EuroTimes Vol. 22 - Issue 2

SPECIAL FOCUS CATARACT & REFRACTIVE LENS CORNEA

MANAGING COMMON POST-OP DRY EYE COMPLAINTS

RETINA

LASER LIGHT SOURCE: IMPROVED VISUALISATION AND INCREASED SAFETY February 2017 | Vol 22 Issue 2

TORIC

LENSES

GLAUCOMA

IOP CONTROL GOOD WITH ONE STENT – AND BETTER WITH TWO OR THREE

AddOn® fine-tuned correction for pseudophakic eyes AddOn® toric

AddOn® SML

worldwide patented German Engineering

AddOn® progressive

Sulcus Fit through 4 flexible haptics

AddOn® spherical

Rotational Stability through non-torque design

0,5 mm

Non IOL Touch & Cell Stop through convex-concave optic

Non Iris Capture through square design

1stQ GmbH · Harrlachweg 1 · 68163 Mannheim / Germany · T. 0049 621 7176330 · info@1stq.de · www.1stq.eu

P.8

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward 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

NEWSMAKER

RETINA

3

19 ‘Laser light source may

ESCRS President-Elect Béatrice Cochener: Her vision for the Society

SPECIAL FOCUS CATARACT & REFRACTIVE LENS 4 Cover Story: Nailing toric IOL alignment with new technologies

20 New suprachoroidal

technique – optimising the safety and efficacy of palucorcel

21 Ophthalmologica Update

GLAUCOMA 22 IOP control good with

11 Ridley Medal Lecture:

23 The benefits of treatment

lens for patients with macular disease

Iris claw lenses stand the test of time

FEATURES CATARACT & REFRACTIVE 12 Everything you ever

wanted to know about small pupil phacoemulsification – Part 2

14 JCRS Highlights 15 New EBO-ESCRS exam: Certifying excellence within cataract and refractive subspecialty

P.3

be the next step in the evolution of illumination systems for VR surgery’

8 New injectable add-on

one stent – and better with two or three with preservative-free medications

24 ‘Open-angle glaucoma

subtypes have distinct causes requiring specific treatment’

PAEDIATRIC OPHTHALMOLOGY 25 Genetic microcephaly – children frequently display ocular anomalies

REGULARS 27 Research 29 Industry News 31 ESCRS News 32 Book Reviews 35 ESASO Update 37 Hospital Diary 38 Travel 39 Calendar

P.12

CORNEA 16 Using a femtosecond

laser to standardise the ‘big-bubble’ technique in DALK

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.

www.eurotimes.org

Supplement February 2017

New Advances In Nutrition And Eye Health Laboratoires Théa Satellite Symposium 16th EURETINA Congress 10 September 2016 Copenhagen, Denmark

17 Managing common post-op dry eye complaints

Included with this issue...

Laboratoires Théa supplement EUROTIMES | FEBRUARY 2017

2

EDITORIAL A WORD FROM RUDY MMA NUIJTS MD, PhD

A WARM WELCOME

The 21st ESCRS Winter Meeting takes place in Maastricht, The Netherlands, from 10–12 February

T

he 21st ESCRS Winter Meeting is a unique meeting the Belgian Society of Cataract and Refractive Surgeons takes for me as it is taking place in my home town place on Sunday. and I am delighted and honoured that this is the The Netherlands and Belgium are small countries, but they have first time an ESCRS Winter Meeting is being held in played a major role in so many areas of ophthalmic surgery, and The Netherlands. we will discuss some of these innovations at this symposium.

For once the conference is coming I realise that, with so much to me, instead of me coming to the conference! It activity taking place over three The extended didactic will feel strange to be able to leave my home every days, it will be impossible programme includes courses morning and travel directly to the conference centre, for delegates to attend every in Basic Optics, Cataract, instead of heading to the airport and booking into a single session. The good news hotel in a foreign country, but I am looking forward to is that the EuroTimes team Refractive and Cornea and the experience. are reporting at the meeting, I hope these courses will I am also very happy to get the opportunity to work producing a daily newspaper offer a valuable opportunity with my colleagues from the Netherlands Intra Ocular featuring some of the main for residents and those in Implant Club and the Belgian Society of Cataract and highlights. Reports from the Refractive Surgeons for this meeting, and we hope you meeting will also appear in training to gain a deeper enjoy the programme we have to offer. future editions of EuroTimes understanding of the basics of The extended didactic programme includes courses and also on the website at: the different subspecialties in Basic Optics, Cataract, Refractive and Cornea and I www.eurotimes.org hope these courses will offer a valuable opportunity for Delegates can also log on to residents and those in training to gain a deeper understanding of the Education Portal on the ESCRS website and access the sessions the basics of the different subspecialties. and didactic courses on ESCRS On Demand and ESCRS iLearn.

The meeting also includes a Young Ophthalmologists Interviews and video presentations featuring some of the main Programme, four main symposia, free paper sessions, moderated presenters at the meeting will also be available in the coming poster sessions, ePoster presentations and a range of surgical skills months on the ESCRS Video Player at: player.escrs.org training courses.

Finally, I would encourage delegates to take some time out to Among the topics being covered in the main symposia are explore our historic city, visit our excellent restaurants, and enjoy crosslinking, stents in glaucoma and the long-term outcomes in our hospitality. refractive surgery.

The Annual Cornea Day has been organised once again in conjunction with EuCornea and I would like to thank EuCornea for their continued participation in the meeting. Among the hot topics being discussed are lamellar keratoplasty, intraoperative optical coherence tomography and infectious disease.

A major highlight of the meeting is the live surgery session, which is being transmitted from the Maastricht University Medical Centre on Saturday afternoon and which will Dr Rudy MMA Nuijts is Professor of Ophthalmology at the include a DMEK case and a MIGS case this year. A symposium University Eye Clinic Maastricht UMC+, The Netherlands, organised by the Netherlands Intra Ocular Implant Club and and Treasurer 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)

EUROTIMES | FEBRUARY 2017

NEWSMAKER

ESCRS President-Elect Béatrice Cochener Sets Out Her Vision for the Society

I

t is a great honour to b e c o m e E S C R S President and it is also somewhat of a surprise for me, but personally, I take it as a gift. It has inspired me to make a true mission of being a good European citizen and to promote the continuing progress of ophthalmology throughout Europe. The ESCRS has played an essential role in defining current best practices and has great potential to influence policies that will raise the standard of care for our patients.

The ESCRS continues to expand the scope of its activities, which encompass education and debate as well as research. Education has always been our primary aim and I expect it shall continue ESCRS President-Elect Béatrice Cochener to be so in the future. In that regard, I think the quality of the programme in our congresses has improved dramatically over the last decade. That is because the Programme Committee and the entire ESCRS Board have made huge efforts to offer a model format for promoting the exchange of ideas during the congress, and also to use the Internet to provide continuous support for education throughout the year.

Moreover, we have become better at designing our meetings in ways that reflect the educational needs and interests of our members. In particular, the programmes dedicated to the education of young ophthalmologists have really brought a breath of fresh air to the organisation, and brought the society closer to fulfilling the needs and expectations of young members. This has not only helped the society to become more well-known, but has also made it more open to innovation and responsive to new ideas.

One big challenge over the next few years will be to ensure that we organise our meetings in ways that will meet the requirements of the new regulations regarding conflicts of interest and industry sponsorship. While we cannot hold our congresses without the support of industry, we need to be strong in our defence of evidence-based medicine so that we train our students according to what is the state-of-theart rather than being the tool of the industry.

Outside the congress, I envisage the ESCRS taking on an increasingly important role in research, organising multicentre studies and epidemiological studies in order to answer some key questions about hot topics and to define what is the stateof-the-art based on evidence.

Our organisation is strong enough to be representative of Europe and perhaps define some guidelines in terms of ophthalmic practices all around Europe. There are also many things we can do to provide better recognition of new diagnostic technologies and treatment options, which will benefit both patients and the ophthalmic industry.

I am currently the Secretary of EuCornea and I strongly believe that we should consider the relationship between these two societies. EuCornea and the ESCRS have many concerns in common, crosslinking for iatrogenic ectasia and keratoconus is an example that quickly comes to mind, and we will continue to have sessions and symposia connected to corneal surgery at the ESCRS meetings.

We should also keep the joined format for our meetings because, first of all people like it, and it also brings together a wider knowledge base, which really helps our members find answers to their questions.

Another direction that can be further developed is in strengthening our links with the developing world. Besides supporting humanitarian missions, the ESCRS should extend its educational programme to these parts of the world, because we know that there is a need there.

Finally, I should add that 2016 saw the passing of many influential and inspiring figures, including our own past president and a true pioneer, Dr Peter Barry. However, I have no doubt that his spirit will live on, not only in the hearts of those to whom he was near and dear, but also in our continuing effort to educate doctors and to provide the best for our patients.

Béatrice Cochener MD, PhD is Head of the Ophthalmology Department at the University Hospital of Brest, France • Interview by Roibeard O’hEineachain EUROTIMES | FEBRUARY 2017

3

4

COVER STORY: CATARACT & REFRACTIVE LENS

TORIC

LENSES

Nailing toric IOL alignment with new technologies.

T

oric intraocular lenses (IOLs) provide a safe and predictable method of correcting pre-existing corneal astigmatism in cataract patients, so why are they implanted in only a small percentage of the eyes that would benefit most from their astigmatism-correcting properties?

Several factors are responsible for the failure of toric IOLs to reach their full market potential. Price certainly plays a major part, as the lenses are more expensive EUROTIMES | FEBRUARY 2017

Dermot McGrath reports than traditional spherical monofocal IOLs and are only partly reimbursed, if at all, by national health systems. But that’s not the whole story, as Rudy MMA Nuijts MD, PhD, Professor of Ophthalmology at the

University Eye Clinic Maastricht UMC+, The Netherlands, told EuroTimes. “We are a little bit disappointed and concerned by the low uptake of toric lenses.

Even at a conservative estimate, at least 20%

...at least 20% of cataract patients are eligible for toric lenses. About half of these patients do not want to pay extra for a toric lens...

Rudy MMA Nuijts MD, PhD

COVER STORY: CATARACT & REFRACTIVE LENS of cataract patients are eligible for toric lenses. About half of these patients do not want to pay extra for a toric lens, but that still leaves 10% that are eligible. Yet the toric implantation rate in The Netherlands is only 3.5% to 4%,” he said.

