EuroTimes Vol. 21 - Issue 7/8 by EUROTIMES

SPECIAL FOCUS CATARACT & REFRACTIVE GLAUCOMA

FIRST NEW IOP-LOWERING DRUG CLASS IN TWO DECADES SET TO REACH MARKET Jul/Aug 2016 | Vol 21 Issue 7/8

REVIEW

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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

3 Obituary: Dr Peter Barry, a life well lived

FEATURES

SPECIAL FOCUS

CORNEA 23 Treatment of cataracts

CATARACT & REFRACTIVE 4 Cover Story: SMILE

24 Binkhorst Medal Lecture:

8 Newsmaker:

25 Transplantation for

9 Fast and simple

GLAUCOMA 27 First new IOP-lowering

makes transition to mainstream technique Dr José Güell on the iris-claw lens capsulotomies

10 Pushing the limits of SMILE

12 Point-of-care

testing for quicker, more accurate diagnoses

14 Are IOL designs

holding back FLACS?

15 ‘New lenses may

prove to be the Holy Grail of presbyopia treatment’

16 ‘Posterior capsule tear does not rule out implantation of single-piece IOL’

17 ASCRS expanding

education programmes

in eyes with limbal stem cell disease Advances in epi-on CXL, ectasia screening

limbal stem cell deficiency

drug class in two decades set to reach market

28 External sustainedrelease ocular drug delivery devices in development

RETINA 35 Intraoperative OCT:

New technologies improve visualisation and tissue manipulation

37 OCT angiography can

provide new insight into retinal diseases

39 DME management –

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REGULARS 40 42 44 47 48 51 52 55 56 58 59

EBO Diploma Update JCRS Highlights Hospital Diary Ophthalmologica Update Book Reviews ESCRS News Industry News ESASO Update Review Travel Calendar

evolution continues with advances in technology

P.56 As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2015 and 31 December 2015 is 46,515.

EuroTimes & JCRS

Included with this issue... Allergan supplement

1996–2016 EUROTIMES | JULY/AUGUST 2016

EDITORIAL A WORD FROM SOOSAN JACOB MS, FRCS, DNB

REASONS TO SMILE? Small incision lenticule extraction establishing itself as a superior means of refractive correction

ith advantages such as lack of a flap, less incidence the first to implant SMILE lenticules into animal eyes. Ganesh et of flap-related complications, better retention of al used it for the treatment of hyperopia and keratoconus. I have biomechanical strength, less dry eye, better and personally used it as a PrEsbyopic Allogenic Refractive Lenticule faster recovery of corneal sensation, as well as (PEARL) inlay for the treatment of presbyopia, with very proven predictability, efficacy and safety, small good results, because of increased depth-of-focus secondary incision lenticule extraction (SMILE) to induced hyperprolacity. Unlike is slowly establishing itself as a superior means of most presbyopic inlays, the SMILE is bringing forth new refractive correction. extremely small size (1mm) gives Less dependence on external influences such as room a normal surrounding zone within possibilities in refractive temperature and humidity, corneal hydration and the pupil for largely unaffected treatment as well as in other other factors, together with faster workflow, are added distance vision. areas. Improving machines advantages over LASIK. It’s not therefore surprising that Reported good outcomes by and algorithms contribute SMILE is steadily gaining in the number of surgeons Mehta, Ganesh and Sun, as well as performing it, as well as the number of patients opting good results in my own personal to constantly improving for it over LASIK. experience, may indeed be the results. Will it completely But is it always a win-win situation? As with any new beginning of the re-emergence replace LASIK eventually? procedure, trade-offs and spin-offs emerge. The initial of highly precise additive high investment required, as well as the need to still have treatment technology as originally a LASIK machine for hyperopic treatments and for patients who envisioned by José Barraquer. Technological advancements cannot afford the generally higher-cost SMILE, are disadvantages. will help make these inlays non-antigenic, further increasing Though astigmatism has been shown to be tackled effectively the safety profile. with SMILE, there is scope for further improvement with regard to To summarise, SMILE is bringing forth new possibilities in better algorithms and compensation for cyclotorsion. Wavefrontrefractive treatment as well as in other areas. Improving machines based treatments are not possible. Newer complications, such and algorithms contribute to constantly improving results. Will as partial lenticular retention and implantation of epithelial it completely replace LASIK eventually? One cannot say. Will cells under the cap, can be more difficult to manage, and techniques such as PEARL become widely adopted? Again, only with constantly increasing numbers being performed, still newer time can tell. complications may yet be reported. However, one thing is for certain – the future is exciting and I look forward to it, as I am sure do all eye care practitioners everywhere, to seeing where this technique will eventually take us. SPIN-OFFS

Spin-offs that emerge are of course related to the by-product of the SMILE surgery – a beautifully carved lenticule of precise dimensions obtained from a cornea in its normal physiological state and hydration. The possibilities this offers are many and it has been utilised by researchers to substitute synthetic inlays, which have disadvantages related to biocompatibility and oxygen and nutrition diffusion across the cornea. All tissue additive techniques employ implantation of a precise lenticule as an allograft for refractive correction. Jod Mehta was

Dr Soosan Jacob is a member of the EuroTimes International Editorial Board, and Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

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

EUROTIMES | JULY/AUGUST 2016

OBITUARY

PETER BARRY 1948 – 2016

By Prof David Spalton Peter’s sudden and tragic death is a shock for all of us. He was a particularly good friend to me and to many of you who are reading this. Peter co-organised the European Intraocular Implant Club meeting in Dublin, Ireland in 1990. It was at this meeting that the decision was taken to change the name of the society to the European Society of Cataract and Refractive Surgeons, and from that time Peter served as a board member, treasurer, then as president, and finally as a director. Throughout all these years he was a steady guiding hand, the work of the society never far from his heart, and the formative role he had in the success of the ESCRS cannot be overstated. In my opinion this success was due to two strong personality attributes – the first being a superb ability to chair a committee meeting, and the second being a dogged determination to see something through to the end once he had started on it, strongly aided by some Irish charm and a puckish sense of humour. Time and time again I would watch in admiration as, during a committee meeting, after a sometimes lengthy and rather stringent discussion, he would summarise the problem and come up with the common-sense solution that we had all missed, which we could all agree on, and then we would move on to the next item on the agenda. Through his friendship with Ulf Stenevi and Mats Lundström, he led the way in developing the society’s studies in the prevention of postoperative endophthalmitis and benchmarking surgical outcomes with the EUREQUO database. His greatest memorial will be the endophthalmitis study which eventually turned out to be the biggest antibiotic study ever undertaken. He conceived the project, raised the finance and put together a dedicated and expert team, and then saw the project through the trials and tribulations of regulation, bureaucracy and recruitment until its eventual success.

As we all know now, the intracameral injection of cefuroxime at the end of surgery reduces the incidence of infection five-fold. The study has become the standard of care in many countries and we, as surgeons, and more importantly our patients have good reason to be grateful to him. Few of us will ever leave such a legacy. Peter was educated at Gonzaga College in Dublin. At one time he contemplated a career in the Church and few of us knew he retained a strong Christian faith throughout his life. However, he went into medicine instead, graduating from University College Dublin in 1974, where he won the Medical Society Gold Medal and also the Gibson Cup, the Irish Medical Schools Debating Cup (perhaps an early sign of later achievements). He was a resident at Moorfields Eye Hospital in London from 1976 to 1979, followed by a retina fellowship at the University of Wisconsin, Madison, USA. After this he returned to a consultant appointment at the Royal Victoria Eye and Ear Hospital and St Vincent’s Hospital in Dublin. His funeral took place on the most perfect Irish summer day at the church opposite St Vincent’s Hospital, with a congregation packed to standing room only with his family, his friends and colleagues, golfing chums, and I suspect a large number of grateful patients too. Lisa, his 20-year-old daughter, with great courage and fortitude, gave a eulogy none of those present will ever forget. It was an incredibly sad end to a life so well lived and we all extend our sympathy to his wife Carmel, and his children David, Stephen, Simon and Lisa. Prof David Spalton is President of the ESCRS To make a lasting commemoration to Peter’s enormous contribution to the society, the ESCRS intends to inaugurate the Peter Barry ESCRS Travel Fellowship for a trainee to spend a year abroad in a centre of excellence EUROTIMES | JULY/AUGUST 2016

COVER STORY: CATARACT & REFRACTIVE

SMILE MOVES TO THE MAINSTREAM In just a few short years, SMILE has made the transition from niche surgical curiosity to mainstream technique. Dermot McGrath reports

housands of small incision lenticule extraction (SMILE) procedures have now been performed internationally, enabling surgeons to understand more about the technique’s advantages and limitations. Data has also been accumulating in the scientific literature attesting to the safety and efficacy of SMILE for myopia. As clinicians become more familiar and confident with the technology, SMILE has begun opening new frontiers into hyperopia, presbyopia and keratoconus treatments. The recently published longterm results (Br J Ophthalmol, doi:10.1136/ bjophthalmol-2015-306822) for SMILE are EUROTIMES | JULY/AUGUST 2016

very promising, said Jesper Hjortdal MD, PhD, Clinical Professor, Aarhus University Hospital, Denmark, who uses SMILE as his first-choice refractive procedure for suitable myopic patients. “The results showed that the refraction is stable over the long-term, and if anything the best corrected visual acuity improves and higher-order aberrations decrease from three months to three years,” he said. Dr Hjortdal’s indications for SMILE include myopia from -1.0D to -10.0D, although the majority of patients he treats are usually more than -5.0D. “In the lower range, we still find that surface ablation is a good option,” he said. With Zeiss recently expanding the indications for myopic SMILE backed by

robust safety and efficacy data, interest in the procedure has gathered significant momentum in the past year or two.

JUMP ON THE SMILE TRAIN “It has really taken off in a big way. Wherever I travel now I have the feeling that everyone wants to jump on the SMILE train, or feels that they're going to miss out on something if they don’t offer this treatment,” said Walter Sekundo MD, Chairman of the Department of Ophthalmology at the Philipps-University of Marburg, Germany, and one of the pioneers of intrastromal lenticule extraction. Dr Sekundo said that around 750 surgeons worldwide are now officially

COVER STORY: CATARACT & REFRACTIVE

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

registered to perform SMILE procedures, but that the real figure is probably well over 1,000 and growing all the time. While SMILE’s increasing popularity is undoubtedly good news for Zeiss, the fact that the procedure can only be performed using the company’s VisuMax femtosecond laser inevitably restricts its uptake, points out Mike Holzer MD, FEBO, Vice Chairman and Director of Refractive Surgery at the University of Heidelberg, Germany. “I think it is important to emphasise that this procedure can only be performed with a specific laser, and sometimes if you read all of the articles and journals it seems like SMILE is a procedure that is available to everybody. The proviso is that first of all you need to invest in the specific femtosecond laser machine, you still should have an excimer laser available, and at the moment there is no other laser manufacturer offering anything like SMILE,” he said. As a result, the bottom line is that many physicians find it hard to justify the additional outlay on the Zeiss platform when highly predictable and consistent outcomes can already be obtained with standard femto-LASIK treatments. “At the moment, looking at the postoperative healing time and the postoperative outcomes, I think there is not really a big advantage that the patient or doctor can really feel or see. We should also bear in mind that, as more surgeons perform this procedure, so we will see an increase in complications such as incomplete lenticular removal, which can be quite challenging to deal with. On the other hand, a smaller incision is definitely better than a big LASIK flap and we are seeing an increased demand for it in Germany from patients who like the idea of a flap-free procedure. Overall, I think there is a big future for SMILE and we are still on the way to finding ways to optimise this procedure,” asserted Dr Holzer. For Dan Z Reinstein MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO, Medical Director of the London Vision Clinic, UK, the process of optimisation is already well under way and the five-year results should not be interpreted as a definitive reflection of the procedure’s capability. “While it is important to document the longer-term outcomes for SMILE as for any procedure, I don’t think that there was any doubt that the long-term outcomes would be any different to LASIK given the similarity between the procedures. Also, these results are for the earliest populations treated, so before all the work had been carried out to optimise the laser energy and spot spacing settings. They were also performed using the

Box plots of the achieved optical zone diameter based on both tangential and axial curvature difference maps for SMILE, with 6.36.7mm programmed optical zone compared with matched LASIK controls with both 6.50 and 7.00mm programmed optical zone

200kHz laser, whereas now we are using the 500kHz version,” he said. Surgical technique and instruments have also greatly improved with time and experience, and understanding of the SMILE nomogram has increased refractive accuracy, particularly for astigmatism, added Dr Reinstein. “With this learning curve we have seen the published results steadily improving, meaning that the results in the five-year studies will not have as good results as the more recent papers,” he said.

HYPEROPIA HOPES With safety and efficacy already well established for myopia, investigators have been turning their attention to hyperopia treatments, with mixed results. An initial off-label, investigator-initiated study carried out by Osama Ibrahim MD and colleagues at Alexandria University, Egypt, delivered less impressive outcomes than those for myopia, with limited correction up to +4.5D and some regression. “Hyperopic SMILE is more challenging as the lenticule thickness at the centre is very thin and care needs to be taken not to perforate it. Also, the thick edge causes a

Hyperopic SMILE is more challenging as the lenticule thickness at the centre is very thin... Osama Ibrahim MD

trough that stimulates epithelial hyperplasia and hence regression. The company is testing a new software algorithm with a different edge design and a larger transition zone and the results will be released shortly by Dr Sekundo and Dr Reinstein. We also did cases with hyperopic and mixed astigmatism using a large transition zone, and our results were very encouraging in the first pilot group with less regression,” Dr Ibrahim told EuroTimes. The refinements to the optical zone, transition zone, and minimum lenticule thickness certainly appear to have yielded dividends, with early results from Dr Reinstein’s hyperopia study, carried out in conjunction with Kishore Pradhan at the Tilganga Institute of Ophthalmology, Kathmandu, Nepal, deemed sufficiently robust for Dr Reinstein to offer hyperopic SMILE in his London clinic in the near future. The first phase of the study was done for amblyopic eyes in which topographic centration was demonstrated to be similar to a LASIK control group, and achieved optical zone diameter for a 6.3 programmed optical zone was demonstrated to be equal to the achieved zone for 7mm LASIK with the MEL 80. For the subgroup of 31 sighted eyes with corrected distance visual acuity of 20/40 or better, the refractive accuracy and safety at three months were similar to matched LASIK controls, with 65 per cent within ±0.50D, compared to 53 per cent within ±0.50D for the matched LASIK control group. EUROTIMES | JULY/AUGUST 2016

COVER STORY: CATARACT & REFRACTIVE For his part, Dr Sekundo said that the early results of the hyperopia study carried out with Marcus Blum MD were extremely promising and he hoped to present the six-month data for all patients at the XXXIV Congress of the ESCRS in Copenhagen in September.

SMILE through a minimally invasive 2mm incision

Courtesy of Soosan Jacob MS, FRCS, DNB, Dr Agarwal’s Eye Hospital, Chennai, India

EXPERIMENTAL APPROACHES Intrastromal techniques such as SMILE have also prompted interest in the possibility of using tissue-addition procedures to treat hyperopia, presbyopia and keratoconus. The basic idea is that refractive lenticules might be stored so that reimplantation can be performed at a later date if a patient develops ectasia, for instance, or if their myopia progresses to presbyopia. But reimplanted lenticules might also potentially come from other patients. Following initial work by Pradhan et al, Sri Ganesh MD in Bangalore, India reported the results of a series of nine eyes in which cryopreserved lenticules from patients with myopia were reimplanted into patients with hyperopia. Although there was an undercorrection of the hyperopia in all eyes, the mean undercorrection of 21 per cent was less than the 50 per cent found in the first case report by Pradhan (although this case was for attempted correction of +10D), and the procedure was deemed safe with minimal risk of rejection of the implanted lenticule. For treatment of mild to moderate keratoconus, Dr Ganesh and colleagues refined the surgical technique to punch a doughnut-shaped lenticule from a central 3mm portion of tissue. This lenticule was then implanted into a pocket created in the cornea by femtosecond laser at 100-micron depth, and followed by accelerated crosslinking. Of nine eyes treated in this fashion with a mean follow-up of 12 months, the authors observed a significant improvement in visual acuity with reduction in mean keratometry, asphericity, and total higher order aberrations. Biomechanical stability was also improved postoperatively. For presbyopia, Soosan Jacob MS, FRCS, DNB, in Chennai, India, has recently described a technique in which a lenticule is marked and trephined at its centre to 1mm diameter, and implanted in the cornea under a 120-micron femtosecond cap in the non-dominant eye (S Jacob, EuroTimes, Volume 21, Issue 4, 42-43). The PEARL (PrEsbyopic Allogenic Refractive Lenticule) inlay acts by creating a small central area of hyper-prolateness on the cornea. The extremely small size of the PEARL inlay creates a small hyperprolate area surrounded by normal topography,

both of which lie within the pupillary zone. This allows improved depth-of-focus while still preserving good distance vision, unlike larger implants which can degrade quality of vision. The other advantage of PEARL is that the allogenic material of the inlay ensures good biocompatibility and avoids inflammation related to insertion of synthetic material into the cornea. Although such approaches push the boundaries for SMILE, they nevertheless remain niche, experimental techniques that will take a long time to percolate into dayto-day practice, if ever, advises Dr Hjortdal. “While we have not yet corrected hyperopia at our own clinic, we have treated penetrating keratoplasty patients for high astigmatism and ametropia using SMILE with good results. For keratoconus, milder cases may be treated, but the future will show whether SMILE in combination with lenticule inlays may be a viable treatment. As for the presbyopia treatment, in Europe and the USA, this is considered a corneal transplant procedure and the transplanted tissue needs to be checked under regulations applying to normal corneal transplantation with corneal donor tissue,” he said. Quality of vision may also be a potential issue for the tissue-added approach to presbyopia, said Dr Reinstein. “This procedure aims to intentionally create a central island in order to have a central

