SPECIAL FOCUS CATARACT & REFRACTIVE RETINA
FOCAL LASER PHOTOCOAGULATION REMAINS THE GOLD STANDARD
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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon
CONTENTS
Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983
A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY
www.eurotimes.org
SPECIAL FOCUS
FEATURES
CATARACT & REFRACTIVE
RETINA
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22 There is still a role for
Looking back to the early days of phaco surgery
6 Innovation versus the
status quo, phaco surgery’s slow route to acceptance
7
EUREQUO celebrates 10 years
8 Everything you ever
wanted to know about manual small incision cataract surgery – Part 1
10 In its 90 years, Clinique
Sourdille has become one of the most prestigious institutions in France
12 We interview Béatrice
Cochener, ESCRS presidentelect, about women in ophthalmology
14 Ask the experts:
cataract surgery in posterior polar cataracts
16 Same-day drop-less
bilateral surgery can safely boost efficiency
17 Flanged haptic ends in scleral wounds stabilise IOL in damaged capsule
laser and surgery for diabetic retinopathy in the anti-VEGF era 24 Removing annoying floaters can be done with minimal side-effects 27 Ophthalmologica update
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CORNEA 29 Innovative treatments are changing the management of dry eye disease
YOUNG OPHTHALMOLOGISTS 40 In a new feature, we hear
GLAUCOMA 30 Changing the frequency
of visual field testing can lead to more efficient disease detection
34 Searching for new
ways of reducing intraocular pressure
from a young doctor about how a mentor helped shape their career
REGULARS 41 ESCRS news 43 Book reviews 44 Industry news
GLOBAL OPHTHALMOLOGY
47 Exploring Belgrade
37 Dr Soosan Jacob reports
49 Random thoughts
from the inaugural IIRSI conference
51 Calendar
18 Avoiding dry eye in refractive surgery
19 A new micro-
Supplement October
2017
interventional device can fragment any grade of cataract
20 The changing profile of LASIK patients
21 JCRS highlights
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VISI T VISIBO US AT T OT PA H VI 22 US AT 0 ES P2BO00 LLIO CR OT N 2 S H
As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2016 and 31 December 2016 is 43,593.
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EDITORIAL A WORD FROM PROF DAVID SPALTON
THE MARCH OF HISTORY The only certainty in ophthalmology is that progress is certain
A
pparently, Mao Tse Tong, when asked what he thought of the French Revolution, replied: “It’s too early to tell.” Fortunately, advances in cataract surgery move at a rather faster pace, and the past 50 years have seen the most remarkable advances where, in the western world, surgery has advanced from being a sight-saving operation to one to enhance the quality of vision. As a resident at Moorfields in the 1970s, cataract surgery was intracapsular with aphakic glasses, acuity had to be reduced to 6/60 or less to justify surgery and unilateral cataracts could only be corrected with contact lenses. The operation was performed under GA, there was a ceremonial first dressing the next day and patients were in hospital for a week, leaving with a temporary pair of +10D aphakic glasses until their refraction had stabilised three months later. It is not surprising that many of our elderly patients still remember the ordeal their parents went through. As a resident, intraocular lenses were never discussed, which surprises many people, but in many ways, this was not surprising. Harold Ridley had little clinical judgement, his ideas were way before their time with a lack of understanding of ocular physiology, a lack of technical support, and the clinics were littered with patients with devastating complications and losing their sight. I well remember a 30-year-old lady with bilateral anterior chamber IOLs, corneal decompensation, peripheral anterior synechiae and glaucoma for which, in those days, there was no effective surgical treatment. Some years later, when I put up a plaque at St Thomas’ to commemorate the first implant, one of my senior colleagues remarked it should be accompanied by another to commemorate those patients who lost their sight in the process. A few years ago, I found the old operating book for 1949 (see the ESCRS historical online archive) and it was a surprise to find Ridley’s first implant was done as a secondary procedure. The patient, a 49-year-old lady with a unilateral cataract, had surgery in November 1949 and then a secondary procedure to implant the lens in February 1949. This was something Ridley never admitted, it being highly controversial to subject a patient to what was in effect a second sight-threatening operation. Serendipity, though, was on his side, as four months later the posterior capsule had fibrosed sufficiently to support the weight of the heavy lens: if it had been done as a primary procedure, dislocation into the vitreous would have happened and ophthalmic history not been made. The 1980s and 90s saw rapid advances. Healon arrived, and this transformed implant surgery from a virtuoso technique into something within the realm of all surgeons. It was so novel and expensive that I remember one syringe would be divided for three operations. Eric Arnott was a gifted and elegant surgeon who pioneered implants in the
UK with flair, and his contribution, in my opinion, has never been fully acknowledged. Remarkably, he was to sue Alcon for infringement of his IOL patent, and in a winner-takes-all case and with nerves of steel he won a million-dollar settlement. The most important development, however, was the invention of the flexible J-loop posterior chamber lens by Shearing, making it possible to put the lens back to where it belonged. Advances in surgical technique followed in parallel. The early phaco machines had enormous post-occlusion surge, with devastating consequences. Phaco became safer with the advent of capsulorhexis, which at the time seemed the most sophisticated intraocular manoeuvre, and we all went on courses to learn it. Wound size decreased with foldable IOLs to single-stitch closure, then rapidly to no sutures and clear corneal incisions. It has been an amazing voyage for me and at times I have wondered whether the operation could get any better, but the fertility of human imagination knows no bounds. As my Presidency of the ESCRS nears completion at the end of this year it is a time for reflection. Is FLACS here to stay? We have yet to show it is a better or safer operation for the patient; it certainly isn’t cheaper. Multifocal IOLs in their various forms get even better, EDOF lenses are a major advance, improving near vision with less dysphotopsia, with more designs to come, but for the present a truly accommodating IOL remains a distant project. More fundamentally, we are starting to enter an era of almost science-fiction, where medical treatment of cataracts is beginning to appear. Lanosterol can clear cataractous lenses in dogs, lens regeneration can be achieved in children and the topical drug from Encore Vision has the potential to reverse presbyopia. The only certainty is that progress is certain. The Presidency of the ESCRS is an enormous privilege. It is an active, executive role and is an immensely enjoyable experience, and I am constantly surprised and pleased by the willingness of our colleagues to give up their time for the good of the Society. They make a tremendous and unacknowledged contribution to our success and this is an opportunity to express my gratitude. In January Béatrice Cochener takes over the Presidency. She is a lady with huge experience, enormous ability and a massive work ethic. Our future is in safe hands.
Prof David Spalton is President of the ESCRS
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), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), 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-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)
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SPECIAL FOCUS: CATARACT & REFRACTIVE
EuroTimes looks back to the early days of phaco surgery in the US and Europe. Sean Henahan reports
ifty years ago, 1967 was a year of revolutionary ideas in culture, politics, science and medicine. That year saw the debut of the Beatles’ Sgt. Pepper’s album, the summer of love, the first pocket calculator and the first heart transplant. It was during this time of creative ferment that a struggling eye surgeon in New York had an epiphany in a dentist’s chair that would forever change the way cataract surgery would be performed. EUROTIMES | OCTOBER 2017
Charles Kelman MD was an American surgeon who had trained in Switzerland and, by his own account, was more interested in music than medicine in his residency years. He ultimately committed to ophthalmology and began developing ways to improve cataract surgery. At that time, cataract surgery was performed via a large incision, often under general anaesthesia, leaving patients aphakic and with a long period of convalescence. Patients would then be fitted with bulky glasses. “Charlie’s original idea for phaco was to have an operation that would allow patients
to leave hospital in a short amount of time, not have them lying around with pillows around their head for weeks so the eyes didn’t fall apart,” noted Richard Packard MD in an interview with EuroTimes. Dr Kelman was convinced that cataract surgery could and should be done by way of small incision. He had initially developed a cryotherapy probe that showed some potential to improve intracapsular surgery, but then began looking for some other way to break up and remove the cataract through a small incision. He tried all manner of drills and cutters with no success and had reached an impasse.
SPECIAL FOCUS: CATARACT & REFRACTIVE To clear his mind, he decided to get a haircut and visit his dentist for a teeth descaling. He describes his eureka moment in his lively memoir Through my Eyes, The Story of a Surgeon who Dared to Take on the Medical World. “I sat in his chair as he reached over and took a long silver instrument out of its cradle and turned it on. A fine mist came off the tip, but the tip didn’t seem to be moving.” He inquired about the device and learned that it was an ultrasonic probe that vibrated at 25K/sec, cleaning teeth via the principle of acceleration. This was exactly what he had been looking for, a way that would allow the cataractous lens to be broken up without moving the lens in the eye during surgery. He reports that he actually hugged and kissed his dentist and ran out of the office. His insight that the ultrasonic probe could be repurposed to break up a cataract safely through a small incision would completely revolutionise cataract surgery, yielding improved safety and efficiency, not to mention better visual outcomes. Dr Kelman did not have much success when he first tried to share his ideas with the ophthalmology world. Indeed, he says in the early years his ideas only met with “scepticism, laughter, rejection and professional jealousy, even sabotage”.
PHACO IN EUROPE
The first phaco operation, performed by Dr Charles Kelman
I encountered dogma and abysmal ignorance regarding small incision surgery from so many peers when championing modern forms of cataract surgery
Dr Kelman persevered and began giving courses for surgeons interested in the controversial technique. It was at a Barraquer symposium in Spain that Eric Arnott, at the time a promising young surgeon from the UK, would first encounter Dr Kelman and his novel technique. Mr Arnott subsequently learned phaco from Dr Kelman. He performed the first phaco cataract surgery in Europe, in London, on October 27, 1973. Mr Arnott soon became an active proponent of the technique. He recounts in his own memoir A New Beginning in Sight that he too encountered strong opposition from the establishment. “I encountered dogma and abysmal ignorance regarding small incision surgery from so many peers when championing modern forms of cataract surgery.” At that time phaco was performed with a very basic machine, mostly under general anaesthesia without the benefit of
viscoelastics. Patients usually went home the next day and were fitted with contact lenses. “The settings were very simple. There was no linear phaco power at all. The settings allowed a flow rate of 25cc/min and a vacuum of 47mmHg, that was it. Generally, you started with 100% power, until most of the nucleus was done, then you would finish and manually put it at 50% power,” said Mr Packard, who had a ringside seat at that time as a senior registrar working with Mr Arnott at the newly opened Charing Cross Hospital in London. Shortly thereafter, German surgeon Ulrich Dardenne MD became the first to do phaco on the continent. He encountered a storm of resistance from the German ophthalmology establishment and nearly lost his career when senior surgeons called for him to be struck off the rolls. Phaco was not an overnight success story in the US or Europe. Aside from institutional resistance, the machine was
A UKISCRS meeting for the 25th anniversary of phaco in Europe
Dr Eric Arnott mid-operation
The Cavitron machine used by Dr Charles Kelman
Dr Eric Arnott, who pioneered phaco in Britain
expensive and the surgeons needed to learn a whole new technique through training courses. But the tide turned eventually, notes Mr Packard. “Finally, what happened was that the senior residents (registrars) pushed to learn phaco. They actually ended up teaching many of the consultants how to do the procedure. It was an evolution from the bottom up.” The major change that persuaded more surgeons to get on board was foldable IOLs. Of course, there have been many innovations and improvements in phaco technology to make the surgery safer and faster. Added to this such developments as topical anaesthesia, viscoelastics, and advanced technology IOLs have made phaco become the standard of care for cataract surgery. Richard Packard: eyequack@vossnet.co.uk
EUROTIMES | OCTOBER 2017
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CATARACT & REFRACTIVE
PHACO PIONEERS Innovation versus the status quo, phaco surgery’s slow route to acceptance. Sean Henahen reports The new face of green
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hacoemulsification, now the treatment of choice and standard of care in cataract surgery, was by no means an overnight success. On the contrary, phaco met with considerable professional scepticism and institutional resistance in the early days, first in the US, then in the UK. But perhaps nowhere did the procedure meet with more initial hostility than in Germany. First introduced in the US by Dr Charles Kelman in 1967, phaco next appeared in the UK in the early 70s thanks to Mr Eric Arnott. Subsequently, a German surgeon in Bonn, Dr Michael Ulrich Dardenne, learned the procedure and became the first to perform it on the continent. Dr Dardenne began to perform the surgery in the early 1970s. In spite of having a reputation as an excellent surgeon, Dr Dardenne met a harsh response from the German medical establishment. He was accused of malpractice and unethical behaviour by the board of the Germany Ophthalmological Society (DOG). In 1981, the board took the extreme step of attempting to expel Dr Dardenne and end his career in eye surgery. Professor Thomas Neuhann, then in the early stages of his career, had a ringside seat. “You could write a book about this topic. Dr Dardenne was not the chairman of the department in Bonn. He was a senior staff person. Keep in mind that the German system at that time was extremely authoritarian and hierarchic. By doing something that was not explicitly approved, even clearly disapproved by the chairman, he committed the most deadly sin in the German university system at that time: not subduing to the classic personal and ‘crowd’ authority,” Dr Neuhann, in private practice and head of the eye department of the Re-Cross Hospital, Munich, told EuroTimes. In addition to challenging the status quo, Dr Dardenne’s “crimes” included making money from the new skill he had learned and stating publicly that the new technique was superior to the then state-of-the-art procedure performed by everybody else, namely ICCE, explained Dr Neuhann, a former president of the ESCRS. “There was also a lot of professional jealousy and academic arrogance – ‘If I haven’t invented it, it can’t be good – because, if it were, l would have invented it myself!!’ It seems the more fundamental the innovation, the more the resistance will be. This is not strictly a Teutonic characteristic, but is universally human: Just remember Derrick Vale’s apodictic statement in 1962 (!): ‘Cataract Surgery has been developed to its ultimate state and any improvements from this date on will be insignificant,’ and his outright condemnation of the innovation and the innovator, when Harold Ridley presented the artificial lens in the US,” he commented. Dr Dardenne survived the challenge from the establishment and went on to create a well regarded clinic. After visiting legendary cataract surgeon Richard Kratz, Dr Neuhann helped to legitimise phaco in Germany and is credited with many other important contributions to the field, not least the development of the capsulorhexis. Dr Thomas Neuhann: prof@neuhann.de
EUROTIMES | OCTOBER 2017
CATARACT & REFRACTIVE
TEN YEARS OF EUREQUO ESCRS registry yields quality insights, shows improving cataract outcomes. Howard Larkin reports
I
n 2007, European ophthalmology took a bold step toward making evidence-based medicine a reality. Led by the ESCRS, 11 national ophthalmic societies won a European Union grant to create a European registry of surgical outcomes for the purposes of studying, benchmarking and improving cataract and refractive surgery – one of the first international outcomes registries attempted by any specialty. Thus, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) was born. A decade later EUREQUO has met and even exceeded many of its initial goals, said Mats Lundström MD, PhD, of Karlskrona, Sweden. His pioneering work founding the Swedish National Cataract Registry (NCR) in 1992, and extending its activities throughout Europe in 1995 through 2008 as the European Cataract Outcome Study (ECOS), laid the groundwork for EUREQUO.
