSIOIRS in Athens.

After the presentation, Dr Güell delivered the prestigious HSIOIRS Fyodorov Lecture on the topic of “Modern approach for keratoconus patients”.

The Board of Directors of HSIOIRS also awarded the Spyros Georgaras scholarship to Zisis Gatzioufas, Lampros Lamprogiannis and Dimitra Portaliou.

The scholarship was presented to the young ophthalmologists by Konstantina Koufala, president-elect of HSIOIRS, and Dimitris Kyroudis, general secretary of HSIOIRS.

George Chatzilaou, Greece, took first prize in the Cataract Category of the Poster Awards at the Winter Meeting. His poster, “Nanosecond laser cataract surgery: contralateral endothelial cell study”, described a study involving 82 eyes of 41 patients who underwent standard coaxial ultrasound phacoemulsification in one eye and coaxial nanosecond-laser-assisted cataract surgery (NL) on the other.

The study showed that eyes which underwent nanosecond-laser-assisted cataract surgery with the new laser probe had less endothelial cell loss than those in the ultrasound phacoemulsification group. Preoperatively, the two groups had nearly identical endothelial cell counts, but by two years’ follow-up cell count was 2287 cells/mm2 in the ultrasound group, compared to 2420 cells/mm2 in the nanosecond-laser group.

REFRACTIVE WINNER First prize in the Refractive Category of the Poster Awards went to Aashish K Bansal, India, for “Post small incision lenticule extraction (SMILE) interface fluid collection: a case of ‘shifting ectasia’”.

The poster described the case of a patient who underwent SMILE for correction of compound myopic astigmatism in both eyes, but presented with decreased vision in his right eye two days postoperatively.

Topography showed corneal steepening with an axis of astigmatism that kept on shifting on successive visits.

Anterior-segment optical coherence tomography revealed the presence of fluid in the interface. The patient responded to topical hypertonic saline drops and vision recovered to 6/6. Intraocular pressure remained normal throughout without the addition of any anti-glaucoma therapy.

METHODICAL APPROACH A methodical approach provides the smoothest path to successful cataract surgery, said Richard Packard FRCS, UK, who presented his most common tips for trainee cataract surgeons at the Young Ophthalmologists Programme of the 20th ESCRS Winter Meeting in Athens.

Dr Packard noted that he tells his students to regard their position as being at 12 o’clock on the eye’s meridians, when performing a capsulorhexis.

Creation of the rhexis begins with drawing a ‘C’ on the capsule with a cystotome, then grasping and pulling at each clock hour in a sequential manner to reduce the risk of a capsular tear. The flap created in this way will be twice the size of the original ‘C’, he said.

EUROTIMES | APRIL 2016

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RESEARCH

THEORIES OF ACCOMMODATION

Spencer P Thornton MD, FACS reviews

T

the different theories of accommodation through the ages

he mechanism of accommodation has been one of the most studied aspects of visual physiology over the last two centuries.

On accommodation the pupil constricts with contraction of the ciliary muscle, the lens becomes more spherical, and the vitreous pushes forward, moving the lens forward, increasing its effective power.

Although lenticular-based focusing was first proposed by Descartes, it was Thomas Young who in 1793 demonstrated changes in the crystalline lens that occurred on changing focus from distance to near, and Hermann von Helmholtz who in 1856 advanced the first widely accepted explanation of the accommodative process.

MÜLLER In 1854 Heinrich Müller described the circular muscle of the ciliary body – theorising that the contraction of the ciliary muscle pulled vitreous forward, forcing the lens forward, with resulting power increase.

Müller’s theory is described by Frans Donders, as follows: “Müller's theory is based on his anatomical

VON HELMHOLTZ The most widely held theory of accommodation was proposed by von Helmholtz in 1856: “When viewing a far object, the circularly arranged Müller’s ciliary muscle is relaxed, allowing the lens zonules and suspensory ligaments to pull on the lens, flattening it in the periphery.

The source of the tension is the pressure that the vitreous and aqueous humours exert outwards onto the sclera.”

According to von Helmholtz, when viewing a near object, the ciliary muscles contract (resisting the outward pull of the sclera) causing the lens zonules to relax which allows the lens to spring into a thicker form.

EUROTIMES | APRIL 2016

Ciliary body with zonules and Müller’s muscle

investigations of the ciliary muscle… he sees in the action of the most external layers of the ciliary muscle a means of augmenting the pressure of the vitreous humour, of pushing the lens forwards, of diminishing the increased convexity of the posterior surface, and, by the resistance of the simultaneous contraction of the iris, of increasing that of the anterior surface.”

RESEARCH

DONDERS Frans Donders favoured von Helmholtz when he wrote On the Anomalies of Accommodation and Refraction of the Eye in 1864. They were colleagues and friends, and no one dared question von Helmholtz for years because of Donders’ influence.

JOHNSON Dr Lindsay Johnson of Durban, South Africa, in 1924 questioned the rationality of von Helmholtz's theory, because it ignored the action of the circular muscle of Müller.