This procedure aims to intentionally create a central island in order to have a central steep zone for near vision Dan Z Reinstein MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO EUROTIMES | JULY/AUGUST 2016

steep zone for near vision. But this will inevitably be associated with a reduction in quality of vision and reduction in safety, as we know from experience with early excimer lasers, central islands cause problems for many patients. Some patients will be extremely happy because they get distance and near vision and are able to adapt to the multifocality, but there may be a sizeable percentage who will be unhappy due to quality of vision issues,” he said. While only time will tell whether these newer techniques ever make the leap into daily clinical practice, SMILE’s place as a viable and safe alternative to LASIK for treating a broad range of refractive errors seems assured. “We are definitely not at the end of SMILE’s development, but are probably somewhere in the middle. We can now produce very good, reproducible results and have brought it to the stage where every surgeon can get good outcomes. So it is a technique that is not just for the select few. A lot of the demand is also being driven by patients, who like the sound of a flap-free, painless procedure with a more stable cornea. LASIK is a wonderful procedure and will be around for a long time to come. However, having SMILE gives us even more treatment options and that has to be a good thing for our patients,” Dr Sekundo concluded. Jesper Hjortdal: jesper.hjortdal@dadlnet.dk Walter Sekundo: sekundo@med.uni-marburg.de Mike Holzer: mike.holzer@med.uni-heidelberg.de Dan Reinstein: dzr@londonvisionclinic.com Osama Ibrahim: ibrosama@gmail.com Soosan Jacob: dr_soosanj@hotmail.com

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IRIS CLAW LENS José Güell MD says iris-enclaving haptic design is still going strong after 30 years José Güell MD, Barcelona, Spain, spoke with EuroTimes contributing editor Roibeard O’hEineachain about the iris claw intraocular lens (IOL), the topic of his Ridley Medal Lecture which he will deliver at the XXXIV Congress of the ESCRS in Copenhagen.

have chosen as the topic of my Ridley lecture a long-term assessment of the iris claw lens, the brainchild of the late Prof Jan Worst. It seems fitting to devote a lecture named after the first IOL designer to honour another who followed in the same pioneering tradition so admirably. I first became acquainted with Prof Worst’s fantastic idea of an iris claw IOL when it first became commercially available in 1987. I was still in my residency around that time I met with Prof Worst and we discussed a lot of fabulous projects. Since then I've been involved in the clinical evolution of this particular way of fixating the lens in several different projects. The original PMMA lenses are still in use, but there have been many new versions of the lens for different indications, and composed of different materials and additional optical designs. In my lecture, I shall be reviewing the results achieved with these lenses in large international trials and also in my own extensive experience with the implants. Originally the iris claw implant was designed for use in aphakia and I began to use it for that purpose, especially in paediatric patients. That was because the lens had the advantage of needing only standard biometry for lens power calculation. It was also not necessary to calculate the angle-to-angle or the sulcus-to-sulcus diameters for the lens. Because of its particular means of fixation to the peripheral iris, the lens can be implanted in any eye with sufficient iris to support it. In addition, the iris claw lenses tend to fare much better than angle-supported phakic lenses in terms of endothelial cell loss. Their location in the anterior chamber is almost on the same plane as the iris, which means there is a much greater distance between the optic and the endothelium.

I first became acquainted with Prof Worst’s fantastic idea of an iris-claw IOL when it first became commercially available in 1987 José Güell MD

These advantages have lent themselves well to other indications for iris claw lenses, with new optic designs and materials. Most especially there are the toric and non-toric myopic and hyperopic Artisan/Verisyse models for phakic ametropes. There are also flexible versions of the toric and non-toric lenses, called the Artiflex. There is also a multifocal version of the Artisan, although it is not in great demand due to shallower anterior chambers of presbyopes and the much shorter interval between implantation of the lens and cataract onset compared to the younger ametrope, although it might be an excellent option as a secondary explant for those who like multifocality in previous monofocal pseudophakes. The edge of the myopic lens is thicker than that of the hyperopic model, but that is generally balanced by the larger anterior chambers of myopic eyes. Conversely, some of the advantage of the thinner edge of the hyperopic implant is lost through the shallower anterior chambers of hyperopic eyes. Moreover, in the aphakic eye, many surgeons are now implanting the iris claw lenses on the underside of the iris to enhance endothelial safety. Whichever implant you're using and however you’re implanting it, you should obtain accurate measurements of the anterior chamber anatomy with the modern imaging instruments, to judge whether there will be a safe distance between the endothelium and the lens. When you implant this kind of lens you should always advise your patients that they will require postoperative controls for the rest of their lives. The anterior chamber in phakic eyes tends to gradually collapse as people age, bringing the lens closer to the endothelium than it was initially. Therefore, every one-to-three years they should undergo endothelial cell counts and optical coherence tomography anterior segment imagining. Over the years, iris claw lens design has proved very versatile and can provide a good option in some unusual and difficult situations. The aphakic lens can be useful as a primary procedure in eyes with congenital or post-traumatic subluxation, where capsular fixation is not possible. The phakic lenses can also be effective in paediatric patients with significant anisometropia, and in patients who for one reason or another cannot wear contact lenses. One exciting possibility to emerge in recent years is using these these kind of implants in the management of a keratoconic eye after intracorneal ring implantation and/or collagen crosslinking. Also very promising is the recent development of iris claw lenses with optics composed of an acrylic material, which are likely to become commercially available late in 2016 or early in 2017. There will be both phakic and aphakic versions of the lens with the new material, so for the first time we will be able to implant the lens in paediatric and adult aphakes using a conventional small incision. José Güell: guell@imo.es

РОССИЙСКИЙ ВЫПУСК Visit: www.eurotimesrussian.org EUROTIMES | JULY/AUGUST 2016

RUSSIAN LANGUAGE EDITION NOW ONLINE

SPECIAL FOCUS: CATARACT & REFRACTIVE

CAPSULOTOMY LASER First experience with CAPSULaser – fast, simple capsulotomies. Leigh Spielberg MD reports

e have tried to approach the capsulotomy from a different angle,” said Pavel Stodůlka MD, PhD, of the Gemini Eye Clinics in the Czech Republic. He presented his experience with the CAPSULaser laser during an interactive free paper session on femto laser-assisted cataract surgery at the XXXIII Congress of the ESCRS in Barcelona, Spain. “The advantages of laser capsulotomies are by now well known. They are perfectly round, and can be generated with precise diameters that can be consistently reproduced for every case,” said Dr Stodůlka. “However, the disadvantages of femtocapsulotomy are equally widely known: the laser device is extremely costly and the entire process can be very time-consuming, as the patient often has to be moved from one operating room to another,” he added. Dr Stodůlka also pointed out the relative complexity of the whole femtocapsulotomy procedure. The CAPSULaser is a yellow laser with continuous emission that mounts to existing operating microscopes. This eliminates the need to purchase a large unit as well as the need to transport the patient between steps. “A high-quality capsulotomy provides the foundation for the whole surgery. What we’re all looking for is a reliable and stable

The corneal lens is designed to be disposable, but could theoretically be reusable

reusable. It provides good, convenient centration while the patient fixates on the light generated by the operating microscope,” he said. Complete circular capsulotomy was achieved in all 10 eyes, and there were no adverse events. “The edge is as smooth as the edge of a manual capsulorhexis, and it is quite firm. I observed no tears or tags at the edge of the rhexis. Further, I didn’t encounter any problems with post-capsulotomy miosis,” he said, referring to a well-known problem seen with laser capsulotomies. One-month results were consistent with femtosecond laser-assisted surgeries. At one month postoperatively, 80 per cent of eyes had a visual acuity of 20/20 or better. All intraocular lenses were well centred. There were no corneal epithelial or stromal issues, no postoperative flare, no iris damage, no capsular fibrosis, no increases in intraocular pressure and no fundus abnormalities. “Three-month results confirmed stable effective lens position with no complications whatsoever, and with usual endothelial cell counts,” added Dr Stodůlka. Dr Stodůlka was unable to discuss the technical parameters of the laser, as this information is currently still confidential. The CAPSULaser, which is being developed by a company in California’s Silicon Valley, is in the clinical validation phase. “My first experience has been very positive, and I think this is a promising new technique. This laser is significantly less complex and less expensive compared to current femtosecond lasers, which might make laser capsulotomy more accessible for cataract surgeons worldwide than the current standards,” said Dr Stodůlka.

Pavel Stodůlka MD, PhD

Pavel Stodůlka: stodulka@lasik.cz

effective lens position with a low incidence of posterior capsular opacity. Proper capsulotomy size and shape are crucial to achieving these goals,” he said. Dr Stodůlka reported the results of a feasibility study of 10 eyes with standard cataract and no other intraocular pathology or previous ocular surgery. Patients were aged 68.9 ± 9.0 years. Mean axial length was 23.05 ± 1.06mm, with a mean anterior chamber depth of 3.03 ± 0.40mm. Cataract grade was approximately evenly distributed among grades 1, 2 and 3. After corneal incisions were made and intraocular anaesthesia was administered, the capsule was stained with trypan blue for 30 seconds. The dye was then washed out by Ringer's solution, and after the anterior chamber was filled with OVD the capsulotomy took place. The CAPSUlaser’s yellow laser interacts with the blue stained anterior lens capsule to cut a given diamtere capsulotomy. “We have used 5.0mm capsulotomy at our patient series. The laser works with various commercially available blue dyes,” explained Dr Stodůlka. Dr Stodůlka showed delegates a video of the procedure in which a precise, freefloating capsulotomy was rapidly produced and immediately removed via a side port corneal incision using fine forceps. “The corneal lens is designed to be disposable, but could theoretically be

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SPECIAL FOCUS: CATARACT & REFRACTIVE

PUSHING SMILE LIMITS With outcomes rivalling LASIK, flapless refractive procedure is gaining converts. Howard Larkin reports

efractive and visual outcomes from small incision lenticule extraction (SMILE) rival those of femtosecond laser LASIK (fLASIK) for myopia up to -10.0D with less risk of complications, presenters told the XXXIII Congress of the ESCRS in Barcelona, Spain. With clinical evidence mounting, several surgeons said they now prefer SMILE to any LASIK procedure. Introduced commercially in 2012, SMILE does not require cutting a flap or removing epithelium to reshape the stroma. Instead, a femtosecond laser cuts an intrastromal lenticule of about 6.5mm and an access tunnel of 2.0mm to 4.0mm. Via the tunnel, the lenticule is then completely separated from surrounding tissue with a spatula, and removed with forceps. Detlev RH Breyer MD, Duesseldorf, Germany, credits this minimally invasive approach for better patient comfort after surgery and comparable visual and better safety results. “ReLEx SMILE with 130, 140 or 150-micron cap thickness replaced fLASIK completely for the last five years,” he said. Petri Oksman MD, Helsinki, Finland, reported similar findings in a large retrospective study comparing 1,991 myopic eyes receiving SMILE with 1,895 receiving fLASIK. He said that “fLASIK and SMILE are equally accurate and stable”.

OUTCOMES AND SAFETY Dr Oksman’s retrospective study involved patients with -0.75D to -10.0D myopia treated at two clinics from 2012 through to 2014. Three and six months after surgery, patients with initial myopia of -3.0D SEQ or less treated with fLASIK had about two ETDRS letters better mean uncorrected visual acuity (UCVA) than SMILE patients. At intermediate and high myopia fLASIK had a one to two letter advantage. However, these differences are not clinically relevant, and are well within

Results for mean monocular uncorrected distance visual acuity (UDVA) in all four groups (SMILE with 130, 140 and 150µm cap thickness, and fLASIK with 100µm flap thickness). The only significant (p<0.05) postoperative difference is fLASIK at one day being slightly better than the SMILE groups

the repeatability range of visual acuity (VA) testing, which is ±3.5 to 9.0 letters, Dr Breyer pointed out. He believes other advantages of SMILE outweigh any slight VA advantage fLASIK may have. “In patient counselling we discuss the speed and ease of the operation, reduced dry eye, no flap-related complications and corneal integrity,” he said. In Dr Breyer’s retrospective study, fLASIK eyes had slightly better VA one day after surgery, but were similar to SMILE eyes with all cap thicknesses at one week, one month, three months, six months and one year after surgery (see Figure 1). The SMILE groups reported less dry eye, less pain and better comfort. SMILE eyes also had a better safety profile (see Figure 2). Less than 12 per cent lost one line of corrected vision among 125 SMILE eyes with 130-micron caps and 90 eyes with 140-micron caps, Dr Breyer said. By contrast, 33 per cent of 40 fLASIK eyes

ReLEx SMILE with 130, 140 or 150-micron cap thickness replaced fLASIK completely for the last five years Detlev RH Breyer MD EUROTIMES | JULY/AUGUST 2016

lost one line or more. About 21 per cent of SMILE eyes with 150-micron caps lost one line, and two per cent two lines, though these results are less certain due to smaller numbers and shorter follow-up, he said. Wavefront analysis found the SMILE eyes had lower ocular aberrations, including spherical and coma, over a 6.0mm optical zone, Dr Breyer said. Predictability and visual outcomes were similar for all cap thicknesses, suggesting that thicker caps do not affect outcomes. Looking at postoperative videokeratography, the ablation zone in ReLEx SMILE corneas is much more even than in fLASIK corneas, maybe explaining less corneal aberration induction and nearly no photopic phenomena drivinig at night time in ReLEx SMILE eyes. Indeed, thicker caps may be resulting in less change in the total tensile strength of the cornea post-op. Speaking from the audience, Dan Z Reinstein MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO, London Vision Clinic, UK, noted that the tensile strength of anterior stroma is about twice that of posterior stroma. Therefore, a thicker cap preserves more corneal strength since more of the lenticule is cut from the weaker posterior tissue. In effect, leaving 80 microns of anterior

SPECIAL FOCUS: CATARACT & REFRACTIVE

stroma is equivalent to leaving 160 microns of posterior stromal bed, making the cornea stronger with SMILE than an equivalent photorefractive keratectomy.

SMILE may also be preferable to LASIK for myopia exceeding -10.0D because it eliminates risk of heat build-up and environmental exposure seen with long excimer treatments, said Moones Abdalla MD, of the International Femto-Lasik Centre, Cairo, Egypt. As an off-lable, prospective non-comparative trial, 86 per cent of 365 eyes of -10.0D to -14.0D treated with SMILE were within ±0.5D of their refractive target at six months. Mean sphere was -1.28D and cylinder -0.83D, while corrected vision improved from a mean of 0.67 to 0.74 Snellen decimal. No eye lost two lines, 1.0 per cent lost one line and 18 per cent gained one or more lines of distance vision, and overall quality of vision was better than expected, Dr Abdalla observed. “This marked flattening should be troublesome, but it is very acceptable with SMILE. You don’t cut a flap so the spherical aberrations are less,moreover the functional optical zone in SMILE is much wider than in LASIK, as tissue removal affects cornal biomechanics differently,” he said. In a pilot study of SMILE for hyperopia as an investigator-initiated study, 24 patients with a mean preoperative sphere of +3.41D, cylinder 2.86D, achieved +0.29 sphere and -0.76 cylinder one week after surgery, Osama Ibrahim MD, PhD, Alexandria University, Egypt, reported. However, at six months this regressed to +0.74D sphere and -0.96D cylinder. This regression was improved by adding a transition zone and is expected to be even better with newer software and better algorithms.

Courtesy of Detlev RH Breyer MD

HIGHER MYOPIA

Distribution of the differences between monocular post- and preoperative corrected distance visual acuity (CDVA) for all four groups (SMILE with 130, 140 and 150µm cap thickness, and fLASIK with 100µm flap thickness)

“SMILE for hyperopic astigmatism is safe and effective but less predictable and less stable than for myopia or myopic astigmatism,” Dr Ibrahim said. Higher hyperopia led to more regression, while increasing lenticule diameter and the transition zone lessened regression. Thickening the lenticule by a uniform, non-refractive 20-30 microns also made it easier to remove the thin central area without damage, he noted. “Some less experienced surgeons can

encounter problems with the SMILE surgical technique, and therefore may not achieve as good results,” Dr Breyer added. Detlev RH Breyer: d.breyer@augenchirurgie.clinic Petri Oksman: petri.oksman@medilaser.fi Dan Z Reinstein: dzr@londonvisionclinic.com Moones Abdalla: moones.abdalla@gmail.com Osama Ibrahim: ibrosama@gmail.com

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SPECIAL FOCUS: CATARACT & REFRACTIVE

P0INT-OF-CARE TESTS In a series of articles sponsored by ISOPT Clinical, Penny A Asbell MD, FACS, MBA says point-of-care testing will allow quicker, more accurate diagnoses

urrently, when we talk about dry eye disease (DED), we typically start with therapy that is the same for all patients – artificial tears, then maybe plugs, topical anti-inflammatories etc. Is this the best approach? Looking at another common problem, joint pain, the doctor would not treat osteoarthritis the same as rheumatoid arthritis; we all know that joint pain has different mechanisms of pathology and treatment is directed accordingly. It is time that our approach to DED got more specific, based on mechanisms, and point-of-care testing may help move us forward to this patient-centred approach.