HUNDREDS OF CENTRES That EUREQUO’s cataract outcomes database continues to attract active participation from hundreds of centres worldwide is itself a great success, because it makes possible international studies that help advance surgical practice. As of December 2016, the EUREQUO database included more than 2.2 million cataract extraction cases. “The logistics of setting up the database was a major achievement,” said Paul Rosen FRCS, FRCOphth, London, UK. Because EUREQUO interfaces directly with many electronic medical record systems, most datasets are filed without the need for manual entry – though a manual web interface is also available. Over 10 years, EUREQUO data has shown a slow but steady trend toward better cataract surgery visual outcomes. In 2008, post-op corrected distance visual acuity was a mean 0.088 logMAR, improving nearly continuously to a mean 0.041 in 2016. Over the same period, mean spherical equivalent biometry error also improved slowly from 0.48D, with 67.3% within ±0.5D, to 0.412D, with 73.5%, within ±0.5D. Dr Rosen, who sits on the EUREQUO steering committee with Dr Lundström and five others, believes that the registry’s
2007 – 201 7 use as a benchmarking tool is responsible for some of this improvement. “It is very good for an individual surgeon to carry out their personal audits. If you are an individual surgeon, you can enter your outcomes on the web and compare your results anonymously with national, regional and international benchmarks.” Dr Rosen believes more surgeons will find this valuable as national health systems require audits for re-certification. Dr Lundström credits ESCRS’s support for the project’s continuing success. “EUREQUO survived the three-year EU project period due to the interest and financing from the ESCRS. It is because of the ESCRS this project sustained after the EU financing stopped.”
PRACTICE GUIDELINES Developing evidence-based practice guidelines for cataract surgery was a major EUREQUO goal, and a first round of these was published in 2012 (Lundström M et al., J Cataract Refract Surg 2012; 38:1086– 1093). Based on more than 500,000 surgeries reported from 2009 through 2011, these include recommendations on second-eye surgery, outpatient procedures, pre- and postoperative visual tests and refractive outcomes, managing co-morbidities and complex cases, anaesthesia, phaco v ECCE approach, IOL lens type and materials, reporting followup data and managing postoperative complications. Dr Lundström considers the neutral nature of EUREQUO studies as one of their greatest strengths. “There is a great benefit to the general ophthalmic society to be able to follow trends and realworld outcomes without any personal or company related influences. This is also true for the benchmark opportunity.” The breadth, and perceived neutrality and credibility of EUREQUO data makes it useful for studying new technologies,
such as femtosecond laser-assisted cataract surgery (FLACS). EUREQUO data supported the largest study to date comparing visual, refractive and safety outcomes of 2,814 patients undergoing FLACS procedures, with 4,987 patients undergoing conventional phaco cataract surgery matched for age, preoperative visual acuity and similar number of ocular co-morbidities and surgical difficulty variables. It found visual and refractive outcomes were similar between the two groups, although FLACS patients had slightly more postoperative complications (Manning S et al., J Cataract Refract Surg Dec 2016; 42:1779-1790). However, the study also identified differences in patient populations and expectations, such as younger age and higher incidence of previous corneal refractive surgery among FLACS patients. Similarly, EUREQUO data are valuable for assessing relatively low-incidence complications, such as “refractive surprise”. Dr Lundström’s analysis of 2014 EUREQUO data, including more than 142,000 cases, found that 1.8% had refractive outcomes 2.0D or more off target, and more than half of these were associated with intraoperative surgical complications, most often capsulerelated, and post-op complications, mostly corneal oedema. Errors of 4.0D or more usually involved rare and complex circumstances. Going forward, the value of EUREQUO will be as much in refining its data collection to reflect evolving practice as its breadth and volume, Dr Lundström said.
Mats Lundström: mats.lundstrom@karlskrona.mail.telia.com Paul Rosen: phrosen@rocketmail.com EUROTIMES | OCTOBER 2017
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CATARACT & REFRACTIVE
BROWN CATARACT
PHACOEMULSIFICATION Everything you ever wanted to know about manual small incision cataract surgery – Part 1. Dr Soosan Jacob reports anual Small Incision Cataract Surgery (MSICS) is a form of extracapsular cataract extraction that combines the sutureless, self-sealing, small-incision, minimally astigmatic advantages of phacoemulsification with advantages of speed, ease of surgery, low cost and low dependence on machines. It is an effective alternative to phacoemulsification that is widely accepted and practised in the developing world. In experienced hands, the additional safety it offers with hard brown and black cataracts, especially in patients with borderline endothelial counts, makes it an essential skill for every surgeon to learn. This article deals with wound construction in MSICS – an integral part of the surgery responsible for intraand postoperative wound and anterior chamber stability.
ASTIGMATICALLY NEUTRAL INCISIONAL FUNNEL: The incisional funnel was described by Paul Koch in 1991. Gills and Sanders further concluded that corneal astigmatism is directly proportional to the cube of the length of incision and inversely proportional to its distance from the limbus. Thus, the astigmatically neutral zone is funnel shaped. To remain astigmatically neutral, incisions closer to the limbus need to be smaller and conversely, longer incisions may be constructed further from the limbus.
EXTERNAL SCLERAL INCISION: For adequate exposure and for facilitating nucleus expression later in the surgery, a superior rectus bridle suture is preferred to allow the eye to be rotated downwards. A fornix-based conjunctival flap is made and major bleeders cauterised. Extensive scleral cautery should be avoided to avoid EUROTIMES | OCTOBER 2017
Manual Small Incision Cataract Surgery: A, B: Frown-shaped external incision (green arrows), funnel-shaped tunnel (yellow arrows) and forward-curved internal incision (white arrows) are seen. The internal incision is longer than the external incision. C: straight- and D: L-shaped (black arrows) external incisions are seen.
postoperative scleral necrosis. An angled 2.8mm bevel-up crescent blade or a BardParker (no 15) blade may be used for creating the incision. The location, shape, length, depth and distance from the limbus are all important parameters. The depth of the incision is about half the thickness of the sclera. Shallow tunnels tend to gape and buttonholing is more likely. Excessively deep tunnels can enter the supraciliary space, cause scleral disinsertion or premature entry. If the depth is incorrect, the tunnel can be restarted at the correct depth or it may be abandoned and a new site chosen. A blunt dissector or a dissector directed excessively upwards tends to cause buttonholing. A sharp dissector or one
directed excessively downwards tends to go deep. The dissector should follow the curve of the globe during both forwards and sideways movement and should be just seen through the overlying sclera. The chord length of the incision is generally about 6-7mm. However, denser nuclei may require longer incisions. Commonly used incisional shapes are straight and frown. The frown incision, described by Singer in 1991, is more stable than a linear one, which in turn is more stable than a limbus parallel incision. Beginners, however, may start out with a straight incision 2mm from the limbus and apply a few sutures at the end of surgery before transitioning to the most commonly used frown incision.
CATARACT & REFRACTIVE Straight incision induces more againstthe-rule astigmatism, and sutures help close this incision securely, as well as making it less astigmatic. The distance from the limbus at the closest point of the frown incision is generally about 2mm, and at its furthest point about 4mm. The chevron-shaped incision was described by Pallin and consists of two linear incisions at 90 degrees to each other in the form of an inverted V. An L-shaped external incision with a large internal incision has also been described.
TUNNEL: The tunnel is extended forwards as well as sideways using the crescent blade, making sure that the depth of the scleral tunnel is maintained uniformly throughout. This can be attained by initiating the tunnel at a uniform depth by first passing the crescent blade held horizontally along the entire length of the incision at the desired depth. Once this horizontal step is created, it is extended forwards by swivelling the blade to and fro while holding the globe firmly. The globe should not be stabilised by holding the tunnel lip, to avoid compromising it. The correct depth of tunnel is indicated by the blade being just seen through the overlying sclera. The tunnel is enlarged sideways to create pockets on either side that are broader
TOM_ANZ_2017_OA2000_178x130_Print2.indd 1
than the external incision. As the cornea is steeper than the sclera, the crescent dissector is angled upwards at the limbus to avoid a premature entry. The tunnel is then extended forwards uniformly in the cornea to up to about 1.5-2mm. The total length of the tunnel from the external scleral incision to the internal corneal incision is therefore about 3.5-4mm and it has an inverted trapezoid configuration. The nucleus is able to mould itself through this funnel-shaped tunnel.
INTERNAL CORNEAL INCISION: The internal corneal incision is responsible for the stability and self-sealing nature of the tunnel. Lack of an adequate corneal valve mechanism can result in a non-selfsealing incision and astigmatism induction. Coating the tunnel with viscoelastic facilitates passing a 2.8 or 3.2mm keratome smoothly up to the anterior-most end of the tunnel. The anterior chamber is then entered into with the keratome and extended on either side up to the limbus, so that the forward-curving internal incision is larger than the external incision. The keratome is held parallel to the iris and care is taken not to allow the anterior chamber to shallow while extending the internal incision, in order to maintain a uniform internal lip throughout the extent.
Though an 8mm internal wound is generally sufficient, very large nuclei may rarely require an incision of up to 10mm. The inner lip creates a valvular mechanism that seals the incision and makes sutureless surgery possible. It prevents the iris from prolapsing out during surgery, as well as avoiding wound leak and endophthalmitis postoperatively. The corneal incision makes the tunnel multi-planar. MSICS can cause some against-therule astigmatism, more so if the tunnel gapes or is compromised at the end of surgery. Though most surgeons prefer to do a superior MSICS, the incision may be placed on the steep corneal axis if desired. 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.
Scan this QR code to view the live surgery
13.07.17 15:32
EUROTIMES | OCTOBER 2017
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SPIRIT OF CONTINUITY BURNS BRIGHT From humble beginnings, Clinique Sourdille has grown and become one of the most prestigious medical institutions in France. Philippe Sourdille reflects on the clinic’s evolution
H
ISTORY
intraocular lenses (IOLs) has been a continuous field of creativity: original designs and collaboration with several laboratories are part of the developments history of IOLs. Since 1982, Didier Ducournau developed retino-vitreal techniques, including retinal detachment microsurgery, preretinal and internal limiting membranes peeling. For the past 20 years, non-penetrating glaucoma surgery techniques (Philippe Sourdille, Pierre Yves Santiago) have been designed, published, taught and continuously improved. The unique spirit of Clinique Sourdille is made of internal and external networking. We have constantly benefited from collaboration with French and international institutions such as the Société Francaise d’Ophtalmologie (SFO), the French Implant and Refractive Surgery Association (SAFIR), and, above all, the ESCRS.
In 1928, Gilbert Sourdille, the first ophthalmologist to successfully treat some cases of retinal detachment 10 years earlier (1918), created with his brother Maurice, a world pioneer of deafness surgery, a clinic under their name. My father Gabriel-Pierre, son of Gilbert, after a residency and fellowship in Paris, started an academic and private career in Nantes. His work on corneal grafts dates from the late 1930s, together with Louis Paufique from Lyon. He was recognised internationally as one of the initiators of corneal grafting, especially in the field of lamellar surgery to improve the results at a time where no proper suture material was available. In 1970, after a residency and fellowship in Lyon, under the guidance of Louis Paufique and Jacques Charleux, I came back to the place where I had decided, when I was 15 years old, to try to walk in the steps of the founders. The medical team then expanded and new buildings were created: lacrymal duct surgery, ocular motility and strabismus were added to our skills by Jean-Pierre Métaireau and Alain Gouray. In 1974 the International Symposium on Micro Surgery was held in Nantes, where the first phacoemulsification on French soil was performed by Dr Charles Kelman. The first European ophthalmic microsurgery course followed in December 1974, and over Philippe Sourdille the next three decades many similar sessions took place. From 1979 to current times, intracapsular placement of EUROTIMES | OCTOBER 2017
WHAT MADE IT A SPECIAL PLACE? Four key components, I think, are important factors in the clinic’s success: first, a creative, familial ownership and influence through three generations, nourished by French and international visits and meetings. In this way, Clinique Sourdille has established strong links with major institutions and colleagues all over the world. Second, a permanent search for motivated young ophthalmologists to continue and develop improvements in all fields of ophthalmic surgery. Several generations of practitioners have had wonderful careers here in Nantes,
CATARACT & REFRACTIVE
The unique spirit of Clinique Sourdille is made of internal and external networking. We have constantly benefited from collaboration...
sharing their ideas and values for the next generation of ophthalmologists. Third, the permanent dialogue with the ophthalmic industry made possible a number of new developments, with a special focus on ocular imaging, refractive surgery, cataract, glaucoma and vitreoretinal surgery. Last but not least, ophthalmologists are only a part of the history: for 90 years, our exceptionally skilled anaesthesiologists, managers, nurses, and administrative personnel have been a major part of our success story.