Von Helmholtz had theorised that the lens stayed compressed in the eye when it was not accommodating, because the ciliary muscles were under constant tension, stretching the zonules. Johnson pointed out the lack of logic in this theory, pointing out that muscle tension in a relaxed state is not normal, and the theory not rational.

Johnson described compression of fluid in the circumlental space on accommodation, with bulging of anterior lens surface and anterior movement of the lens. Aqueous under pressure is forced into the spaces of Fontana during accommodation, and flows back into the chamber upon relaxation of accommodation. Johnson concluded that the increased curvature of the lens was producd by hydraulic pressure, not by relaxation of the ciliary muscle’s tension on the zonules as von Helmholtz claimed.

COLEMAN D Jackson Coleman, in 1970 and again in 1986, showed that contraction of the ciliary body produced a rise in vitreous pressure, with hydraulic effect on lens deformation producing anterior displacement, confirming Johnson’s theory. He described the interface of vitreous and lens-ciliary body complex as a catenary (the curve formed by a perfectly flexible, inextensible cable suspended from its endpoints).

In 1970 Coleman proposed the Catenary theory, that the lens, zonules and anterior

Courtesy of Spencer P Thornton MD, FACS

TSCHERNING Marius Tscherning is best known for his theory regarding the mechanism of accommodation.

In 1894 Tscherning proposed that accommodation occurred through an increase of zonular tension at the lens equator with contraction of the ciliary muscle, and therefore a bulging of the lens in accommodation was created by compression rather than by passive relaxation. Furthermore, he stated that during accommodation, while the central part of the anterior surface of the lens is bulged, the peripheral portion of the lens is flattened (this theory was first proposed by Antonie Cramer in 1851). At the suggestion of Donders, Cramer used a microscope to demonstrate that accommodation should be ascribed to an increase in the curvature of the lens (in the 1990s Schachar (qv) took up this theory as his own).

33

Real-time A-scan of distance (left) and near (right) fixation showing anterior chamber shallowing with axial movement of the lens

vitreous comprise a hammock-like diaphragm between the anterior and vitreous chambers of the eye. Ciliary muscle contraction initiates a pressure gradient between the vitreous and aqueous compartments that support the anterior lens shape in the mechanically reproducible state of a steep radius of curvature in the centre of the lens with slight flattening of the peripheral anterior lens, i.e the shape, in cross section, of a catenary, not a parabola.

The anterior capsule and the zonules form a trampoline or hammock-shaped surface that is reproducible depending on the circular dimensions, i.e the diameter of the ciliary body (Müller’s muscle). The ciliary body thus directs the shape like the pylons of a suspension bridge, but does not need an equatorial traction force to flatten the lens.

Coleman’s 1970 study showed that contraction of the ciliary body brought about a rise in vitreous pressure, which in turn had a hydraulic effect on crystalline lens with anterior displacement, confirming Johnson’s findings. Again in 1986 Coleman verified the anterior displacement of the lens as a component of accommodation.

THORNTON In 1985 and 1986 Spencer P Thornton published real-time A-scan ultrasonography showing anterior movement of the vitreous (and intraocular lens/IOL) on accommodation. This was the first photographic documentation of power increase on anterior movement with an IOL rather than increase in sphericity of the natural lens on accommodation. The accommodating IOL (patent 4,718,904) was based on Johnson’s and Coleman’s observations.

Many investigators have verified that the anterior movement of the lens is a component of accommodation, and most report restored accommodation with IOL forward movement. Most accommodating IOLs depend on this movement for their accommodative effect. Langenbucher and colleagues demonstrated the forward shift of an implanted posterior chamber lens optic, showing that its accommodation is measurable subjectively by usual methods (retinoscopy, videorefractometry, pushup and defocusing) and objectively by measuring anterior chamber (AC) depth decrease with paraxial geometric optics.

Their study showed similar theoretical

and measured amplitude increase with decreased AC depth.

SCHACHAR Ronald Schachar in 1992 proposed a theory similar to that of Tscherning (qv) which indicates that focus by the human lens is associated with increased tension on the lens via the equatorial zonules; that when the ciliary muscle contracts, equatorial zonular tension is increased, causing the central surfaces of the crystalline lens to steepen, the central thickness of the lens to increase (anterior-posterior diameter), and the peripheral surfaces of the lens to flatten. While the tension on equatorial zonules is increased during accommodation, the anterior and posterior zonules are simultaneously relaxing.

RANA, MILLER, NAWA Rana A, Miller D and colleagues at Cornea Consultants of Boston, USA, in 2003 demonstrated that good distance and near vision could be achieved with movable IOLs. They state: “The stronger the power of... the IOL... the smaller the amount of movement needed to achieve +2.5 diopters of pseudoaccommodation.”