The real reason for such slow uptake, believes Dr Nuijts, stems from the reluctance of many surgeons to offer toric IOLs to their patients.

“A recent survey of IOL implantation rates in European countries reported only one in three ophthalmologists expressing an interest in using toric IOLs. Many surgeons simply don’t want the hassle of dealing with extra measurements, marking of the eye, alignment and so forth. There is also the idea that if the lens can rotate in the eye then it is perhaps better not to take the risk at all,” he said.

The only way to counteract such hesitancy is through better advocacy and education, said Dr Nuijts. “It is evident from randomised controlled trials that lenticular solutions are much better than incisional solutions, and even femtosecond laser incisions are not going to be comparable with toric IOLs. We need to work harder to convince our colleagues of the benefits of these lenses,” he said.

HIGH-TECH INTRAOPERATIVE TOOLS Advocates of toric IOLs can point to a long and growing body of controlled studies in the scientific literature attesting to the improved accuracy, visual outcomes and rotational stability of the latest-generation toric IOLs. Improvements have been made in all areas: lens designs and materials have helped, as have more precise and comprehensive preoperative measurements which take account of factors such as posterior corneal curvature and surgicallyinduced astigmatism.

But perhaps the greatest evolutionary step has been the proliferation of intraoperative technologies designed to remove some of the remaining sources of error in toric IOL procedures such as corneal marking, axis alignment and centration of the lens.

“I think we are much more confident now putting in toric IOLs with lower cylindrical correction, which has a lot to do with the predictability of the measurements and the more accurate placement of the lens during surgery,” said Erik Mertens MD, FEBOphth, an ophthalmologist in private practice in Antwerp, Belgium.

In Dr Mertens’ practice, toric lenses represent about 22% of the lenses implanted, a reflection of the confidence he has in the array of technology he uses to fine-tune his toric IOL outcomes.

For preoperative measurements of the anterior and posterior cornea, Dr Mertens uses the Sirius System (CSO), combining a Scheimpflug camera and Placido disk. As well as topography and corneal aberrometry, the Sirius provides keratometry (K)-readings and tools to assist

I think we are much more confident now putting in toric IOLs with lower cylindrical correction...

Erik Mertens MD, FEBOphth

with the optical placement of the IOL to correct astigmatism. Further K-readings are obtained using the manual JavalSchiotz keratometer and swept-source optical coherence tomography (SS-OCT, IOLMaster 700, ZEISS), which also provides advanced biometry of the eye.

To complete the preoperative analysis, Dr Mertens performs spectral-domain OCT (SD-OCT, Optovue) with particular emphasis on the patient’s epithelial thickness profile. “When the epithelium is not evenly distributed over the cornea, it can induce astigmatism. This usually stems from a tear film problem and needs to be monitored closely to ensure it does not impact on the performance of the premium IOL being implanted,” he said.

implanting a toric lens may result in a large standard deviation and is not very accurate.

“We have by far the best results with the least standard deviation if we use OCT technology. We showed this in a study looking at the percentage of error deriving from different measurement devices, with Scheimpflug performing worst with a score of 44.6%, then keratometry with 30.0%, topography with 29.2% and finally SS-OCT with 22.7%.

OCT and keratometry combined gave the least errors with a score of 18.8%. If we combine different devices that measure different aspects of the cornea, both posterior and anterior, then we can still improve the outcome,” he said.

GREATER ACCURACY

New high-tech tools are also available to provide digital image guidance for toric IOL alignment, and may offer some advantages over traditional marking and alignment methods.

In a recent prospective comparative study of digital and manual marking methods carried out at the University Hospital of Bordeaux, France, more precise anatomical toric alignment and better reproducibility was found in 25 patients using the VERION™ Image Guided System (Alcon).

While the better alignment with digital marking was not associated with improved clinical outcomes, Cédric Schweitzer MD, PhD told EuroTimes that several factors might explain this apparent parity between the two methods.

In the quest for greater accuracy and predictability with toric lenses, SS-OCT should also prove an invaluable ally as awareness grows of its clinical utility, believes Nino Hirnschall MD, PhD, Vienna Institute for Research in Ocular Surgery, Austria.

“With the SS-OCT we get better images of the entire cornea, the anterior chamber depth and the lens thickness. All this information can be used for a better prediction of the postoperative refractive outcome,” he said.

Dr Mertens agrees with that assessment.

“The SS-OCT has become invaluable in my practice. It provides very accurate and predictable readings, it shows whether the patient was fixating at the right point and indicates whether there is a tilt or decentration of the crystalline lens. This is very important to avoid postoperative refractive surprises with these toric lenses,” he said.

Measuring the posterior surface of the cornea to get a clearer picture of the total corneal astigmatism is also very important, said Dr Hirnschall. Furthermore, using Scheimpflug measurements alone for the prediction of the remaining astigmatism after

DIGITAL MARKERS

EUROTIMES | FEBRUARY 2017

5

COVER STORY: CATARACT & REFRACTIVE LENS

6

Courtesy of Cédric Schweitzer MD, PhD

“The results would probably have been statistically significant with the inclusion of higher mean preoperative astigmatism.

The higher the astigmatism, the more important the clinical impact of a toric IOL misalignment,” said Dr Schweitzer, Department of Ophthalmology, CHU Pellegrin, Bordeaux, France.

Another factor worth mentioning is the importance of total corneal power in the final refractive outcome, said Dr Schweitzer, taking account of anterior and posterior corneal surfaces and the surgically induced astigmatism.

Another recent study of the VERION carried out at the University Eye Clinic Maastricht came to broadly the same conclusion as Dr Schweitzer’s group. While the digital marking device decreased the misalignment by about 50% compared to

Cumulative distribution of toric IOL misalignment at one month between the digital marking method (yellow line) and the manual marking method (green line). The horizontal line represents degrees of misalignment and the vertical line represents the percentage of studied eyes. While 63% of the eyes treated with the manual marking method had a misalignment below 5°, the digital marking method provided more accurate anatomical outcomes with 80% of eyes below 5° of misalignment

manual methods, this did not translate into better clinical outcomes.

Dr Nuijts suggests several possible reasons for this, including the fact that the study was conducted using first-generation calculators, which did not take posterior astigmatism into account, and also an early version of the VERION algorithm which has since been updated to take account of effective lens position and posterior corneal astigmatism.

“We know that it is more crucial to have limited misalignment when dealing with patients with high astigmatism than when implanting a lens of 1.0D or 1.5D, because the optical system is quite forgiving up to around five degrees misalignment and not a lot is going to change clinically with 0.3 or 0.4D of residual astigmatism,” he said.

INTRAOPERATIVE ABERROMETRY Intraoperative aberrometry measurements in cataract surgery have also become more prevalent in recent years, and are particularly useful for toric IOL implantation according to several surgeons familiar with these devices.

Dr Mertens has been using the Optiwave Refractive Analysis (ORA™ System) intraoperative wavefront aberrometer (Alcon) for the past five years and feels it is a useful addition to his practice.

“The only time I use this device is for toric lenses in virgin eyes or in post-refractive surgery eyes. It is easy to use and it works well. There is a learning curve, however, as the management of intraocular pressure during ORA measurement is vital to get accurate results. A good ocular surface is also critical and the surgeon needs to be careful with the speculum and to ensure that there are no other external sources of pressure on the eye when measuring,” he said.

The higher the astigmatism, the more important the clinical impact of a toric IOL misalignment Cédric Schweitzer MD, PhD EUROTIMES | FEBRUARY 2017

Dr Nuijts said that, while he was initially sceptical of the concept of intraoperative aberrometry, recent upgrades to the ORA System seem to have improved the accuracy and reproducibility of its measurements.

“There is some progress in the field and the results seem to be improving, especially for those patients at the higher end of the astigmatism spectrum,” he said.

Not all surgeons, however, are convinced of the virtues of intraoperative aberrometry.

George Beiko BM, BCh, FRCSC, in private practice in St. Catharines, Canada, believes that the current clinical evidence is too flimsy to justify investing in an intraoperative aberrometer.

“Current presentations and publications do not show any significant impact on determining the power of the astigmatism to correct, but do support some benefit to the alignment of toric IOLs with a about a two-degree improvement in accuracy.

However, the cost of this is significant and I believe using IOLs that are more forgiving of misalignment such as the Precizon (Ophtec) and TECNIS® Symfony (Abbott) is more cost effective,” he said.

INNOVATIONS AHEAD While much progress has been made in recent years in improving toric IOL outcomes, there is still further room for improvement, according to Dr Beiko.

“I believe that the challenge is still the ability to predict IOL power – currently we are only able to get about 80% of patients within +/-0.50D of targeted outcome.

Extended-depth-of-focus lenses and improvements in them should allow us to improve on this,” he said.

For Dr Nuijts, the next challenge is to find ways to personalise the surgically induced astigmatism and posterior astigmatism for every patient.

“Currently we are using average values based on empirical data, large databases etc, but for corneas with high anterior keratometry values the induced astigmatism is also going to be higher. For posterior astigmatism in the small percentage of corneas with 5.0D or 6.0D of astigmatism, we are using a mean level of 0.3 in the calculators when it can in fact be as high as 1.2D or 1.5D. For these special cases we need to come up with a personalised nomogram, and not just one based on average values that will work well for the average cataract patient,” he said.

Rudy MMA Nuijts: rudy.nuijts@mumc.nl Erik Mertens: e.mertens@medipolis.be Nino Hirnschall: nino.hirnschall@googlemail.com Cédric Schweitzer: cedric.schweitzer@chu-bordeaux.fr George Beiko: georgebeiko@hotmail.com

LISBON2017 7–11 OCTOBER XXXV CONGRESS of the ESCRS

FIL – Feira Internacional de Lisboa, Portugal

Abstract Submission Deadline: 15 March 2017

www.escrs.org

8

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

IOL FOR AMD PATIENTS

The add-on Scharioth Macula Lens (A45 SML, Medicontur, Hungary). Note the 10D add in the central 1.5mm of the IOL

inconvenient and awkward to use in public.