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THE FUTURE STARTS NOW In 1990 the Sourdille family decided to sell the clinic to Générale de Santé, one of the very first investors in private health, in order to fulfil our development needs. This industrial partnership continued in 2011, with Vivalto Santé buying the premises from Ramsay Générale de Santé. The historical buildings in downtown Nantes are now too small. We therefore have to move to a new place. The 90th anniversary of Clinique Sourdille will be celebrated in a modern facility of approximately 5,000 square metres, a few miles away from our birth place. Elsan, one of the two leading French private hospitals groups, has acquired from Vivalto Santé the brand Clinique Sourdille, and the ownership for an ambitious programme. Clinique Sourdille will become Institut Sourdille Atlantique. Initially, 30 ophthalmologists will work there, half of them from Clinique Sourdille and half from Polyclinique de l’Atlantique, Kervision group. Among other creative actions this group created Phacomania, an annual international meeting on phacoemulsification, also held in Nantes. The new buildings are currently under construction and will open at the end of next year. The medical team will grow, sharing the same ethics and motivation. It will cover most fields of ophthalmology, with an innovative mind. Special cases of refractive surgery and OCT-assisted microsurgery (cornea, retino-vitreal surgery) are routinely performed. Addressing the ocular needs of an ageing population is a major part of our programme. We are extremely proud to be involved in the International Consortium for Health Outcomes Measurement (ICHOM) programme for cataracts. Elsan sponsors this revolutionary approach to outcomes, which is expected to induce major changes in medical practice and in insurance coverage. Partnering with Clinique Chénieux Ophtalmologie in Limoges, another prestigious private hospital, will further strengthen our development. Our two leading centres will be the first French institutions to participate in the global ICHOM programme. Continuous surgical education in Sourdille Atlantique will also be made possible by the acquisition of a surgical simulator and by a permanent live video transmission. The past 90 years have profoundly transformed Clinique Sourdille, but I think that if Gilbert and Maurice were with us today they would recognise the same virtues that marked their own careers in medicine: a passion for science and innovation and a relentless dedication to patient care. That is the continuity that lies at the heart of Clinique Sourdille as it begins the next chapter in its ongoing story.
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EUROTIMES | OCTOBER 2017
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BREAKING THE BARRIERS Béatrice Cochener, ESCRS President-elect, discusses gender bias, glass ceilings and the challenges facing women in ophthalmology with EuroTimes
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Their achievement highlights the capacity of career accomplishment of women nowadays...
uroTimes: Women currently hold the leading ophthalmologists in Europe? role in many of the most prestigious ophthalmic BC: The situation appears organisations, and you will soon join their ranks to be the same all over as incoming president of the ESCRS. Is this an the world. In France, for indication that women have finally achieved equal instance, there are two key status and respect in ophthalmology? reasons for the progress of Béatrice Cochener: I think that this specific period with so women ophthalmologists: many women at the head of key institutions usually dominated first, the access to a medical by men shows the achievement of parity. We currently have specialty is based on a several female presidents: Bonnie An Henderson (ASCRS), graded examination, Anja Tuulonen (European Glaucoma Society), Cynthia which ranks Bradford (American Academy of Ophthalmology), ophthalmology at Emily Chew (Association for Research in Vision and the top. It has been Ophthalmology), Cynthia Mattox (American Glaucoma noted that women Society), and Hiroko Bissen-Miyajima (Japanese Society perform better of Cataract and Refractive Surgery). Their achievement than men in this exam and usually get better scores. highlights the capacity of career accomplishment of In addition, ophthalmology offers the opportunity Cynthia Bradford women nowadays and the legitimate position of women to decide the type of practice you want. There is a (American Academy in medicine in general and ophthalmology in particular. high guarantee of success and the freedom to choose of Ophthalmology) I think this shows that things have evolved and private, academic, medical or surgical careers, as well as attitudes have changed for the better. Women were whether to practise full or part-time. I think this appeals once considered confined to the medical field of equally to men and women who want to find an optimal ophthalmology and some male doctors remained work-life balance and develop an interesting career reluctant to recognise the equal capacities of women without sacrificing their personal lives. in surgical skills. However, those biases have gradually EuroTimes: Have you ever experienced blatant disappeared in ophthalmology thanks to the evolution sexism and gender bias in your own career? of society as a whole. BC: I must admit that I did not really have to face EuroTimes: Half of medical students and residents such clear-cut reactions of sexism during my career. in the United States are now female and women are However, two small anecdotes spring to mind. The first Emily Chew increasingly visible in practices, at the podium and in incident occurred at the time of my residency when (Association for Research in academia. Are we doing enough to encourage women I had the opportunity to obtain a grant for a year’s Vision and Ophthalmology) EUROTIMES | OCTOBER 2017
CATARACT & REFRACTIVE research and was told by my boss: “You don’t need to take this grant because girls never look for an academic position!” The second one is actually a common message that I receive from patients, who regularly express their surprise when they discover that the head of the surgical department is Bonnie An Henderson a lady: “Congratulations on being (ASCRS) a woman who has managed to be a mother and a Professor in surgery! It must be so challenging and you are so deserving.” EuroTimes: Are there still barriers that are specific to female ophthalmologists? Do women have to work harder to prove themselves that their male colleagues? BC: Definitely. I am convinced Anja Tuulonen that a woman has to invest (European Glaucoma Society) twice as much energy in her work to demonstrate her level of performance. They are judged not just on their medical expertise but also on criteria such as their ability to debate and present, their age and how they look. Actually, these barriers are not specific to ophthalmology but are applicable to any profession. However, the achievement of so many women ophthalmologists who are shouldering a high level of responsibility in our specialty indicates that mentalities have changed and social barriers have progressively fallen. EuroTimes: Do women bring a particular skill set to ophthalmology or medicine? Without generalising too much, do you think there are some things that women tend to do differently, or better, than their male counterparts? BC: If it is commonly said that “a woman can deal with three things at the same time when a man can only manage one thing at a time”; I am not sure that this ability changes the practice of a woman in medicine compared to a man. For instance, having trained successive generations of female and male fellows, I did not really see any differences in their approach to surgery. EuroTimes: As incoming president of the ESCRS, what can you do in concrete terms to promote the cause of women in ophthalmology? BC: Over the past decade we have seen an increased number of women in medicine and their role as surgeons is now widely accepted, so perhaps we don’t really need to Cynthia Mattox over-emphasise gender differences. I believe (American Glaucoma Society) that equality will be truly achieved when we will talk only about the talent and quality of each individual person without establishing a link to their gender. In ophthalmology, the price for career advancement is higher for a woman but it is no longer unattainable. On a personal note, and to echo the words of Martin Luther King, I have a dream, which is to hear people say at the end of my term of presidency that “she has been a good Hiroko Bissen-Miyajima president for the ESCRS” without adding (Japanese Society of Cataract “for a woman!” and Refractive Surgery)
I am convinced that a woman has to invest twice as much energy in her work to demonstrate her level of performance
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CLINICAL QUESTIONS
ASK THE EXPERTS Our Medical Experts answer readers’ questions about current issues in ophthalmology
Manish Mahabir
Senior Resident, All India Institute of Medical Sciences. Q. What should be our approach to cataract surgery in posterior polar cataracts?
José Güell Director of Cornea and Refractive Surgery Department, Instituto Microcirugía Ocular (IMO), Barcelona, Spain A. Posterior polar cataracts remain a significant challenge for anterior segment surgeons. Although new imaging technologies such as high-definition OCT and UBM may help in preoperatively evaluate the adhesion characteristics between the posterior cortex and the capsule, they still provide a number of surgical surprises (false positives and negatives). That is why we should follow certain general strategic rules during the surgery. My recommendations are: 1. Properly size the capsulorhexis diameter either manually of with the FS laser to 4-5mm, in order to have it ready for a possible sulcus implantation with an optic capture through the rhexis. 2. Slowly hydrodeliniate the nucleus, avoiding cortical hydrodissection, because the latter is the classical trigger for “exploiting” the posterior capsule. 3. Emulsify first the nuclear content with low fluidics. 4. Using a slow injection of viscoelastic, try to dissect the posterior cortex from the posterior capsule and, again, proceed with I-A under low fluidics setting. 5. In all cases, you should be ready for anterior vitrectomy because, despite of all
preventive manoeuvres, the number of eyes with PC rupture is high. 6. If an anterior vitrectomy should be performed, some surgeons would prefer to do it from the corneo-limbal incisions and others through the pars plana. The advantage of the latter is that the possibility of increasing the size of the rupture is smaller, as well as there being less chance of leaving strands of vitreous in the anterior segment and thus, in a number of cases we will still consider an “in the bag IOL” implantation (in some cases we might be able to create, from the rupture, a continuous posterior capsulorhexis and then consider to luxate the “in the bag IOL” optic through it). 7. Finally, and especially because it will usually be an intraoperative individual decision, we must have ready and properly calculated our favourite IOLs to be implanted, both in the bag and at the sulcus. John SM Chang Director, GHC Refractive Surgery Centre, Hong Kong A. Preoperative differentiation: Anterior segment OCT is useful to evaluate a suspected posterior polar cataract (PPC). The posterior capsule (PC) is intact in a pseudo PPC, no defect is seen in the PC, and there is a gap/clear space between the cataractous lens and the PC. In True PPC, there may be
a defect seen in the PC. However, if the lens is dense the PC may not be visible. Surgical technique: All cases should be treated as a case of PPC, because even if the PC is intact it can be weak. Preventing PC rupture and nucleus drop is the target of performing a PPC extraction, it is important to avoid transmitting pressure and stress to the posterior capsular bag. After CCC, a hydrodelineation is preferred rather than a hydrodissection. Fluid is injected intralenticularly from the central core of the nucleus to the outside, this technique avoiding fluid being injected into the subcapular plane and keep the cortical shell intact. The nucleus can be separated and floated up with viscoelastic, allowing a phacoemulsification to be performed in the anterior chamber (AC). The nucleus is phacoed first, then hydrodilineation and phaco the cataractous lens layer by layer outward, leaving the PC with possible defect to last. Every step has to be performed slowly and gently. The last remaining cortex with the posterior plaque should be irrigated and aspirated slowly. It is important to maintain a constant pressure in the AC to prevent AC collapse and PC tear. If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org
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INDICATION FOR USE. The iStent® Trabecular Micro-Bypass Stent (Models GTS100R and GTS100L) is indicated for use in conjunction with cataract surgery for the reduction of intraocular pressure (IOP) in adult patients with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication. CONTRAINDICATIONS. The iStent® is contraindicated in eyes with primary or secondary angle closure glaucoma, including neovascular glaucoma, as well as in patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS. Gonioscopy should be performed prior to surgery to exclude PAS, rubeosis, and other angle abnormalities or conditions that would prohibit adequate visualization of the angle that could lead to improper placement of the stent and pose a hazard. The iStent® is MR-Conditional meaning that the device is safe for use in a specified MR environment under specified conditions, please see label for details. PRECAUTIONS. The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. The safety and effectiveness of the iStent® has not been established as an alternative to the primary treatment of glaucoma with medications, in children, in eyes with significant prior trauma, chronic inflammation, or an abnormal anterior segment, in pseudophakic patients with glaucoma, in patients with pseudoexfoliative glaucoma, pigmentary, and uveitic glaucoma, in patients with unmedicated IOP less than 22 mmHg or greater than 36 mmHg after “washout” of medications, or in patients with prior glaucoma surgery of any type including argon laser trabeculoplasty, for implantation of more than a single stent, after complications during cataract surgery, and when implantation has been without concomitant cataract surgery with IOL implantation for visually significant cataract. ADVERSE EVENTS. The most common post-operative adverse events reported in the randomized pivotal trial included early post-operative corneal edema (8%), BCVA loss of ≥ 1 line at or after the 3 month visit (7%), posterior capsular opacification (6%), stent obstruction (4%) early post-operative anterior chamber cells (3%), and early post-operative corneal abrasion (3%). Please refer to Directions for Use for additional adverse event information. CAUTION: Federal law restricts this device to sale by, or on the order of, a physician. Please reference the Directions for Use labeling for a complete list of contraindications, warnings, precautions, and adverse events. ©2016 Glaukos Corporation. Glaukos and iStent are registered trademarks of Glaukos Corporation. 400-0370-2016-US Rev. 0
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CATARACT & REFRACTIVE
OFFICE-BASED SURGERY Less regulation, same-day drop-less bilateral surgery can safely boost efficiency. Howard Larkin reports
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rom his Kaiser Permanente health plan office near Denver, Colorado, USA, Richard K Stiverson MD sees the future of cataract surgery – quite literally. “We have performed more than 36,000 cataract surgeries in our office suite,” he told the opening session of the 2017 American Society of Cataract and Refractive Surgery Symposium in Los Angeles, USA. Clinical results of Kaiser Permanente’s first 21,000 officebased cases published last year “were just as good if not better than in many hospitals and ambulatory surgery centres (ASC)” where the health plan logs most of its 100,000 annual cataract extractions, Dr Stiverson said. Visual outcomes and surgical complication rates were similar, while hospital admissions and falls after surgery were significantly lower (Ianchulev T et al. Ophthalmology 2016;123:1-6). So why bother? Moving cataract surgery from a highly regulated ASC to a similarly equipped, but more flexible, office suite saved Kaiser Permanente between $2 million and $3 million the first year, Dr Stiverson said. Office cataract surgery is more efficient because it allows delivery of high-quality, high-technology care without ASC rules that aren’t needed for cataract surgery, Dr Stiverson explained. “We don’t do surgery in a broom closet,” he said. But many ASC requirements that add cost without adding quality can be
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eliminated, such as excess operating room floor space, a separate surgical waiting room, extra timeouts before surgery, and even bouffant hair covers rather than surgical caps. With payers, both government and private, demanding better outcomes, lower costs and higher volume from ever-fewer ophthalmologists, change is needed, Dr Stiverson said. “We believe a cornerstone for future cataract surgery for some practices will be that it is office based. This will fulfil most of what payers and patients want: better access, lower cost, equivalent visual outcome and, at least in our practice, increased safety.”