NEED FOR BIOMARKERS IN DED Current DED evaluation involving vital dye testing and Schirmer testing is well known to be variable and neither sensitive or reproducible; these tests make it hard to diagnose and determine efficacy of treatment. What we need is minimally invasive objective metrics. Biomarkers are defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic process, or pharmacologic responses to a therapeutic intervention”. (NIH Definitions Working Group. Biomarkers and surrogate endpoints in clinical research: definitions and conceptual model) The DEWS report of 2007 defined dry eye as follows: “Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.” Since then several in-office point-of-care tests have become available addressing key issues in DED.

TEAR OSMOLARITY Hyperosmolar tears have long been associated with DED and considered a hallmark of it. Laboratory research has demonstrated that hyperosmolar solutions are injurious to surface cells and lead to an increase in the production of inflammatory markers. TearLab’s OcuSense measures tear osmolarity, indirectly through electrical impedance, with only nanolitres of tears. It is easy and fast to find the tear osmlarity of each eye. Subsequent peer-reviewed articles have been mixed on its role in diagnosing DED. A literature review published in 2015 supported by TearLab found 72 per cent positive, 21 per cent neutral and seven per cent negative. (Clin Ophthalmol. 2015 Nov 2;9:2039-47) Unclear issues include: Is variability the key finding?; Is one test per eye enough?; And, does a normal reading rule out DED? Review of peer-reviewed Penny A Asbell MD, FACS, MBA publications over the last two

...we all know that joint pain has different mechanisms of pathology and treatment is directed accordingly

EUROTIMES | JULY/AUGUST 2016

decades confirms the growing interest in DED and matches the growing body of literature highlighting that inflammation is a core mechanism for DED. The problem likely involves both innate and adaptive immune response, with a dysregulation of a balance in the immune response. Clinical research work is investigating inflammatory markers on the ocular surface through impression cytology sampling of conjunctival surface and tear analysis of cytokines. Going forward, this work may allow for a better understanding of the mechanisms contributing to DED and open up new targets for pharmaceutical treatment and possible new point-of-care tests. The point-of-care test for inflammation is InflammaDry®, which measures one inflammatory mediator, MMP-9, and gives a ‘yes’ or ‘no’ answer, similar to a pregnancy test. The tip is rubbed along the conjunctiva before placing any eye drops, then placed in a container for several minutes, and the coloured stripes are then evaluated: ‘pink’ means the concentration of MMP-9 is greater than 40ng/ml – considered the upper limits of normal. RPS, the manufacturer, feels that only 40-60 per cent of DED symptomatic patients have significant inflammation and that these patients will respond best to use of antiinflammatory treatments.

IMAGING IN DED Imaging is integral in most of ophthalmic care and a regular component for a glaucoma and retinal evaluation. Now, imaging of the ocular surface may add an additional dimension in understanding DED and perhaps help in differentiating aqueous deficit from evaporative DED. The Keratograph® from OCULUS images (without the use of any eye drops or vital dyes): noninvasive tear break-up time (NITBUT), tear meniscus height, redness score, and meibomian gland imaging (meimography). Other devices, including LipiView, give metrics of lipid thickness in addition to meimography.

THE FUTURE Look for expanding opportunities for in-office testing in DED. Be sure to evaluate carefully data on repeatability (precision), accuracy (does the test give a true value?), sensitivity and specificity. Is the result clinically significant? Is the test responsive to treatment? Ongoing studies and future trials should help us all understand how best to use point-of-care tests in DED and continue to progress to personalised care for ocular surface disease, including DED. Further references available on request Prof Penny A Asbell is Professor of Ophthalmology, Director of Cornea and Refractive Services, Director of the Cornea Fellowship Programme, Department of Ophthalmology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, USA Penny A Asbell: penny.asbell@mssm.edu

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SPECIAL FOCUS: CATARACT & REFRACTIVE

SYNERGETIC EFFECT Are IOL designs holding back femtosecond laser-assisted cataract surgery? Howard Larkin reports

esigning intraocular lenses (IOLs) to take advantage of the precision afforded by femtosecond laser-assisted cataract surgery (FLACS) will likely encourage FLACS development and adoption, according to experts who spoke at the Ophthalmology Futures Forum Barcelona 2015, in Spain. “I don’t think the lack of lenses today is retarding femtosecond cataract technology; it is going forward by itself. But there is huge potential for IOL improvement. If new IOL technology gives a benefit to femtosecond laser surgery there will be a synergetic effect that will propel this complex forward in the years to come,” said Boris Malyugin MD, PhD, Chief of Cataract and Implant Surgery at the S Fyodorov Eye Microsurgery Complex, Moscow, Russia, who Lens fragmentation pattern following FLACS moderated a panel discussion on the topic. However, with current IOLs the benefits are unclear, so some surgeons advised caution in adopting FLACS. “My clinic has a mission statement and the first sentence is 'patient satisfaction is the number one priority'. Right now I can’t justify femtosecond cataract surgery because it does not improve the performance of current lenses,” said Arthur Cummings MB, ChB, MMed(Ophth), FCS(SA), FRCSEd, of Wellington Eye Clinic, Dublin, Ireland.

FUTURE LENS DESIGNS That could change quickly, Dr Cummings added. “If future lens designs have real benefits – I’m thinking real accommodation – and they fit better in an eye treated with a femtosecond laser, that is what will drive (widespread FLACS adoption).” For example, FLACS might one day make possible emulsifying and removing cataracts, through a very small incision, followed by re-inflation of the capsular bag with an accommodating gel, he added. A decade of follow-up with the bag-in-lens design by Marie-José Tassignon

I don’t think the lack of lenses today is retarding femtosecond cataract technology; it is going forward by itself

EUROTIMES | JULY/AUGUST 2016

Boris Malyugin MD, PhD

Courtesy of Boris Malyugin MD, PhD, Nikolay Sobolev MD and Natalia Anisimova MD, S Fyodorov Eye Microsurgery Complex State Institution, Moscow, Russia

MD, PhD, FEBO, shows that capsulotomy-fixated lenses are stable, resisting anterior movement associated with capsule fibrosis and contraction over time. Better stability may also allow larger IOL optics offering better vision quality, he said. Sunil Shah MBBS, FRCOphth, FRCS (Ed), FBCLA, a consultant ophthalmologist at Midland Eye, Solihull, UK, is conducting a study of the LENTIS IOL, focusing in part on outcomes with less-experienced surgeons. His early results suggest that the technology may produce better results even among surgeons with 20 or fewer procedures, but it’s still too early to tell for sure.

IS FLACS BETTER? Before looking to new lenses that optimise FLACS, the question of whether femtosecond technology is superior to phacoemulsification should first be addressed, said Béatrice Cochener MD, PhD, Professor and Chair of the Ophthalmology Department at

University Hospital Brest, France. She underlined that, actually instead of asking if femto is better than phaco, we should consider that we are not comparing two competitive techniques but just refining phaco with femto for potentially better safety and accuracy. “Is perfect lens centration guaranteed to perfect positioning of the lens? We don’t have an answer for that. Will the capsular bag act the same after FLACS as it does after phaco? We don’t know,” she said. Another issue with FLACS is it can make polishing the capsule more difficult, increasing the risk of posterior capsule opacification (PCO), Dr Cochener added. This could gravitate against FLACS because overcoming PCO is a major issue in improving outcomes. “We need to think about what we need to eliminate in cataract outcomes, we need to improve predictability of IOL positioning and to eliminate PCO,” she added. Early results of a multicentre French study will focus, among the various evaluated parameters, on the occurrence of PCO. Fibrosis and bag contraction may appear earlier after femtocataract, but it is too early to tell for sure, or if the differences is significant, Dr Cochener said. “We need to see if FLACS itself is better than phaco alone, and then come back to evaluate specific lenses that need to be designed to achieve the targeted perfection of predictable and stable implantation,” said Dr Cochener. Boris Malyugin: boris.malyugin@gmail.com Arthur Cummings: abc@wellingtoneyeclinic.com Sunil Shah: sunilshah@doctors.net.uk Béatrice Cochener: beatrice.cochener@ophtalmologie-chu29.fr

SPECIAL FOCUS: CATARACT & REFRACTIVE

IOLS GIVE HOPE New generation of accommodative IOLs bringing hope to presbyopes. Roibeard O’hEineachain reports

ntraocular lenses (IOLs) designed to produce an accommodative effect have as yet come short of their goal, but new IOLs that are now in early trials or still under development may yet prove to be the Holy Grail of presbyopia treatment, said Gerd U Auffarth MD, PhD, FEBO at the XXXIII Congress of the ESCRS in Barcelona, Spain. “People have been looking for the Holy Grail for centuries and nobody has found it, and I hope that will not be the fate of accommodating lenses,” said Dr Auffarth, University of Heidelberg, Germany. He noted that the two principal approaches to restoring physiological accommodation with an IOL are those based on the forward movement of the optic and those based on a change of curvature of the optic.

LIMITED RESULTS Lenses in the first category include single optic IOLs such as the Crystalens and dualoptic IOLs such as the Synchrony (AMO). The single-optic accommodating IOLs have not functioned as designed, showing little forward movement and at most half a dioptre of true accommodation, a small amount of pseudoaccommodation and perhaps some mini-monovision, Dr Auffarth said. He cited a prospective randomised trial involving 31 patients which showed that patients who received one of three types of single-optic accommodating IOL had no significant advantage in terms of near visual acuity compared to patients targeted for mini-monovision using monofocal IOLs, where there is only a slight disparity between the postoperative refraction of the two eyes. The Synchrony dual-optic IOL is a more sophisticated movement-based lens, combining a high-power optic and a lowpower minus lens so that it requires much less forward movement of the anterior optic to achieve an accommodative effect. Dr Auffarth noted that, in his experience, the lens provides patients with fair intermediate vision and a near visual acuity

ranging from 0.8 logMAR to 0.4 logMAR. Measurements with aberrometry show about 1.0D of accommodation. Yet defocus curves show that patients can achieve 2.5D of combined real accommodation and pseudoaccommodation. On the other hand, another trial found no significant difference between 27 patients implanted with the single-optic Crystalens and 26 eyes implanted with the dual-optic Synchrony lens, in terms of near or intermediate visual acuity, he added. Recent years have seen the introduction of a couple of lenses that emulate natural accommodation through a change of curvature in response to the action of the ciliary muscle. The advantage of this approach is that the amount of increase in curvature necessary for a lens to achieve an accommodative effect is small compared to the amount of optic movement required to achieve the same effect. Two shape-shifting IOLs that have made it into clinical trials are the NuLens (NuLens) and the FluidVision IOLs (PowerVision). The NuLens consists of two parts, one placed on top of the bag and the other in the sulcus. It operates on the principle of reverse accommodation. Early trials with the NuLens have shown that it can improve distance and near visual acuity of low-vision patients. The FluidVision lens is a silicone oilfilled IOL which pushes fluid from an outer reservoir through small channels into the optic, in response to the relaxation of the zonules that occurs with contraction of the ciliary muscle. That in turn changes the curvature which translates into a change in refraction. In a study Dr Auffarth and his associates conducted involving six patients implanted with the FluidVision IOL, mean uncorrected visual acuity at six months was 20/20 for distance and intermediate, and 20/23 for near.

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Gerd U Auffarth: gerd.auffarth@med.uni-heidelberg.de Dr Auffarth has received research grants from PowerVision, AMO and Alcon

People have been looking for the Holy Grail for centuries and nobody has found it... Gerd U Auffarth MD, PhD, FEBO EUROTIMES | JULY/AUGUST 2016

SPECIAL FOCUS: CATARACT & REFRACTIVE

RUPTURE REMEDY

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The Netherlands

Posterior capsule tear does not rule out implantation of single-piece IOL. Roibeard O’hEineachain reports

well-centred single-piece intraocular lens (IOL), securely positioned in the capsular bag, is possible in eyes with posterior capsule ruptures, provided the tear is not too big, the anterior hyaloid face is intact and the surgeon acts promptly and appropriately, according to Brian Little FRCS, FRCOphth, of Moorfields Eye Hospital, London, UK. “One of the problems that we often have is a tendency towards denial whenever something like this happens, and that delays making the right decision and taking action,” he told the 20th ESCRS Winter Meeting in Athens, Greece. Once there is a tear in the bag, continuing with phacoemulsification will only exacerbate the problem and enlarge the tear, he said. Enlarging the tear not only makes the capsular fixation of a single-piece lens less possible, it also further increases the risk of rupture of the anterior hyaloid face and vitreous loss.

DISASTROUS COMPLICATIONS

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Vitreous loss increases the risk of several potentially disastrous complications, including suprachoroidal haemorrhage, cystoid macular oedema, endophthalmitis, glaucoma and retinal detachment. In fact, a recent publication from a UK national dataset showed that vitreous loss increased the risk of retinal detachment 40-fold. Dr Little noted that, when the tear occurs during the early part of the procedure, often too little of the posterior capsule remains to support a single-piece IOL. However, the prospects of good capsular support are improved when the posterior capsule tear occurs later in the procedure. In these cases, a reasoned, stepwise approach will result in a postoperative situation almost identical to that which would have occurred if there had been no Brian Little capsular rupture, Dr Little said. He noted that in all such cases it is essential to tamponade the posterior capsule in order to prevent further enlargement of the tear by pushing back the anterior hyaloid face. This is best achieved by maintaining irrigation whilst removing the second instrument from the side port, and then inserting the ophthalmic viscosurgical device (OVD) cannula. The OVD is steadily injected as the irrigation is simultaneously turned off, thereby maintaining tamponade of the posterior capsule. Turning off or removing the irrigation from the eye without OVD exchange will cause the anterior chamber to decompress, allowing the vitreous to push forward, resulting in the rupture of the anterior hyaloid and vitreous prolapse. A controlled posterior capsulorhexis can then be performed using forceps, taking the existing tear and circularising it. The anterior and posterior leaflets of the bag can then be maximally separated with more OVDs and a single-piece IOL safely inserted into the bag, he explained. Brian Little: brian.little@moorfields.nhs.uk

EUROTIMES | JULY/AUGUST 2016

SPECIAL FOCUS: CATARACT & REFRACTIVE

ADVANCING TECHNOLOGY Kerry Solomon MD takes the reins as ASCRS expands education programmes. Howard Larkin reports

esponding to members’ increasing need to keep up with rapidly advancing ophthalmic technology, the American Society of Cataract and Refractive Surgery has greatly expanded its education programmes, outgoing president Robert Cionni MD told the opening session of the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. These include more regional meetings and webinars, as well as annual meeting clinical seminars, said Dr Cionni, of Salt Lake City, USA. Dr Cionni thanked industry supporters for helping make new programming possible with $4.5million in educational grants this year. Other popular ASCRS programmes are the online intraocular lens (IOL) power calculators, used 145,000 times last year; and the annual clinical survey, which used responses from 2,000 surgeons to help identify helpful education topics. Later this year the ASCRS•ASOA 365 App will launch, connecting members directly to free online learning and CME, and information on upcoming seminars, said incoming ASCRS president Kerry Solomon MD, of Mount Pleasant, South Carolina, USA, in his inaugural address. “We are working hard to find new ways for you to get involved with ASCRS,” he said. Dr Solomon also encouraged members’ political involvement, noting that ASCRS leadership in legislative and regulatory efforts can benefit patients and surgeons. Recent victories include heading off a proposed cut in cataract surgery payment through the national medicare insurance programme for senior citizens. However, preserving access to care and reasonable compensation for physicians is an ongoing battle requiring constant attention and

Outgoing ASCRS president Robert Cionni (right) welcomes incoming president Kerry Solomon at the society’s annual event in New Orleans

support from members, who are among the best patient advocates, he noted.

EUROPEAN PRESENCE In a symposium highlighting research and developments in Europe, Carlos Lisa MD, Spain, presented information on intraoperative optical coherence tomography in corneal surgery. Real-world uses for this advanced imaging technology include assessing cannula depth in anterior lamellar keratoplasty to avoid creating incomplete delamination bubbles, and assessing grafts and stroma in endothelial keratoplasty. A new toric IOL from Ophtec, which is more tolerant of slight axis misalignment, was also presented by José Güell MD, of Barcelona, Spain. Twelve-month results from photorefractive intrastromal corneal

crosslinking (PiXL), a targeted corneal crosslinking procedure intended to improve refractive outcomes, showed some benefit, but requires more development, said Anders Behndig MD, Umeå, Sweden. Rudy MMA Nuijts MD, PhD, Maastricht, The Netherlands, presented interim data from the ongoing ESCRSsponsored PREMED study comparing corticosteroids with combined nonsteroidal anti-inflammatory drug (NSAID) corticosteroid treatment for preventing cystoid macular oedema after cataract surgery. The masked data hint at better visual outcomes for diabetic patients who receive NSAID therapy, but little difference for the general population, Dr Nuijts said. He anticipates presenting the final unmasked results at the ESCRS Congress in 2017.

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EUROTIMES | JULY/AUGUST 2016

10–14 September

2016

XXXIV Congress of the ESCRS Bella Center, Denmark

Main Symposia 

Modern Corneal Transplantation



Cataract, AMD and Beyond



Astigmatism Management in Cataract Surgery



Femtosecond Laser Ophthalmic Surgery



Management of the Ocular Surface before and after Refractive Surgery



Better Outcomes in Glaucoma

Ridley Medal Lecture José Güell SPAIN 30 Years of ‘Iris Claw’ IOLs

Presbyopia Day Tuesday 13 September  

Presbyopia Workshop Main Symposium: Management of the Ocular Surface before and after Refractive Surgery



Free Paper Session



Instructional Courses



Presented Poster Session

Young Ophthalmologists Programme Poster Village 122 Instructional Courses 65 Surgical Skills Courses

www.escrs.org /ESCRS @ESCRSOfficial ESCRS

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XXXIV

Congress of the ESCRS

10–14 September 2016

Saturday 10 September

Lunchtime Symposia

13.00 – 14.00

The FEMTO LDV Z8 – New Experiences to Evolutionize your Practice

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Boxed Lunch Included

Chairperson: T. Seiler SWITZERLAND Moderators: T. Seiler SWITZERLAND B. Pajic SWITZERLAND Speakers: T. Seiler SWITZERLAND B. Pajic SWITZERLAND J. Mehta SINGAPORE R. McAdams USA Sponsored by

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LENTIS Comfort & Comfort Toric – Pioneers in Modern EDOF Technology!