They are also much easier to implant and remove than intraocular telescope IOLs, said Sathish Srinivasan FRCSEd, FRCOphth, FACS, University Hospital Ayr, Ayr, Scotland, UK. “The injectable add-on SML appears to be safe and effective in the short- to medium-term in improving the corrected near visual acuity (CNVA) in patients with

Courtesy of Sathish Srinivasan FRCSEd, FRCOphth, FACS

mplantation of the add-on Scharioth Macula Lens (A45 SML, Medicontur, Hungary) can improve the near visual acuity of pseudophakic patients with age-related macular degeneration (AMD) without impairing their distance visual acuity, according to the results of a prospective European multicentre clinical trial presented at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

A number of external magnifying devices are currently available for use, but all of these restrict field of view, causing discomfort and therefore limited acceptance by patients.

With this in mind, an increasing amount of focus has been placed on visual rehabilitation of these patients using optical principles.

A variety of intraocular implants including intraocular telescopic systems and intraocular lenses (IOLs) have recently become available.

Most of these intraocular magnifying IOLs are based on the Galilean telescope principle and have the downsides of requiring a very large incision to implant them and they severely impact the visual field.

This new IOL represents an alternative to external low vision aids for macular disease patients, which can be uncomfortable,

Courtesy of Medicontur

I

New injectable add-on lens can improve reading vision in patients with macular disease. Roibeard O’hEineachain reports

A clinical photograph showing the second and third Purkinje image from the slit beam from the primary IOL in the capsular bag and the add-on SML in the ciliary sulcus

A clinical retroillumination photograph demonstrating (oil droplet sign) the central +10D add in the IOL

ESCRS

Glaucom� Day 2017 Friday 6 October FIL – International Fair of Lisbon, Portugal

glaucomaday.escrs.org

EUROTIMES | FEBRUARY 2017

AMD, and our data also suggests that the corrected distance visual acuity (CDVA) remains unaffected,” added Dr Srinivasan.

The prospective multicentre European study involved 35 pseudophakic patients with dry or inactive wet AMD, recruited over seven clinical centres in six countries.

All satisfied the inclusion criteria of being over 55 years of age and having a CDVA of 0.1 to 0.4 (decimal). In addition, all were able to achieve an improvement of at least three lines of CNVA when tested with a +6.0D reading addition at 15cm, compared to when tested with a +2.5D reading addition at 40cm with a ETDRS near vision chart.

Dr Srinivasan and his associates implanted the SML in the ciliary sulcus in one eye of each patient using a 2.75mm incision and a customised injector system. The implant has a bifocal optic, with a central 1.5mm diameter optical zone equivalent to +10D add and providing a mathematically calculated two-fold magnification on average. The peripheral zone of the lens is optically neutral, although other dioptric powers are possible.

In addition, the optic of the lens has polished round edges to reduce photic phenomena.

At a follow-up of three months, the mean decimal CNVA had improved from 0.25 preoperatively to 0.55. In addition, mean best corrected distance visual acuity remained stable throughout follow-up, and was 0.16 at one day, 0.19 at one week, 0.2 at one month, and 0.19 at three months. There were no intraoperative complications. Two patients underwent SML explantation due to postoperative glares and halos.

“Three months’ data from our prospective multicentre trial indicates that the SML is safe and effective in eyes with macular disease,” Dr Srinivasan concluded.

Sathish Srinivasan: sathish.srinivasan@gmail.com

Scientific Programme organised by

Yo ur Yo vo ur ic e.

Yo sp ur ec Yo ia fu lt ur tu y. ti r e m . e to jo in .

Belong to something personal. Join us.

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10

ADVERTISING FEATURE

Capsular Bag Stability and Posterior Capsule Opacification Hydrophobic glistening free acrylic material enhances excellent outcomes combined with double C-loop haptics platform. Cheryl Guttman Krader reports

F

indings after two years of followup in a contralateral eye-controlled clinical trial comparing two singlepiece (double C-loop), aspheric, acrylic IOLs differing only in material demonstrate slight differences in rotational stability and posterior capsule opacification (PCO) favoring an IOL constructed of a glisteningfree (G-free®) hydrophobic acrylic (PodEye, PhysIOL) over the hydrophilic acrylic IOL comparator (Pod AY, PhysIOL).

Overall, however, the results show that the symmetrical, double C-loop haptics design shared by the two implants provides excellent capsular bag stability and is associated with a low amount of posterior capsule opacification (PCO), said Oliver Findl, MD during the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

“To my knowledge this is the first clinical trial to isolate the effect of IOL

G-free® material patented by PhysIOL

Hydrophobic IOL with glistenings

material on capsular bag performance and PCO inhibition,” stated Dr Findl, Chief, Department of Ophthalmology, Hanusch Hospital, Vienna, Austria.

Providing perspective on the findings, he said, “IOL centration, stability within the capsular bag, and the avoidance of PCO are all critical for achieving good visual quality after cataract surgery and especially with aspheric, toric, and multifocal optics.

For every 3° of rotational misalignment, the efficacy of toric IOL correction is reduced by 10%.

Today, PCO remains the most common long-term ‘adverse event’ after cataract surgery, and it tends to be higher with plate haptics than with an open loop design.”

CLINICAL COMPARISON Dr Findl conducted the prospective single-centre study that included 14 patients scheduled for bilateral cataract surgery. Implantation of the two IOLs was determined by randomisation. Follow-up examinations were conducted at 1 hour, 1 week, 3 months, 1 year, and 2 years after surgery and included measurements to determine rotation, decentration, and tilt. PCO was quantified at 1 and 2 years using dedicated software to analyse retroillumination images.

Mean±standard deviation (SD) rotation between 1 hour and 3 months after surgery was minimal with both IOLs, but significantly less with the G-free® hydrophobic IOL compared with the hydrophilic lens (1.6±1.61° vs 2.4±1.85°; P=0.016). Similarly, there was very little rotation of either IOL between 1 and 2 years, and while it was less with the G-free® hydrophobic IOL than with the

Double C-loop haptics design provides excellent capsular bag stability associated with a low amount of PCO Oliver Findl MD EUROTIMES | FEBRUARY 2017

hydrophilic IOL, the difference did not achieve statistical significance (1.8±1.0° vs 2.3±1.3°; P=0.09). “ Typically, most IOL rotation happens within the first 3 months after surgery. The 2.4° of rotation with the hydrophilic IOL is similar to PodEye (Combination of Double C-loop what is seen with platform and G-free® material) other lenses on the market, while the amount of rotation of the G-free® hydrophobic IOL, both early after surgery and during the second year of follow-up, is significantly lower with 1.6°,” Dr Findl said.

He added, “One might expect a tendency for more rotation in very myopic eyes with larger capsular bags. We found no correlation between axial length and amount of rotation for either IOL, although because there were very few myopic eyes, it is not possible to reach any conclusions.”

Analyses of data collected at 1 year after surgery with a Purkinje meter showed identical, minimal decentration with both IOLs (mean±SD, 0.30±0.16 mm).

The hydrophilic and G-free® hydrophobic IOLs also displayed similarly low amounts of horizontal tilt (2.3±1.7° and 2.1±1.7°, respectively) and vertical tilt (2.9±1.6° and 2.5±1.85°, respectively).

PCO “ACQUA” scores, graded on a scale of 0 (none) to 10 (maximum), were very low for both the hydrophilic and G-free® hydrophobic IOLs at 1 year (1.2±2.1 and 0.8±1.9, respectively) and 2 years (2.5±2.6 and 2.2±2.1, respectively).

Although the results were numerically better for the G-free® hydrophobic IOL at both visits, neither difference was statistically significant.

“Obviously, this is still early follow-up for PCO, but the data slightly favor the G-free® hydrophobic material,” Dr Findl said.

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

IRIS CLAW IOLS Iris claw lenses stand the test of time after decades.

O

ver 40 years after Prof Jan Worst developed the first iris claw intraocular lens (IOL) for the correction of aphakia following cataract surgery, the concept of an iris-fixated lens has stood the test of time and still offers a safe, efficient and predictable surgical procedure for both phakic and aphakic eyes, according to José L Güell MD, PhD, Spain.

“Among the advantages are the reversibility, preservation of accommodation in phakic high ammetropic eyes and broad spectrum of ametropic correction. This lens also appears to be a valid option, with a favourable complication rate, for the treatment of aphakic eyes without capsular support,” he told delegates attending his Ridley Medal Lecture at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

Focusing initially on the use of irisfixated IOLs for aphakia with inadequate capsular support, Dr Güell said that options to surgically correct aphakia include implantation of a transsclerally sutured posterior chamber (PC) IOL, angle-supported anterior chamber (AC) IOL, or an iris-fixated IOL. Angle-supported AC IOLs are rarely used because of the high incidence of secondary glaucoma, pupil distortion, endothelial cell loss, IOL instability and other complications, he said. While transsclerally- or iris-sutured PC IOLs do preserve AC anatomy, and have a relatively low risk of associated complications, when they occur they can be very severe (vitreous haemorrhage, retinal detachment etc.) and are technically challenging to implant.

“By contrast, iris-fixated IOLs have been successfully used to correct primary and secondary aphakia in many countries, although they do not yet have FDA approval in the USA. The lenses are easy to implant, deliver favourable visual outcomes and have a relatively low incidence of intraoperative and postoperative complications,” he said.

The main advantages of the irisclaw concept include good centration of the lens, reliable fixation for precise astigmatism correction, safe positioning of the IOL in the AC and respect for the anterior segment anatomy. The fact that the phakic lenses are foldable is another advantage, said Dr Güell, with a foldable aphakic model also expected to become commercially available in the near future.

Dr Güell noted that the incidence of significant complications appears

Dermot McGrath reports

José L Güell delivering his Ridley Medal Lecture in Copenhagen

...iris-fixated IOLs have been successfully used to correct primary and secondary aphakia in many countries...

José L Güell MD, PhD acceptable with an endothelial cell loss of around 2% per year, which is similar to standard phacoemulsification. While the comparison of results with scleral-fixated IOLs is difficult, most available data favours the Artisan iris-fixated lens because of the surgical time and simplicity, and the severity of the complications.

“There is, however, a clear need for more prospective, long-term, multicentre studies for evaluating anterior versus posterior fixation and iris-fixated versus sclerafixated IOLs,” he said.