DROP-LESS, SAME-DAY SECOND-EYE SURGERY Cost and patient convenience pressures also will accelerate adoption of immediate sequential bilateral cataract surgery, Dr Stiverson said. Kaiser Permanente surgeons have already carried out more than 15,000 same-day bilateral procedures without a single case of endophthalmitis, and excellent visual outcomes. However, unlike most practices, Kaiser Permanente benefits financially from same-day bilateral surgery. It is paid a fixed amount per diagnosis rather than per procedure, so it banks any operating savings. “At some point payers will accept that same-day bilateral surgery will save hundreds of millions of dollars. We absolutely agree there must be fair reimbursement for both office procedures and for the second eye surgery.” Pioneers like Minnesota Eye Consultants co-founder Richard L Lindstrom MD follow the logic. “Reimbursement drives a lot of these decisions. If tomorrow a payer in Minnesota gave me $1 million to do 1,000 cataracts, I would go to same-day bilateral sequential surgery immediately, and put a sign that says ‘office’ over the A in ASC.” Better clinical and financial outcomes will also drive adoption of drop-less cataract surgery, in which a combined intravitreal injection of moxifloxacin-triamcinolone replaces topical antibiotics and steroids, Dr Stiverson said. “My colleagues in California have been drop-less for some time, with great success.” In Dr Stiverson’s brave new world of cataract surgery, subspecialists will separately handle phaco-MIGS, complex and routine cases. For routine surgery, the entire process, from biometry to counselling to bilateral surgery, will occur in half a day, with patients meeting the surgeon for the first time in the operating room. Excess sedation will disappear, and with it risks of falls and injury during recovery. Recovery room expenses also will disappear because recovery rooms will disappear, as they already have in Dr Stiverson’s office. “Patients have a light breakfast, and frequently go out to lunch with their families afterward.” Kaiser is already experimenting with one-day cataract surgery. Issues include scheduling, work-life balance and differences in compensation fairness perception across generations, Dr Stiverson said. Nonetheless, he believes the change is inevitable. He also sees new technologies, including cheaper femtosecond laser devices, eventually supplanting mature phacoemulsification technology. “This is going to be very, very exciting,” Dr Stiverson concluded. Richard K Stiverson: richard.stiverson@kp.org Richard L Lindstrom: rllindstrom@mneye.com
CATARACT & REFRACTIVE
FLANGED IOL FIXATION
OPHTEC | Cataract Surgery
Flanged haptic ends in scleral wounds stabilise IOL in damaged capsule. Howard Larkin reports
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minimally invasive procedure requiring no suturing or glue makes it possible to stabilise a three-piece intraocular lens (IOL) in the posterior chamber position even when the chamber itself is badly damaged, Shin Yamane MD told the 2017 American Society of Cataract and Refractive Surgery Symposium in Los Angeles, USA. The procedure provides stable, significantly improved vision in eyes with aphakia, dislocated IOLs or subluxated crystalline lenses without the need for a large scleral incision to insert and suture or glue the lens in place. The procedure involves inserting the lens through a standard corneal incision. The sclera is then penetrated by two thin-walled needles at a shallow downward angle running tangentially into the globe toward the haptic ends. The haptic ends are captured in the needle lumens and pulled simultaneously through the scleral tunnel. Outside the globe, the haptic ends are dried and flanged using a cautery device, increasing their end diameter from about 0.15mm to about 0.3mm. The flange is then pushed back into the scleral tunnel, which Shin Yamane may be slightly widened at the entrance to accommodate the flange, which is too wide to be pulled back through the rest of the tunnel. When the scleral wounds heal, the IOL is held firmly in place, resulting in stable, significantly improved visual acuity (VA) with few complications and minimal endothelial cell loss, said Dr Yamane, of Yokohama City University Medical Centre, Japan.
GOOD POSITIONING In a study involving 137 eyes in 134 patients, four different threepiece lens designs were inserted. Three months after surgery, mean best corrected visual acuity improved to 0.12±0.34 logMAR, or a little worse than 20/25, from a pre-operative mean of 0.33±0.53, or a little worse than 20/40. Mean endothelial cell counts fell from 2,341±481 to 2,243±488, a decline of about 4.2%. Mean lens tilt was 3.29±2.51 degrees, indicating good positioning. Follow-up at six, 12 and 24 months found VA and endothelial cell counts stable, with no lenses losing fixation. The most common early complications were vitreous haemorrhage at 3.6%, hypotony and intraocular pressure elevation at 2.2% each and corneal oedema at 0.7%. Late complications were iris capture of the IOL at 5.8%, and cystoid macular oedema and IOP elevation at 2.2% each. Dr Yamane emphasised the need for proper technique, including using thin-wall needles, creating the scleral wounds in the proper positions and inserting the needles at the proper angle. He plans to develop instruments to help guide needle insertion. “The procedure is simple but not easy,” he said. Shin Yamane: shinyama@yokohama-cu.ac.jp
Treat astigmatism with confidence ASPHERICAL CYLINDER PUPIL INDEPENDENCE 1) Precizon Toric is part of OPHTEC’s
ENHANCED TOLERANCE TO MISALIGNMENT 2) PROVEN STABILITY 3) 1) Bench study Kim MJ, Yoo YS, Joo CK, Yoon G; (J Cataract Refractive Surg. 2015;41(10:2274-2282)) 2) Data on File - study report Dr Erik Mertens, ESCRS 2014 3) Vale C, Menezes C, Firmino-Machado J, Rodrigues P, Lume M, Tenedório P, Menéres P, Brochado MC; (Clinical Ophthalmology 19, January 2016) This product is not available in the US
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CATARACT & REFRACTIVE
AVOIDING DRY EYE The incidence of dry eye following refractive surgery ranges from 5% to 30%. Dermot McGrath reports
D
ry eye is one of the most common complications of corneal refractive surgery, with careful preoperative evaluation needed to identify patients with active dry eye disease who should not undergo surgery, according to François Malecaze MD. “Prevention is always better than cure. Dry eye can have an impact on the surgery in terms of safety, patient satisfaction and outcome, so we need rigorous preoperative screening of high-risk patients and specific postoperative care,” he told delegates attending the European Society of Ophthalmology (SOE) Congress in Barcelona. The incidence of dry eye following refractive surgery ranges from 5% to 30% in the scientific literature, said Dr Malecaze. “There is a large variability between the studies depending on the diagnosis criteria of dry eye, the study protocol used in terms of inclusion criteria, patient characteristics and type of surgery, and also the follow-up period,” he said. Dry eye after refractive surgery is an important issue because of its potential impact on the outcomes, said Dr Malecaze. “There is a real safety concern with severe dry eye disease in 0.05% of cases. The consequences after surgery are a decline in satisfaction in terms of symptoms and vision quality and a decrease in refractive predictability,” he said. While there are multiple theories as to how LASIK contributes to dry eyes, the main proposed cause is iatrogenic corneal nerve damage, noted Dr Malecaze, as LASIK disrupts the dense sub-basal nerve plexus and stromal corneal nerves. Identifying patients at risk for severe dry eye is important to optimise surgical outcomes, said Dr Malecaze. There are several diseases that are more likely to increase the risk of dry eye that need to be diagnosed before corneal refractive surgery, such as Sjögren’s syndrome, diabetes mellitus, patients undergoing treatment for acne and so on. The type of surgery also has a bearing on healing response, said Dr Malecaze. One study showed that corneal sub-basal nerve density does not recover as well after LASIK, compared to photorefractive keratectomy. While some studies suggest that small-incision lenticule extraction may result in less nerve damage and may better preserve corneal sensitivity, further controlled studies are necessary to evaluate the real clinical impact, said Dr Malecaze. He said it was vital to treat contributing factors prior to surgery, and during the first three months afterwards to reassure the patient using tear substitutes and gels systematically, reducing the use of preserved eye drops. François Malecaze: malecaze.fr@chu-toulouse.fr EUROTIMES | OCTOBER 2017
Dry eye can have an impact on the surgery in terms of safety, patient satisfaction and outcome François Malecaze MD
CATARACT & REFRACTIVE
MICRO DEVICE FOR SURGERY New device fragments nucleus and polishes capsule with no ultrasound energy. Howard Larkin reports
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micro-interventional device that can be inserted through a 1.5mm incision to fragment any grade of cataract was unveiled at ASCRS and is now commercially available in the US. The manual device makes possible extraction of grade 1 and 2 cataracts with no ultrasound energy, and harder nuclei with greatly reduced energy, Sean Ianchulev MD, MPH, told the 2017 American Society of Cataract and Refractive Surgery Symposium in Los Angeles, USA. The MiLoop device consists of a retractable loop of microthin Nitinol filament, which is a super-elastic memory-shaped material used to make stents and other microsurgical devices, attached to a handle. The loop is inserted into the capsule after hydrodissection, opened radially and pulled down around the nucleus in the hydrodissection plane. When the loop reaches completely around the nucleus, it is cinched into the handle, cutting through the nucleus from the outside in. The procedure can be repeated to chop even the hardest nuclei into four, six or more segments that can then be easily aspirated, said Dr Ianchulev, who is professor of ophthalmology at the New York Eye and Ear Infirmary, Icahn School of Medicine, Mount Sinai, New York City, USA. The loop is the first of a suite of micro-interventional devices in development by Iantech, Inc (iantechmed.com). Unlike conventional nucleus disassembly, the MiLoop does centripetal lens fragmentation without the need of phaco or second instrument. It also puts less stress on the capsule and zonules even when fragmenting a hard nucleus because it exerts pressure from the outside in. “Where we now do in-out fragmentation by cracking, with this we do out-in, in what I call centripetal fragmentation,” Dr Ianchulev said.
ENDO The real ARGON experience
LEARNING FROM MIGS The MiLoop, in development by Dr Ianchulev’s company Iantech, is part of an effort to overcome some of the shortcomings of phacoemulsification, Dr Ianchulev said. These include unnecessary energy dispersion in all types of cataracts and avoiding excessive trauma removing harder cataracts. Beyond requiring no ultrasound energy and reducing pressure on the capsule, it reduces the need for irrigation and aspiration and multiple chopping instruments. Additional instruments to reduce trauma and dispersed energy in cataract surgery are in the works, Dr Ianchulev said. The goal is a clear cornea on day one, and a refractive outcome comparable to LASIK. “Ultimately we can achieve true north and be the best that we can be for our patients.” Dr Ianchulev was inspired to design the MiLoop by his work developing glaucoma devices and observing loops used in other surgical procedures. He has a long track record as an innovator as head of development for Lucentis, the inventor of intraoperative aberrometry and the developer of the first supraciliary MIGS device – the CyPass Micro-Stent. The ASCRS presentation on this technology is available online at: https://vimeo.com/216698609
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CATARACT & REFRACTIVE
EVOLUTION OF LASIK
Incision Capsulorrhexis Forceps Micro
French study looks at the changing profile of LASIK patients over a decade. Dermot McGrath reports
Ideal for incisions as small as 1.8 mm
A
marked increase in the number of younger patients and hyperopes being treated with LASIK were among some of the most significant findings of a French study looking at the evolution of LASIK patients over a 10-year period, according to Laurent Gauthier-Fournet MD. “Our study showed that all categories of the population undergo LASIK. The ratio of male-to-female patients has remained stable over the last 10 years, with a slight majority of female patients. We have seen a clear increase in LASIK for two specific age groups: patients under 30 years of age and those over 50. In terms of the ametropia treated, there is a progression in the percentage of hyperopes treated and this is partially linked to age,” he said. Addressing delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting in Paris, Dr Gauthier-Fournet, in private practice in Saint Jean de Luz, France, said that the study also found very little difference in the ratio of male-to-female patients before and after 45 years of age. “I would interpret this as a clear sign that what we are doing is not perceived as aesthetic surgery by the majority of the population but as a functional medical procedure,” he said.
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The goal of the study, said Dr Gauthier-Fournet, was to try to shed some light on the profile of LASIK patients over a defined period of time. “We all recognise that this type of data is difficult to obtain. The industry partners in this field are very diverse and a lot of information is not shared. I wanted to get away from the vague impressions and anecdotal evidence in order to obtain something more precise and objective,” he said. Dr Gauthier-Fournet’s study included three populations of LASIK patients operated on over a 10-year period: 469 patients and 843 surgeries in 2005; 538 patients and 1,016 surgeries in 2010; and 517 patients and 966 surgeries in 2015. All 2,825 procedures were performed by the same surgeon and no cases of photorefractive keratectomy were included. “Bilateral surgery slightly increased over the study period. This is probably explained by the thinner flaps and higher precision lasers, which enable us to avoid the need for unilateral phakic implants combined with LASIK,” said Dr Gauthier-Fournet. The overall average patient age of 40 remained the same between 2005 and 2015, with patients under 30 constituting the largest treatment group (32%) in 2015 compared to 24% in 2005, noted Dr Gauthier-Fournet. For the type of ametropia corrected, the past decade has seen a drop in myopic patients, from 81% in 2005 to 64% in 2015, and a marked increase for hyperopia, from 19% in 2005 to 36% in 2015. Laurent Gauthier-Fournet: lgauthier@ophtaluz.com
EUROTIMES | OCTOBER 2017
CATARACT & REFRACTIVE
JCRS HIGHLIGHTS VOL: 43 ISSUE: 7 MONTH: JULY
OBSTACLES TO BETTER IOL POWER CALCULATION The percentage of cataract patients who are not within 0.5 dioptre of predicted outcome postoperatively ranges from 10 to 20%, and worse for difficult eyes. The second in a series of editorials commissioned by the JCRS to stimulate progress in this area looks at some of the remaining obstacles towards attaining the elusive goal of perfect IOL power calculation. Dr Warren Hill and colleagues note that for those willing to use all available resources in the best manner possible, outcomes have never been better. This would include more advanced vergence formulas and ray-tracing methods, along with approaches that involve hybridisation as well as other non-traditional methods such as artificial intelligence. They discuss the importance of factors such as measurement errors, validation criteria and the use of optimised lens constants. W Hill et al., JCRS, “Pursuing perfection in IOL calculations. II. Measurement foibles: Measurement errors, validation criteria, IOL constants, and lane length”, Volume 43, Issue 7, 869–870.