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Pentacam® AXL and Corvis® ST: New Approaches for Combining Tomography with Biometry and Biomechanics

AngioVue OCT – Angiography from Cornea to Choroid: Already more than 2 Years’ Experience

Moderator: C. Roberts USA

M. Rispoli ITALY OCTA in the management of AMD: an indispensable tool

C. Roberts USA Two novel stiﬀness parameters for the Corvis® ST R. Vinciguerra ITALY The normality values of corneal biomechanics: the Vinciguerra screening report P. Vinciguerra ITALY A novel Corvis® biomechanical index for the screening of corneal ectasia R. Ambrósio BRAZIL Ultimate ectasia detection: integrating Pentacam® & Corvis® ST

Moderator: A. Gaudric FRANCE

A. Gaudric FRANCE The role of OCTA in diabetic retinopathy and other retinal pathologies G. Hollo HUNGARY OCTA for glaucoma: current and future applications A. Tufail UK New indications for OCTA in the anterior segment Sponsored by

T. Kohnen GERMANY Pentacam® AXL - comparative studies and IOL calculation

PiXL™: Non-Invasive Vision Improvement

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Providing a Premium Solution for a Broad Range of Patients Speakers: J. Vukich USA R. Ang PHILIPPINES S. Bafna USA Sponsored by

PiXL™ for low myopia Trans-epithelial cross-linking for low myopia Panel Discussion Sponsored by

Saturday 10 September

Sunday 11 September

Lunchtime Symposia

13.00 – 14.00

Boxed Lunch Included

Controversies in Cataract and Refractive Surgery

Mini WELL, the Progressive EDOF IOL: One Year Later

Moderator: B. Dick GERMANY

Moderator: G. Auﬀarth GERMANY

M. Shaﬁk EGYPT Wavefront guided vs. topography guided laser vision correction

D. Pinero SPAIN New preclinical optical assessments

B. Dick GERMANY Laser assisted vs. traditional phaco cataract surgery M. Amon AUSTRIA Extended Range of Vision vs multifocal IOL’s – part I F. Carones ITALY Extended Range of Vision vs multifocal IOL’s – part II Supported by an unrestricted educational grant from

G. Savini ITALY Clinical results on MINI WELL and predictors of visual performance E. Ng IRELAND Case selection for MINI WELL, extended depth of focus IOL G. Auﬀarth GERMANY Personal experience with a progressive IOL Sponsored by

Alcon Satellite Meeting

Saturday 10 September

Evening Symposium 18.15

VSY Biotechnology Satellite Meeting Sponsored by

Sunday 11 September

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Rayner Satellite Meeting Sponsored by

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Complex Cataract Cases, The Simple Truths Moderator R. Osher USA

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Near Live Surgery: A World of Choice Innovative Procedures Across all Patient Ages Moderator: T. Neuhann GERMANY R. Bellucci ITALY Smart technology: LASIK with the TENEO™ 317 & SUPRACOR™ LASIK for the presbyopic patient J. Fernández SPAIN The complete premium package with the VICTUS® femtosecond laser platform and the Versario® multifocal 3F IOL L. Hoﬀart FRANCE A therapeutic procedure with the VICTUS® femtosecond laser platform H. Kasaby UK Ease of use with the EyeCee® one preloaded IOL following femtosecond laser cataract surgery Sponsored by

Heidelberg Engineering Satellite Meeting

R. Osher USA Diﬃcult cases rescued by the new Malyugin Ring

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B. Malyugin RUSSIA Small pupil and FLACS

Nidek Satellite Meeting

S. Masket USA Little instruments can help big problems Sponsored by

A New MIGS on the Block Moderator: N. Koerber GERMANY Speakers: M. Khaimi USA M. Gallardo USA Sponsored by

Moderator: S. Daya UK Speakers: S. Daya UK D. Gatinel FRANCE E. Ligabue ITALY Sponsored by

Improving Eﬃciency in your Cataract Practice Sponsored by

C O P E N H A G E N

Sunday 11 September

Monday 12 September

Lunchtime Symposia

13.00 – 14.00

Boxed Lunch Included

Pillars for Building a Premium Cataract and Refractive Practice Moderator: J. Stevens UK TBC New advances in aberrometry and excimer technology J. Stevens UK The transition from standard phaco to laser cataract surgery D. Chang USA Tips and pearls for an optimized phaco procedure A. Hamid UK Extended Range of Vision IOL – a solution to meet the visual needs of the modern patient Supported by an unrestricted educational grant from

Three Generations with ZEISS Refractive Laser Solutions – PRK ͦ LASIK ͦ SMILE

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New Technology for Improved Refractive Outcomes with the LENSTAR Sponsored by

Towards Less Drops in Cataract Surgery Moderator: J. Güell SPAIN

S. Slade USA U.S. study of SMILE for myopia and myopic astigmatism K. Pradhan NEPAL SMILE for hyperopia: successful pilot and ﬁrst study outcomes D. Reinstein UK PRESBYOND: mechanism and outcomes and why I chose PRESBYOND for my own eyes S. Ganesh INDIA PRESBYOND: my clinical decision pathway for presbyopic patients and why I chose PRESBYOND for my own eyes Sponsored by

A New Era of Trifocality by PhysIOL Moderator: K.G. Gundersen NORWAY S. Marcos SPAIN Chromatic aberration in patients implanted with hydrophylic and hydrophobic PhysIOL IOLs O. Findl AUSTRIA Clinical outcomes of the double C-loop platform with G-free raw material D. Gatinel FRANCE A new era of trifocality: clinically relevant optical properties

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Sunday 11 September

Evening Symposium 18.00

P. Stodulka CZECH REPUBLIC A new era of trifocality: ﬁrst clinical outcomes

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Alcon Satellite Meeting

Floaters: To Treat or Not to Treat?

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Moderator: K. Brasse GERMANY

Moderator: R. Shah INDIA R. Shah INDIA SMILE at 7 1/2 years - a test over time

Boxed Lunch Included

Monday 12 September

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Alcon Satellite Meeting Sponsored by

Speakers: K. Brasse GERMANY I. Singh USA J. Conrath FRANCE Sponsored by

Paediatric Cataract. Challenges and Successes in Developing Countries Moderator: R. Walters UK Speakers: D. Neely USA K. Nischal USA/UK Sponsored by

Santen Satellite Meeting Sponsored by

CORNEA

STEM CELL DYSFUNCTION Restorative treatments can provide good results. Roibeard Oâ&#x20AC;&#x2122;hEineachain reports

he correct approach to the treatment of cataracts in eyes with limbal stem cell disease depends on the stage and severity of both conditions, said Friedrich Kruse MD, of University Hospital Erlangen, Germany, at the XXXIII Congress of the ESCRS in Barcelona, Spain. He noted that limbal stem cell dysfunction is caused by a decrease in the population or function of corneal epithelial stem cells. That, in turn, makes the cornea unable to maintain the normal homeostasis of corneal epithelium. When the epithelium degenerates, the conjunctiva moves on top of the cornea, leading to visual impairment. The conjunctivalisation is frequently accompanied by corneal vascularisation, scarring and recurrent epithelial defects.

Have you made your choice yet?

DIAGNOSTIC CRITERION However, the most important diagnostic criterion of limbal stem cell disease is the presence of goblet cells on the corneal surface. That can be determined by impression cytology or by in vivo biomicroscopy with the HRT II (Heidelberg). A simpler way to test for limbal stem cell dysfunction is staining the corneal surface with fluorescein and waiting to see if the stain clears within 10 minutes. If it does not, this is a sign of the loosened epithelial degradation caused by limbal stem cell dysfunction. In eyes with partial limbal stem cell disease, there are many ways of working around the difficulties, making cataract surgery quite straightforward. However, poor surface quality can still cause some problems with intraocular lens calculation. In most patients with partial stem cell Friedrich Kruse disease, a procedure called sequential sectoral conjunctival epitheliectomy can enhance the corneal surface quality. A simple method, developed by Prof Harminder Dua, it involves removal of the focal fibrovascular tissue with a crescent blade followed by placement of an amniotic membrane. Although the procedure needs to be repeated, it can significantly enhance the ocular surface quality in some patients with partial limbal stem cell disease, allowing straightforward cataract surgery.

SLOWLY PROGRESSING CATARACTS For eyes with total stem cell disease, but early and slowly progressing cataracts, there are a number of stem cell graft procedures that can be used to repair the surface prior to the cataract surgery. Among the best established procedures is the conjunctival limbal autograft, which involves peeling the fibrovascular tissue from the recipient cornea and then replacing it with conjunctival limbal tissue from the uninjured donor eye. In bilateral cases, cadaverous conjunctival limbal autografts have been used. There is the need for heavy immunosuppression and therefore the longevity of the procedure is limited, Dr Kruse added.

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Friedrich Kruse: friedrich.kruse@uk-erlangen.de EUROTIMES | JULY/AUGUST 2016

CORNEA

EPI-ON CXL ADVANCES In his Binkhorst Medal Lecture, R Doyle Stulting MD, PhD reviewed early data from his CXLUSA corneal crosslinking trial. Howard Larkin reports

he problems of penetrating the epithelium in corneal crosslinking (CXL) may be solved, R Doyle Stulting MD, PhD told the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. In his Binkhorst Medal Lecture, Dr Stulting reviewed early 12-month and 24-month data from his study under a CXL protocol that leaves the epithelium intact. This new epi-on approach achieves crosslinking results that appear to be similar to those obtained with the classic epi-off Dresden protocol out to two years – without the risks of infection, non-healing epithelial defects, corneal haze, sterile infiltrates, and perforation associated with epithelial removal. Previous epi-on CXL attempts have not been as effective as those obtained with epi-off – primarily because the epithelium blocks the penetration of riboflavin into the stroma. There are other significant aspects of the CXLUSA protocol that may also explain the results he obtained. Previously, investigators of epi-on CXL have reported loss of effect after one year. This is the first report of improved visual acuity after epi-on CXL that remains stable from year one to year two after treatment. The new CXLUSA epi-on protocol uses a reformulated riboflavin compound that better penetrates the epithelium, explained Dr Stulting, Director of the Stulting Research Center at Woolfson Eye Institute, Atlanta, USA. The result is corneal riboflavin concentration more than four times that obtained with previous epi-on formulations. These concentrations are similar to those obtained after epithelial removal.

LIGHT EXPOSURES In his clinical study, riboflavin concentrations were verified by slit-lamp examination and comparison to standard photographs before patients were exposed to ultraviolet (UV) light to ensure adequate stromal saturation. No additional drops were added during UV exposure, to avoid blocking UV radiation. The UV source was pulsed to allow oxygen to diffuse into the corneal stroma between light exposures. Of 137 keratoconus and ectasia patients treated with the new protocol, mean best corrected visual acuity improved from 20/36 before treatment to 20/27 at 12 months, with a mean gain of 1.5 lines, Dr Stulting reported. Some patients experienced gains as great as 20/100 to 20/20 at 12 months. Thirty-three patients followed to 24 months maintained these gains. Structurally, CXL demarcation lines visualised by optical coherence tomography were deeper than those reported previously with epi-on procedures. While CXLUSA patients did not achieve as much corneal flattening as is typically seen with epi-off CXL, they did obtain a significant decrease in higher order aberrations, Dr Stulting noted. He believes that Kmax may not be the best indicator of efficacy for CXL procedures, and that high-order aberrations may be a better objective measure of functional best spectacle-corrected vision than Kmax. “At one and two years, the technique used by CXLUSA achieves visual results that appear to be at least as good, and possibly better, than some epi-off procedures,” said Dr Stulting. “Even if epi-on CXL does not leave corneas as resistant to progression of ectatic diseases as epi-off does, it is certainly safer and may be 'good enough',” Dr Stulting said. “If it isn’t, epi-on CXL can safely be repeated or followed by epi-off treatment,” he added. Dr Stulting also reviewed the Ectasia Risk Score System (ERSS) he developed with colleagues at Emory University. In 2003, initial analysis of 10 eyes in seven post-LASIK ectasia patients identified EUROTIMES | JULY/AUGUST 2016

R Doyle Stulting receives the Binkhorst Medal from ASCRS president Kerry Solomon. Dr Stulting reviewed risk scoring for post-LASIK ectasia and shared new data on epi-on corneal crosslinking in his medal lecture

thinner pre-op corneas, higher pre-op refractive error, thinner residual stromal bed and form fruste keratoconus as statistically significant risk factors (Randleman et al, Ophthalmology 2003). In 2006, analysis of eight ectasia cases without any of these characteristics identified age as another risk factor (Klein et al, Cornea 2006). These five risk factors were validated at high statistical significance in large retrospective case control studies, and formed the basis of the ERSS in 2008 (Randleman et al, Ophthalmology 2008). Applied to the initial study population operated in 1994 and 1995, ERSS correctly identified more than 90 per cent of ectasia cases with nine per cent false negatives and four per cent false positives, Dr Stulting said. Similar results obtained by scoring a second, independent population validated the system (Randleman et al, AJO 2008). Yet studies applying ERSS to more recently operated cases found ERSS less sensitive. Only a little over half of high-risk patients were correctly identified in populations operated after 2000 (Spadea et al, Clinical Ophthalmology 2012; Colin et al, Clin Exp Ophthalmol 2010). And new risk factors, such as anterior horizontal coma, were identified (Buhren et al, JRS 2013). However, this is not evidence for the failure of ERSS, but a testament to its success, Dr Stulting said. The system, along with its supporting research, alerted surgeons to the identified risks, and consciously or not they avoided treating high-risk patients, he explained. Indeed, patients with pre-op form fruste keratoconus fell from 88 per cent of ectasia cases reported in 2003 to zero in 2013. Preop cornea and mean residual stromal bed thickness also increased. Yet the mean age of ectasia patients fell, increasing its significance, Dr Stulting noted. “Age follows an opposite pattern because surgeons are still operating on young patients, and elimination of other factors makes age a stronger predictor of ectasia,” he explained. Likewise, previously unidentified risk factors emerge as patients with known factors are eliminated, Dr Stulting observed. Therefore, he recommends a two-step screening process that accounts for newly identified factors without ignoring those discovered earlier. “New analysis will not identify risk factors that currently prevent patients from being treated. But future screening methodologies must recognise all risk factors lest we forget what we have learned,” Dr Stulting added. R Doyle Stulting: dstulting@woolfsoneye.com

CORNEA

LSCD STRATEGY Advances in disease classification seen as a foundation for launching new era of customised surgery. Cheryl Guttman Krader reports

he concept of a one-size-fits-all approach to transplantation for limbal stem cell deficiency (LSCD) is completely out-ofdate, and a more individualised strategy that recognises different methods may be warranted depending on the severity of the disease, according to Sophie X Deng MD, PhD. Progress toward that goal, however, will depend on the development of better techniques for diagnosing and grading LCSD, she told the 2016 annual meeting of the Association for Research in Vision and Ophthalmology in Seattle, USA. To that end, Dr Deng and colleagues have been investigating the use of in vivo laser scanning confocal microscopy to establish parameters for quantifying stem cell function. “Quantification of limbal stem cell (LSC) function in vivo could help to classify LCSD severity, monitor its progression, and objectively measure the efficacy of our therapies,” said Dr Deng, Associate Professor, Stein Eye Institute, UCLA, Los Angeles, USA.

CELLULAR LEVEL Findings from their research support a role for using the diagnostic technique that provides high resolution images at

cellular level detail. Dr Deng presented cases considered to have total LSCD that were found with confocal microscopy to harbour “hidden normal limbal epithelial cells”. Their studies have also shown that the morphology of the corneal and limbal epithelium begins to change in eyes with early LCSD, whereas eyes with late-stage disease lack any phenotypically normal corneal or limbal epithelium.

SURPRISING FINDING In addition, they have found that basal epithelial cell density and epithelial thickness in both the central cornea and limbal region is significantly decreased in eyes with LSCD, and for both parameters, the extent of the decrease correlated with LSCD severity. As a somewhat surprising finding, corneal sub-basal nerve density was also seen to be significantly decreased in eyes

with LSCD. The change was noted even in eyes with early-stage disease, whereas many eyes with late-stage LSCD had no detectable nerve fibres, Dr Deng said.