Nawa and associates in Nara, Japan, in a 2003 article titled Accommodation Obtained With IOL Forward Movement, showed the power increase with 1mm IOL forward movement to vary with the preop length of the eye and steepness of the cornea, varying from 0.8D in a long eye to 2.3D in a short eye, varying inversely with corneal power. They concluded that “short eyes with high power IOLs would obtain relatively large accommodation with any given amount of forward IOL movement”.

A number of studies show that anterior movement of the lens is at least partially responsible for accommodation.

CONCLUSION In summary, in contrast to the von Helmholtz theory that is limited to the “natural” lens of the eye, it may be that all theories, including those of von Helmholtz, Tscherning, Müller, Johnson, Coleman and Thornton, are involved both in the phakic and IOL implanted eye.

References available on request Spencer P Thornton: spthornton@comcast.net EUROTIMES | APRIL 2016

Membership POWERFUL DATA | CLINICAL TRENDS

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ESASO

16TH RETINA ACADEMY The ESASO Retina Academy is a great chance to learn about latest scientific and clinical advances

T

he annual ESASO Retina Academy has established itself as one of the leading educational conferences on diseases of the retina. Widely appreciated as a top event in level and spirit, it attracts world-class faculty and aspiring young ophthalmologists year after year.

The 16th ESASO Retina Academy will be held in Estoril, Portugal, from 23-25 June 2016 at the Estoril Congress Center.

The final scientific and practical educational programme can be found on the ESASO website. ESASO has applied for 12 CME credits with UEMS. The success of the Retina Academies is based on their scientific, clinical and teaching excellence, which is guaranteed by its first-rate faculty. This years’ plenary presentations, lectures and sessions cover the most advanced scientific insights and technical state-of-the-art developments in areas such as VMA/VMT/MH, AMD, DME, RVO, PM, retinal nonperfusion, OCT techniques development, retinal pharmacology, geographic atrophy, central serous chorioretinopathy, uveitis, dystrophy, rehabilitation, and artificial vision.

Rupert Bourne (UK) will deliver a keynote lecture on “The emerging and changing causes of vision impairment worldwide and how this fits within the context of global health – The Global Vision Database and the Global Burden of Disease Study”.

The second keynote lecture will be presented by Rajat Agrawal (India, USA) on “Global impact of retinal diseases – finding sustainable solutions for access to retinal care”. The third keynote will be presented by Alain Gaudric (France) on “New insights in etiopathogenesis and manifestations”.

EYE IMAGING WORKSHOP One of this year’s highlights will take place on the first afternoon of the event – an eye imaging workshop will be held with the use of up-to-date imaging devices, provided by industrial partners. In rotating small groups, participants will be trained to operate all these devices and to interpret the diagnostic medical images.

The particular success of our interactive advanced masterclasses, with their special collegial spirit, has encouraged us to enlarge this programme to nine such masterclasses this year. Among these are four surgical masterclasses, for the first time. Faculty and delegates will discuss videos of surgical Francesco Bandello, innovations and particularly instructive cases.

Congress President Beyond the formats already mentioned above, the programme will include debates between experts, rapid-fire poster presentations, ESASO-style debates and the well-appreciated “Retinamour” case study workshops.

For promising young eye doctors and scientists, the ESASO Retina Academy 2016 provides an attractive opportunity to learn about the latest scientific and clinical advances in retinal disease, with world-class ophthalmologists.

www.esaso.org

For further information visit: www.esaso.org/16th-esaso-retina-academy-2016 EUROTIMES | APRIL 2016

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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: 42 ISSUE: 1 MONTH: JANUARY 2016

LONG-TERM CATARACT OUTCOMES Patients undergoing cataract surgery can expect good long-term visual rehabilitation, a prospective longitudinal population-based cohort study conducted in Sweden suggests. The study included 190 patients who were interviewed and evaluated 15 years after undergoing surgery in a similar time frame. Fifteen years after surgery, the median corrected distance visual acuity (CDVA) in the operated eye had deteriorated from 20/20 postoperatively to 20/25 (P = .0001). Sixty per cent of the patients had worsening of CDVA of less than 0.1 logMAR units compared with postoperatively.

All patients answered the same Visual Function-14 (VF-14) questionnaire preoperatively, four months postoperatively, and five, 10 and 15 years after surgery. Fifty-four per cent had no deterioration in subjective visual function, and 79 per cent had 10 points of decline or less. Previous Nd:YAG laser capsulotomy was more common in those younger than 65 years at surgery (49 per cent versus 25 per cent), which was highly statistically significant.

The most common comorbidity causing large functional loss 15 years after surgery was age-related macular degeneration.

E Monestam, JCRS, “Long-term outcomes of cataract surgery: 15-year results of a prospective study”, Volume 42, Issue 1, 19-26.