Turning to discussion of iris-fixated phakic lenses, Dr Güell said that Artisan/ Artiflex IOLs can be used to correct a wide range of refractive errors in phakic eyes.

“The incorrectly named phakic IOLs are now part of the standard surgical options for the correction of primary and secondary refractive errors,” he said.

The iris-fixated phakic IOL includes many of the same advantages as the aphakic lens, said Dr Güell. “Centration and fixation are the main advantages with these IOLs, and compared to other phakic lenses, they have the distinct advantage of preserving the AC anatomy,” he added.

Dr Güell also emphasised the importance of patient education in helping to reduce long-term complications.

“All of our patients should understand the relevance of periodic postoperative controls throughout their lives, as well as the temporality of the phakic IOL procedure. We need to stress that the anatomy of the eye changes as we get older, so it is critical to monitor the situation on a regular basis to avoid long-term problems with these implants,” he said.

Summing up, Dr Güell said that despite implantation difficulties associated with phakic iris-fixated lenses, he believed that most published complications are surgeondependent and related to patient selection and surgical technique.

“The Artisan/Artiflex group are my favourite phakic IOLs and I think the near future will possibly see an improvement in our current outcomes with the introduction of multifocality and acrylic material with these lenses,” he said.

José L Güell: guell@imo.es Dr Güell discusses iris claw IOLs in an Eye Contact video interview on the ESCRS Player.

To view the video go to: player.escrs.org/eurotimes-eye-contact /30-years-of-iris-claw-iols-jose-guell EUROTIMES | FEBRUARY 2017

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CATARACT & REFRACTIVE

SMALL PUPILS Everything you ever wanted to know about small pupil phacoemulsification – Part 2.

Dr Soosan Jacob reports

M

y last column (EuroTimes December 2016/January 2017, Vol 21 Issue 12/ Vol 22 Issue 1, Page 8-9) dealt with preoperative and intraoperative considerations for small pupil phacoemulsification. This column deals with the various pupil expander devices available for aiding surgery.

IRIS STRETCHING DEVICE: The Beehler Pupil Dilator™ (Moria, USA) is a tri-pronged device that utilises three retractable micro-fingers together with an external micro-hook to stretch the iris.

Once stretched, the instrument is removed and phacoemulsification continued.

Cycloplegics must be given preoperatively.

An irrigating model with two flexible U-shaped retractors, together with an external micro-hook, is also available that provides three-point stretch.

IRIS HOOKS: Prolene iris hooks were introduced by de Juan and metal hooks by Mackool. Prolene hooks are the most commonly used, are disposable, and the degree of dilatation depends on the amount that the silicone tyre is slid down over the hook.

Iris hooks should be introduced through

Iris hooks

EUROTIMES | FEBRUARY 2017

small, short, peripheral paracenteses parallel to the iris plane in order to expand the pupil sideward towards the limbus.

Creating paracenteses that are more clear corneal and angled downwards tents the iris upwards towards the cornea, causes obstruction to the passage of instruments, produces iris chafing, thermal damage and also shallows the anterior chamber.

The most commonly used configuration is that of four hooks applied in a square or diamond (Oetting et al) configuration, the latter having advantages of better visualisation and manoeuvre-ability of the phaco probe. Iris hooks may cause damage to the pupillary margin, especially in rigid pupils and also if the iris has been stretched excessively. Dilatation should therefore be done only to the degree required to uneventfully perform phacoemulsification, generally 5mm.

The Assia Pupil Expander (APX Ophthalmology Ltd, Israel) utilises two tiny, spring-loaded devices inserted 180 degrees from each other, perpendicular to the phaco incision. Each device is like a miniature blunt scissor, the arms of which open out to hold the iris expanded.

EXPANDING RINGS: There are many ring designs available. These have advantages of being able to be inserted through the phaco incision and not requiring

Malyugin Ring

additional paracentesis incisions. These mechanically dilate the pupil and have advantages of creating the least amount of sphincter damage, providing vertical stability to iris tissue, preventing undue movement, iris billowing or iris prolapse during surgery. They are very useful in intraoperative floppy iris syndrome (IFIS).

Malyugin Ring® (MicroSurgical Technology, USA): The Malyugin Ring, which has proven very popular, was designed by Boris Malyugin.

It has a square design with loops at all four corners which engage the iris margin. It has the advantage of retaining a round pupillary shape when the device is in situ by giving eight points of fixation. It is available in two sizes – 6.25mm and 7mm and is also now available in a newer model that allows insertion through less than 2.2mm incisions.

A special injector allows safe implantation and explantation. Care should however be taken while explanting that the edges of the loop go inside the injector before withdrawing the ring.

I-Ring® Pupil Expander (Beaver Visitec, USA): This is a single-use pupil expander made of polyurethane. It gives uniform pupillary expansion of about 6.3mm. It has hinges that enhance flexibility and fold-ability, channels that safely hold the pupillary margin, four corners that hold the iris stroma in place and positioning holes for safe positioning with the Sinskey Hook.

There is an inserter for easy implantation and explantation.

B-HEX Ring™ (Med Invent Devices, India): Created by Suven Bhattacharjee, this has a uniplanar design that engages the pupil in the same plane as the device. It is waferthin (0.075mm) and comes in a preloaded carrier which presents the device sterile at the incision. Simple manoeuvers with a Sinskey Hook are used to glide the device through the incision (0.9–2.8mm) and tuck alternate flanges under the pupil margin. The eyelets

CATARACT & REFRACTIVE

I-Ring

B-HEX Ring

and the micro-notches on the flanges help in engaging the pupil. At the end of surgery, the device is disengaged with a reverse Sinskey and explanted with a McPherson forceps.

COMPLICATIONS:

OTHERS: The Graether Pupil Expander™ (Eagle Vision, USA) is an incomplete silicone ring with a groove on the outer surface that engages the pupillary margin to give an expanded inner pupillary margin of 6.3mm. The Morcher® Pupil Dilator 5S is a 300-degree, semicircular, elastic PMMA ring which gives a pupil size of about 5-6mm.

The Perfect Pupil® device (Milvella Ltd, USA) is made of flexible polyurethane with a small arm that remains externalised and provides a window for the phaco probe.

It has a groove, scalloped tabs for 315 degrees, fenestrations for manipulation and gives dilatation to 7mm. The Siepser Iris Protector™ (Eagle Vision, USA) and the Clarke Ring are other models.

Stretching devices can cause sphincter tears as well as make the iris flaccid, leading to intraoperative iris prolapse. Devices creating circular expansion are more physiological than those with four-point dilatation. Intraoperatively, implantation and explantation of all devices should be done taking care not to damage other intraocular structures such as corneal endothelium, iris, angle and lens capsule, and these should be inserted only under viscoelastic cover.

If implanted after creating the rhexis, care should be taken not to unintentionally engage and stretch or tear the rhexis. Intraoperative disengagement may occur causing accidental iris aspiration. Explantation should be done gently to avoid iridodialysis from rough handling.

Minimal damage to the iris sphincter may occur secondary to the stretch and

CALL FOR

ENTRIES

can cause intraoperative bleeding and pigment dispersion.

Varying degrees of postoperative mydriatic pupil, pupillary atony or irregularity in the shape may be seen. These are more significant in patients with an atrophic or rigid pupil and fibrotic sphincter.

There may be an increased inflammatory response postoperatively with all pupillary dilators, especially in predisposed patients (uveitis, pseudoexfoliation, diabetes), and this should be anticipated and treated accordingly with topical steroids and nonsteroidal anti-inflammatory drugs.

In case of a posterior capsular rent, care should be taken to avoid the device from dropping into the vitreous.

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India. She has a patent pending for the Glued Capsular Hook dr_soosanj@hotmail.com

Scan this QR code to view the live surgery

JOHN HENAHAN

PRIZE 2017

Young ophthalmologists are invited to write a 900-word essay on

“How does commercial interest affect my career?”

First prize is a €1,000 travel bursary to the XXXV Congress of the ESCRS in Lisbon, Portugal.

Closing date Friday 31 march 2017 Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org

EUROTIMES | FEBRUARY 2017

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CATARACT & REFRACTIVE

JCRS SYMPOSIUM

Controversies in Anterior Segment Surgery Monday, May 8, 2017 1:00–2:30 PM

JCRS HIGHLIGHTS

VOL: 42 ISSUE: 11 MONTH: NOVEMBER 2016

TRANSEPI-PRK OR FEMTO-LASIK FOR MYOPIA? Transepithelial photorefractive keratectomy (PRK) treats refractive errors by superimposing a defined epithelial thickness profile with a corneal aspheric ablation profile. Femtosecond-assisted LASIK procedures involve laser-assisted stromal flap creation and subsequent stromal ablation to compensate for the refractive error. Researchers compared one-year outcomes with the two procedures in a retrospective analysis of 196 patients. Visual outcomes were equivalent for both treatment approaches at one year. However, patients treated with transepithelial PRK had longer recovery times with more variation in outcomes than in the femto-LASIK patient group. M Luger et al, JCRS, “Myopia correction with transepithelial photorefractive keratectomy versus femtosecond− assisted laser in situ keratomileusis: One-year case-matched analysis”, Volume 42, Issue 11, 1579-1587.

TORIC IOL IMPLANTATION, RESIDUAL ASTIGMATISM

Management of Residual Refractive Errors After Cataract Surgery Best Refractive Procedure for Moderate to High Myopia Intraocular Antibiotics for Cataract Surgery Moderators: Nick Mamalis, MD Sathish Srinivasan, MD During the ASCRS Symposium on Cataract, IOL and Refractive Surgery Los Angeles, California, USA

EUROTIMES | FEBRUARY 2017

Residual astigmatism after toric intraocular lens (IOL) implantation reportedly ranges from 0.00 to 2.25D depending on the preoperative astigmatism. This could be because either the IOL is not in the appropriate orientation to correct the astigmatism, or the IOL has too much or too little cylinder power, or both could occur. In an effort to gain a better understanding of suboptimum outcomes with toric IOLs, investigators used an online toric back-calculator to analyse 12,812 cases with a mean postoperative refractive astigmatism of 1.89 dioptres.