POWER CALCULATION IN SHORT EYES IOL power calculation is particularly challenging in short eyes. Accurate prediction of effective lens position is known to be more important in short eyes because of the high IOL powers and the relatively short distance between the IOL and the retina. Researchers in the US compared measurements from seven IOL calculation formulas in 86 eyes of 67 patients. The Hoffer Q and Holladay 2 formulas produced slightly myopic refractive prediction errors, and the Olsen formula produced hyperopic refractive prediction errors. When the mean numerical refractive prediction error was adjusted to zero, no statistically significant differences in the median absolute error were found between the seven formulas. SE Gökce et al., JCRS, “Intraocular lens power calculations in short eyes using 7 formulas”, Volume 43, Issue 7, 892–897.
MANUAL CAPSULORHEXIS AND LENS TILT The femtosecond laser can be used to create remarkably good capsulorhexes, but does this represent a step beyond what can be achieved with the manual approach? Researchers in Vienna conducted a prospective study in 255 eyes undergoing cataract surgery, looking at manual capsulorhexis size, shape and position on postoperative axial position, tilt, and centration of IOLs. Followup evaluations at one hour and three months postoperatively showed that modern IOL designs were not significantly influenced by a slightly imperfect capsulorhexis shape in terms of IOL tilt, IOL decentration, or ACD shift. Moreover, the postoperative change in the shape of the capsulorhexis was not different between a round capsulorhexis shape and an imperfect capsulorhexis shape. O Findl et al., JCRS, “Effect of manual capsulorhexis size and position on intraocular lens tilt, centration, and axial position", Volume 43, Issue 7, 902–908.
THOMAS KOHNEN European editor of JCRS
Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal
EUROTIMES | OCTOBER 2017
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RETINA
DIABETIC RETINOPATHY There is still a role for laser and surgery in the anti-VEGF era. Dermot McGrath reports
W
hile the introduction of anti-VEGF therapies is transforming the clinical management of diabetic eye disease, laser and surgical options are still important treatments, reported researchers at the European Society of Ophthalmology (SOE) 2017 Congress in Barcelona, Spain. For example, the success of antiVEGF notwithstanding, focal laser photocoagulation still remains the gold standard in the initial treatment of the diabetic macular oedema (DME) disease, according to David Pelayes MD, Professor of Ophthalmology, Buenos Aires University, Argentina. “We now have more options thanks to anti-VEGF therapies, but focal laser is not going to disappear from our treatment arsenal. Reducing the side-effects and improving the safety and efficacy of the therapy are some of the central aims of contemporary laser photocoagulation,” he said. “Vision loss is mainly due to DME, which arises from leakage of plasma into the central retina. It has been reported that of patients who had been diabetic for 20 or more years, around 29% suffered from DME. Visual acuity is reduced irreversibly over time as the neurons involved die,” he said. The Early Treatment Diabetic Retinopathy Study (ETDRS) showed that laser photocoagulation for DME helped reduce visual loss by 50% at three-year follow-up. “However, traditional photocoagulation with grey or grey-white laser spots inevitably scars the retina, destroys photoreceptors and is associated with vision scotoma,” said Dr Pelayes.
Figure 1: 35-year-old man with extensive proliferative vitreoretinopathy in the nasal arcades dragging the macula towards the optic disc. At that time, BCVA was 20/400;
EUROTIMES | OCTOBER 2017
Contraindications for focal laser treatment include ischaemic maculopathy, diffuse DME and patients who fail to appreciate the risk-benefit profile of the treatment, he added. To try to minimise some of the side-effects, the parameters of laser photocoagulation have evolved in recent clinical studies by incorporating shorter pulse durations and lower laser energy, said Dr Pelayes. “Clinical trials have demonstrated that lower energy can reduce side-effects and risks while effectively alleviating DME,” he said. The general macular settings for the laser now include an exposure time of 10-to-20 milliseconds, resulting in sharply decreased energy density and thermal diffusion, he explained. “Furthermore, studies have shown that the retinal photocoagulation induced by 10-to-30ms exposure time can stimulate inner retinal healing responses and is associated with less destructive effects than traditional methods,” he said.
NEW SURGICAL APPROACHES TO PDR New techniques and instrumentation are also transforming the surgical management of proliferative diabetic retinopathy (PDR), José García-Arumí MD told delegates. “New technologies have increased the anatomical and functional outcome in PDR, with tractional macular detachment still the first indication for surgery. Diagnostic advances such as wide-field angiography and swept-source OCT are also proving very helpful for the evaluation of ischaemia, traction and oedema,” said Dr García-Arumí, Full Professor of Ophthalmology, Universidad Autónoma de Barcelona, Spain.
Figure 2: After vitrectomy, bimanual dissection of the proliferative fibrovascular membranes, BCVA improved to 20/60
PDR surgery outcomes have improved, due to advances in vitreoretinal instrumentation, techniques, perioperative medical management and changes in practice patterns, with earlier intervention leading to better outcomes, said Dr García-Arumí. “Innovations in small-gauge instrumentation have helped, as have the introduction of anti-VEGF therapies prior to surgery, and also at the end of surgery in cases of postoperative vitreous haemorrhage. Other approaches that have also helped include the use of viscodissection associated with the use of microincisions, the staining of membranes with blue dyes and the use of perfluorocarbon liquid and silicone oil in combined traction and rhegmatogenous retinal detachment,” he said. The use of preoperative intravitreal antiVEGF has produced promising results in some recent studies, noted Dr García-Arumí, leading to regression of retinal neovascularisation and facilitating fibrovascular membrane dissection with less intraoperative bleeding, less postoperative vitreous haemorrhage and reduced postoperative complications. Furthermore, a 2013 meta-analysis of randomised controlled trials involving vitrectomy with or without preoperative intravitreal bevacizumab for PDR found compelling evidence for use of anti-VEGF therapy before surgery. Of 414 eyes of 394 participants in eight different trials, there was a shorter overall surgical time (mean difference 27 minutes), a smaller number of endodiathermy applications, less intraoperative bleeding and less recurrent vitreous haemorrhage for those who received bevacizumab before surgery. However, Dr García-Arumí noted that some adverse consequences following antiVEGF treatment in PDR have been reported, including a profibrotic switch comprised of a significant reduction in the neovascular component and marked increase in the contractile elements of the proliferative membranes over time. The use of 23- and 25-gauge pars plana vitrectomy is gaining popularity, said Dr García-Arumí, with more stable fluidics from diminished flow, less bleeding and easily closed sclerotomies among the advantages of this approach. While smaller gauge instrumentation allows more precise dissection of membranes, it also poses higher difficulty at the periphery working through microcannulas, he explained. David Pelayes: davidpelayes@gmail.com José García-Arumí: jgarcia.arumi@gmail.com
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RETINA
REMOVING FLOATERS Large series finds floater removal usually effective with few complications Howard Larkin reports
M
any vitreoretinal surgeons avoid ‘floater’ surgery because the risks of vitrectomy often seem to outweigh the benefit of removing what are usually thought of as minor visual disturbances. Even laser vitreolysis is suspect, I Paul Singh MD told the 2017 American Society of Cataract and Refractive Surgery Symposium in Los Angeles, USA. Many surgeons express concern that laser vitreolysis may not be effective, and could produce inflammation or retinal detachment based on a few published cases, said Dr Singh, who heads Eye Centres of Racine and Kenosha, Wisconsin, USA. “The question I get from colleagues is, ‘is it safe to fire three, four or five mJ of laser energy 300 to 400 times into the eye?’” In Dr Singh’s experience with more than 1,200 cases, the answer is unequivocally “yes”. Nd:YAG laser vitreolysis using pulse power double or more those typical for posterior capsulotomy not only is safe, it usually is highly effective in relieving patients of visually debilitating floaters. Floaters often interfere with reading, driving, watching TV and other daily activities, and can be visually disabling, Dr Singh noted. On average, patients would risk more to avoid them, including possible blindness or reduced lifespan, than they would to rid themselves of diabetes or HIV, according to one large study (Am J Ophthalmol. 2011; 152(1): 60-65). While this finding may or may not hold in real life, “we tend to underestimate the impact of floaters on patients’ lives”, Dr Singh said.
1,272 CASES, 10 COMPLICATIONS Dr Singh presented results from 1,272 consecutive laser vitreolysis cases in 680 patients treated with an Ultra Q Reflex Nd:YAG laser (Ellex), using a Singh MidVitreous lens (Volk) with an adjustable depth of focus extending
from the posterior lens surface to the retina. All patients were seen at one month, three months and one year after the procedure, and 146 patients were followed for at least four years. Optical coherence tomography of the macula was performed after the procedure on the first 362 patients. Dr Singh has no financial interest in the lens and is a paid speaker and consultant for Ellex. An average of 562 laser pulses were fired per treatment session, and a mean 2.4 sessions were required per case. Laser pulse energy ranged from 2.5mJ for treatment close to the phakic lens or retina, up to 12mJ in the mid-vitreous, though most work was done in the 4.0-to-6.0mJ range, Dr Singh said. The laser pulse vaporises target tissue and creates an acoustic shock wave travelling back toward the source, but wave depth does not increase linearly with power, he explained. A 1.0mJ pulse creates a 110-micron shock wave while 10.0mJ increases it to only 220 microns, making 4.0-to-6.0mJ a good compromise of power and precision with a shock wave of about 150 microns. The energy beam is also truncated, which allows for less energy needed to cause a plasma spark. The pulse is also very short, about four nanoseconds, which means energy is dispersed before the next shot is fired and does not build up. Results were generally best when the floaters were isolated Weiss rings, which required fewer pulses and visits, or large amorphous clouds in the mid-vitreous, Dr Singh said. Small floaters were more difficult to visualise and treat, and patients were generally less satisfied with the results. Complications included seven intraocular pressure spikes, two phakic lens hits, and one retinal haemorrhage, for a total adverse event rate of 0.8%. Six IOP spike patients resolved with topical drug treatment, with one remaining on treatment. One phakic lens hit later required cataract surgery and the other is under observation. The retinal haemorrhage resolved in three months, with no long-term negative effects.
The procedure was safe and painless, effective and minimally invasive, there were no post-laser activity restrictions, and patients were highly satisfied Mohammed Idrees FRCS Edin EUROTIMES | OCTOBER 2017
No go zones
Dr Singh noted that all complications occurred in the first 50 cases, before he understood how to use his laser’s coaxial illumination and off-axis illumination to precisely locate floaters and aim the laser. High-risk patients also did well, Dr Singh said. Four with a history of uveitis did not worsen, 27 with diabetic retinopathy did not develop macular oedema, and two of four with vitreomacular traction saw their VMT resolve after the procedure. No retinal defects were observed in any patient. Mohammed Idrees FRCS Edin, of Aldara Hospital and Medical Centre in Riyadh, Saudi Arabia, reported similar results treating 68 patients for floaters with an Nd:YAG laser. Overall, 87% were completely satisfied and another 9% satisfied, with 4% not satisfied. Ten percent required two treatment sessions, and 7% more than two. No loss of best corrected vision or other adverse events were observed, Dr Idrees reported. “The procedure was safe and painless, effective and minimally invasive, there were no post-laser activity restrictions, and patients were highly satisfied,” Dr Idrees said. “Use of proper technique and technology is the key for the successful outcome of this amazing laser procedure to relieve the feeling of annoying floaters,” he added. “When you respect the no go zones, then chances of complications are minimal.” He noted, however, that laser vitreolysis is technically demanding and requires training and practice to aim the laser precisely. He recommended careful patient selection and making sure the pupil is well dilated. If the target is close to the lens, a slight posterior defocus will help avoid hitting the lens. I Paul Singh: ipsingh@amazingeye.com Mohammed Idrees: sightsaver88@yahoo.com
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RETINA
OPHTHALMOLOGICA VOL: 238 ISSUE: 1-2
SILICONE OIL MAY HAVE RETINAL TOXICITY Silicone oil tamponade following vitrectomy may cause significant retinal thinning, new data suggests. In a cross-sectional study of 40 eyes with macula-off retinal detachment, spectral domain OCT with automated layer detection showed that compared to 20 eyes with gas tamponade, 20 eyes treated with silicone oil (SiO) had a significant thinning in all fields of the inner ring of the ETDRS map, including the inner plexiform layer in the nasal, superior and temporal quadrants, and the outer plexiform layer in the nasal quadrant. K. Purtskhvanidze et al., “Thinning of Inner Retinal Layers after Vitrectomy with Silicone Oil versus Gas Endotamponade in Eyes with Macula-Off Retinal Detachment”, Ophthalmologica 2017, Volume 238, Issue 3.
AFLIBERCEPT EFFECTIVE IN EYES WITH POLYPOIDAL CHOROIDAL VASCULOPATHY Intravitreal aflibercept (Eylea, Regeneron) can bring about stabilisation of BCVA and anatomical improvement in eyes with polypoidal choroidal vasculopathy (PVC), according to the results of a prospective, open-label, single-arm multicentre clinical trial. The study included 50 treatment-naïve PCV patients, all received IVA (2.0 mg) every two months after three initial monthly doses. One year after the initiation of aflibercept treatment BCVA was maintained or improved in 97.6% of the patients, and mean logMAR BCVA had improved from a baseline value of 0.33 to 0.12 logMAR (p < 0.001). In addition, mean central foveal thickness decreased from 356 to 239μm (p < 0.001) and there was complete regression of polypoidal lesions was seen in 72.5% of eyes. Y. Oshima et al., "One-Year Outcomes following Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy in Japanese Patients: The APOLLO Study”, Ophthalmologica 2017, Volume 238, Issue 3.
BASELINE OCT PREDICTS AFLIBERCEPT OUTCOMES IN EYES WITH AMD Baseline OCT findings can predict the likelihood of morphological improvements in neovascular age-related macular degeneration (AMD) patients switching from ranibizumab to aflibercept, the findings of a retrospective study suggest. In 45 consecutive AMD patients with limited response to ranibizumab, central retinal thickness and intra-retinal fluid (IRF) height were significantly reduced 18 months after commencing treatment with aflibercept on a treat-and-extend regimen. In addition, the recurrence-free treatment interval (RFTI) increased from 7.0 to 8.5 weeks (p = 0.01) and visual acuity remained stable. A comparison of outcomes with baseline OCT findings showed that the presence of hyper-reflective foci predicted better morphological outcome, while subretinal fluid predicted a shorter RFTI, and IRF predicted a longer RFTI after switching to aflibercept. C. Türksever et al., "Baseline Optical Coherence Tomography Findings as Outcome Predictors after Switching from Ranibizumab to Aflibercept in Neovascular Age-Related Macular Degeneration following a Treat-and-Extend Regimen”, Ophthalmologica 2017, Volume 238, Issue 3.