OCT BIOMETRY Axial length and anterior chamber depth are commonly measured with partial-coherence interferometry (PCI) or optical lowcoherence reflectometry (OLCR) biometers. The OLCR biometer also measures the central corneal thickness, aqueous depth, lens thickness, pupil size, and corneal diameter. However, both biometers are known to fall short in determining the axial length in the presence of a dense nuclear and/or posterior subcapsular cataract. US researchers conducted a prospective evaluation of a new biometer (Argos) with swept-source optical coherence tomography (SS-OCT), and compared results with those obtained with the PCI and the OLCR biometers. They measured axial length, central corneal thickness, aqueous depth, anterior chamber depth, lens thickness, pupil size, corneal diameter, and anterior corneal radius of curvature (RAV). Measurements with the new SS-OCT biometer were repeatable and reproducible. Axial length measurements with the new biometer were comparable to PCI and OLCR measurements, with a faster and higher acquisition rate, even in the presence of a dense nuclear or posterior subcapsular cataract. The new system moved beyond current systems capabilities by using a swept-source that implements quasi-phase continuous tuning combined with multiple beam expanders at a swept rate of 2.5kHz, which is about five to 10 times larger than what can be achieved in current systems.

This swept-source enables very simple measurements of the axial length. H John Shammas et al, JCRS, “Biometry measurements using a new large-coherence–length sweptsource optical coherence tomographer”, Volume 42, Issue 1, 50-61.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | APRIL 2016

PRACTICE MANAGEMENT & DEVELOPMENT

KEY SKILLS AND INSIGHT Exciting Practice Management programme planned for XXXIV Congress of the ESCRS

T

he ESCRS Practice Management and Development Committee, chaired by Dr Paul Rosen, is finalising its programme for the XXXIV Congress of the ESCRS, to be held in Copenhagen, Denmark, from September 10–14, 2016.

The Practice Management sessions will be held on Sunday, September 11 and Monday, September 12. On Sunday there will be a full-day Practice Management and Development masterclass, which will allow delegates to focus on key issues that affect their practices.

This is an interactive session where delegates are encouraged to talk directly about the issues that affect their practices and solutions to problems that they face on a dayto-day basis.

STEP-BY-STEP The session on Monday will focus on practice management and marketing. The session will open with a presentation on “Starting a practice” from Dr Ludger Hanneken, Germany, who will discuss the challenges of setting up a practice.

In this session, he will outline step-by-step what ophthalmologists need to do from the day they decide to go into private practice until the day they open their doors to patients for the first time.

As part of this module, Ed Toland, Ireland, and Kris Morrill, France, will also discuss “How to create, and use, a living business plan”.

“Business plans do not need to be hundreds of pages long. In this session we will explain how to create and use a short presentation with achievable, measurable goals,” Kris Morrill said Ms Morrill.

Ms Morrill will also make a presentation on “A job for life”, where she will discuss how the staff who help you grow your business and who themselves grow with your business are the biggest assets that any practice can have.

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CHALLENGES One of the biggest challenges facing doctors these days is engaging with social media. Caroline Anderson, ESCRS social media manager, will discusss how ophthalmologists should use Facebook, Twitter and other social media platforms to attract patients to their practices.

The Practice Management sessions are free of charge and open to all delegates attending the XXXIV Congress of the ESCRS. The full progamme, when complete, will be available on the ESCRS website at: www.escrs.org

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Please visit us at booth 2831 at the ASCRS in New Orleans

For further information, contact Colin Kerr, Executive Editor of EuroTimes and Project Manager, ESCRS Practice Management and Development: colin@eurotimes.org

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EUROTIMES | APRIL 2016

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BOOK REVIEWS

QUICK DECISION “Which patients should I refer, how urgent is the referral, and which patients can I treat myself?” These are common questions for primary care physicians, and are particularly relevant in ophthalmology.

For most ocular diseases, only careful examination with a slit-lamp microscope and PUBLICATION fundus lens can provide a true FAST FACTS: OPHTHALMOLOGY diagnosis. Very few primary AUTHORS care professionals have received PETER SIMCOCK AND ANDRE BURGER the necessary training for this.

Fast Facts: Ophthalmology, by PUBLISHED BY HEALTH PRESS Peter Simcock and Andre Burger (Health Press), seeks to educate our colleagues regarding the problems most commonly encountered in the community. Its stated goal is to allow the healthcare provider to determine the urgency of each case: refer now, refer later or no referral needed.

The book is mostly organised by patient symptoms such as red eye, blurred vision, double vision, and “gritty, itchy, watery eyes”. Other topics include “children’s eye problems”, eye trauma, eyelid disease and diabetes, hypertension and systemic medications.

I found this 100-page book concise and easy to use - it is both small and light enough to carry around in a lab coat pocket. Particularly useful is the chapter on “abnormal eye appearance”, which covers alarming-looking abnormalities such as thyroid eye disease and orbital cellulitis.

This book is appropriate for any health professional who looks into a patient’s eye: general practitioners, optometrists, ophthalmic nurses, and even pharmaceutical and surgical company representatives.

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Once the patient has been referred, the rest is up to us.

One disease that continues to bedevil ophthalmologists is glaucoma. Many serious studies have clearly indicated that there is significant inter-observer variability, even among experienced glaucoma specialists, regarding the evaluation of the optic disc, both at baseline and regarding progression.