They found that refractive astigmatism was significantly higher with higher IOL cylinder power (P<.01), but was not different

by IOL manufacturer. Some 90% of IOLs were not at the ideal orientation, despite 30% being at the preoperative calculated orientation. Misalignment showed a directional bias for some IOLs but not for others. BA Kramer et al, JCRS, “Residual astigmatism after toric intraocular lens implantation: Analysis of data from an online toric intraocular lens back-calculator”, Volume 42, Issue 11, 1595-1601.

MEASURING NEGATIVE DYSPHOTOPSIA Negative dysphotopsia continues to be a concern following cataract surgery with IOL implantation. A two-part study compared the extension of peripheral visual fields in phakic and pseudophakic patients and evaluated whether Goldmann kinetic perimetry can be used as an objective measure of negative dysphotopsia. The study confirmed that modern cataract surgery was not associated with a reduction in the visual field in pseudophakic patients. Moreover, kinetic perimetry proved to be an effective measurement tool, showing constriction of the visual field or relative scotoma in patients with negative dysphotopsia.

NY Makhotkina et al, JCRS, "Objective evaluation of negative dysphotopsia with Goldmann kinetic perimetry", Volume 42, Issue 11, 1626–1633.

THOMAS KOHNEN European editor of JCRS

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

CATARACT & REFRACTIVE

SETTING THE STANDARD The EBO and ESCRS have announced a new subspecialty cataract and refractive examination. Colin Kerr reports

T

he European Board of Ophthalmology (EBO) and the ESCRS are collaborating on an examination to certify expertise within the cataract and refractive subspecialty. The examination is being developed by the ESCRS and will be accredited by the EBO. Successful candidates will earn the postnominal title of “FEBOS-CR” (Fellow of the European Board of Ophthalmology Subspecialty diploma for Cataract and Refractive surgery). The first examination will be held on Friday, 6 October 2017, prior to the XXXV Congress of the ESCRS in Lisbon, Portugal.

This examination is targeted at surgeons with a strong theoretical understanding as well as advanced surgical experience. The target group will have performed at least 400 cataract surgeries without supervision, including a proportion of complex surgeries.

“This examination confirms the ongoing commitment of the ESCRS to leading the development of valuable and practical education for the cataract and refractive surgery subspecialty,” said Prof David Spalton, ESCRS President.

“This examination is part of the range of subspecialty diplomas being rolled out by the EBO. This is definitely not a 'tick box' exercise," added Prof Spalton.

"The diploma will certify that the candidate has attained a high standard of excellence – patients will perceive them as experts in the field. Their knowledge and expertise will be recognised too by their peers and will consequently attract a practice of challenging cases,” he said.

Prof Marie-José Tassignon, who is the Chair of the ESCRS Examination Board, a group set up specifically to develop the examination, said candidates for this exam will have extensive surgical experience, as well as in-depth knowledge of the cataract and refractive subspecialty. “This goes beyond a licence to practise or a certificate of competency,” said Prof Tassignon.

Prof Marie-José Tassignon

This goes beyond a licence to practise or a certificate of competency

Prof Wagih Aclimandos, Chair of the EBO Subspecialty Committee, said the EBO has an established history of certifying ophthalmologists with the comprehensive European Board of Ophthalmology Diploma. "This has harmonised the level of knowledge expected of ophthalmologists across Europe who hold this certification. New subspecialty examinations extend this to certify the excellence of experienced ophthalmologists within each subspecialty,” said Prof Aclimandos.

Those wishing to take the examination will face an in-depth screening process. In addition to submitting 400 logged surgeries (including complex cases) for the application process, they will be asked for a letter of recommendation signed by their head of department/director of their institution, as well as a brief overview of their surgical and teaching experience and their publications history. Two surgical videos are also required: one of a standard surgery and one of their most complicated cases (which they will discuss during the examination).

The Examination Board will review applications and invite those accepted to take a two-part exam: • MCQ test covering a broad and deep spectrum of issues in cataract and refractive surgery • Viva voce (oral) examination, which will have four parts: - Discussion of a surgical video they submit - Discussion of a surgical case they have not seen before - Discussion of a case study presented to them by the examiner - Critical evaluation of a key paper The curriculum is now available to candidates from the EBO or ESCRS websites: ebo-online.org/newsite/home.asp, www.escrs.org Those interested in taking the examination can email education@escrs.org for more details, and watch out for updates on the EBO and ESCRS websites.

KEY DATES

• 19 December 2016: Process opened • 10 March 2017: All materials submitted by candidates • 30 May 2017: Confirmation for eligible candidates

to sit the exam

• 30 June 2017: Candidates officially confirm intent to sit exam, and pay the exam fee (€650)

• 6 October 2017: Date of first exam in Lisbon

CHINESE LANGUAGE EDITION NOW ONLINE Visit: www.eurotimes.cn EUROTIMES | FEBRUARY 2017

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CORNEA

FS LASER MEETS DALK Femtosecond laser enables standardised big-bubble approach in DALK. Dermot McGrath reports

Watch the latest video content from ESCRS and EuroTimes, FREE on the ESCRS Player l

Eye Contact Interviews

l

Video of the Month

l

l

Video Journal of Cataract & Refractive Surgery Young Ophthalmologists Videos: “My Early Surgeries”

player.escrs.org

U

sing a femtosecond laser may provide a safe and effective means to standardise the “big-bubble” technique in deep anterior lamellar keratoplasty (DALK) procedures in eligible patients, according to Luca Buzzonetti MD. “Our preliminary results suggest that the combination of the femtosecond laser and big-bubble technique could help to standardise this approach in DALK procedures, thereby reducing the learning curve for surgeons and also minimising the risks of intraoperative complications,” he told delegates at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

There are a number of advantages to using a femtosecond laser in DALK procedures, said Dr Buzzonetti. “Using the femtosecond laser increases accuracy in donor and recipient cut and provides a customised procedure to improve the contact between donor/recipient and interface. It also improves the healing process and enables surgeons to reach a deeper stromal depth in order to achieve the big bubble. Finally, it also makes suturing easier,” he said.

In the new big-bubble full femtosecond laserassisted (BBFF) technique, Dr Buzzonetti uses a proprietary femtosecond laser (IntraLase®, Abbott Medical Optics) to create an intrastromal channel that is used as a pathway for the insertion of the air injection cannula.

He reported that the BBFF technique was tested in 10 eyes affected by keratoconus. The approach uses a 9.0mm diameter mask with a fissure 0.7mm wide positioned into the interface Luca Buzzonetti cone of the laser. The laser then performs a circular lamellar cut 100µm above the thinnest point, with photodisruption occurring only in the area of the corneal stroma corresponding to the fissure in order to create a deep stromal channel, explained Dr Buzzonetti, Chief, Department of Ophthalmology, Bambino Gesù Hospital, Rome, Italy.

Once that has been achieved, an arcuate incision is then performed from the corneal surface to the deep stromal channel to provide the entrance through the channel. After the removal of the lamella, the air needle is inserted into the stromal channel and air is injected to achieve a big bubble. After big-bubble formation, debulking of the anterior two-thirds of the corneal stroma is performed and the corneal stromal tissue excised. The donor lamella is then fitted into place using interrupted sutures.

In this study the big bubble was successfully achieved in nine out of 10 eyes and all procedures were completed as DALK, said Dr Buzzonetti.

“There are a lot of advantages to BBFF. We can work at a pre-defined corneal depth and the technique is independent of corneal keratometry. There is no steep learning curve involved and a high percentage of big bubbles can be obtained with a decreased risk of inadvertent perforation.

The only significant downside is economic, due to the high cost of the femtosecond laser,” he said.

Luca Buzzonetti: lucabuzzonetti@yahoo.it

EUROTIMES | FEBRUARY 2017

CORNEA

DRY EYE AFTER LASIK Tips for managing common post-op dry eye complaints.

Leigh Spielberg MD reports

T

he most common complaint after LASIK surgery is dry eye disease, Penny A Asbell MD, FACS, MBA told delegates at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

Almost everyone has symptoms at one week post-op, and between 20% and 40% of patients still have complaints at six months.

But a great deal of it is likely missed, pointing to a need for new diagnostic techniques, said Dr Asbell, Director of Cornea and Refractive Services, Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, USA. “We need new tools to evaluate the ocular surface. After all, early post-phaco cystoid macular oedema was only noted after optical coherence tomography (OCT) became available. The situation is likely to be similar regarding detection and differentiation of ocular surface disease, which is often difficult to identify when typical signs are lacking,” she said.

“Documenting symptoms can be accomplished by getting a good patient history and including patient-completed Ocular Surface Disease Index (OSDI),” she added.

Once a problem has been identified therapy can better be targeted and personalised if a specific cause can be determined. Most of the risk factors for post-LASIK dry eye disease are well known: preexisting dry eye disease, older age, female sex, lid lag and/or a history of contact lens intolerance. It helps to identify other, less obvious, risk factors such as diabetes and systemic medications.

“Dry eye disease is twice as common in diabetic patients, and among diabetics, it is more common among females,” she said.

Understanding the pathogenesis of post-LASIK ocular surface disease helps you and your patient understand potential treatments and the prognosis: surgical disruption of afferent nerve fibres leads to hypoesthesia and subsequent disruption of the lacrimal functional unit. This disruption causes both decreased basal and reflex tear secretion and decreased blink reflex, resulting in changes in tear film composition and quality as well as goblet cell damage.

The end result is hyperosmolarity and inflammation, which is the ultimate cause of ocular surface damage.

She referred to research showing that corneal sensation, necessary for proper lubrication of the epithelial surface, can take months for recovery and in some people nerve abnormalities persist long-term.

from two to five years after LASIK. They are out of proportion to the signs on ocular exam.

The pathogenesis is initiated by environmental stress, leading to inflammation and an immune cell influx. This causes altered gene expression and the release of nerve growth factor. The result is sensitisation of first peripheral and then central nerves. Risk factors for neuropathic corneal pain, especially chronic pain, include female sex, younger age, genetic factors and anxiety or depression.

Diagnosis can be suggested by altered neuronal density and morphology on confocal microscopy, which shows corneal nerve dysplasia. But before advanced examinations are performed, more basic tests can be carried out, such as the proparacaine challenge test. The failure of topical anaesthetic to decrease symptoms is very suggestive for neuropathic pain, she explained.

Management is difficult. Treatment of the concomitant ocular surface and lid disease is of course essential.