FUTURE ADVANCES She also suggested that future advances in LSC transplantation will benefit from better understanding of how trophic factor secretion versus stem cell pool repopulation contribute to epithelium homeostasis and successful ocular surface reconstruction. “Now is an exciting time to be studying LSC function and to look into what is happening after stem cells are transplanted on to the eye. I think the time has also come to have controlled clinical trials comparing different therapies so that we can investigate their relative efficacy,” Dr Deng said. Sophie X Deng: deng@jsei.ucla.edu

Quantification of limbal stem cell (LSC) function in vivo could help to classify LCSD severity... Sophie X Deng MD, PhD

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EUROTIMES | JULY/AUGUST 2016

7th EuCornea Congress

OPENHAGEN2016 9–10 September Bella Center, Denmark

2 Days. 4 Symposia. 8 Focus Sessions. 4 Courses. 6 Free Paper Sessions.

EuCornea Medal Lecture Friday 9 September

16.00 – 17.00 (At the Opening Ceremony) Cultivated Stem-cells for Ocular Surface Disorders: Current Application and Future Perspectives

Corn

Paolo Rama ITALY

C o r n

European Society of Cornea and Ocular Surface Disease Specialists

www.eucornea.org

Friday 9 September | 13.00 – 14.00 Keeping The Ocular Surface Healthy Sponsored by

Perceptions of Care: Working Together to Improve DED Management Sponsored by

Saturday 10 September | 13.00 – 14.00 Corneal Nerves – The Forgotten Factor in Health and Disease Sponsored by

GLAUCOMA

IOP: ROCK INHIBITORS First new IOP-lowering drug class in two decades set to reach market soon. Howard Larkin reports

ho-kinase (ROCK) inhibitors are highly effective in lowering intraocular pressure (IOP), and are acceptably tolerated locally and well-tolerated systemically, Jason Bacharach MD told Glaucoma Day at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. Following successful clinical trials, ROCK inhibitors are likely to become the first new IOP-lowering drug class approved by the US Food and Drug Administration (FDA) in two decades, with a market approval filing expected later this year. Because ROCK inhibitors involve mechanisms of action that complement existing therapies, and are especially effective in patients with lower baseline IOP, they are also likely to be the first drug class offered in combination with prostaglandins in the USA, said Dr Bacharach, of the California Pacific Medical Centre, San Francisco, USA. ROCK inhibitors are thought to lower IOP in three ways, Dr Bacharach said. Firstly, ROCK inhibition relaxes trabecular meshwork cells, and reduces actin stress fibres and local adhesions, increasing aqueous outflow (Wang, Clin Ophthalmol 2104), Dr Bacharach observed. Secondly, at least some ROCK inhibitors, such as netarsudil (Aerie Pharmaceuticals), also inhibit norepinephrine transport, reducing aqueous production (deLong, Invest Ophthalmol Vis Sci 2012). This effect has been validated in a monkey model (Wang, J Glaucoma 2015), said Dr Bacharach, who is an investigator for Aerie. Thirdly, netarsudil may reduce episcleral venous pressure (EVP), reducing the IOP needed to achieve aqueous outflow, Dr Bacharach said. In rabbit eyes, the compound reduced IOP 39 per cent and EVP 35 per cent three hours after administration. While netarsudil is statistically equal to timolol and latanoprost in reducing mean IOP among patients with baselines less than 25mmHg, registration trial data Jason Bacharach show that netarsudil is more effective at lower baseline pressure. For every 1.0mmHg baseline reduction, netarsudil loses just 0.1mmHg efficacy compared with about 0.5mmHg for timolol and latanoprost. “That’s probably because they don’t affect EVP,” Dr Bacharach noted. In clinical trials, a fixed combination of netarsudil with latanoprost lowered IOP more than either alone (Lewis, BJO 2015), and patients previously treated with prostaglandins responded more to netarsudil alone than prostaglandin-naïve patients. Mean IOP in netarsudil patients also rose less at 12 months than with timolol. Safety was good for netarsudil, with no serious adverse events in 12 months. The most common side effect, conjunctival hyperaemia, was mild and sporadic in most cases, Dr Bacharach reported.

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“As a cataract and retina surgeon, I have found the I-Ring Pupil Expander to be a remarkably versatile tool for improving visualization in a wide variety of challenging surgical situations. The I-Ring is easily deployed and removed and consistently produces round, intact postoperative pupil margins.” Harvey Uy, MD University of the Philippines, Manila, Philippines

Call your local sales rep or BVI customer service in the UK at 44.1865.601256. Visit us at www.beaver-visitec.com

Jason Bacharach: jbacharach@northbayeye.com Disclaimer: The views and opinions expressed in the article are those of Dr Bacharach and do not represent or reflect the official policy or position of Aerie Pharmaceuticals. No authorised representative of Aerie Pharmaceuticals was consulted during the preparation of the above article

Beaver-Visitec International, Sales Limited 85c Park Drive, Milton Park, Abingdon, Oxfordshire, OX14 4RY, UK US patent # 8,900,136. Additional US and international patents pending. BVI, BVI Logo and all other trademarks are property of Beaver-Visitec International (BVI) ©2016 BVI

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EUROTIMES | JULY/AUGUST 2016

6/1/16 10:22 AM

GLAUCOMA

SUSTAINED RELEASE External devices that deliver glaucoma drugs getting close to market. Howard Larkin reports

everal external sustained-release ocular drug delivery devices, including punctal plugs, fornix rings, drug-eluting contact lenses and long-acting gels, are in development with some nearing approval, presenters told Glaucoma Day at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. While they are unlikely to supplant eye drops any time soon, these devices may eventually help solve problems with longterm medication adherence and diurnal drug concentration variation seen with current topical glaucoma treatment. Demonstrating the potential of sustained delivery, a polymer ring placed in the conjunctival fornix successfully lowered intraocular pressure (IOP) for up to 13 months without additional treatment, said James D Brandt MD of the University of California-Davis, USA. Inserted under the eyelid, the non-bioabsorbable ring of 24mm to 29mm diameter elutes preservative-free bimatoprost at a therapeutic level for about six months. In a six-month phase 2 clinical trial (Brandt et al, Ophthalmology, ePub in advance of publication), 63 patients treated with the Bimatoprost Ring and artificial tears twice daily saw mean IOP drop nearly as much as IOP dropped in 64 patients treated with timolol 0.5 per cent eye drops twice daily and a non-medicated insert. In a seven-month open-label single-arm trial extension, patients who received a second insert maintained IOP reductions of 4-6mmHg for the entire 13 months. A third insert was then placed, which will extend the ongoing study to 19 months. To his knowledge, this is the longest duration dataset for any of the emerging sustainedrelease platforms, Dr Brandt said. Adverse events were similar to those seen with bimatoprost eye drops, and mostly resolved without complications, Dr Brandt said. Nearly 90 per cent of patients retained the ring without assistance for the first six months, and 97 per cent for the second cycle of seven months (data presented at the 2016 meeting of the American Glaucoma EUROTIMES | JULY/AUGUST 2016

Society). An important advantage of this platform, Dr Brandt said, is that (in contrast to punctal plugs) no patient experienced a dislodgement where they were unaware that the device had popped out of place. The manufacturer, ForSight VISION5, Inc. has received guidance from the US FDA on a trial design needed to bring the

ring to market, Dr Brandt said. The phase 3 programme is planned for later this year. “My personal prediction is that within five years we are going to see a growing number of glaucoma patients who have MIGS supplemented by one of the sustained-release platforms, all in an attempt to avoid the use of daily drops,” Dr Brandt added.

Placement of the Bimatoprost Ring under the upper lid

Placement of the Bimatoprost Ring under the lower lid

The Bimatoprost Ring insert in place

Courtesy of ForSight VISION5, Inc.

GLAUCOMA

IN THE PIPELINE The search for extended-delivery devices goes back at least to 1976, with the Ocusert, a ring placed in the lower cul-de-sac that delivered pilocarpine for one week, noted Richard Lewis MD, Sacramento, California, USA. But delivery was uneven – too high early in the week causing side effects, and too low later reducing efficacy, and the device was not a big hit. Among current devices in clinical trials that overcome the challenge of steady elution are punctal plugs. Mati Therapeutics has latanoprost glaucoma and olopatadine allergy devices, and Ocular Therapeutix has a travoprost glaucoma device as well as a dexamethasone antiinflammatory device, Dr Lewis said.

These non-invasive devices deliver preservative-free medication for up to three months. However, medication may be flushed into the nasal passages instead of the eye, and they can dislodge, which is a major concern, Dr Lewis said. Both firms claim retention rates of over 95 per cent in clinical trials. Further out in the pipeline are drug eluting contact lenses, Dr Lewis said. A latanoprost contact lens has maintained therapeutic levels in rabbit eyes for up to 28 days, which may make it suitable for long-term drug delivery, or drugs that cannot be delivered by drops, he added (Ciolino et al. Biomaterials. 2014 Jan; 35(1): 10.1016). Eye drops that solidify into a stable gel on the ocular surface and elute medication for up to one month have been tested in rabbits, Dr Lewis said. They appear nonirritating and 100 per cent were retained for 28 days in preclinical trials at the University of Pittsburgh, USA. The SoliDrop combines a thermoresponsive hydrogel carrier with drug-loaded polymer microspheres. It is designed to be self-administered by patients,

Compliance and adherence problems with chronic disease must be addressed... Richard Lewis MD

but is not yet in human trials. “This may be good for specific types of treatment, but I’m not sure it is best for glaucoma where we need years of treatment,” Dr Lewis said. Also in development are subconjunctival inserts, which have been tested in humans in a phase 1 trial, Dr Lewis said. These deliver medications for three to six months with a target of one year, but achieving therapeutic levels has been problematic. Indeed, all sustained drug delivery technologies face significant hurdles, Dr Lewis added. Unknowns include whether long-term constant level exposure to drugs, particularly prostaglandins, is good or bad for IOP control. Development, even with approved molecules, is expensive and time consuming, with punctal plugs in development for more than 10 years. Also, peer-reviewed studies of these devices are almost entirely lacking. “Compliance and adherence problems with chronic disease must be addressed, and punctal plugs, contact lenses, new gels and subconjunctival implants offer many advantages. But eye drops are not going away in the near future,” Dr Lewis concluded. James D Brandt: jdbrandt@ucdavis.edu Richard Lewis: rlewiseyemd@yahoo.com To read the full article on the six-month phase 2 clinical trial in Ophthalmology, go to: www.aaojournal.org/article/ S0161-6420(16)30203-2/abstract

n gs tio in ra k st oo gi l B N Re ote PE H O

Glaucoma Day 2016 ESCRS

Friday 9 September Bella Center, Copenhagen, Denmark Immediately preceding the XXXIV Congress of the ESCRS 10–14 September

Full programme details available at

http://glaucomaday.escrs.org

Scientific Programme organised by

EUROTIMES | JULY/AUGUST 2016

8–11 September 2016

COPENHAGEN 16th EURETINA Congress

Bella Center, Denmark

10 Main Sessions 20 International Society Symposia 30 Free Paper Sessions 45 Instructional Courses 4 Surgical Skills Courses

EURETINA Lecture Keynote Speaker: José Cunha-Vaz PORTUGAL The Blood-Retinal Barrier in Retinal Disease Management

Inaugural Richard Lecture Keynote Speaker: Gisbert Richard GERMANY Restoration of Sight: Prospects and Limitations of Artiﬁcial Vision and Stem Cell Therapy

Kreissig Lecture Keynote Speaker: Emily Chew USA Nutrition, Genes and Age-Related Macular Degeneration: What Have We Learned from the Trials?

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EURETINA is delighted to announce the

5th Retina Race at the 16th EURETINA Congress in Copenhagen

Date: Saturday 10 September, 6.30am Registration Fee: Ă?30 in aid of Orbis Information at www.euretina.org

8–11 September 2016

O P E N H A G E N

EURETINA CONGRESS

Thursday 8 September

Friday 9 September

Lunchtime Symposium

Lunchtime Symposia

13.00 – 14.00

Allergan Satellite Meeting

Anti-VEGF Outcomes in Retinal Diseases

Geographic Atrophy: The Patient Perspective

Sponsored by

The importance of vision gains: a patient perspective

Moderator: F. Holz GERMANY

Boxed Lunch Included

Outcomes of comparative clinical trials

Friday 9 September

Morning Symposia 10.00 – 11.00 Aflibercept Mode of Action: Exploring the Effect of Anti-VEGFs on Retinal Disease The dual action of aflibercept Unravelling the role of cytokines in retinal disease

The action of aﬂibercept on retinal disease

Study results with aﬂibercept across retinal diseases Translating clinical trial outcomes to real life Sponsored by

Transforming Retinal Diseases: The Design. The Decade. The Diﬀerence. Moderator: A. Koh SINGAPORE N. Eter GERMANY Development with an eye on design A. Koh SINGAPORE

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Delivering the promise of performance in choroidal neovascularization

ZEISS Satellite Symposium

P. Schlottmann ARGENTINA Delivering the promise of performance in macular edema

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F. Boscia ITALY Redeﬁning retinal disease management through data Sponsored by

Boxed Lunch Included

F. Holz GERMANY Welcome and Introduction N. Bressler USA Beyond visual acuity: patient-centred outcome measures for GA U. Chakravarthy UK Functional impact of GA: insights into the natural history of GA from electronic care records G. Staurenghi ITALY Assessment of disease severity in GA F. Holz GERMANY Pathophysiology and progression of GA F. Holz GERMANY Concluding Remarks Sponsored by

C O Friday 9 September

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Heidelberg Engineering Satellite Meeting Sponsored by

The Clinical Advantages of Swept Source OCT Angiography Sponsored by

Optos Satellite Meeting Sponsored by

Saturday 10 September

Morning Symposia 10.00 – 11.00

Alcon Satellite Meeting Sponsored by

Moderator: E. Midena ITALY Speakers: E. Souied FRANCE S. Rizzo ITALY N. Luft AUSTRIA Sponsored by

Alimera Satellite Meeting Sponsored by

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 The Need for Continuous Innovation in Retinal Care: Challenge Accepted

Allergan Satellite Meeting

Moderator: U. Chakravarthy UK

Sponsored by

R. Tadayoni FRANCE

Gene Therapy for RPE65-Mediated Inherited Retinal Dystrophy – History and Current State Sponsored by

Nidek Satellite Meeting

Saturday 10 September

U. Chakravarthy UK Unmet medical need Extension: improving outcomes with anti-VEGFs

P. Dugel USA Expansion: new pathways F. Holz GERMANY Exploration: new horizons in ophthalmology Sponsored by

Retinal Disease Management: Evolution of a Proactive Anti-VEGF Treatment Regimen The principles of the ideal treatment regimen Treat-and-extend with antiVEGFs: data from clinical trials and the real world

Panel discussion: the role and implementation of a T&E regimen in the clinic Sponsored by

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Saturday 10 September

Lunchtime Symposia

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Boxed Lunch Included

DORC Satellite Meeting Sponsored by

Does Retinal Laser Therapy Still Make Sense in 2016? Moderator: V. Chong UK V. Chong UK Laser or Anti-VEGF injections? G. Staurenghi ITALY

How to laser better in 2016?

S. Fauser GERMANY V. Chong UK Micropulse laser therapy J.P. Hubschman USA

Future of retinal laser therapy

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RETINA

INTRAOPERATIVE OCT New technologies improve visualisation and tissue manipulation in retinal surgery. Roibeard O’hEineachain reports

Courtesy of Nikolaos E Bechrakis MD, FEBO

ntraoperative optical coherence tomography (OCT) and smallgauge, high-speed vitrectomy can enhance the success rate in a variety of retinal procedures, said Nikolaos E Bechrakis MD, FEBO at the 15th EURETINA Congress in Nice, France. Dr Bechrakis described his experience from a one-week trial of intraoperative OCT using the RESCAN 700 (ZEISS), and also from one year’s experience with 27-gauge high-speed vitrectomy. Using video clips from his surgery, he showed how intraoperative OCT enabled visualisation of the progress of surgery during procedures such as inner limiting membrane peeling, retrieval of lens fragments in an eye with a lens subluxated during cataract surgery, and removal of epiretinal membranes. He also demonstrated how, in an eye with proliferative vitreoretinopathy, intraoperative OCT provided clear visualisation of the epiretinal membrane

Intraoperative OCT image

This is very elegant and gives you a lot of control of peeling, without producing too much traction over the tissues Nikolaos E Bechrakis MD, FEBO and the flattening of the retina following injection of perfluorocarbon liquid, showing residual undulations in the outer retina. Following fluid-air exchange, the return of subretinal fluid to the macula was also clearly visualised, as was the re-flattening of the retina following silicone oil injection.

HIGH-SPEED Dr Bechrakis also showed some clips of his experience with 27-gauge surgery using a high-speed, 7,500 cuts-per-minute vitreous cutter. He and his associates have adopted the new technologies since December 2014,

when they first became available. He noted that grasping an epiretinal membrane can be slightly more difficult with the 27-gauge cutter. He therefore first opens the membrane with the forceps and then performs a vitrector-assisted peeling. “This is very elegant and gives you a lot of control of peeling, without producing too much traction over the tissues. However, you need a flap of membrane tissue large enough to occlude the opening of your vitrector,” said Dr Bechrakis, Professor and Chairman, Department of Ophthalmology, Innsbruck Medical University, Austria. Small-gauge surgery can also be used in complicated cases such as a retinal detachment. He noted that he has found it easy to perform such surgery bimanually with indentation, although 27-gauge instruments are more flexible compared to 23-gauge. In the first series of 27-gauge vitrectomy for primary rhegmatogenous retinal detachment, they have had an 85 per cent primary attachment rate after a follow-up of five to nine months. “I think high-speed, small-gauge vitrectomy can give you a lot of safety and good control over tissue manipulation and it is very efficacious surgery,” added Dr Bechrakis. Nikolaos E Bechrakis: nikolaos.bechrakis@i-med.ac.at EUROTIMES | JULY/AUGUST 2016

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RETINA

EN FACE IMAGING

Get a fresh perspective on dry eye.