Fast Facts: Glaucoma, by Paul R Healey and Ravi Thomas (Health Press), is a very basic reintroduction to the disease.

This book is not intended to provide new and surprising insights, but rather to reiterate the spectrum of known facts in a simple fashion.

Particularly useful aspects include the glaucoma medical management algorithm, which was adapted from national guidelines, and an overview of the various classes of intraocular pressure-lowering medications, with their systemic and local side effects, period of peak effect, and washout period.

Fast Facts: Glaucoma is most appropriate for ophthalmology residents in training, non-glaucoma specialist ophthalmologists seeking to brush up on their knowledge, and primary care physicians interested in a disease that affects so many of their patients.

LEIGH SPIELBERG Books Editor

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

EUROTIMES | APRIL 2016

INDUSTRY NEWS

OCULUS Corvis® ST

INDUSTRY

NEWS Rayner has launched a new ophthalmic viscosurgical device (OVD) – Ophteis® FR Pro. “A revolution in OVDs, Ophteis® FR Pro with sorbitol is unparalleled in protecting the corneal endothelium from free radical energy caused by phacoemulsification,” said a company spokeswoman.

“Since Sir Harold Ridley’s first intraocular lens implant in 1949, there have been several innovative leaps forward, such as the invention of foldable lenses, development of phaco techniques, and use of OVDs to alleviate the risk of anterior chamber collapse and tissue damage by surgical instruments. However, as technology evolves, so must the surgical environment,” she added.

“Rayner’s Ophteis® FR Pro is a uniquely bio-engineered OVD containing sorbitol, added at four per cent concentration to the two per cent NaHA. Sorbitol is a highly stable antioxidant molecule, found naturally in the aqueous humour. When combined in Ophteis® FR Pro, sorbitol has a neutralising or ‘scavenging’ effect on free radicals, enabling a new level of corneal endothelial protection from phaco induced trauma.” www.rayner.com

Corvis® ST Highspeed Scheimpflug camera sets a milestone in ophthalmology

CE MARK APPROVAL Smart Vision Labs, a maker of portable and smart autorefractors, has announced that SVOne has received CE mark approval, which grants the company entitlement to market and sell the device in European countries.

The company says that SVOne, a handheld ShackHartmann wavefront aberrometer, accurately measures objective refractive error in children and adults.

“The CE mark is a significant step forward in the commercialisation of SVOne in Europe,” said COO and co-founder Marc Albanese.

“We’ve had a lot of interest from this market. With the CE Mark, our company’s mission to make vision care globally accessible will be even more attainable,” he added. www.smartvisionlabs.com

Please note: The availability of the products and features may differ in your country.

Specifications and design are subject to change. Please contact your local distributor for details.

THE NEXT STEP

Highspeed Scheimpflug camera in combination with non-contact tonometer: •

Precise measurement of the IOP

•

•

Precise measurement of corneal thickness

Information on biomechanical response

•

Safe & efficient screening

WE WANT YOUR NEWS If you want your company news considered for inclusion in this section, send your press releases and high resolution images to Colin Kerr, Executive Editor, EuroTimes.

Email: colin@eurotimes.org

www.oculus.de

EUROTIMES | APRIL 2016

39

HOSPITAL DIARY

CLIMBING HIGHER In his new Hospital Diary column, Dr Leigh Spielberg discusses the transition from resident to fellow

N

ow that I’m no much more. ‘How did they get longer a resident, so advanced?’ I often find myself I have to make the wondering. ‘Are they naturals?’ transition to being Although prior ophthalmic a vitreoretinal surgical experience is a major surgery fellow. plus for a VR fellow, it does not Residency itself is a all translate into VR success. transformative experience. A There are so many variables. good fellowship builds upon VR surgery training is also this experience, taking the very different from cataract freshly-minted ophthalmologist surgery training. Most cataract from the base camp of general mentors will scrub into every ophthalmic skills and hoisting one of a resident’s first 150 or him or her into more rarefied so phacos, watching every step air. Fellowship mentors are of every procedure through the entrusted with guiding their microscope. The mentor will fellows into what might be be there, offering advice and termed the high-altitude peaks guiding the trainee through the of performance, encouraging whole ordeal. them to leave the comfort and safety of base camp behind.