SEBASTIAN WOLF Editor of Ophthalmologica The peer-reviewed journal of EURETINA
EUROTIMES | OCTOBER 2017
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European Society of Cornea and Ocular Surface Disease Specialists
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CORNEA
Innovative treatments changing blepharitis management. Dermot McGrath reports
G
reater understanding of the ocular surface and in particular the lipid layer has helped to spark a wave of innovative treatments for meibomian gland dysfunction (MGD), the leading cause of evaporative dry eye disease, according to Béatrice Cochener MD, PhD. “Innovations in MGD treatments have been brought on by progress in ocular surface research in recent years and we now have a much better understanding of the role of the lipid layer. The traditional treatments of MGD consist of the ‘warm and moist’ approach using warm compresses, lid massage and improved eyelid hygiene, as well as antibiotics and antiinflammatory agents aiming at improving the quality of the meibum,” she told delegates attending the European Society of Ophthalmology (SOE) Congress in Barcelona. Dr Cochener explained that the goal of all the treatments of MGD is to improve the flow of meibomian gland secretions, thus leading to normal tear film stability. While the ‘warm and moist’ approach has proven its efficacy over time, such treatments may be frustrating to patients and ophthalmologists and adherence is frequently an issue over the longer term. The use of topical antibiotics and corticosteroids to suppress the bacterial colonisation and inflammation of the eyelid margin associated with MGD has been shown to be effective in the relief of symptoms and the signs of MGD, said Dr Cochener, with the inflammatory and infectious components underlying MGD still not fully understood. Two different Demodex mite species, Demodex folliculorum and Demodex brevis, have also been found to cause blepharitis, and are often overlooked in the differential diagnosis of corneal and external disease, she said. Progress has also been made in the production of artificial tears and ointments to combat dry eye, said Dr Cochener, with charged microemulsions such as the cationic Cationorm (Santen Pharmaceutical) showing improvements in symptoms and corneal staining compared with traditional aqueous eye drops. Eyelid-warming devices such as goggles and masks have also undergone systematic improvements to help relieve symptoms of MGD. The Blephasteam goggles (Thea Laboratories), for instance, are worn for 10 minutes twice daily followed by an eyelid massage and cleansing with sterile wipes, she said. More controversial, however, is the use of intense pulsed light therapy. “These are popular in vascular skin diseases but the mechanism of action in MGD is unknown and further studies are needed to confirm their safety and efficacy, said Dr Cochener. Automated thermodynamic treatments are also proving increasingly popular. The LipiView Interferometer is a diagnostic device for measuring the quality of the tear film and ocular surface and quantify the residual functional MG, and is used in conjunction with the LipiFlow thermal pulsation device. “Results show it is with one single treatment at least as efficient at three months versus daily hygiene care and lid massages, but we need more controlled studies to validate its performance over the longer-term,” she concluded.
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Béatrice Cochener: beatrice.cochener@ophtalmologie-chu29.fr EUROTIMES | OCTOBER 2017
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GLAUCOMA
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DETECTING PROGRESSION Consider risk factors for frequency of testing in glaucoma patients. Roibeard O’hEineachain reports
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The method to identify deterioration applied in the early manifest glaucoma trial (EMGT) required at least five fields, two at baseline and three at follow-up, to identify deterioration. On average, when deterioration was detected, the mean deviation changed by about 2dB. Subsequent research has suggested that, for a new patient with no prior data, if only one visual field is performed per year, with typical variability in the visual field test result, it would take six years to identify a rate of change of 2dB per year; six tests performed over two years will detect that rate of change. However, there aren’t sufficient resources to perform tests so frequently in all patients. A more efficient approach is therefore necessary. A study published in 2007 showed that testing every three months or testing once every year until progression is suspected, and then repeating the test, could detect progression earlier than testing every six months. Testing yearly until progression was suspected also yielded fewer false positives than testing every three months. The WGA’s current strategy thus combines the advantages of more frequent testing and a yearly examination until progression is detected approach, Dr Garway-Heath said. David Garway-Heath: david.garway-heath@moorfields.nhs.uk
EUROTIMES | OCTOBER 2017 ADV_Eurotime_Hill-RBF_Method_17-08-2017.indd 1
clustered approach to spacing visual field tests, with the first cluster at baseline and then, if progression is suspected, at a follow-up exam, will result in a more efficient use of resources without loss of diagnostic accuracy than regular (and more frequent) testing approaches, said David F GarwayHeath MD, FARVO, Moorfields Eye Hospital, London, UK. “Glaucoma is a potentially blinding disease, but not everybody becomes blind from it. We have to identify those patients who are at greatest danger,” he told the 7th World Congress of Glaucoma in Helsinki, Finland. The risk factors for faster glaucoma deterioration identified in peer-reviewed studies include higher intraocular pressure levels, older age and pseudoexfoliation; older patients with higher intraocular pressure progress on average faster than younger patients with lower intraocular pressure, he noted. The current World Glaucoma Association (WGA) consensus statement on visual field testing recommends first obtaining a collection of baseline visual fields over a short period of time. Afterwards, a yearly follow-up examination is adequate in lowto-moderate risk patients. However, the frequency of testing should be increased as soon as progression is suspected to have occurred. High-risk patients should be tested more frequently. The WGA’s recommendations are based on studies comparing different visual field testing protocols for detecting a meaningful rate of deterioration, for instance 2dB per year. “If we assume that the normal visual field is 0dB and that blindness is -30dB, the time from normal to blind, at a rate of 2dB per year, would be 15 years, about the average residual life expectancy of a glaucoma patient at diagnosis. We need to be able to detect such a rate of change,” he said
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REDUCING PRESSURE New targets in glaucoma’s pathophysiology identified. Roibeard O’hEineachain reports
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he recent advent of Rho-kinase-associated protein (ROCK) inhibitors as a topical treatment for glaucoma underscores the potential benefits of finding new targets for IOP-lowering medication, said Toshihiro Inoue MD, Kumamoto University, Honjo, Kumamoto, Japan. The idea of using ROCK inhibitors as an IOP-lowering therapy goes back to 1974, with a report that cytochalasin B increases the outflow facility in the eyes of cynomolgus monkeys. Interest in ROCK inhibition increased in 2001 with the publication of a study on the effects of ROCK inhibitor Y-27632 on intraocular pressure and aqueous outflow. There followed the publication of a phase 1 clinical trial of the selective ROCK inhibitor K-115 (ripasudil), which showed good IOP-lowering in glaucoma patients as well as in healthy volunteers. Those findings gained support from subsequent randomised clinical studies and, since, approval in Japan in 2014. The evidence of ripasudil’s safety and efficacy has continued to accumulate, Dr Inoue said. For example, randomised clinical trials have shown an additive IOP-lowering effect of ripasudil when combined with timolol and latanoprost. In addition, promising results were achieved in a pilot study investigating ripasudil as a secondline medication in addition to a prostaglandin analogue in patients with exfoliation glaucoma, Dr Inoue continued. The main side-effect observed with ripasudil has been transient conjunctival hyperaemia. It occurs in more than 60% of patients but with no irritation, discharge or pain. The sideeffect lasts about an hour and most patients find it acceptable. However, 10% of the patients develop chronic blepharitis, which is generally not relieved until they stop using the medication.
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Other targets include modulation of the effects of TGF beta pathophysiological pathways and the emulation of the effects of interleukin-6 in decreasing fibrinolysis, Dr Inoue said. He noted that TGFβ activates ROCK-signalling in trabecular meshwork cells, which in turn leads to polymerisation of actin and the formation of focal adhesions. “It is well known that it is involved in glaucomatous pathophysiology. The aqueous humour in glaucomatous eyes contains more TGFβ 2. TGFβ 2 may also increase the production of extracellular matrix, and it also increases fibrinolytic activity of trabecular meshwork cells,” he added. Although ROCK-inhibition reduces some of TGFβ’s downstream effects, it does not inhibit them all. It does not inhibit TGFβ-induced activation of the gene transduction molecule of SMAD 2/3 in trabecular meshwork cells. That is where interleukin (Il-6) trans-signalling may come in, he said. Dr Inoue noted that as-yet unpublished research he and his associates have carried out suggests that the activation of trans-signalling of Il-6 suppresses the SMAD-signalling of trabecular meshwork cells. Toshihiro Inoue: noel@da2.so-net.ne.jp
EUROTIMES | OCTOBER 2017
BIOMECHANICS MEETS TOMOGRAPHY
HEY CORVIS ST I just took a look at the tomography. These values call for caution. I don’t think I would operate.
HI PENTACAM The biomechanics looks good, though. The cornea is very stable. I don’t see any problem with operating.
O.K. TOGETHER NOW Tomography and corneal biomechanics together make the decision easier: Surgery could be an option.
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4th World Congress of Paediatric Ophthalmology and Strabismus
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GLOBAL OPHTHALMOLOGY
COMING TOGETHER
Refresh
The annual conference of the IIRSI 2017 was held in Chennai, India. Dr Soosan Jacob reports
your dry eye practice.
T
he annual conference of the Intraocular Implant and Refractive Society of India (IIRSI) 2017 was held on 8 and 9 July at the ITC Grand Chola Hotel, Chennai. More than 3,000 Indian and international ophthalmologists assembled at the meeting. The conference was inaugurated by the Honourable Minister for Health and Family Welfare, K Vijay Bhaskar MD, and the Guest of Honour was Mr K Vijay Kumar, IPS, famous for his role in shooting dead the notorious forest bandit Veerappan. Susan MacDonald MD, the internationally acclaimed ophthalmologist from the Tufts School of Medicine, was given the Distinguished Honour award for becoming President of Women in Ophthalmology. Elizabeth Yeu MD from Virginia Eye Consultants and Kendall Donaldson MD from the Bascom Palmer Eye Institute were among others honoured with the Special IIRSI Gold Medal by the Minister. Foreign faculty included Drs MacDonald, Yeu, Donaldson, Michael Patterson, Mitchell Jackson, Mark Kontos, Arun Gulani, Maria Soledad Romero, Roberto Zaldivar, Roger Zaldivar, Roberto Pineda, Sean Ianchulev, Shady Awwad, William Wiley, Alain Saad, José Luis Bulacio, Andreas Borkenstein and others. Various topics of interest were discussed, including premium IOLs, management of complicated cataracts, capsular dehiscence, loose zonules, corneal biomechanics, Brillouin optical microscopy, corneal inlays for presbyopic correction, endothelial keratoplasty and more. The Eye Tech Ophthalmology session had speakers talking on various new innovations. The author (Soosan Jacob MD) spoke on her new techniques of using allogenic corneal tissue: CAIRS (Corneal Allogenic Intrastromal Ring Segments) for keratoconus and PEARL (PrEsbyopic Allogenic Refractive Lenticule) as a presbyopic allogenic corneal inlay, as well as discussing the various advantages that these had over the currently available synthetic inlays. Other innovations discussed were double-infusion cannula technique (DICT) and single-pass four-throw pupilloplasty (SFT) in PDEK by Sumathi A MD, trocar anterior chamber maintainer by Minu Mathen MD, tracking of pseudophacodonesis using Purkinje images by Dhivya Ashok MD and an innovative software for autoperimetry utilising a head-mounted autoperimeter based on virtual reality by Mr Vamsi Chintalapati. The Dare to Bare session chaired by Surya Gupta MD focused on identifying complications or signs of an impending complication as key for successful surgery. Finally, 75 videos on cataract surgery and complications, cornea refractive surgeries, new innovations and other specialties were entered for the Film Festival awards. The winners were Drs Sheetal Mahuvakar, Nikhil Kandurwar, Dhivya Ashok Kumar, Viraj Vasavada and Rengaraj Venkatesh. The Grand Prize was given to Dr Mahuvakar. Rohit Sreenath MD received the gold medal for best poster. Soosan Jacob: dr_soosanj@hotmail.com
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EUROTIMES | OCTOBER 2017
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ADVERTISING FEATURE
ERGOJECT
TM
TODAY‘S WAY TO INJECT IOLs Interview with Medicel‘s CEO Volker Dockhorn on the launch of the new state-of-the-art ERGOJECT injector In April 2017, you presented the ERGOJECT at the ASCRS in San Diego for the first time. Does Ophthalmology really need another IOL injector? It is funny that you ask this first. Surgeons who supported us during the design phase asked the very same question when we first approached them. Another injector? What can you do differently to the ones on the market? That is exactly what I would like to know. There have always been two worlds of IOL injection systems. The one where surgeons prefer to use one hand for injection and have the other free for manipulations and therefore use the classic syringe-type injector. And then there is the other world where surgeons want absolute control over the lens, the advancing of the lens and the injection itself. They prefer using screw-type injectors, which are still the most popular IOL injection systems to this day. Our declared aim was to combine the two worlds. We asked ourselves what a one-handed screw injector could look like. What seemed to be paradox and a contradiction in itself ended eventually in the development of this brand new ERGOJECT injector.
Volker Dockhorn CEO Medicel AG
We asked ourselves what a one-handed screw injector could look like.
How can one picture a one-handed screw injector? Different from the classical screw injectors, ERGOJECT does not function with a screw thread. Instead, the plunger is advanced
by turning the operating wheel which is connected to a gear drive. How did you come up with that? As a Swiss company, one cannot avoid looking at the successful Swiss watch industry. We have taken these famous precision gears as an example and wanted to use them in our IOL injection system. The high precision during movement and the almost powerless transmission was especially important for us.
The power felt is actually only one quarter of the power which was initially invested. What advantage does a gear-driven injector have for the user? The gear drive works with a quadruple reduction. This means that the power felt is actually only one quarter of the power which was initially invested. It does not matter how quickly or slowly you would like to inject, the lens always follows the surgeon‘s directions given by turning the operation wheel accordingly. What is the function of the small lever on the top of the injector?