OCT angiography can provide new insight into retinal diseases. Roibeard O’hEineachain reports

hree-dimensional angiographic imaging with the RTVue XR Avanti (Optovue) optical coherence tomography (OCT) system can provide a wealth of new information not obtained through fluorescein angiography in a wide range of retinal diseases, said Daniel Pauleikhoff MD, Saint Franziskus Hospital, Münster, Germany. Dr Pauleikhoff stressed the revolutionary nature of the new technology, likening it to the advent of mobile phones and their subsequent rapid evolution into the smartphones of today. “We should not imagine that we will continue to do the same thing for 20 or 30 years like fluorescein angiography, but rather that new technologies that are developing will give us totally different things and possibilities of which we at the moment are probably not aware,” he said. He noted that the principle behind OCT angiography is that the horizontal volume scan and the vertical volume scan are both performed within a very short interval. The difference between the two scans, as measured with split-spectrum amplitudedecorrelation angiography (SSADA) software, enables the detection and quantification of Daniel Pauleikhoff blood flow in the vasculature being examined. Furthermore, the technology enables the en face segmentation of the intraocular anatomy into different layers, allowing visualisation of the three-dimensional structure of the total retinal and choroidal vascularisation within seconds. The Optovue Avanti is the first OCT device to provide OCT angiography, while others coming online include the angiography modules for the SPECTRALIS (Heidelberg Engineering) and the CIRRUS HD-OCT (ZEISS) devices.

BENEATH THE SURFACE Dr Pauleikhoff noted that his initial experience with the Optovue device showed a good correlation with findings obtained through fluorescein angiography. The technology provides a clear differentiation between occult and classic choroidal neovascularisation (CNV). It also reveals previously hidden aspects of the disease. For example, with OCT angiography it becomes clear that occult CNV lesions extend into the choroid and corneal capillaries, and the classic CNV lesions extend to the outer retinal pigment epithelium and the outer retina, he noted. OCT angiography also reveals changes deep in the retina, not visible with fluorescein angiography, in eyes with branch vein occlusion, diabetic macular oedema and macular telangiectasia type 2. However, he noted that the more three-dimensional vascular changes, like the neovascular complex found in exudative agerelated macular degeneration (AMD) will require a more sophisticated diagnostic analysis strategy, which has still to be developed. He proposed a grading system based on the amount of distinctness of the suspected neovascularisation from the surrounding vasculature. Daniel Pauleikhoff: dapauleikhoff@muenster.de

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RETINA

REFINING DME MANAGEMENT Evolution continues with advances in diagnostic and laser technology. Cheryl Guttman Krader reports

lthough retinal laser photocoagulation has been the gold standard for treatment of diabetic macular oedema (DME), the paradigm may change in the future because of developments in laser therapy and imaging technology, according to David Pelayes MD. At WOC 2016 in Guadalajara, Mexico, Dr Pelayes spoke about refined approaches to laser management of DME using a subumbral approach and swept-source optical coherence tomography (SS-OCT) imaging and angiography. “Using these new modalities and anti-VEGF therapy, we will be exploring new questions about the treatment of DME that may lead us in the future to change our criteria for DME evaluation and treatment selection,” said Dr Pelayes, Full Professor of Ophthalmology, Buenos Aires University, Argentina, and Full Professor of Ophthalmology, Maimonides University. Discussing subumbral laser treatment, Dr Pelayes explained that it is performed using a 577nm yellow multi-spot laser with proprietary software (PASCAL Streamline 577™ laser system with Endpoint Management, Topcon). He explained that, compared with 532nm green light, 577nm yellow light is a more efficient wavelength for DME treatment because it is subject to less scatter by ocular structures and penetrates better to pigmented and vascular retinal structures. These features enable lower power and shorter pulse duration laser settings.

YELLOW WAVELENGTH In addition, the yellow wavelength is particularly attractive when treating near the macula or foveal regions, because it penetrates to and is absorbed by the retinal pigment epithelium (RPE) with less diffusion to the choriocapillaris. “Higher efficiency gives the surgeon finer control and the ability to fine-tune laser parameters, and it also improves patient comfort. With this laser we can produce the burn in the area we want to treat. Still, more evidence about its efficacy is needed,” he told delegates. Compared with standard laser photocoagulation, the subumbral treatment approach creates a minor photothermal injury with lesions in Bruch’s membrane and RPE. Although the lesions are not visible, evidence of the limited tissue damage is available from multimodal imaging and histology studies of rabbit eyes. It has also been demonstrated by posttreatment imaging of human eyes using autofluorescence, OCT, and fluorescein angiography. Endpoint Management is a titration protocol for performing subumbral laser therapy that uses tissue modelling and advanced algorithms to ensure treatment precision while controlling laser power and exposure duration. First, treatment is titrated outside of the macula to produce a barely visible endpoint (100 per cent level). This “landmark” is placed at the corners of the grid pattern, and the power for spots inside the grid is set at a lower level to create the subvisible burns.

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David Pelayes: davidpelayes@gmail.com EUROTIMES | JULY/AUGUST 2016

EUROPEAN BOARD OF OPHTHALMOLOGY

Courtesy of Laboratoires Théa

EBO president Peter J Ringens addresses delegates in Paris

EBOD SETS NEW RECORD Participation in the EBOD exam continues to grow.

Dermot McGrath reports

record-breaking 619 candidates from 26 European countries took part in this year’s European Board of Ophthalmology Diploma (EBOD) examination. “Once again I get to stand here at the podium and congratulate all the candidates for coming to Paris in such large numbers to take part in this increasingly popular examination,” said Peter J Ringens MD, PhD, FEBO, president of the European Board of Ophthalmology. Prof Ringens paid special thanks to the French Society of Ophthalmology (SFO), which hosts the exam every year in conjunction with its annual meeting, emphasising that the exam would not be possible without the support of the SFO. The EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices, and to harmonise and compare ophthalmology training programmes throughout the EU. “The increasing number of candidates also demands another organisation of the exam for the future. We are thinking about tablet-based written examination, and in 2017 there will be one official language (English) for the viva voce exam, because we are now dealing with over 300 examiners, plus German and French for the MCQ exam,” added Prof Ringens. Catherine Creuzot-Garcher, president of the SFO and a past president of EBO, said the French society remains deeply committed to

EUROTIMES | JULY/AUGUST 2016

the EBO exams and is honoured to play its part in preparing candidates for their future careers in ophthalmology. “There will always be a place for the EBO examination here in Paris at the annual SFO meeting. There is a long history of collaboration between these two organisations and this partnership will continue to benefit European ophthalmology in the future,” she said. For the second year the EBO has organised, in close collaboration with the EGS (European Glaucoma Society), the glaucoma subspecialty exam and awarded the FEBOS-Glaucoma Diploma to three successful candidates. “This is not just one more exam for the sake of it. Rather this exam is designed to really reflect the realities of modern practice and recognise expertise and excellence in a given field. By setting standards of knowledge, the EBO subspecialty exams will help to improve the quality of training in various subspecialties across Europe. In the very near future other European societies (ESCRS, paediatrics, neurophthalmology etc.) will organise their subspecialty exams in collaboration with the EBO,” said Gordana Sunaric Mégevand MD, presidentelect of EBO and a member of the EGS executive board. Peter J Ringens: p.ringens@mumc.nl Catherine Creuzot-Garcher: catherine.creuzot-garcher@chu-dijon.fr Gordana Sunaric Mégevand: g.su.meg@gmail.com

JOSÉ LUIS MENEZO AWARDED MEDAL The renowned Spanish ophthalmologist José Luis Menezo MD, PhD, FEBO was honoured at the EBOD awards ceremony as the recipient of the Peter Eustace Medal for his contribution to ophthalmic education in Europe. “As an educator, innovator, teacher, academic and ophthalmologist, José Menezo is a very deserving recipient of this prestigious medal. Reading his long list of accomplishments really brought home to me how little those of us in northern European countries sometimes know about what is going on in regions where we do not speak the language,” said Peter J Ringens MD, PhD, FEBO, president of the European Board of Ophthalmology. He noted that Prof Menezo, founder and past president of the ‘Sociedad Española Cirugia Ocular Implanto-Refractiva’ (SECOIR), and Professor of Ophthalmology at Valencia University from 1989 to 2006, is a member of numerous international societies, and an active participant in the annual EBOD examinations. Among his many achievements, Prof Menezo was one of the first to introduce intraocular lenses into Spanish clinical practice and he is credited with designing a number of surgical instruments including the Acarus Lens. He has published over 500 peer-reviewed scientific papers, and served on the editorial board of a number of prestigious journals. The Menezo Medal, awarded to prominent young ophthalmologists, was also established in his honour by SECOIR.

Courtesy of Laboratoires Théa

José Luis Menezo (right) receives the medal, with Prof Ringens

Prof Menezo has published 14 books and monographs. He has also served as Associate Professor of Ophthalmology at Valencia University, from 1988-1989. He was awarded a PhD from the University of Barcelona in 1963, and also served as Assistant Professor of Ophthalmology at University Eye Clinic, Barcelona. Prof Menezo said that he was very honoured and proud to have been appointed as the recipient of the prestigious Peter Eustace Medal and said that the EBO held a special place in his heart. “I feel extremely proud to have contributed my two cents to the construction and development of the EBO. It is a great honour for me to have been involved in the cause of ophthalmic education over so many years, but I am utterly aware that there is still much work left to be done in this construction of a European project,” he said. José Luis Menezo: joseluis.menezo@gmail.com

EUROPEAN BOARD OF OPHTHALMOLOGY

Courtes yo fL

A VERY POSITIVE EXPERIENCE ora ab

s toire

Th é a

Quentin de Bosredon

Quentin de Bosredon, France, Overall Award Winner 2016 The standardisation of theoretical knowledge was the main motivation for me to take this exam. To me, being a Fellow of the European Board of Ophthalmology (FEBO) is mandatory to start a fellowship with a solid foundation. It is also a symbolic way to end the residency programme. The viva voce part of the examination was the most interesting, as you can discuss cases with a wonderful panel of examiners coming from the European Union. It can be stressful

if you are not trained to speak in public, and even more so if you are uncomfortable not speaking your mother tongue. It was very gratifying being with my residency classmates, who all passed the exam, and A receiving the overall winner award. There was a strong and positive emulation among us during our residency training and I want to thank them for that. It was a very positive experience overall. I would encourage any EU resident to take the EBO examination in order to be recognised as a fully trained ophthalmologist, with

global knowledge on the wide spectrum of ophthalmological subspecialties. My future plans in ophthalmology are a clinical fellowship at Bordeaux University Hospital in the Anterior Segment B by Prof David C Department run Touboul, for the next two years. My work will be focused on glaucoma, cataract/FLACS and refractive surgery. I am currently working on the SOMAL study, a prospective study on glaucoma imaging. Working with leaders in their fields and cutting-edge technology is very exciting.

A CHANCE TO BE PART OF THE LARGER COMMUNITY Jonathan C P Roos, UK, Joint 2nd Place Overall Award

Jonathan C P Roos

There were several reasons behind my motivation to take the EBO exam. As an expatriate Swede who has lived mainly in France and Switzerland, I feel loyal to the bigger European family, and from a personal viewpoint I want to be part of that larger European ophthalmological community. I also wanted to have some formal practice in preparation for the FRCOphth exam in the UK, where I am in my fifth year of training. I found the EBO exam a real privilege to take – the examiners were engaged and enthusiastic,

very keen to extract but also impart experience and knowledge. I learned a lot from taking it. It wasn’t easy and I was not sure I had passed. A It was a very positive experience. It was professionally run and administered, and for a huge number of candidates. That so many European colleagues would give up their time and effort to come and examine was heart-warming. I would definitely recommend other residents take the exam. I made some good friends and greatly enjoyed getting to know A some great ophthalmologists from the UK whom I might

not otherwise have had the opportunity to meet, such as Prof Wagih Aclimandos and Mr Gilbert Ozuzu. The exam B represents a C standard for practising as an ophthalmologist in Europe. Also, from an insurance point of view, it might be helpful to show that one has achieved an internationally recognised standard of competence. For the future, I am excited about a career in orbital surgery and am exploring fellowship options with B in Europe and C leading centres the US, including Prof Freitag, Dr Bohman, Mr Malhotra and Prof Rose.

ACHIEVING A GIVEN EUROPEAN STANDARD Vincent Qin, Belgium, 3rd Place Alan Ridgway Award

Vincent Qin

My initial motivation for taking the EBO exam was mandatory professional recognition. In Belgium, the EBO examination, among others, counts as the national examination at the end of residency in order to be recognised as a specialist ophthalmologist. Furthermore, all of my predecessors at university took the same exam over the years, which establishes a strong precedent and tradition. I also viewed it as the ideal opportunity to systematise and consolidate all the knowledge that

we acquired during our residency A years, as examinations are still the surest way to assess theoretical knowledge. Finally, a pan-European professional recognition seemed to me as an attractive way to achieve a given European standard in terms of ophthalmological competence, at least from a theoretical point of view. Overall, taking the exam was a positive experience. It is a wonderful A challenge to take, and a gratifying experience to feel “knowledgeable” after the exam is over. Meeting up with hundreds of other European residents or young ophthalmologists was definitely a cool thing. I think

the EBO label B is becoming more C popular across Europe. An exam like this compels one to study aspects of ophthalmology which you would not necessarily have studied before, but which are nonetheless useful in future practice. It is also great to be part of the same European professional certification, which reaches beyond our national borders, and B C being all in the same boat. For the future, I am planning to do a fellowship either in anterior segment surgery or in oculoplastics, and in the longer-run will be developing my career in those fields.

EUROTIMES | JULY/AUGUST 2016

JCRS

JCRS Symposium Controversies in Cataract and Refractive Surgery

Sunday, September 11, 2016 14.00 –16.00 Chairpersons: T. Kohnen GERMANY (EUROPEAN EDITOR) S. Srinivasan UK (EUROPEAN ASSOCIATE EDITOR)

Best refractive procedure for low to moderate myopia (<6 Diopters) 14.00 D. Reinstein UK Small-incision lenticule extraction is the procedure of choice 14.10 J. Stevens UK Femtosecond-assisted LASIK is the procedure of choice 14.20 E. Mertens BELGIUM Phakic IOL implantation is the procedure of choice 14.30 Discussion

Surgical correction of low to moderate astigmatism during lens surgery 14.43 L. Nichamin USA Manual peripheral corneal relaxing incisions 14.53

D. Koch USA Femtosecond laser: Intrastromal relaxing incisions

15.03 R. Nuijts THE NETHERLANDS Toric IOLs 15.13

Discussion

Surgical correction of presbyopia 15.26 G. Grabner AUSTRIA Solutions at the corneal plane (inlay, excimer) are the best 15.36 B. Cochener FRANCE Solutions at the lenticular plane are the best 15.46 Discussion 16.00 End of session

JCRS HIGHLIGHTS

VOL: 42 ISSUE: 5 MONTH: MAY 2016

NEW TORIC IOL CALCULATOR Researchers have reported promising results with a new regression formula (Abulafia-Koch) which was developed to calculate the estimated total corneal astigmatism based on standard keratometry measurements. The error in the predicted residual astigmatism was calculated by the Alcon and Holladay toric intraocular lens (IOL) calculators, with and without adjustments by the Abulafia-Koch formula. A retrospective study of 78 eyes compared the new and old formulae. The Alcon and the Holladay toric calculators had a higher proportion of eyes within ±0.50D of the predicted residual astigmatism with the Abulafia-Koch formula than without it. There were no significant differences between the results of the Abulafia-Koch-modified Alcon and the Holladay toric calculators and those of the Barrett toric calculator. A Abulafia et al, JCRS, “New regression formula for toric intraocular lens calculations”, Volume 42, Issue 5, 663–671.

OPTICAL BIOMETRY A new optical biometer (AL-Scan) produced highly comparable measurements to those obtained with standard Scheimpflug anterior segment tomography, report researchers. They conducted a prospective randomised study comparing mean central corneal thickness (CCT), anterior chamber depth (ACD), and keratometry measurements in 121 healthy patients. The mean difference in CCT was 1.61μm. The mean difference in the aqueous depth and ACD was 0.02mm. For the 2.4mm K readings from the new biometer versus the standard K readings from the Scheimpflug tomographer, the mean difference for flat K, steep K and mean K was 0.10D, 0.05D, and 0.08D, respectively. C McAlinden et al, JCRS, “Agreement of anterior ocular biometric measurements with a new optical biometer and a Scheimpflug tomographer”, Volume 42, Issue 5, 679–684.