PAY ATTENTION Or so, it feels to me. “All the Why? Because cataract surgery serious problems end up at the can go very wrong at any vitreoretinal surgeon’s doorstep,” moment. This makes it not only said one of my mentors. “And if worthwhile to pay attention, you can’t solve them, no one can. but also somewhat exciting. On So, pay attention and make sure the other hand, watching a VR you know what you’re doing, fellow perform a core vitrectomy because you’re the patients’ last is boring. A new fellow operates chance. Once you enter the eye so slowly that watching the with your trocars, there’s no procedure is like watching grass turning back. And beware. Any Residency itself is a transformative grow: almost nothing happens. problems you create… you have So, once a mentor realises that experience. A good fellowship builds to solve them yourself.” a fellow is competent enough to When a nucleus is dropped, upon this experience... avoid damaging the lens or the the cataract surgeon’s main retina with the vitrectome, (s) priority is to clean up as much he will tend to recede into the of the mess as possible, limit the background to do something useful for the next hour. damage and refer the patient to the VR surgeon. The same thing In the heat of the moment, simply remembering the correct applies to postoperative endophthalmitis and pseudophakic order of the steps of a long operation can be difficult. I often find retinal detachment. But a retinal surgeon has to fix whatever myself asking myself questions like: ‘Is it best to first cauterise the goes wrong during or after surgery. On the other hand, a retinal horseshoe tears in a retinal detachment, so I can find them later, surgeon has the luxury of having more control during a procedure. or first shave the tractional vitreous so the tear doesn’t enlarge?’

Missteps can often be fixed. This is due to the varied and versatile There is no single correct answer, but which will work best for me? instrumentation, continual fluid infusion with oversight of IOP, and Once I get through an operation, my attention shifts to diathermy to treat haemorrhage. tomorrow. Seeing vitreoretinal post-ops early in the fellowship is emotionally crushing, and it has been a difficult part of my AN UNUSUAL EXPERIENCE fellowship to get used to. An eye often does not look particularly But how does one become a VR surgeon? Fellowship. good after VR surgery. Subconjunctival haemorrhage, anterior Being a fellow is an unusual experience. A fellow embodies chamber flare and cells, a bit of hyphema and wild fluctuations an unusual combination of authority and subordination, ability in IOP are all common. Patients are generally not in good spirits. and inadequacy, knowledge and ignorance, respect for skills After phaco, most patients are enthusiastic to have the second previously obtained and the realisation that there’s so much eye operated as soon as possible. Not so during the first few weeks more to learn. The residents with whom I trained find it quite after retinal surgery. impressive that I’m doing vitrectomies on my own. While they’re I imagine most fellows have a moment during which they think: worrying about completing their first phaco, I spend my days ‘Should I continue climbing up into the peaks, or shall I settle for in the OR doing phaco as simply the first step of a combined the relative comfort of base camp?’ procedure for a retinal detachment or macular hole.

This is a great feeling. On the other hand, a VR fellow spends Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent most of his time with his surgical mentors, who can simply do so University Hospital, Belgium Illustration by Eoin Coveney

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EUROTIMES | APRIL 2016

TRAVEL

Copenhagen’s Design Museum

COPENHAGEN

3

TO NOTE...

COPENHAGEN

LANGUAGE: Danish, but English is widely spoken COUNTRY CODE: +45 TIME: GMT +1

You may well pass Copenhagen’s Medical Museum on your way to the Design Museum; it’s a one-minute stroll away at Bredgade 65.

The building dates from 1787, when it opened as the Royal Academy of Surgeons. It retains its period pharmacy and beautiful lecture hall.

Today, the university medical museum is known for integrating contemporary medicine into its field of interest. Guided tours in English on Wednesday, Thursday and Friday at 14.00, and on Sunday at 13.30. The museum is closed on Monday, Tuesday and Saturday. Check opening hours on the website: museion.ku.dk The Louisiana Museum, in Humlebaek, is a 35-minute drive or taxi ride north of the Bella Center. It is an immensely popular museum of contemporary art. Visit for the art, landscape, architecture, or the views. The museum is directly on the shore of the Øresund Sound.

When it opened as a museum in 1958, the founder intended it as a home for modern Danish art, but it soon became an international museum with many world-renowned works.

It has undergone seven extensions, the most recent in 2006. All were carried out by the museum’s original architects, Jorgen Bo and Vilhelm Wohlert, who were influenced by San Francisco Bay Area buildings and Japanese aesthetics. Open: Tuesday to Friday, 11.00-22.00; and Saturday, Sunday, and holidays, 11.00-18.00. The cafe/restaurant serves snacks and meals from Tuesday through to Friday from 11.00-21.30, and on Saturday, Sunday and holidays from 11.00-17.30. Closed on Mondays. Website: en.louisiana.dk At Kongen Nytorv 2, in the colourful Nyhavn area, there’s a picturesque old building marked Ravhuset Amber Museum and Amber Shop. The ground-floor shop sells objects made of amber, but a door in the back leads up to two tiny floors of the museum. One of the many attractions is a collection, shown under magnifying glass, of more than 100 pieces of amber that encase insects and plants that are more than 30 million years old. Open daily from 10.00-20.00 from March through to October. For more details, visit the website at: houseofamber.com

MARVELLOUS MUSEUMS

Copenhagen’s museums mark Danish contribution to a variety of crucial areas. Maryalicia Post reports Copenhagen has a wealth of fine museums – but which ones to visit? Here are a few suggestions for delegates attending the upcoming XXXIV Congress of the ESCRS.