With this lever, you can block an unintended backward-movement of the injector plunger. If you activate the lever, you can only advance the plunger forward. This makes sense for small incision surgeries,
when the counterforce on the lens increases and the lens is automatically being pushed backwards. In this case, the operation wheel would always turn back when you would like to advance the plunger. This would be very disruptive, and therefore we have added the lever to block the backward movement. As mentioned, this is an especially useful feature for small cartridges such as ERGOJECT 1.6, 1.8 or 2.0. Obviously, the back rotation lock can be deactivated at any stage during the injection again. Why does the operation wheel need to be turned backwards in order to advance the plunger? It is somewhat illogical. When you look at it that way, it is indeed illogical. Our first design drafts were designed with an operation wheel to be turned forward in order to advance the plunger. However, we realized quickly that it did not feel right. Anatomically, the hand is constructed to grab and therefore it is more comfortable to pull back with your finger rather than push forward. There is almost no power required. We have therefore decided to turn back the wheel using your index finger instead of pushing the wheel forward. It is simply more ergonomic. Hence the name ERGOJECT? Yes exactly. We have not really considered an ergonomic handling on previous products the way we did for this injector. This can be seen on various points. Apart from the pulling direction of the operation wheel, the position is also very important. The operation wheel has been placed as far forward as technically possible, which means that the force applied by the surgeon is closer to the eye, in comparison to syringe-type injectors. For these injectors, the load application is done more than 2cm further away from the eye than ERGOJECT. As a consequence,
ADVERTISING FEATURE this creates a bigger lever arm which leads to nervous motions especially when there are larger forces. The near-to-eye position and handling of the ERGOJECT injector reduces the leverage forces and therefore minimizes the power related movements of the injector.
The near-to-eye position and handling of the ERGOJECT injector reduces the leverage forces and therefore minimizes the power related movements of the injector. Did you have to design the injector this big due to the gear drive? No, at the very beginning, we designed it to be small and narrow despite the gear drive. The ergonomic aspects, however, played a bigger role in the end. If you press your thumb and middle finger together and then try to pull your index finger backwards, you realize that this is not very comfortable. The tendinous connections in the hand enable the index finger to move freely only when the thumb and middle finger are approximately a finger width apart. This is exactly the reason why we have designed the injector housing to be finger width - so that the injector lies nice and relaxed in your hand. The line management does not resemble the classical injectors That‘s correct. Previously, injectors were designed according to the manufacturability of metal injectors where classical turning and milling geometries were used. Today, state-of-the art injection molding procedures enable completely different geometrics. The front part of the injector has been kept deliberately narrow not to restrict visibility on the eye. The middle part with the operation wheel has an unconventional shield shape which has always guaranteed the stability of all different variations of hand positions in our studies. Additionally, we have added reinforced grooves to increase the grip considerably. The back of the injector is designed to lie stable and without unintended rotation, between thumb and index finger. All of these aspects are ergonomic benefits which for metal injectors would result in enormous expenses and efforts if applied. Is it difficult for the surgeon to get used to holding the injector like a pen? We were very anxious at first but thankfully when conducting the clinical tests, it turned out the surgeons only needed a minimum of time to get used to holding the injector like a pen. Most of the surgeons have mentioned
that they are used to holding I/A instruments this way so that it was not completely alien to them. They felt that it was a familiar and comfortable handling of the injector.
You have mentioned ERGOJECT 1.6. What is the necessary incision and which lens can be injected through such a small incision?
Does this bid farewell to the simple syringe -and screw type injectors?
The incision size depends on the applied injection technique, just like for any other injector. When applying docking-technique, incisions of 1.6mm can be used. For woundassisted techniques, which means that the injector is slightly inserted into the eye but not as far as the capsule, a 1.8mm incision is suitable. Surgeons who prefer inserting the injector deeper into the eye (into-the-bag) can still use a 2.0mm incision only. However, I have also experienced surgeries where cartridge tips were inserted deeply into the eye through a 1.6mm limbal incision. In principal, almost any lens which could be injected through an ACCUJECT 1.8 or VISCOJECT 1.8 can now be injected through a 1.6mm incision. The 1.6 cartridge tip is now a Medicel standard and will eventually replace the 1.8 cartridges. The same cartridge tip is also available for ACCUJECT and VISCOJECT-BIO injectors.
Classic injectors will still be available in the coming years, but ERGOJECT is not just another simple syringe on the market. It is a high-quality surgical instrument which will set completely new standards. Can one still afford this in today‘s cost pressure within the health care system? Absolutely yes. We made sure during the entire development of ERGOJECT that it will not exceed pricing of our current highend line ACCUJECT. Surgeons therefore get a high-precision, gear unit assisted, ergonomic designed product for the same price she or he paid before. What about being copied? For this technology, we have applied for patents and we are confident that they will be granted. Therefore, it can be assumed that Medicel will be the exclusive manufacturer of this technology. Which IOLs ERGOJECT?
can
be
injected
with
With almost any one-piece lens. Our cartridge sizes range from 1.6mm up to 3.0mm, depending on the lens and diopter.
Reference: Dr. Florian Sutter Eyecenter Herisau, Switzerland
No preloaded lenses? Of course, preloaded lenses as well. ERGOJECT is completely compatible with the preloaded system ACCUJECT PRO. ACCUJECT PRO users of preloaded hydrophilic lenses can easily insert the oading chamber which includes the preloaded lens into the ERGOJECT PRO preloaded injector also. For hydrophobic preloaded lenses, the lens manufacturer provides the preloaded ERGOJECT PRO injector. We are currently speaking with almost all of our customers of preloaded injectors about upgrading to ERGOJECT PRO. I assume that in the near future you will see many preloaded lenses combined with our ERGOJECT injector.
ERGOJECT is not just another simple syringe on the market. It is a highquality surgical instrument which will set completely new standards. Doesn’t the cartridge split this way? No, although cartridge splits can occur when using the classical cartridges with low cost injectors, this does not apply to our modern cartridges such as ERGOJECT, ACCUJECT and VISCOJECT-BIO models. It is no longer easy to just purchase raw material and produce cartridges. Nowadays, in order to have the outstanding mechanical properties of these cartridges, we have to change the raw material in a technically extensive process within a chemical reactor. In a worst case scenario, the cartridge tip may dent and the lens may get stuck but it will never split and therefore, it cannot result in a critical condition for the patient. With this technology, we are certainly market leaders.
Scan QR code to learn more about Medicel‘s ERGOJECT injection system
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YOUNG OPHTHALMOLOGISTS
HARD WORK AND LOVE In the first of a new series, Dr Alina Aligera talks about her mentor Dr Valda Ligute
M
y first mentor greatly affected not only my career in ophthalmology, but also one extremely important period of my life in general. My story is not just about learning cataract surgery. It is also the story of the most interesting journey in my life that taught me how to believe in myself and the people around me, to love what I do and to do everything possible and possible to fulfil my dreams. All the time she was next to me – my first mentor and now a very special person for me Dr Valda Ligute. My journey started with a lot of days assisting Dr Ligute. I was looking at my doctor, mostly at her hands precisely carrying out all the surgical steps as her blue eyes calmly looked through the microscope. I could never believe I would be able to do the same. Did she believe in me? I hardly remember my first incisions, followed by IOL implantations and other steps of cataract surgery. However, I do remember the day when I first completed surgery from start to finish.
Courtesy of Alina Aligera MD
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Dr Alina Aligera (right) with her mentor Dr Valda Ligute
It is still one of the happiest moments in my life, and I was delighted to share it with her. On our way, there was my month-long additional phacoemulsification course in
India that carried great importance as well, but I would not benefit at all without my first lessons. She never said I did anything badly. After every surgical day, we discussed the cases and she pointed out my mistakes. I was not afraid of her and as she later revealed she trusted me as well. I do believe our common sense of responsibility, trust and patience has helped us on the way. Some people point out our similar traits of character and behaviour. We don’t get bored with each other and we have so many things to discuss besides ophthalmology. But what makes our relationship as mentor and resident so special? Actually, only we know how it all was. There is no one, special secret how to be a good mentor or a talented student. It’s all about hard work, persistence and love. Dr Alina Aligera is a young ophthalmologist from Riga, representing the Young Baltic Ophthalmologists group Alina Aligera: alinaaligera@gmail.com
22nd ESCRS Winter Meeting In conjunction with the Serbian Society of Cataract and Refractive Surgeons
9 – 11 February 2018 | Abstract Submission Deadline: 31 October 2017
www.escrs.org EUROTIMES | OCTOBER 2017
Sava Centar, Belgrade, Serbia
ESCRS NEWS
Dr Oliver Findl in conversation with Sean Henahan
Visitec® I-Ring® Pupil Expander “As a cataract and retina surgeon, I have found the I-Ring to consistently produce round, intact postoperative pupil margins.”
ESCRS
NEWS
— Harvey Uy, MD Peregrine Eye and
EYE CONTACT LISBON Following the success of the EuroTimes Eye Contact and ESCRS Video of the Month series in Copenhagen in 2016 and Maastricht 2017, a new series of videos is being filmed in Lisbon featuring key opinion leaders at the XXXV Congress of the ESCRS. Oliver Findl MD, secretary of the ESCRS and chairperson of the ESCRS Young Ophthalmologists Committee, said the videos had proven to be very popular, especially with trainees. “The ESCRS has always been conscious of the need to use multimedia to help train our young ophthalmologists,” he said. “In 2008, we broadcast our first audio podcasts, which were sponsored by EuroTimes. But as technology has developed, so have the expectations of our trainees, and in 2015 we recorded our first video interview at the XXXIII Congress of the ESCRS in Barcelona, Spain,” said Dr Findl. “Since then we have recorded more than 50 Eye Contact videos at our annual congresses and winter meetings, and we have also introduced another category, ESCRS Video of the Month, which has also proven to be very popular.” One of the reasons that the video series had proven to be so successful was that it allowed trainees to hear about the latest surgical procedures and technologies from some of Europe’s top ophthalmologists. “My colleagues have been very generous in sharing their time and expertise with us,” said Dr Findl, “and we have had the privilege of interviewing José Güell, Marie-José Tassignon, David Spalton and Paul Rosen, to name but a few.” The Eye Contact and Video of the Month videos can be viewed on the ESCRS player at http://player.escrs.org.
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EUROTIMES | OCTOBER 2017
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REGISTER AND BOOK HOUSING ADDITIONAL PROGRAMS ASCRS REFRACTIVE DAY • APRIL 13 ASCRS GLAUCOMA DAY • APRIL 13 CORNEA DAY • APRIL 13 ASOA WORKSHOPS • APRIL 13 T&N TECH TALKS • APRIL 13 TECHNICIANS & NURSES PROGRAM • APRIL 14–16
AnnualMeeting.ascrs.org Programming will be held in the Walter E. Washington Convention Center.
BOOK REVIEWS
THE LACRIMAL SYSTEM With the increased specialisation of knowledge, and its concentration in the hands and minds of superspecialists, handbooks have been following suit. The Lacrimal System: Diagnosis, PUBLICATION Management and Surgery THE LACRIMAL SYSTEM: (Springer), edited by Adam J. DIAGNOSIS, MANAGEMENT Cohen, Michael Mercandetti AND SURGERY and Brian Brazzo, focuses solely EDITORS on lacrimology in one volume. ADAM J. COHEN, This 200-page handbook MICHAEL MERCANDETTI is primarily concerned with AND BRIAN BRAZZO surgical management. This is PUBLISHED BY SPRINGER evident from the first chapter, “Anatomy of the Lacrimal System”, all the way through the book, which is packed with surgical photographs, endoscopic views and “before and after” photos. There is a good balance between readable prose text, sharp photographs and schematic drawings in each chapter. Topics covered range from the common and broad, such as “lacrimal trauma,” to the highly specific: “radiofrequency dacryocystorhinostomy” and “application of antimetabolites in lacrimal surgery”. As such, this book is primarily intended for those expected to perform these procedures, such as orbital and oculoplastics fellows and practitioners. Residents can also expect to benefit from the information supplied.
BOOK
REVIEWS
CETUS NANO-LASER
Laser Cataract Surgery
You still use
HEAVY METAL?
We play
GENTLE !
KEEPING UP TO DATE WITH OPHTHALMOLOGY IMAGING I can say with certainty that you, dear reader, are not up to date on everything that has been introduced in ophthalmology imaging in the past year. There, I said it. But don’t despair. Not only are you not the only one, but you can find a lot of the most current information in books, rather than having to dig through journals and attend every meeting. New Investigations in Ophthalmology (Jaypee), edited by Tanuj Dada, Meha Midha and Tarun Arora, is one of these books. Covering primarily anterior segment imaging, this 325-page handbook discusses advances in the familiar techniques such as OCT and corneal topography, but also delves into more advanced imaging such as confocal microscopy, ocular response analyser and adaptive optics. The book discusses each imaging machine in depth, including its strengths and limitations. In fact, it might be useful for anyone starting a practice and trying to decide which imaging modalities to invest in. Also useful for researchers, general ophthalmologists and ophthalmology residents.
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
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* J Cataract Refract Surg. 2016 May;42(5):725-30. doi: 10.1016/j. jcrs.2016.02.039. Tanev I, Tanev V, Kanellopoulos AJ. Nanosecond laser-assisted cataract surgery: Endothelial cell study.
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EUROTIMES | OCTOBER 2017
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INDUSTRY NEWS
INDUSTRY
NEWS
TABLETOP REFRACTION
See into the future of eye surgery and patient care.