Anti-inflammatory agents might help break the cycle, and scleral lenses can decrease stimuli. Furthermore, Dr Asbell recommends peripheral nerve regenerative therapy, which may consist of autologous serum eye drops, nerve growth factor, and platelet-rich plasma. If this all proves insufficient, systemic pharmacotherapy for pain might be necessary.

Penny A Asbell: penny.asbell@mssm.edu

NEUROPATHIC PAIN But what if ocular surface disease is not even the actual cause of the complaints?

“Post-LASIK pain is most often due to ocular surface disease. But once ocular disease has been ruled out, we have to consider neuropathic pain,” she said.

Neuropathic pain is due to a lesion of the corneal neurons themselves. Dr Asbell contrasted this to nociceptive pain, which is pain caused by damage to non-neural tissue, such as a scratched cornea. Symptoms of neuropathic pain are often chronic, continuing

Dry eye disease is twice as common in diabetic patients, and among diabetics, it is more common among females

The SurgiCube® creates a work environment for cataract procedures.

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SurgiCube® and Toul Meditech® combined forces to innovate HEPA filtered air devices.

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Penny A Asbell MD, FACS, MBA EUROTIMES | FEBRUARY 2017

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17th EURETINA Congress 7â&#x20AC;&#x201C;10 September 2017 CCIB, Barcelona, Spain

Abstract Submission Deadline: 15 March 2017 www.euretina.org

RETINA

LASER-BASED LIGHT SOURCE Improved visualisation, increased safety and new opportunities.

Cheryl Guttman Krader reports

A

laser light source may be the next step in the evolution of illumination systems for vitreoretinal surgery, because it provides brighter and safer illumination, tunable colour and microfibre capability, said Carl C Awh MD at the 16th EURETINA Congress in Copenhagen, Denmark.

Being introduced by Katalyst Surgical, LLC, the new technology uses three lasers emitting 450nm blue light, 520nm green light, and 638nm red light that can be combined to create virtually any colour.

“Conventional adjustment of light colour by coloured filters results in reduced brightness because the filters subtract light by absorption, resulting in a coloured light much less intense than the original white light. In contrast, colour tuning with the laser source occurs by light addition, with no loss of intensity. We are now able to create virtually any colour by combining different proportions of the three light colours,” said Dr Awh, who is in private practice with Tennessee Retina, Nashville, USA. Higher power density is another important benefit of the laser light source, because power density is a major limiter of the diameter of optical fibre through which light can be effectively transmitted. The laser light source is capable of projecting light through optical fibres that are much smaller in diameter than those used with current xenon, mercuryvapour, and LED technology.

Yellow Scan Laser Photocoagulator YLC-500 Vixi

YLC-500 A 577 nm Yellow Laser with Multiple Scan Patterns OPSL method for stable and reliable laser delivery 22 preprogrammed scan patterns User friendly features Wide range of selectable delivery units

OPTICAL FIBRE With the latter conventional light sources, 15 to 40 lumens of light can be delivered through optical fibres that range in diameter between 250μm and 750μm. A 250μm optical fibre, which can fit within a 27-gauge instrument, transmits a maximum 20 lumens of light if connected to a conventional light source. In contrast, the laser light source can deliver the same 20 lumens of light through a 50μm fibre and 30 lumens of light through a 100μm fibre, Dr Awh explained.

“This could lead to a new generation of illuminated multifunction devices. As an example, with the laser light source we can create illuminated infusion lines that provide useful light without loss of flow. Using new tubular fibre optics, we may also be able to create lighted cannulas or vitrectomy cutters. The increased brightness of the laser light should now make it possible to create a variable field illuminator that delivers both focal and wide-field illumination,” he said.

Using videos, Dr Awh demonstrated the increased light intensity provided by the laser source and its benefits for improving intraocular visibility. He also showed how the appearance of different tissues and pathologies could be enhanced by tuning the light colour.

Highlighting another advantage of colour tunability, Dr Awh noted that the ability to eliminate blue wavelengths of light could virtually eliminate the risk of retinal phototoxicity.

Dr Awh concluded that continued development of the laser light source bring surgeons the advantages of brighter safer light, tunable colour, and microfibre capability.

NEW

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Carl C Awh: carlawh@gmail.com EUROTIMES | FEBRUARY 2017

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RETINA

Bringing simplicity to basic diagnostics.

ZEISS Essential Line

SUBRETINAL DELIVERY Novel technique to deliver and retain cell therapy at target site.

Cheryl Guttman Krader reports

I

Slit Lamp Exam

Eye Care Data Management

Pretests

Glaucoma & Retina Screening

Subjective Refraction

Smartly optimize your diagnostic workflow.

The basic diagnostic devices of the ZEISS Essential Line offer connectivity options for easy data transfer and archiving as well as enhanced patient throughput. www.zeiss.com/essential-line

Explore use cases

nvestigators are hoping that a new suprachoroidal technique for subretinal delivery will optimise the safety and efficacy of palucorcel (CNT02476, Janssen BioTherapeutics) as a treatment for geographic atrophy (GA).

Palucorcel represents a cell therapy approach for reversing vision loss from dry age-related macular degeneration (AMD). It comprises allogenic, non-dividing human umbilical tissue-derived cells secreting cytokines with trophic effects that are believed to be beneficial for treating retinal diseases – most notably, dry AMD. The suprachoroidal approach for subretinal delivery was implemented in the ongoing Phase 2b PRELUDE study and described by Christopher D Riemann MD at the 16th EURETINA Congress in Copenhagen, Denmark.

“Palucorcel has exciting potential for treating degenerative retinal disorders by favourably influencing diseased or dying cells.

To optimise the effect of the trophic factor release, the cell product needs to be in close vicinity to the target cells, and to successfully treat GA, a non-retinal penetrating delivery is required to prevent the cells from escaping into the vitreous cavity,” explained Dr Riemann, Cincinnati Eye Institute, and Volunteer Professor of Ophthalmology, University of Cincinnati, USA. Palucorcel was first investigated in a Phase 1A trial enrolling seven patients with retinitis pigmentosa and then advanced into a Phase 1/2A trial including 33 patients with GA. In those earlier studies, the cell product was successfully placed into the subretinal space with a microcatheter delivery system via an ab externo approach and was well tolerated.

There were no problems with immune reaction, and 25% of the GA patients gained three lines of vision. However, the surgery was long, complicated, required two surgeons, and was associated with an unacceptably high retinal detachment rate.

A team of engineers, surgical human form factor experts and surgeons collaborated to develop a technique to address the surgical challenges. The suprachoroidal approach was chosen from among four candidate techniques that were rigorously evaluated in a porcine model to assess procedural safety, complexity and efficiency. As a next step, enhancements were made to the prototype instrumentation and surgical procedure. Briefly, the delivery procedure involves insertion of an eye chandelier port, conjunctival dissection, stamping the sclera with a suture template guide and placement of a suture loop assembly for guiding and stabilising the delivery cannula.

The cannula that contains a micro-needle is inserted through the sclerotomy into the suprachoroidal space and advanced posteriorly to the target delivery site. Next, the needle is advanced through the choroid into the subretinal space and BSS is infused to create an entry bleb. Palucorcel is injected after confirming the retina has not been penetrated. Then, the needle is retracted, the cannula removed, and the sclerotomy sutured closed.

“There is no reason that this procedure could not be used for other drugs and substances that need to access the subretinal space,” Dr Riemann said.

Christopher D Riemann: criemann@cincinnatieye.com

EUROTIMES | FEBRUARY 2017

RETINA

it Vis

us

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ter Win S ‘17 R 6 ESC th #E2 Boo

OPHTHALMOLOGICA VOL: 236 ISSUE: 4

SLOW RESPONDERS CATCH UP Patients with neovascular age-related macular degeneration (AMD) who are slow to respond initially to intravitreal ranibizumab catch up on the more rapid responders in terms of letters of visual acuity (VA) gained within a year, according to a retrospective review of the results of the MARINA, ANCHOR, HARBOR, and CATT studies.

Among the 1,631 patients participating in the studies, 18-29% were early responders, gaining 15 or more letters within three months. A further 15-16% were delayed responders, gaining 15 or more letters by 12 months but not by three months. By 12 months, delayed gainers reached nearly the same level of response as early gainers who maintained their response. The only statistically significant predictive factor was baseline VA, which was lower among early responders. R Gale et al, "Characteristics and Predictors of Early and Delayed Responders to Ranibizumab Treatment in Neovascular Age-Related Macular Degeneration: A Retrospective Analysis from the ANCHOR, MARINA, HARBOR, and CATT Trials”; Ophthalmologica 2016, Volume 236, Issue 4.

INTRAVITREAL IMPLANT EFFECTIVE FOR POSTOPERATIVE OEDEMA The intravitreal dexamethasone implant (Ozurdex®, Allergan) is an effective therapy for postoperative macular oedema, a new study suggests. In 12 eyes of 12 patients with macular oedema after cataract surgery or vitrectomy who underwent injection of the steroid implant, the mean VA improved from 0.74 logMAR to 0.49 logMAR (p<0.01) after a mean of 437 days and one month after the last injection. Furthermore, mean central macular thickness decreased from 608µm to 300µm. In addition, four patients had no recurrence, and recurring macular oedema was completely reduced by re-injection in the remaining eight patients. Seven patients required topical antiglaucomatous therapy. A Klamann et al, “Intravitreal Dexamethasone Implant for the Treatment of Postoperative Macular Edema”; Ophthalmologica 2016, Volume 236, Issue 4.

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A treat-and-extend regimen of aflibercept appears to be effective for all subtypes of exudative AMD, according to a retrospective study. In 37 eyes receiving the treat-and-extend regimen for either typical choroidal neovascularisation (CNV) or retinal angiomatous proliferation (RAP) secondary to exudative AMD, best corrected visual acuity improved significantly from 0.6 to 0.4 logMAR after one year. The final mean numbers of injections and the numbers of visits did not differ significantly between the different subtypes of CNV (p>0.05). Castro-Navaro et al, "One-Year Outcomes of the Treat-and-Extend Approach with Aflibercept in Age-Related Macular Degeneration: Effects on Typical Choroidal Neovascularization and Retinal Angiomatous Proliferation"; Ophthalmologica 2016, Volume 236, Issue 4.