THE DESIGN MUSEUM Beginning in the 50s, Danish designers like Poul Henningsen, Kaare Klint and Arne Jacobsen changed the look of objects familiar to us all. See their work here along with that of others, Danish and international, who helped shape today’s domestic environment. There is also an additional reason to visit – throughout 2016, a unique exhibition of Japanese art and crafts in tribute to the influence of Japanese applied art on the Danish aesthetic.

The museum building is itself worth seeing. It’s an 18th century rococo structure, Denmark’s first public hospital.

Weather permitting, enjoy a coffee in the serene garden. Address: Design Museum, Bredgade 68. Open: Tuesday to Sunday, 11.00-17.00, with late opening until 21.00 on Wednesdays. Closed on Mondays.

Website: designmuseum.dk

winding corridors of fractured passageways and slanting floors trace the Hebrew word “Mitzvah”. Exhibitions mark 400 years of Jewish life in Denmark, and the dramatic evacuation of most of the Jewish population by sea to neutral Sweden in October 1943.

Address: Proviantpassagen 6 at the Royal Library Garden. Website: jewmus.dk

THE WORKER’S MUSEUM The museum covers the period from the end of the 1800s to 1980, with special focus on daily life in the 1930s. There’s a furnished 1930s apartment, a grocery store, a union office, and a stately meeting and banquet hall. The building itself was built and paid for by unionised workers in 1878.

The basement cafe/restaurant, “1892”, is particularly enticing, and you should also take time to visit the well-stocked boutique. Address: Rømersgade 22. Open: Monday to Sunday, 10.00-16.00. Website: www.arbejdermuseet.dk Looking back to the past in Copenhagen’s Design Museum

THE DANISH JEWISH MUSEUM Unique among all other European Jewish museums, the Copenhagen museum represents a blessing – a “Mitzvah” – as its architect Daniel Libeskind explains: “Danish Jews were, by and large, saved through the effort of their compatriots and neighbours during the tragic years of the Shoah (Holocaust). It is this deeply human response that differentiates the Danish Jewish community and is manifested in the form, structure and light of the new museum.”

The first in Denmark to be dedicated to a minority group, the museum has been fitted into the 17th century Royal Boat House. The EUROTIMES | APRIL 2016

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EYE ON TECHNOLOGY

PEARL INLAY

A new technique for correction of presbyopia using intrastromal lenticule implantation. Dr Soosan Jacob reports

P

resbyopia is the most common refractive error and affects a significant percentage of the population. Corneal inlays such as the small aperture inlays (Kamra™, AcuFocus, USA), shape change inlays (Raindrop®, ReVision Optics, USA), refractive optic inlays (Flexivue Microlens™, Presbia, USA), and Icolens (Neoptics AG, Switzerland) are becoming a favoured modality for presbyopia correction.

Corneal inlays have an advantage over monovision LASIK and presbyLASIK in being additive technologies, thereby preserving future options for presbyopia correction. However, all current inlays utilise synthetic material that is implanted into the cornea and may therefore be associated with complications such as inflammatory response, potential interference with glucose and ionic diffusion into the anterior stroma above the implant, peri-inlay deposits etc.

A technique pioneered by the author (SJ) is described here that uses a femtosecond laser carved allogenic corneal inlay for the treatment of presbyopia.

TECHNIQUE: A SMILE lenticule (between -1.75 to -3.00DS) is extracted and stored in Optisol storage medium. Prior to use, the lenticule is spread out and dried with surgical sponge and the centre marked with a fine inked Sinskey hook. A 2mm trephine is then centred on the inked mark to fashion a smaller donor allogenic presbyopic corneal inlay. The light constricted pupil of the patient is marked and a femtosecond pocket is created at 120 microns depth. The lenticule is then aligned and spread out in the pocket under the marked pupillary centre.

In our initial series of six patients, no intraoperative complications were encountered in any eye. Centration on the inked mark was achieved with relative ease.

EUROTIMES | APRIL 2016

Six months postoperative appearance showing well centred and clear implanted allogenic corneal inlay

Zoomed-up view of inlay

DISCUSSION:

satisfactory binocular distance visual acuity and ability to perform all routine visual tasks without difficulty.

Similar to other inlays, the PEARL inlay gave very good uncorrected near and intermediate vision in the operated eye with a slight decrease in distance vision. It should therefore be reserved for use in the non-dominant eye and after appropriate patient counselling. The ideal patients as with other presbyopic solutions would be expected to be those with an easygoing personality and without unrealistic expectations, with limited night driving needs and willing for the gain in near vision at the expense of some decreased distance vision in the operated eye.

For phakic presbyopic patients, any pre-existing refractive error can be corrected by simultaneous LASIK under the flap. PEARL may also be performed in pseudophakic patients. It may be combined with cataract surgery, either simultaneous or sequential. However, sequential PEARL is preferred as any residual post-cataract refractive error may be taken care of simultaneously by performing a LASIK under the flap.

In this small series, fundus visualisation and imaging was possible in all patients.