Belong to something inspiring. Join us. www.escrs.org
EUROTIMES | OCTOBER 2017
NIDEK has launched the TS-310 Tabletop Refraction System. “The TS-310 is a tabletop subjective refraction system that integrates chart and refractor into a single unit,” said a company spokesperson. “NIDEK’s recognised quality examination is embodied in a new, groundbreaking design that redefines the conventional refraction systems and significantly minimises the examination footprint,” said the spokesperson. The compact design of the TS-310 enables easy installation and office assimilation. “The unit has the triple-performance combination of operation-oriented control box, sophisticated refractor and reliable chart unit,” said the spokesperson. “The super space-saving design enables easy installation and flexible room arrangement. The TS-310 fulfils the need for simple and reliable refraction, in an attractive design, wherever space limitations exist.” www.nidek.com
DIGITAL SOLUTIONS
CLINICAL TRIAL
Zeiss has acquired Veracity Innovations. Veracity interfaces with many electronic medical records and diagnostic devices to present the most relevant and critical data for each step – from the initial patient consultation through to the procedural and postoperative process. “ZEISS already provides advanced digital solutions that support doctors in their clinical decisions and provide for efficient data management,” says Jim Mazzo, Global President, Ophthalmic Devices, at Carl Zeiss Meditec. “Now we are complementing this with the Veracity platform – a simple solution that provides doctors the information they need at each step in the process.” www.zeiss.com
Salutaris Medical Devices has announced the start of a clinical trial investigating the use of its ophthalmic brachytherapy device to treat neovascular age-related macular degeneration (nAMD) Dr Reid Schindler, and Dr Leonard Joffe of Retina Specialists of Southern Arizona are currently recruiting subjects. Expertise is provided by Dr Russell Hamilton of the University of Arizona, with Dr Baldassarre Stea as the consulting radiation oncologist. The trial has the primary objective to determine the safety of the SMD-DA system concomitant with an anti-VEGF treatment regimen. www.clinicaltrials.gov
365 Curriculum
Saturday, November 11 The Astigmatism & Presbyopia Forum: Providing Premium Surgical Results to Patients With Growing Expectations
Register now! meetings.eyeworld.org
Supported by educational grants from Alcon Laboratories Inc., and Johnson & Johnson Vision. Additional grants pending.
Registration and reception: 5:30 PM – 6:00 PM Program: 6:00 PM – 8:00 PM New Orleans Marriott 555 Canal Street Moderator: Bonnie An Henderson, MD
Sunday, November 12 What Next? Customizing Modern OSD Therapies to Individual Patient Needs Supported by educational grants from Allergan, Shire, TearLab, and TearScience. Additional grants pending.
Registration and breakfast: 6:30 AM – 7:00 AM Program: 7:00 AM – 8:00 AM New Orleans Marriott 555 Canal Street Moderator: Terry Kim, MD
Monday, November 13 Laser-Assisted Cataract Surgery: Balancing Incremental Clinical Advantages with Learning Curves Supported by educational grants from Alcon Laboratories Inc., Bausch + Lomb, and Johnson & Johnson Vision. Additional grants pending.
Registration and breakfast: 7:00 AM – 7:30 AM Program: 7:30 AM – 8:30 AM New Orleans Marriott 555 Canal Street Moderator: Richard L. Lindstrom, MD This activity is approved for AMA PRA Category 1 Credits.TM
New Orleans 2017
EXPLORING BELGRADE
The Museum of Aviation, Belgrade
Belgrade
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TO NOTE...
BELGRADE
CURRENCY: the Dinar, RSD, (previously CSD) TIME DIFFERENCE: GMT +1 LANGUAGE: Serbian, some English, phrase book useful Zemun, a 15-minute taxi ride from the Sava Centar, is an attractive historical district, perfect for a leisurely stroll. Until WWI, Zemun was part of the Austria-Hungary empire; the old town of Zemun reflects the spirit of 18thand 19th-Century urban life. Cobbled streets, cosy cafes, picturesque old churches and the 19th-Century Gardoš or Millennium Tower, named not after the recent millennium but the previous one. It was built to celebrate a thousand years of the Austrian empire. A good dinner choice in Zemun is Saran, a traditional fish restaurant on the riverside (with steak and chicken for non-fish eaters). Open Monday: 15.00-23.00 Tuesday to Saturday: 12.00-01.00 Sunday: 12.00-23.00 Telephone for reservation +381 (11) 2618235 or +381 (69) 2618235. Website: www.saran.co.rs Take a walk down Belgrade’s Knez Mihailova, a central street lined with shops, where the facades are a textbook of architectural styles from the 19th and early 20th Century. At No 42 is the Secessionist building, originally a 1920s bank, which is now the Zepter Museum, Serbia’s first private museum, showcasing the nation’s 20th-Century and contemporary art. Open Tuesdays, Wednesdays, Fridays and Sundays: 10.00-20.00; Thursdays and Saturdays: 12.00-20.00. www.zeptermuseum.rs. Or explore Savamala for its art galleries, with a stop at the Supermarket concept store on Uzun Mirkova street. More than 100 local and international brands, from streetwear and high-fashion accessories to culinary gadgets and gifts. The in-store Bar 8 serves artisan coffee, craft beer and wine. Open Monday-Saturday: 10.00-22.00; Sunday: 12.00-20.00. www.supermarket.rs Good to know: Change some money at an airport ATM for Dinars. Credit cards are not accepted in taxis and not always accepted elsewhere. Pleased with the service in a restaurant? Leave a 10-to-15% tip. At bars and in taxis round up the amount. Three recommended taxi services: Pink Taxi (+381 11) 19803; SMS: 5353; Lux Taxi (+381 11) 30 33 123, SMS: 3033; Beo Taxi (+381 11) 970, SMS: 9700.
BRUTAL BEAUTY
Discover the new and old faces of Serbia’s capital city at the ESCRS Winter Congress. Maryalicia Post reports New Belgrade, once a marshy wasteland, was developed in the 1970s as a brand new capital city for the socialist Federal People’s Republic of Yugoslavia. The huge modernist building that housed the Central Committee of the Communist Party (now Palace of Serbia, known as SIV) is located here, as is the luxurious Hotel Jugoslavia, which has welcomed notables ranging from Queen Elizabeth II to Tina Turner. The balance of the area, developed in the rationalist style dubbed ‘brutalism’, consists of block after block of identical towers, currently housing more than 200,000 residents. Cross to the other side of the Sava river to explore Old Belgrade and sample the country’s traditional food and drink. To get you started, drop in at the quaint Rakia Bar, which offers more than 50 flavours of this potent local brandy, including the traditional plum rakija. In winter, treat yourself to a warm rakija with cinnamon and clove. Rakia Bar, Dobračina 5, http://www.rakiabar.com Visit an old-fashioned ‘kafana’ to enjoy the local specialty ćevapčiči – a skinless sausage. The Kafana Čubura Mačvanska 1 is a good choice. www.mojakafana.com. (in Serbian) For fine dining with river views try the Carda Sara Koliba, a floating restaurant where the accent is on seafood. Book at www.starakoliba.rs. (Note: smoking is permitted in bars and restaurants.) Belgrade’s two biggest museums, the National Museum and the Contemporary Art Museum, have been shuttered for more than 10 years, but there are others of interest. The museum dedicated to the great Serbian engineer and inventor, Nikola Tesla, is housed in a 1929 residential villa at Krunska 51. Open Tuesday to Sunday, 10.00-20.00. http://nikolateslamuseum.org
The Ethnographic Museum showcases folk costumes and crafts; its shop is a treasure trove of potential souvenirs – copies of medieval jewellery, glassware etc. (Credit cards are not accepted.) Open Tuesday to Saturday from 10.00-17.00 and Sunday from 09.00-14.00 at Studentski trg no.13. http://www.etnografskimuzej.rs The Military Museum is inside the historic Belgrade Fortress in Kalemegdan Park. Outside are tanks, howitzers and armoured cars, some of which were captured from Nazi and Axis forces. The exhibit includes parts of a US F-117 stealth aircraft downed by a Serbian S-125 Neva/ Pechora. www.muzej.mod.gov.rs Back in New Belgrade, the aviation museum displays about 75 planes and a number of engines in a mushroom-like building near the airport. Winter hours 1 November to 1 April: Monday to Sunday: 08.00-16.00 (last entry at 15.30) www.muzejvazduhoplovstva.org.rs A view from the Gardoš Tower, Zemun
EUROTIMES | OCTOBER 2017
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RANDOM THOUGHTS
TO DO OR NOT TO DO? EuroTimes Content Editor Aidan Hanratty follows in the footsteps of Thomas Edison, Benjamin Franklin and Leonardo da Vinci
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s an ophthalmologist, do you use to-do lists? They’re a handy way to keep on top of your business, from such mundane things as buying toilet roll or milk to more important matters like noting which eye you’ll be operating on. It’s not a new phenomenon. Benjamin Franklin famously kept to a 13-point self-improvement plan that he carried out on a weekly basis four times a year. Themes included temperance, frugality and resolve. Thomas Edison kept lists of ideas and plans throughout his life, in particular a five-page list of “Things doing and to be done”. These included what may seem like standard inventions now but were not exactly household items in 1888. “Artificial Silk”; “Silver wire wood cutting system”; “Red Lead pencils equal to graphite”. None of this compares to the wildly ambitious to-do list of Leonardo da Vinci from the 1490s. The Renaissance polymath sought to learn as much as possible about a host of tasks. Da Vinci kept a book hanging from his belt at all times, in which he would jot down ideas or thoughts as they came to him. A list attributed to the artist, translated by NPR’s Robert Krulwich from a book by Toby Lester (Da Vinci’s Ghost: Genius, Obsession, and How Leonardo Created the World in His Own Image), contains references to experts in other fields that he wished to communicate with and learn from, showing humility alongside his hunger; acknowledging one’s own shortcomings is important when it comes to making headway into new territories. As well as intending to calculate the measurements of Milan and several buildings in the city, he expressed an interest in learning how to square a triangle, how people travelled on ice in Flanders (ice skating?), how to repair locks and mills on canals and more. He also wrote on his list, simply: “Draw Milan.” It brings to mind a short story by Jorge Luis Borges entitled On Exactitude in Science. A simple paragraph, it imagines a fictitious empire where cartographers draw up a map that matches the realm in size. Perhaps I’m jumping to conclusions. Maybe Da Vinci merely intended to paint a view of the city. Regardless of the size of his drawing, one can imagine the intensity of purpose that would have gone into such a task. A 2009 study (AMIA Annu Symp Proc. 2009; 2009: 624–628.) found that care teams often used a vague to-do list or “signout” sheet, which could feature specific directions for patient care as well as more vague notes or suggestions. The study created a hierarchical model of tasks based on these forms that provided insight into the nature of clinical tasks and their management. Working with this knowledge, it suggested how such to-do lists could be integrated with a patient’s electronic health record in order
to enhance workflow as a kind of Plan B to such a muddied approach. Further studies are under way at present that expand on such models while taking into account patient concerns over privacy. Perhaps if Da Vinci were alive today he would be able to suggest a manner in which the quest for efficiency and fears over personal privacy could be reconciled. For now, that task is left for us mere mortals to complete. Aidan Hanratty: aidan@eurotimes.org
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NOVEMBER
AAMC Annual Meeting: LEARN SERVE LEAD 3–7 November Boston, Massachusetts, USA https://www.aamc.org/meetings/annual/
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New Orleans Conference for Educators 2017
LAST CALL
OCTOBER 2017
8th EuCornea Congress 6–7 October Lisbon, Portugal www.eucornea.org
South East European Congress of Ophthalmology 6–8 October Sarajevo, Bosnia and Herzegovina www.ophthalmologia2017.com
XXXV Congress of the ESCRS 7–11 October Lisbon, Portugal www.escrs.org
Inaugural APSPOS Congress 11–12 October 2017 Hong Kong http://2017.apspos.org/
3rd European Congress on Ophthalmic Imaging: From Theory to Current Practice 13 October Paris, France http://www.vuexplorer.fr
11 November New Orleans, USA https://ico.formstack.com/forms/ confeds_neworleans2017
AAO 2017 11–14 November New Orleans, USA www.aao.org/ annual-meeting
XXXIX Inter-American Course in Clinical Ophthalmology 19–22 November Miami, Florida, USA http://bascompalmer.org/cme/ inter-american-course-in-clinicalophthalmology
International Conference on Ophthalmology 21–23 November Dubai, United Arab Emirates http://oap-conferences.org/ ico-2017
4th International Symposium “Low Vision and the Brain” 24–26 November 2017 Berlin, Germany http://www.4r-vision.com/
VOS Congress 2017 24–26 November 2017 Hanoi, Vietnam http://www.vos2017.org.vn/
Next steps for eye care services and treating visual impairment: quality, innovation and STPs 24 October London, UK http://www.westminsterforumprojects.co.uk/conference/ eye-health-2017/25677
NOVEMBER
Annual Ophthalmologists Meeting 29–30 November Atlanta, Georgia, USA http://ophthalmology. alliedacademies.com
DECEMBER
WCPOS IV: 4th World Congress of Paediatric Ophthalmology and Strabismus 1–3 December Hyderabad, India wspos.org/india-2017
Asia-Pacific Vitreo-Retina Society Congress (APVRS) 8–10 December Kuala Lumpur, Malaysia http://2017.apvrs.org
2018
JANUARY
COECSA 2018
Date TBC 2018 Addis Ababa, Ethiopia http://www.coecsa.org/
Basic Science Course in Ophthalmology 8 January – 2 February New York, USA http://columbiaeye.org/education/ the-basic-science-course
9th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery 10–12 January Vienna, Austria http://www.ophthalmictrainings.com/ workshops
Annual Conference on Ocular Microsurgery 10–13 January 2018 Eilat, Israel www.eyemeetingeilat.com/en/
The Next steps for eye care services and treating visual impairment: quality, innovation and STPs conference takes place in London
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22nd ESCRS Winter Meeting 9–11 February Belgrade, Serbia www.escrs.org
2nd International Swept Source OCT & Angiography Conference 16–17 February Paris, France https://www.issoct.com/
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Frankfurt Retina Meeting 2018
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3rd World Eye Bank Symposium 15 June Barcelona, Spain http://www.gaeba.org/events/ 3rd-world-eye-banksymposium-gaeba/
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24–25 March Mainz, Germany www.eckardt-frankfurt.de
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16–19 June Barcelona, Spain www.icoph.org
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36th Congress of the ESCRS
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