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

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EUROTIMES | FEBRUARY 2017

21

22

GLAUCOMA

MULTIPLE STENTS IOP control good with one stent – and better with two or three.

Roibeard O’hEineachain reports

I

mplantation of the iStent® (Glaukos) trabecular bypass device as a standalone procedure provides significant intraocular pressure (IOP) reduction over the long-term for patients with open-angle glaucoma and the effect is enhanced through the use of multiple stents, said Antonio Maria Fea MD, PhD, Clinica Oculistica, Universita di Torino, Italy.

Dr Fea presented the 30-month followup results of an ongoing prospective randomised trial comparing outcomes with one, two, or three of the stents as a standalone treatment for open-angle glaucoma patients, at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

The study showed that all three treatment groups maintained a mean IOP below 18mmHg throughout the follow-up period.

However, the groups implanted with more than one stent lasted for a longer period postoperatively without requiring IOPlowering medication.

“Both IOP and medication use were reduced through 30 months after implantation of a single trabecular microbypass stent as a sole procedure in openangle glaucoma. Additional IOP reduction to less than 15mmHg has been shown with multiple stents,” Dr Fea said.

The study was carried out by the MIGS study group at the S.V. Malayan Ophthalmological Center in Yerevan, Armenia, where visiting and staff surgeons performed the surgeries. In total, 119 eyes of 119 patients were included in the trial. At the time of Dr Fea’s presentation, 117 had reached 30 months' follow-up. The MIGS

best corrected visual acuity (BCVA) was comparable in the three groups and was 20/40 or better in nearly 80% of eyes. There was a postoperative loss of one or more lines of BCVA in four eyes in the one-stent group, three eyes in the two-stent group and four eyes in the three-stent group, although nine of these 11 eyes had BCVA of 20/40 or better.

Dr Fea noted that the findings of his study appear to confirm previous clinical observations that, as standalone procedures, IOP REDUCTIONS implantation of one iStent achieves longThe mean medicated preoperative IOP term, stable IOP control, and use of two was 19.8mmHg in the one-stent group, or three iStents results in further IOP 20.1mmHg in the two-stent group lowering than that achieved with a and 20.4mmHg in the threesingle stent. stent group. Preoperative postThe enhanced IOP reduction washout IOP was 25.0mmHg may be due not only to each in the one-stent group, stent providing additional 25.0mmHg in the two-stent drainage of the aqueous. group and 24.9mmHg in the It may also result from the three-stent group. increased chance surgeons At 30 months have of placing a stent in an postoperatively, mean IOP optimum position in relation to was 15.2mmHg in the one-stent Antonio Maria Fea collector channels of Schlemm’s group, 15.0mmHg in the two-stent canal, he said. group and 13.0mmHg in the three-stent To optimise the placement of the iStent group. Furthermore, excluding patients who implants, Dr Fea and his associates have underwent subsequent cataract surgery, only devised a means of localising the collector about 10% of patients in the three groups channels by using a special dye. However, required IOP-lowering medication during whether this will improve outcomes will the first postoperative year. not be known until the completion of However, by 30 months the proportion randomised control trials. requiring medication had risen to about “In this present series of patients receiving 25% among those with only one stent, a single stent or multiple stents as sole but remained unchanged in the other two therapy, there was a sustained reduction in treatment groups.

IOP with a reduction in drug burden in all The safety profile of the procedures patients through 30 months,” he concluded. was also favourable, Dr Fea said. There were no intraoperative or perioperative Antonio Maria Fea: antoniofea@interfree.it complications. In addition, postoperative

study group will continue monitoring the patients for five years of follow-up.

The patients in the study had a mean age of 67 years and were randomised into three similarly sized groups to undergo implantation of one, two, or three of the original snorkelshaped iStent devices. One patient in the twostent group had pseudoexfoliative glaucoma, and the remaining patients had primary open-angle glaucoma.

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OCULAR: GLAUCOMA FEATURE

IMPROVING OUTCOMES Preservative-free medications provide benefits in the short-term and long-term.

Cheryl Guttman Krader reports

G

laucoma treatment with preservative-free preparations has a positive impact on quality of life, medication adherence, overall costs, and long-term disease outcomes, Norbert Pfeiffer MD told a session of ESCRS Glaucoma Day 2016 in Copenhagen, Denmark.

Dr Pfeiffer, Professor of Ophthalmology, Mainz University, Germany, reported that evidence from available clinical studies now favours this approach.

He explained that understanding how study endpoints are affected by use of a preservative-free intraocular pressure (IOP)lowering medication is important when one considers that the goal of glaucoma treatment, as stated in the European Glaucoma Society Guidelines, is “to maintain patients’ visual function and (vision related) quality of life… at sustainable cost”.

He reminded attendees that benzalkonium chloride (BAK), which is commonly used as a preservative in ophthalmic medications, can

cause allergic reactions and ocular surface disease. “Most likely, these side effects will have an effect on quality of life,” said Dr Pfeiffer, as he presented findings from an open-label study supporting his statement.

MEDICATION ADHERENCE The investigation, conducted by Dr Pfeiffer and colleagues, included 158 patients who were experiencing adverse ocular signs and/ or symptoms after being on preservativecontaining prostaglandin analogue for at least six months. After enrolment, patients were switched to a preservative-free prostaglandin analogue product. Assessments performed after 12 weeks showed patients benefited, with significant reductions in the severity of their ocular signs and symptoms.

In another study conducted by Dr Pfeiffer, 200 glaucoma patients were asked about their medication adherence.

The results showed a higher self-reported adherence rate among patients using IOPlowering medications without preservatives

compared with patients using preservativecontaining medications (87.5% vs. 68.0%).

“In theory, long-term outcomes should be better if adherence is better, but proof of that concept would require a long-term comparative study,” Dr Pfeiffer said.

As no such trial exists, Dr Pfeiffer and colleagues sought to investigate the issue by inputting published data into a model comparing 10-year outcomes when patients received first-line prostaglandin analogue monotherapy and second-line combination treatment with timolol using medications preserved with either BAK or a less cytotoxic alternative, polyquaternium-1 (Polyquad).

The model analysed what proportions of patients would remain on first- or secondline medical treatment. Assuming different adherence rates, the results favoured treatment with IOP-lowering products containing Polyquad versus BAK. Norbert Pfeiffer: norbert.pfeiffer@unimedizin-mainz.de

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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. ©2017 Glaukos Corporation. Glaukos and iStent are registered trademarks of Glaukos Corporation. 400-0370-2016-US Rev. 0

EUROTIMES | FEBRUARY 2017

23

24

GLAUCOMA

REDEFINING POAG Open-angle glaucoma subtypes: distinct causes requiring specific treatment. Howard Larkin reports

€50,000 ESCRS Peter Barry Fellowship The ESCRS has launched an annual Fellowship to commemorate the immense contribution made by the late Peter Barry to European and global ophthalmology, and to the ESCRS. The Fellowship of €50,000 is to allow a trainee to work abroad at a centre of excellence for clinical experience or research in the field of cataract and refractive surgery, anywhere in the world, for 1 year.

Applicants must be a European trainee ophthalmologist, 35 years of age or under on the closing date for applications and have been an ESCRS member for 3 years by the time of starting the Fellowship.

The Fellowship will be awarded at the ESCRS Annual Congress in Lisbon in September 2017, to start in 2018.

To apply, please submit the following: l l

l

l

A detailed up-to-date CV A letter of intent of 1-2 pages, outlining which centre you wish to attend and why A letter of recommendation from your current Head of Department A letter from your potential host institution, indicating that they will accept you if successful

Closing date for applications: 1 May 2017 Applications and queries should be sent to Danielle Maher at: danielle.maher@escrs.org

T

o better diagnose and treat patients, primary open-angle glaucoma (POAG) should be redefined in terms of several identifiable subtypes, Louis R Pasquale MD, FARVO, of Harvard Medical School, Boston, USA, told Glaucoma Subspecialty Day at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago, USA. “POAG is a remarkably heterogeneous disease with distinct but overlapping subtypes,” Dr Pasquale said in his American Glaucoma Society Lecture.

Each has its own distinct age of onset, intraocular pressure (IOP) profile and structural optic nerve features. Biochemical markers specific to each subtype also point to specific biochemical pathways that may be successfully targeted for treatment.

Louis R Pasquale

PC-OAG Paracentral OAG, or PC-OAG, in which vision loss is mainly in the paracentral region, is marked by low IOP and difficulty keeping IOP low enough to prevent progression, Dr Pasquale said. 16mmHg is a high number for these patients.

PC-OAG appears to be related to nitric oxide (NO) signalling, and patients should be encouraged to eat foods with nitrates such as leafy green vegetables. Medications targeting NO are in development, Dr Pasquale added.

AD-OAG African-derived OAG, or AD-OAG, appears in young patients and progresses quickly, sometimes leading to blindness in patients in their third and fourth decades, Dr Pasquale said.

AD-OAG is seen mostly in patients of African descent, with one study finding almost 21% of those 20 to 40 years of age with IOP of 24mmHg or higher, or cup-to-disc ratio of 0.7 or more in one eye. AD-OAG should be screened for and treated early. Siblings and children of patients should be screened.

ED-OAG Estrogen-derived OAG, or ED-OAG, appears related to lower lifetime exposure to estrogen, with late menarche, oral contraceptive use, early menopause and early oophorectomy risk factors, Dr Pasquale said.

Overall, high IOP is not a reliable marker for POAG, with normal IOP observed in up to 90% of glaucoma patients in some populations, Dr Pasquale noted. Pressures of 35 or higher are rare for POAG types, and may indicate steroid exposure or secondary glaucoma. In cases of rapidly progressing glaucoma, diurnal curves should be taken and neuroimaging considered.

More study is needed to determine the nature of the various subtypes and treatments for them, but recognising they exist is a good start, Dr Pasquale concluded.

“Let’s help our patients by taking the ‘P’ out of POAG.” Louis R Pasquale: louis_pasquale@meei.harvard.edu

EUROTIMES | FEBRUARY 2017

PAEDIATRIC OPHTHALMOLOGY

25

GENETIC MICROCEPHALY Ocular anomalies include strabismus, nystagmus and retinal abnormalities.

hildren with genetic microcephaly frequently display ocular anomalies, particularly strabismus, nystagmus and retinal anatomic abnormalities, Eleni Papageorgiou MD, PhD told WSPOS Subspecialty Day 2016 in Copenhagen, Denmark.