The use of an allogenic corneal inlay is a novel means of treating presbyopia.

This 2mm diameter, 40-60 microns thick femtosecond carved lenticule is cut to size using a 2mm trephine. It acts as a shape change inlay by increasing the central radius of curvature and resulting in a hyperprolate corneal shape.

Unlike synthetic implants, since the PEARL inlay is made of allogenic cornea, there is unhindered passage of oxygen and nutrients, thus ensuring stable corneal conditions and a decreased risk for corneal necrosis and melt. The use of allogenic tissue allows good integration into the cornea and also avoids problems such as inflammation related to insertion of synthetic material into the cornea. As with synthetic corneal inlays, it has advantages of reversibility and adjustability.

In an initial case series of six patients, all reported vastly reduced dependence on spectacles and were largely independent of glasses for their day-to-day activity for near. They were also able to perform comfortably for intermediate viewing distance on the computer. There was improvement in binocular uncorrected near and intermediate visual acuity,

EYE ON TECHNOLOGY Autoperimetry was also possible in all patients postoperatively with no interference from the lenticule. No patient gave complaints of glare, halos or night vision problems, though none were predominant night drivers. A larger study population would of course be needed to determine the incidence of these as well as other complications.

Refractive lenticule reimplantation has previously been done in animal models (Angunawala et al; Riau et al) and also in human studies for hypermetropia (Reinstein et al; Sun et al; Ganesh et al), aphakia (Reinstein et al; Ganesh et al) and keratoconus (Ganesh et al) with favourable results and safety profile.

LASIK for inducing monovision following reversal of myopic ReLEx through refractive lenticule reimplantation has been reported in experimental rabbit model (Mehta et al).

However, this is the first series of allogenic corneal inlay implantation in human subjects for the treatment of presbyopia. Cryopreservation of SMILE lenticules is possible (Mehta et al) which would allow transportation of these lenticules for reimplantation at other centres over longer periods than short (McCarey Kaufman) and intermediate term storage media (Optisol, Chiron Ophthalmics Inc, USA) would do.

A potential disadvantage is the risk of stromal rejection from donor tissue,

AS-OCT image of inlay

however this was not seen in our patients despite a relatively short duration of steroids given postoperatively (2.5 months). It is possible that being only 40-60 microns at its thickest point, the antigenic load may be very small to provoke a reaction in the immunologically privileged cornea. With time, repopulation of the lenticule from both sides by the patient's own keratocytes would also be expected to occur, thus decreasing immunogenicity further.

the lenticule, depth of implantation, target refraction to be aimed for when combining with LASIK or cataract extraction as well as for detecting complications. A longerterm follow-up with a larger number of patients is required.

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

CONCLUSION: The feasibility of an allogenic corneal presbyopic inlay technique serves to lay a foundation for a larger study. Prior reports of refractive allogenic lenticule implantation for hypermetropia, aphakia and keratoconus have shown encouraging safety profile. For the treatment of presbyopia, further studies are required for standardising the ideal thickness of

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www.blinkmedical.com EUROTIMES | APRIL 2016

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CALENDAR

MAY

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

LAST CALL

APRIL 2016

OCT and OCT-Angiography

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

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

7th EuCornea Congress 9–10 September Copenhagen, Denmark www.eucornea.org

ASCRS 2016

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

↙

↙

4–8 May Manama, Bahrain www.meaco.org

SEPTEMBER

16th EURETINA Congress

XXXIV Congress of the ESCRS 10–14 September Copenhagen, Denmark www.escrs.org

NEW SFO Congress 2016

12th JOI (Journées d’Ophtalmologie Interactives)

7–10 May Paris, France www.sfo.asso.fr/congres/ congres-sfo-2016

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

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

14th SOI International Congress 18–21 May Milan, Italy www.congressisoi.com

42nd Annual EPOS Meeting 23–25 September Zurich, Switzerland www.epos-focus.org

114th DOG Congress

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

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

JUNE

12th EGS Congress

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

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

OCTOBER

JULY

The European Association for Vision and Eye Research (EVER) Congress 2016

Aegean Cornea 2016

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

5–8 October Nice, France www.ever.be

OCTOBER

AAO 2016

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

NOVEMBER

IMO – Trends in Glaucoma: Surgical & Medical Meeting

18–19 November Barcelona, Spain www.imo.es/glaucoma2016

DECEMBER

NEW ISOPT Clinical 2016 1–3 December Rome, Italy www.isoptclinical.com

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

29th APACRS Annual Meeting 27–30 July Nusa Dua, Bali www.apacrs.org

EYE CONTACT

Rome

STUDIO INTERVIEWS with leading ophthalmologists EXCLUSIVE TO EUROTIMES! EVOLUTION OF THE CAPSULOTOMY

Sean Henahan interviews Dr Richard Packard

Available at http://player.escrs.org/eurotimes-eye-contact and the EuroTimes App

3 reasons to start Nano-Laser Cataract-Surgery.

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