NEW IMAGE-GUIDED SYSTEM A recent study confirms the repeatability and comparability of a new image-guided system which provides K and axis measurements that can be used for surgical planning of IOL implantation. The study compared the VERION™ Image Guided System (Alcon) versus partial coherence interferometry (PCI), Scheimpflug imaging, and optical low-coherence reflectometry (OLCR) devices. The image-guided system's corneal radii measurements were not significantly different from those of the OLCR device. Small, significant differences were found between the image-guided system and the PCI system; and moderate, significant differences were found between the imageguided system and the Scheimpflug device. The position of the steep axes did not differ significantly between the image-guided system and the other devices. A Mueller et al, JCRS, “Comparison of a new image-guided system versus partial coherence interferometry, Scheimpflug imaging, and optical low-coherence reflectometry devices: Keratometry and repeatability”, Volume 42, Issue 5, 672–678.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | JULY/AUGUST 2016

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HOSPITAL DIARY

A NEW LIFE

In a previous issue, Dr Leigh Spielberg described his search for a full-time position in VR surgery. That search concluded

ne evening, I SPECIFIC REQUESTS received a call from I was in a position to make Ghent University some specific requests. I Hospital in Belgium. wanted to have at least one, Prof Bart Leroy, and preferably two full days of an internationally dedicated vitreoretinal surgery. renowned ophthalmic geneticist If possible, I also wanted a and chairperson of the half-day of cataract surgery department, was on the line. to maintain the phaco skills I “We have a lot of interesting had spent so much time and pathology. All the standard effort developing. retinal problems, and more. Lastly, I was interested in Trauma. Rare genetic disorders. doing a half-day of medical Retinopathy of prematurity. retina, in conjunction with one Coats' disease. We currently have of the medical retina specialists, a very good and very experienced for two reasons. Firstly, I had consultant in Fanny Nerinckx, always been interested in but there’s too much work for just retina as a single specialty, as one surgeon. We want someone it is practised in the US: both here full-time,” he told me. medical and surgical retina It was a very attractive offer. treated by one doctor. In much Marc Veckeneer, another highly of Europe, these sub-disciplines experienced retinal surgeon who are divided, which causes a had trained countless fellows certain disconnect between the in Rotterdam, was interested two. This leads to confusion and in joining the team on a partmisunderstanding with cases time basis, on the condition when the two fields have to that there would be a junior collaborate, such as non-clearing vitreoretinal surgeon (me) there vitreous haemorrhage due to full-time, to ensure proper preneovascularisation; submacular and postoperative management haemorrhage due to macular as well as emergency care. Ghent, a beautiful medieval city located degeneration; proliferative Prof Leroy had my undivided diabetic retinopathy; and halfway between Brussels and Bruges, attention. Ghent, a beautiful persistent diabetic macular is a great place to live medieval city located halfway oedema with epiretinal traction. between Brussels and Bruges, is a This could all be arranged. great place to live. The city itself “But are you willing to train residents in cataract surgery?” has everything: museums, restaurants, stores, and entertainment. asked Prof Leroy. It’s close to both the Belgian coastline and the Flemish Ardennes, “Yes,” I replied, somewhat surprised at the confidence he had a hilly region full of good mountain-biking trails. It also has leafy in my freshly minted skills. “Will you supervise their clinics?” he suburbs just a few miles from the city centre. continued. “Yes, no problem,” I said. “OK then, I think we have a deal. Come down to Ghent sometime and I’ll show you around. I A STORIED HISTORY think you’ll like what you see,” he replied. After a few meetings with Prof Leroy, Dr Nerinckx and Dr The ophthalmology department in Ghent University Hospital has Veckeneer in Antwerp and at EURETINA in Nice, I decided that a strong and storied history. Charles Schepens, the Belgian retinal this was a team I could work with and could trust. Prof Leroy is specialist and father of modern retinal surgery, went to medical past-president of EVER and also leads the genetic ophthalmology school at Ghent University, trained at Moorfields, and then moved clinics at the Children’s Hospital of Philadelphia, the cradle of to Boston to invent the binocular indirect ophthalmoscope and ocular gene therapy. Dr Nerinckx has vast experience with difficult found both the Schepens Eye Research Institute and The Retina paediatric cases, and Dr Veckeneer had trained more than a dozen Society. Prof Jules François, a previous department chairperson, retinal surgery fellows. won so many international ophthalmology honours that a new Once my wife, a dermatologist, had found a job in Ghent, I made one was named after him. the decision to sign with the University Hospital. We found a great After I spent more than five years at the Rotterdam Eye Hospital, school for Philippa and Raphael, and a house nearby. We were all set. I had gotten used to working in a well-known institution. Ghent was Spread over two cold winter days, we emptied our house in something I wanted to be a part of. The department was rebuilding. Rotterdam, locked the door behind us, said goodbye to friends, Many ophthalmologists in Belgium choose to enter private practice neighbours and colleagues, and moved our family south to rather than join the staff of a university, for various reasons, but Prof Belgium, where we would start a new life. Leroy had attracted the interest of several young doctors and it looked promising. Both Dr Nerinckx and Dr Veckeneer had expressed their Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent interest in helping to rebuild and were willing to help guide my University Hospital, Belgium transition from fellow to full-fledged vitreoretinal specialist. Illustration by Eoin Coveney

EUROTIMES | JULY/AUGUST 2016

Geographic atrophy: the patient perspective 13:00â&#x20AC;&#x201C;14:00 Friday 9th September 2016 Satellite symposium at the 16th EURETINA Congress Auditorium 15, Bella Center, Copenhagen, Denmark Please join our experts as they highlight the unmet needs in geographic atrophy (GA) with real-world data and discuss the development of functional measurements for disease severity and progression

Chaired by Prof. Frank Holz, Germany

Welcome and introduction Prof. Frank Holz, Germany

Beyond visual acuity: patient-centred outcome measures for GA Dr Neil Bressler*, USA

Functional impact of GA: insights into the natural history of GA from electronic care records Prof. Usha Chakravarthy, UK

Assessment of disease severity in GA Prof. Giovanni Staurenghi, Italy

Pathophysiology and progression of GA Concluding remarks Prof. Frank Holz, Germany

Q&A *Participation by Dr Neil Bressler in this activity does not constitute or imply endorsement by the Johns Hopkins University, the Johns Hopkins Hospital, or the Johns Hopkins Health System.

NP/LAMP/1605/0012

Date of preparation May 2016

OPHTHALMOLOGICA

STEROID INTRAVITREAL IMPLANT SHOWS PERSISTENT EFFECT

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The findings of an observational study appear to confirm the long-term efficacy and safety of the intravitreal dexamethasone implant, Ozurdex® (Allergan), in the treatment of persistent diabetic macular oedema (DME). It showed that, among 51 persistent DME patients receiving the implants, visual acuity (VA) improved by 13.8 letters at six months (p<0.0001), 12.7 letters at 12 months (p=0.0032), and 16.5 letters at 18 months (p=0.0313). In addition, macular thickness decreased by a mean of 159.07μm at six months (p<0.0001), 181.8μm at 12 months (p<0.0001), and 236.17μm at 18 months (p=0.0313). Furthermore, no serious adverse events were reported. I Aknin et al, “Longitudinal Study of Sustained-Release Dexamethasone Intravitreal Implant in Patients with Diabetic Macular Edema”, Ophthalmologica 2016; Volume 235, Issue 4.

VOL: 235 ISSUE: 4

OPHTHALMOLOGICA

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MAPPING THE PROGRESSION OF GEOGRAPHIC ATROPHY A model of VA in geographic atrophy (GA) secondary to agerelated macular degeneration (AMD) derived from fundus autofluorescence imaging may be helpful in assessing progression of disease and the effects of therapy, a new study suggests. An analysis of the course of 226 eyes of 151 patients with GA due to AMD showed that there was a loss of three or more lines of VA in 47 per cent of eyes at four years. Among those with foveal involvement, VA was 0.69 logMAR units lower than in those without foveal involvement (p<0.001) and was decreased by between 0.02 and 0.09 logMAR units per millimetre, depending on the degree of foveal involvement (p<0.001). S Schmitz-Valckenberg et al, “Modeling Visual Acuity in Geographic Atrophy Secondary to Age-Related Macular Degeneration”, Ophthalmologica 2016; Volume 235, Issue 4.

YOUNGER RETINAL ARTERY OCCLUSION PATIENTS PRONE TO THROMBOPHILIA Younger patients with retinal artery occlusion (RAO) have a high prevalence of thrombophilic disorders, the findings of a retrospective study indicate. The study’s authors reviewed 25 patients with RAO less than 60 years of age, and 62 healthy controls. They found thrombophilic defects in 17 patients (68 per cent), compared to only 11 of 62 controls (17.7 per cent; p<0.0001). They also found a statistically significant association between the development of RAO and increased levels of lipoprotein(a) (odds ratio: 9.48; p=0.001) and factor VIII (odds ratio: 6.41; p=0.024). C Kuhli-Hattenbach et al, “Selective Thrombophilia Screening in Young Patients with Retinal Artery Occlusion”, Ophthalmologica 2016; Volume 235, Issue 4.

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

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EUROTIMES | JULY/AUGUST 2016

BOOK REVIEWS

USEFUL GUIDANCE While I was a research fellow in New York, struggling to generate any useful data using the retinal function imager, my mentor encouraged me by telling an interesting story about the random nature of scientific publishing. “The first article to describe the technique of PUBLICATION fluorescein angiography PRACTICAL HANDBOOK was initially rejected by all OF FLUORESCEIN ANGIOGRAPHY the major ophthalmology AUTHORS journals,” he said. Fluorescein BRUNO LUMBROSO & MARCO RISPOLI angiography has, of course, since become indispensable PUBLIISHED BY JAYPEE to ophthalmology, and has allowed the medical retina subspecialty to become a vast and interesting field. Practical Handbook of Fluorescein Angiography (Jaypee), by Bruno Lumbroso and Marco Rispoli, takes us back to the very basics. The foreword is forceful: “The author systematically follows a rational method to interpret medical ophthalmological imaging. Accurate analysis comes before synthesis deduction and diagnosis. Diagnosis is the product of logical processes.” The handbook starts with the usual suspects: a review of retinal anatomy and fluorescein angiography of the normal retina. It then becomes more interesting. The authors devote entire chapters to abnormal hyperfluorescence, hypofluorescence, and abnormalities in circulation time. The book also includes in-depth methodical syntheses of the results obtained from each available imaging modality. A description of the major fluorescein angiography syndromes doesn’t start until the second half of the book, where they are presented with large and detailed images. This book is recommended for ophthalmology residents, retina fellows and general ophthalmologists.

BOOK

REVIEWS

ESCRS membership opens many doors.

CORNEAL IMAGING

Belong to something important. Join us. www.escrs.org

Moving to the anterior pole of the eye, Step by Step: Reading Pentacam Topography (Basics and Case Study Series), from Mazen M Sinjab (Jaypee), covers the basics of corneal imaging. Considering the increasing emphasis on precise refractive outcomes after cataract surgery, attention to corneal topography is essential. This book should help the reader develop a systematic method of interpreting imaging for basic cases. Starting with an introduction to the various types of devices available (curvature-based; elevation-based) and the typical features of ectatic corneal disorders, the manual progresses to an explanation of the steps taken to read a corneal tomography. The book then outlines the clinical approach to the candidate for refractive surgery, with “rules and recommendations”. By the end of the book, the reader should be able to tackle the six case studies with confidence, making this publication ideal for residents and those ophthalmologists interested in taking the step from basic surgical procedures to those aiming for refractive perfection. DR LEIGH SPIELBERG Books Editor

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

EUROTIMES | JULY/AUGUST 2016

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Membership POWERFUL DATA | CLINICAL TRENDS

ASCRS is the only professional organization in ophthalmology offering access to the detailed clinical survey data provided by over 2,000 of its members. Start your ASCRS membership today for your first report.

ASCRS Members receive the latest ophthalmic surgical news, research, and resources.

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TOOLS

Annual meetings and the ASCRS Center for Learning (webinars, clinical reports, post-meeting resources, podcasts, and the Center for CME)â&#x20AC;&#x201D;NEW

Access to almost 500 unique clinical and opinion data points as reported by more than 2,000 ASCRS member surgeons

Post-refractive IOL and Barrett Toric Calculators, Toric Results Analyzer, and more online tools

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PUBLICATIONS

COMMUNITY

Journal of Cataract & Refractive Surgery, Ophthalmology Business magazine, and EyeWorld News magazine

Daily online discussions in eyeCONNECTIONS

Cataract

START YOUR MEMBERSHIP TODAY.

ascrs.org

ESCRS NEWS

Paul Rosen

ESCRS

Practice Management

& Development

ESCRS

NEWS

11–12 September 2016

MARKETING CONTEST With a prize of €1,000, the third annual Marketing Case Study Competition seeks to highlight the innovative ways that ophthalmologists are marketing their practices around the world today. To be judged by Paul Rosen, chairman of the ESCRS Practice Management and Development Committee, and marketing expert Kris Morrill, the winning submission will demonstrate a successful campaign that resulted in an increase in patient volume or practice revenue. Entries should consist of a three-to-four-slide presentation which illustrates the campaign, costs, as well as the results. The winning entry will be announced at the ESCRS Practice Management and Development Workshops on Monday, 12 September, at the XXXIV Congress of the ESCRS in Copenhagen, Denmark. Entries should demonstrate examples of marketing campaigns executed in the 12 months prior to submission. To enter, email Colin Kerr: colin@eurotimes.org. The closing date for entries is: Monday, 22 August.

Copenhagen, Denmark

Marketing and Management Pearls from Top Experts Including...

David Evans

Mike Malley

Rod Solar

Kris Morrill

USA

FRANCE

For full programme visit www.escrs.org

B TRAVEL DISCOUNT FOR COPENHAGEN The ESCRS has arranged reduced-price public transport tickets (for travel by metro, bus and train) in Copenhagen for our delegates and exhibitors at the XXXIV Congress of the ESCRS this September. These discounts are also available to delegates and exhibitors attending the 16th EURETINA Congress, the 7th

EuCornea Congress, WSPOS Subspecialty Day and Glaucoma Day taking place in the same congress centre. The discount will only apply if bookings are made online, and SMS tickets are sent to mobile phones. To book tickets, visit: www.travelpass.dk/ conferences/xxxivcongress-2016

BUSINESS

UTILISE BUSINESS

INNOVATE UTILISE BUSINESS

LEADERSHIP INNOVATE UTILISE BUSINESS

DEVELOPMENT LEADERSHIP INNOVATE UTILISE BUSINESS

EUROTIMES | JULY/AUGUST 2016

INDUSTRY NEWS

INDUSTRY

NEWS

GRAFT PREPARATION

Our members aren’t just predicting the future of eye surgery and patient care, they’re creating it.

Moria has announced an extension in its portfolio for Descemet’s membrane endothelial keratoplasty (DMEK) graft preparation. “In addition to Muraine Punch introduced in 2013 to allow the reverse technique by Prof Muraine (Rouen, France), Moria now releases new Single-Use Donor Vacuum Guarded Punches to safely assist corneal surgeons and/or eye bank practitioners in the preparation of purely endothelial DMEK graft following the SCUBA (“no touch”) technique: the Guarded DMEK Punch (SKU 17207Dxxx),” said a company spokesman. “Its 350-micron guarded blade is designed to make a nonpenetrating trephination of the Descemet’s membrane all around 360° without any hinge, so delamination becomes an easy process,” he added. www.moria-surgical.com

CE MARK

Dr Ludwin Monz

REVENUE INCREASE

Belong to something powerful. Join us. www.escrs.org

EUROTIMES | JULY/AUGUST 2016

Carl Zeiss Meditec AG has announced that it has increased its revenue by 8.6 per cent in the first six months of the fiscal year, to €540.8 million. “The encouraging development of business confirms our strategy. We optimise the clinical benefit of our products without losing sight of the economic aspects of our customers,” said Dr Ludwin Monz, president and CEO of Carl Zeiss Meditec AG. www.zeiss.com/med

OASIS® Medical has obtained a CE Mark opening the doors to the international market for their SOFT SHIELD® Collagen Corneal Shields, which allow for ocular healing to take place by providing a protective barrier over the surface of the eye. “As the shield gradually degrades, a thin layer of collagen is released which helps lubricate the eye,” said a company spokeswoman. “SOFT SHIELD® Collagen Corneal Shields are clear, pliable, thin film of highly purified bovine collagen that has been lightly crosslinked to provide the desired degradation time on the eye,” added the spokeswoman. www.oasismedical.com

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SUBMISSIONS OPEN SEPTEMBER 2016

ESASO

ESASO COURSE SERIES BOOKS New volume on ophthalmologic oncology provides a reliable and comprehensive review

ince 2102, the European School for Advanced Studies in Ophthalmology (ESASO) produces the ESASO Course Series. These books are meant as “advanced introductions”. They provide the content of expert presentations during ESASO modules on subspecialties such as retina, cataract, orbital surgery, cornea and refractive surgeries – and makes them available in print. Series editors Francesco Bandello and Borja Corcóstegui take care that the evidence-based books not only contain preparatory and approved learning material for module participants, but are also useful as works of reference for established ophthalmologists. The volumes include personal experience and full teaching acumen, thus the ESASO Course Series become a device to give practical support to the reader.

NEW VOLUME: OCULAR TUMORS Oncology is developing at a breathtaking pace, and so is ocular oncology. Ever more sophisticated scientific insights have emerged over the last decade, as well as advanced and technically demanding diagnostic procedures and treatments. The new book, Ocular Tumors, provides a reliable and comprehensive review of intraocular tumors. Under the editorial leadership of volume editors Arun D Singh and Stefan Seregard, it is written by foremost experts in the field. Ocular tumors are uncommon and diverse. But being able to recognise them, and to differentiate them from other disorders with a similar appearance is a required skill for every ophthalmologist. Prompt recognition and referral to a specialised centre have a profound impact on the final outcome. Unfortunately, eye tumors are often confused with more frequent but less serious entities. Therefore, access to a reliable and easy-to-use ‘tumor book’ seems essential. An introductory chapter on examination techniques is followed by 10 specialised chapters on topics such as melanocytic uveal tumors, non-melanocytic uveal tumors, intraocular vascular tumors, intraocular metastases and retinoblastoma, among others. The focus of the easy-toread and well-illustrated book is on diagnosis, often with a progression from everyday equipment and examination techniques to highly advanced machinery and expertise. Important treatment aspects are also covered. Thus, the book is a valuable resource for primary care ophthalmologists as well as residents and fellows in the field of ophthalmology. The next volume in the series will cover the latest stateof-the-art advances in glaucoma diagnosis and treatment. It will be edited by Prof Carlo Enrico Traverso and is due in the autumn. It will be a useful manual with practical considerations based on evidence and consensus. The contributing authors are renowned experts in the specialty of glaucoma.

Previous Volumes in this Series Medical Retina

F Bandello, G Querques (2012)

Surgical Retina

F Bandello, M Battaglia Parodi (2012)

Cataract

J Güell (2013)

OCT

G Coscas, A Loewenstein, F Bandello (2014)

Orbital Surgery

R Medel, A Loewenstein, LM Vásquez (2014)

Cornea

JL Güell (2015)

Ocular Tumors

AD Singh, S Seregard (2016)

Medical & Surgical Retina 18 – 21.08.16, Singapore Cornea and Corneal Refractive Surgery

29.08 – 02.09.16, Lugano

Glaucoma

29.08 – 02.09.16, Lugano

Medical & Surgical Retina 27 – 30.11.16, Hanoi Medical & Surgical Retina 03 – 07.12.16, Kuwait

ESASO Course Series books are published by the leading biomedical publisher S Karger AG (Basel, Switzerland). The books are available in print and electronically. Further information is available on the publisher’s website at: www.karger.com/esaso EUROTIMES | JULY/AUGUST 2016

REVIEW

SUBLUXATED CATARACT

Everything you ever wanted to know about subluxated cataract surgery – Part 1. Dr Soosan Jacob reports

subluxated cataract may be detected during routine preoperative evaluation or diagnosed intraoperatively. Whichever the case, the surgeon needs to have a plan for management - be it continuing with surgery or referring to a more experienced colleague. This article will discuss some of the strategies that can be employed depending on the clinical scenario. The article is divided into two parts – Part 1 here deals with formulating a plan and becoming prepared. Part 2 in the next issue of this column will deal with actual surgical principles.

PREOPERATIVE EVALUATION: Successful surgery in subluxated cataract needs proper preoperative evaluation and diagnosis. Identifying conditions with zonular weakness such as pseudoexfoliation, trauma, Marfan's syndrome, ectopia lentis, hypermature cataracts, high myopia, megalophthalmos, post-vitrectomy eyes etc, is therefore paramount as these eyes need to be handled with extra care in order to avoid increase in the degree of subluxation. Planning should be done preoperatively based on the degree of subluxation, the density of nucleus, cause of subluxation, as well as presence of other coexisting morbidity. Presence of vitreous in the anterior chamber (AC) should be looked for. Examination in the sitting posture on slit-lamp may be misleading in some cases and with the patient in the supine position under the operating microscope, the cataract may be found to be dangling into the vitreous cavity. Intraoperatively, the extent of dialysis may be found to be larger than originally estimated on slit-lamp and the surgeon should be prepared to change plans to deal with such an eventuality. Necessary devices, sutures and equipment such as the vitrector should always be kept ready for use if required. A thorough retinal examination should be performed in cases with a view of the fundus, and a B-scan should be performed in cases with no fundus view. EUROTIMES | JULY/AUGUST 2016

THREE CLOCK HOURS SUBLUXATION: Subluxations that are less than three-four clock hours can generally be handled by implantation of a capsular tension ring (CTR). The timing of insertion of the ring depends on the surgical situation. Kenneth Rosenthal MD explains: “The CTR should be implanted as late as you can but as early as you must.” It may be implanted after cortical cleaving hydrodissection using either a CTR injector or by dialling it in. Depressing the ring down to the plane of the rhexis with a Sinskey Hook just before release ensures that the distal tip enters the bag. Good hydrodissection allows easier removal of cortex later in the surgery. Though the ring provides support to all further manoeuvres, it can trap cortex, making cortex aspiration

difficult. The Henderson Ring has uniformlyspaced indentations on it that makes cortex aspiration easier. The CTR may also be inserted after nucleus removal, and in case of small subluxations, may be considered after cortex removal in the non-dialyzed area. Zonular dialysis may extend if irrigation/ aspiration (I/A) is performed in the area of dialysis as the capsular bag is not expanded. Lack of forniceal expansion also results in a floppy bag which can get aspirated into the I/A port. The CTR expands and stabilises the capsular bag, redistributes forces from stronger to weaker areas, makes the capsule taut, and gives counter-traction to all traction manoeuvres. It prevents extension of the dialysis as well as dropping of nuclear fragments, epinucleus or cortex through the area of dialysis.

The Glued Capsular Hook

Rhexis being engaged with the Glued Capsular Hook. Two trans-limbal capsular hooks have been placed for additional capsular support

Haptic tucked into Scharioth tunnel

Postoperative rounded rhexis margin and well centred, stable IOL

REVIEW

FOUR-SEVEN CLOCK HOURS SUBLUXATION: Any subluxation that is more than one quadrant needs scleral fixation of the bag. This may be done through various devices that are available. The Cionni Ring has a hooked element on one side for suture fixation to the scleral wall. The insertion of the ring, as well as timing of insertion, is similar to a CTR. A 9-0 suture or a Gore-Tex suture on a needle is passed trans-camerally through the eyelet and out through the scleral wall under a flap. The knot is tied down after centring the bag. For larger degrees of subluxation, a double-hooked Cionni Ring may be used. One or more Ahmed segments along with a CTR implantation may also be used for the same purpose. A technique started by myself for the same purpose is the Glued Capsular Hook. The hooked element at one end engages the rhexis rim, and the haptic at the other end is passed trans-sclerally under a lamellar scleral flap to be tucked into a intrascleral Scharioth tunnel made at the edge of the scleral flap. The degree of centration of the bag can be adjusted at any stage of surgery by altering the degree of tuck of the haptic. This allows sutureless transscleral fixation of the capsular bag and makes surgery easier and faster than having to pass long and thin needles across the AC as with sutured devices.

Suture-related complications are also avoided. Intraoperative support can be enhanced by using standard translimbal capsular hooks as well, which are removed at the end of surgery. More than one Glued Capsular Hook may be implanted for larger subluxations. The hook gives scleral fixation and centration and a CTR is implanted for forniceal expansion.

MORE THAN EIGHT CLOCK HOURS SUBLUXATION: Subluxations greater than two and a half quadrants may do better with lensectomy and secondary intraocular lens (IOL) fixation with the surgeon’s procedure of choice. This may be in the form of a glued IOL, sutured scleral fixated IOL or iris fixated IOL. AC-IOL, if chosen, should be done only with proper sizing. Scleral fixation of the bag may be opted for in certain select cases.

Part 2, explaining surgical principles, will be dealt with in the next issue of this column Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at: dr_soosanj@hotmail.com. She has a patent pending for the Glued Capsular Hook

DANGLING SUBLUXATION: Cataract removal with bag and secondary IOL fixation is preferred.

NON-PROGRESSIVE SUBLUXATIONS: These are particularly amenable to sutured segments or the sutureless Glued Capsular Hook technique as described above.

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CALLING ALL MARKETING GURUS!

ESCRS

Practice Management

& Development 11–12 September 2016 Copenhagen, Denmark

PROGRESSIVE SUBLUXATION: A well centred and supported IOL after surgery can undergo progressive subluxation with time because of progressive weakness of residual zonules. Lensectomy with secondary IOL fixation is preferred to attain longterm stability of the IOL. If scleral fixation is opted for, a two or three-point fixation may be done at the time of initial surgery itself.

ESCRS Practice Management and Development Marketing Case Study Competition BUSINESS

Winner of a €1,000 bursary will be announced during the XXXIV Congress of the ESCRS in Copenhagen, Denmark UTILISE BUSINESS

To enter email colin@eurotimes.org

INNOVATE UTILISE BUSINESS

Submission Deadline Monday 22 August 2016 LEADERSHIP INNOVATE UTILISE BUSINESS

Further details at www.escrs.org DEVELOPMENT LEADERSHIP INNOVATE UTILISE BUSINESS

EUROTIMES | JULY/AUGUST 2016

TRAVEL

Tivoli Gardens

COPENHAGEN

TO NOTE...

COPENHAGEN

AVERAGE SEPTEMBER TEMPERATURE: 14°C METRO IN SERVICE: 24/7 TIME SAVER: COPENHAGENCARD.COM Take a quick trip to Sweden - it’s a surprisingly easy journey to make by train thanks to the Øresund Bridge. The rail trip takes 35 minutes and is 16km long; on the Danish side the bridge leads to the artificial island of Pepparholm, after which it becomes a 4km-long tunnel under the water before arriving at Malmo, Sweden. Trains run from Copenhagen Central Station to Malmo around the clock, three times an hour during the day and once an hour at night. Buy a ticket before boarding the train. An adult single costs SEK105. Temporary border controls might delay your trip slightly and you’ll need your passport. Malmo is a compact city with attractive cafes and restaurants. For suggestions go to: malmotown.com Spend any time on the Copenhagen waterfront and you’re bound to spot at least one ‘GoBoat’ bobbing along with a cargo of seagoing sightseers. They’ll be seated around a picnic table laden with food and bottles of wine. Rent one of these silent solar-powered boats at the GoBoat pavilion next to Islands Brygge harbour bath. With a speed of three knots (five to six km/hr), the boats are easy to operate, and no prior sailing experience is needed.The GoBoat staff can guide you on routes. Order a picnic basket in advance from GoBoat, or bring your own. Wine can be purchased at the pavilion. The boats accommodate up to eight people. Open: Monday to Sunday, 10.00-20.00. Website: www.goboat.dk Enjoy an individual bike tour of Copenhagen at your own pace, guided by an audiovisual GPS fitted on your handlebars. The brainchild of a city planner, himself an avid biker, ‘Bike the City’ routes are narrated by professional voice-over artists. The eye-opening, entertaining tours showcase lesser-visited parts of Copenhagen. Rent your bicycle at Cykelbørsens bike rental and Bike the City fixes the GPS device to your handlebar. Pick your thematic tour and set out on your own Copenhagen discovery. The GPS batterylasts five hours but the bike is yours until 10.00 the following morning. Website: bikethecity.dk

EUROTIMES | JULY/AUGUST 2016

COPENHAGEN SIGHTS

There’s plenty for conference delegates to enjoy during their spare time. Maryalicia Post reports THE BLUE PLANET As your flight descends into Kastrup, you might glimpse what looks like a silver whirlpool on Copenhagen’s sandy shore. That’s the Blue Planet, the Danish National Aquarium. “The largest aquarium in Northern Europe”, it was designed by Danish architects 3XN and opened in 2013. The whirlpool design underscores the architect’s intention “to draw the visitor down into the world beneath the surface of the sea”. There are 53 exhibits housing some 450 species and five distinct habitat sections, while touchscreen signage keeps you oriented. Don’t miss the outside area where a pair of sea otters, Alaskan orphans Agnes and Mojoe, swim laps and nibble ice cubes. The Blue Planet is situated east of the city centre, a 10-minute taxi ride from the Bella Center. Open: 10.00-17.00 daily including Sunday, and until 21.00 on Monday. Visit their website at: denblaaplanet.dk

TIVOLI GARDENS Tivoli has been entertaining the people of Copenhagen and their guests since 1843. This amusement park in the centre of town is a nostalgic world of lights and music, lawns and flower beds, attractive restaurants, and rides designed to elevate the blood pressure but not induce a stroke. The oldest and best known of these is the wooden rollercoaster, Rutschebanen, built in 1914. The newest is Fatamorgana, a vertiginous spin around a 45-metre tower which was inaugurated this year. Considerately enough, this experience comes in three versions - wild at the top, mild in the middle, with a ride for kiddies at ground level. Tivoli restaurants include the highly regarded Hermann in the Nimb Hotel - the building’s spectacularly lit

Arabian Nights facade fronts on to the gardens. Open: 11.00-23.00 from Sunday to Thursday, and until 24.00 on Friday and Saturday. Website: tivoligardens.com

CHRISTIANIA Christiania is an 85-acre ‘free town’ within Copenhagen, and its flag is a red banner with three yellow disks. The commune started when a group of activists occupied a disused army barracks and the surrounding area in 1971. Today, despite episodic issues with the Danish government, Christiania offers a viable, alternative way of life to its 1,000 inhabitants. The unique, self-built houses and a variety of shops, galleries and places to eat have made Christiania a popular tourist attraction. It is safer not to bring a camera to Christiania at all and to keep mobile phones out of sight. Christiania is a 15-minute taxi ride from the Bella Center. Website: christiania.org Inside the Blue Planet

CALENDAR

2016

SEPTEMBER

↙

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

↙

16th EURETINA Congress

7th EuCornea Congress

LAST CALL

JULY 2016 Aegean Cornea 2016

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

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

3rd Asia-Pacific Glaucoma Conference (APGC) 14–16 July Chiang Mai, Thailand www.apglaucomasociety.org

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

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

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

12th JOI (Journées d’Ophtalmologie Interactives) 23–24 September Toulouse, France www.joi-asso.fr

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

Ophthalmic Imaging: From Theory to Current Practice 30 September Paris, France www.vuexplorer.fr/en

46th ECLSO Congress (European Contact Lens Society of Ophthalmologists) 30 September–1 October Paris, France www.eclso.eu

OCTOBER

AAO 2016

Echography Teaching Services – International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology

2 December Dublin, Ireland Email: hmurphy@materprivate.ie

8th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

5–8 August Kuala Lumpur, Malaysia www.apacrs2016.org

9–14 August San Francisco, USA www.asrs.org/annual-meeting

Joint Irish and UKISCRS Refractive Surgery Meeting

2017

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

AUGUST

ASRS Annual Meeting 2016

1–3 December Rome, Italy www.isoptclinical.com

114th DOG Congress

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

Asia-Pacific Association of Cataract and Refractive Surgery

DECEMBER

ISOPT Clinical 2016

5–8 October Nice, France www.ever.be

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

JANUARY

11–13 January Vienna, Austria www.ophthalmictrainings.com/workshops

7th EURETINA Winter Meeting 28 January Vienna, Austria www.euretina.org

FEBRUARY

3rd Asia-Australia Congress on Controversies in Ophthalmology (COPHy AA) 9–12 February Seoul, South Korea www.comtecmed.com/cophy/ aa/2017/default.aspx

21st ESCRS Winter Meeting

10–12 February Maastricht, The Netherlands www.escrs.org

Retina World Congress

23–26 February Fort Lauderdale, USA www.retinaworldcongress.org

29 August–2 September Munich, Germany www.echography.com

EUROTIMES | JULY/AUGUST 2016

CALENDAR

2017

Vienna

MARCH

8th World Congress on Controversies in Ophthalmology (COPHy)

30 March –1 April Madrid, Spain www.comtecmed.com/cophy/ 2017/default.aspx

APRIL

AAPOS Annual Meeting

2–6 April Nashville, USA www.aapos.org/meeting/ annual_meeting_future_dates

MAY

ASCRS 2017

5–9 May Los Angeles, USA www.ascrs.org

AUGUST

ARVO Annual Meeting 2017

SEPTEMBER

ASRS Annual Meeting 2017

7–11 May Baltimore, USA www.arvo.org

12–16 August Boston, USA www.asrs.org/ annual-meeting

MediterRetina Club International Meeting

SEPTEMBER

DOG 2017

28 September–1 October Berlin, Germany www.dog.org

OCTOBER

EVER – European Association for Vision and Eye Research Congress 2017

11–13 May Parma, Italy www.mediterretina.com

27–30 September Nice, France www.ever.be

JUNE

30th APACRS Annual Meeting

↙

1–4 June Hangzhou, China www.apacrs2017.org

SOE 2017

8th EuCornea Congress

6–7 October Lisbon, Portugal www.eucornea.org

CONTACT

2018

SEPTEMBER

9th EuCornea Congress

7–11 October Lisbon, Portugal www.escrs.org

21–22 September Vienna, Austria www.eucornea.org

NOVEMBER

XXXVI Congress of the ESCRS

11–14 November New Orleans, USA www.aao.org/annual-meeting

EYE

1–3 December New Delhi India wspos.org/india-2017

XXXV Congress of the ESCRS

AAO 2017

10–13 June Barcelona, Spain www.soe2017.org

DECEMBER

4th World Congress of Paediatric Ophthalmology and Strabismus

22–26 September Vienna, Austria www.escrs.org

STUDIO INTERVIEWS with leading ophthalmologists EXCLUSIVE TO EUROTIMES! POSTOPERATIVE AMETROPIA CORRECTION: LASER REFRACTIVE SURGERY

Dr Richard Packard interviews Dr Vikentia Katsanevaki Available at: player.escrs.org and the EuroTimes App EUROTIMES | JULY/AUGUST 2016

Introducing Malyugin Ring 2.0 Nothing’s Changed... Except For Everything Less Compression Force

New Smaller Gauge Material

Easier Pupil Margin Placement

Increased Scroll Gap

New Smaller Cannula

Smaller Cannula means room to spare in incisions larger than 2.0 mm

When contemplating what the next version of the Malyugin Ring should provide surgeons and their patients, we established three goals: 1. Provide the same or better safety as surgeons have experienced and has made the Malyugin Ring “classic” the standard of care for pupil management. 2. Make it easier to place and remove from the pupil margin. 3. Allow for entry in 2.0mm incisions and more room in wounds larger than that. After several years of work, we are proud to introduce the Malyugin Ring 2.0. The second generation of the Malyugin Ring that also can be used in 2.0mm incisions. Mayugin Ring 2.0 requires no surgical technique changes for you, and we believe that you will find it easier to use, that you will appreciate the extra room it affords, and be glad to know that it has softer compression characteristics (in fact Malyugin Ring 2.0 exerts less than half as much pressure on the iris than the “classic” Malyugin Ring). Malyugin Ring 2.0 Only from MST

Malyugin Ring 2.0 MST (MicroSurgical Technology), 8415 154th Avenue NE, Redmond, Washington 98052 425.861.4002 • 1.888.279.3323 • email: info@microsurgical.com • www.mst-surgical.com

Achieving up to 99% of patients within +/– 0.5 D 1 post-op astigmatism.

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1. Clinical data of Dr. Daniel Black presented at ASCRS 2015 based on 161 eyes 2. Clinical data of Prof. Findl / Dr. Hirnschall presented at ESCRS 2013 – technically verified pre- / intraoperative matching precision ± 1.0° in mean

ZEISS Cataract Suite markerless