Optical coherence tomography (OCT) shows significantly thinner perimacular retina, ganglion cell layer, nuclear layers and ellipsoid zone, as well as reduced disc diameters in patients with microcephaly compared with neurologically typical controls. The findings suggest that coincident abnormalities in the retina and central nervous system may have a common genetic cause, said Dr Papageorgiou, who with colleagues at the University of Leicester, UK, conducted an observational study comparing the two groups.

Courtesy of Eleni Papageorgiou MD, PhD

C

Howard Larkin reports

Handheld OCT of the right macula in a four-year-old child with microcephaly (A), and an age-matched healthy child (B). The parafoveal retina of the child with microcephaly is thinner and there is also a mottled appearance of the retinal nerve fibre layer (white arrows)

most common abnormal finding, seen in 59% of patients, followed by strabismus in 52%, amblyopia in 26%, and high refractive error in 22%.

Optic nerve hypoplasia, chorioretinal dysplasia, retinal pigment anomalies and falciform retinal folds were also observed, VARIABLE RETINAL FINDINGS reported Dr Papageorgiou, Consultant Microcephaly is defined as head Paediatric Ophthalmologist, circumference smaller than three Department of Ophthalmology, standard deviations below the University Hospital of mean, and occurs in about Larissa, Greece. one in 10,000 births, Dr On OCT examination, Papageorgiou noted. The thinning of the parafoveal study compared ocular retina was commonly characteristics of 27 children observed among with microcephaly, with a microcephaly patients (see mean age of 9.4 years, with 27 figure), as were foveal pits that age-matched controls, and used were very wide or very steep, Eleni Papageorgiou handheld OCT to assess differences Dr Papageorgiou said. Foveal in the fovea and optic discs. hypoplasia and mottled retinal nerve fibre Ocular abnormalities were observed in and ganglion cell layers were also observed 22, or 82%, of the 27 microcephaly patients. in several cases.

Nystagmus, mostly gaze-evoked, was the Comparing mean retinal layer thickness,

in microcephaly patients overall retinal thickness was reduced (p=0.001), as were the ganglion cell layer (p<0.001), inner nuclear layer (p<0.001), outer nuclear layer (p=0.007), and inner segment-outer segment junction (p=0.014), Dr Papageorgiou said.

While cup diameter and depth were similar in the two groups, disc diameters were consistently smaller in the microcephaly group, though this was not always evident on fundoscopy, Dr Papageorgiou said. OCT revealed a mean disc diameter of 1.12mm in the microcephaly group compared with 1.20mm in controls, she noted. â&#x20AC;&#x153;The findings are possibly due to a reduction in retinal cell number and retinal size parallel to the reduction in brain neurons and brain size observed in microcephaly. We hypothesise there may be some common gene expression in the central nervous system and retina,â&#x20AC;? Dr Papageorgiou concluded.

Eleni Papageorgiou: e_papage@yahoo.com

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RESEARCH REGULAR

A VOICE IN BRUSSELS Prof Einar Stefánsson explains how EU-EYE is lobbying for eye disease research funding at European level. Gary Finnegan reports

T

ens of millions of people in Europe suffer from visual impairment, blindness and eye diseases but they do not receive enough attention at European level. We want to address this discrepancy,” says Einar Stefánsson MD, PhD. Prof Stefánsson is President of EU-EYE, the European Alliance for Vision Research and Ophthalmology, a lobby group representing over 15,000 medical doctors specialising in eye diseases.

The goal of EU-EYE is to put eye health on the map in Brussels and secure greater investment in ophthalmology research.

The potential prize is great. Europe’s Horizon 2020 research programme will be replaced in three years and discussions about the shape of its successor are already under way.

The member organisations of EU-EYE are: the European Society of Cataract and Refractive Surgeons (ESCRS); European Society of Retina Specialists (EURETINA); European Glaucoma Society (EGS); European Association for Vision and Eye Research (EVER); European Eye Bank Association (EEBA); European Paediatric Ophthalmology Society (EPOS); European Society of Cornea and Ocular Surface Disease Specialists (EuCornea); European Association for the Study of Diabetes/ Ophthalmology Section (EASDec); and European Vision Institute (EVI).

CROSS-BORDER COLLABORATIONS With a total budget of €80 billion, Horizon 2020 is the eighth EU research programme, and by far the largest.

From small projects led by a single principal investigator and support for fledgling researchers, to large crossborder collaborations, public-private partnerships, and investment in research infrastructure, European research funding is spread across scientific disciplines. Yet there is a sense that ophthalmology and eye disease have punched below their weight in the past.

“We don’t seek to criticise other disease areas but there are fields where the scale of the clinical problem is relatively modest, but the support from Europe is greater than for eye health,” says Prof Stefánsson.

EU-EYE aims to change that. “What surprised me when we started this work was that all the medical specialities – even other eye care professional societies – were

Vision is such a strong determinant of quality of life and the potential for productivity Einar Stefánsson MD, PhD already doing this in Brussels,” says Prof Stefánsson. “Our voice was missing and, frankly, it is amazing that we left this vacuum for so many years.”

RAISE AWARENESS EU-EYE has held two conferences in European Parliament buildings which were well attended by MEPs and their staff, along with officials working on the Horizon 2020 programme. It was an opportunity to raise awareness of eye health and spell out the urgent need for research funding in a field where demographic pressures imply rising demand for decades to come.

In a town where just about everybody has a lobbyist, standing out from the crowd is a challenge.

One tactic is to tap into policymakers’ pre-existing concerns over diabetes, ageing and the cost of healthcare. That is why EU-EYE co-authored a position paper, Preventing Sight Loss in an Ageing Population. The paper calls on the EU to treat eye health as seriously as other chronic diseases when allocating health and social research funding.

Diabetic retinopathy is a particularly hard-hitting case study of how ophthalmology services and research insights will be essential to managing the fallout from Europe’s burgeoning diabetes epidemic.

“Retinopathy is the most common cause of preventable blindness in the world in people of working age. We are highlighting this to decision-makers to explain why better screening and management are invaluable,” says Prof Stefánsson.

“Vision is such a strong determinant of quality of life and the potential for productivity. The economic arguments in favour of improving research and healthcare are astounding. Whether it’s treating age-related macular degeneration, screening for diabetic retinopathy or supporting cataract surgery, ophthalmology can dramatically improve people’s lives at a relatively low cost,” he added.

To date, the reaction from Brussels has been favourable and other lobbyists are starting to take notice. Starting from a low base, EU-EYE has been raising awareness of eye diseases while building networks with other groups that share their goals – including the European Coalition for Vision (ECV), European Forum Against Blindness (EFAB), and the European Public Health Alliance (EPHA).

BIG CHALLENGE The next step will be to connect with national advocacy groups and professional bodies. “We are supported by pan-European societies but we think that national ophthalmology societies and companies involved in eye care should be brought into the fold,” Prof Stefánsson says.

Looking ahead, the big challenge is to shape the next EU research programme to make it more open to eye research.

The current programme, Horizon 2020, is less restrictive than its predecessor and EU-EYE hopes this trend continues, as broader calls for applications give ophthalmology researcher more scope for securing funds.

With so many other voices at the table, Prof Stefánsson knows that a busy few years lie ahead. Success is not guaranteed but, unless eye specialists are present, failure is certain.

“Lobbying is not the cure-all, but on the other hand, if our voice is not heard at the highest level then the likelihood is we will be ignored,” Prof Stefánsson says.

Einar Stefánsson: einarste@landspitali.is

EUROTIMES | FEBRUARY 2017

27

ASCRS

INDUSTRY NEWS

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YELLOW LASER NIDEK has announced the launch of the YLC-500 Vixi Yellow Scan Laser Photocoagulator/YLC-500 Yellow Laser Photocoagulator.

“The YLC-500 Vixi/YLC-500 is a yellow laser using the innovative OPSL (optically pumped semiconductor laser) method for stable and reliable laser delivery, generating optimal treatment outcomes,” said a company spokesman.

“The 577nm yellow laser is minimally absorbed by xanthophyll and is well absorbed by oxygenated hemoglobin compared to the 532nm laser, making it the wavelength of choice for lesions close to the macula,” he added. www.nidek-intl.com Two month post-op

ENDO ILLUMINATORS Oertli has launched enhanced endo illuminators which the company says will provide even more user benefits.

“A key requirement for 25G light instruments is their stiffness. To prevent bending, even in the case of intense manipulation of the eye, Oertli has attached an additional cannula to the light fibre. The cannula can be inserted into the trocar up to the stop. Thus, it actively supports manipulation.

The achieved increase in stiffness greatly facilitates work,” said a company spokeswoman.

The spokeswoman added that the new comfort-connector maximises light output and allows an easy installation out of the sterile field. www.oertliinstruments.com

OCT ANGIOGRAPHY MODULE Heidelberg Engineering has started delivering the OCT Angiography Module to SPECTRALIS customers outside the USA. “The OCT Angiography Module non-invasively produces detailed three-dimensional representations of the perfused retinal and choroidal vasculatures,” said a company spokeswoman.

“The SPECTRALIS expandable diagnostic imaging platform can be upgraded with the OCT Angiography Module to perform noninvasive, layer-by-layer examinations of flow in the vascular networks of the retina and choroid,” she added. www.heidelberg engineering.com

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ESCRS

NEWS

ESCRS ONLINE MUSEUM The ESCRS has launched an online museum which shows historic videos from some of the great innovators in ophthalmology.

The videos, which are submitted by ophthalmologists, are studied, verified and curated by Dr Richard Packard and Prof Andrzej Grzybowski, and date back to the 1930s. They are featured on the ESCRS Player at: player.escrs.org/category/online-muesum The museum includes the first LASIK procedure in 1990 by Prof Ioannis Pallikaris and a video of a logbook from 1949 showing a summary of Sir Harold Ridley’s operations from 1949 and 1950.

Videos should be submitted to: museum@escrs.org

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Peter Barry

€50,000 FELLOWSHIP AWARDED BY ESCRS The ESCRS has announced details of the annual fellowship set up to honour the immense contribution of Peter Barry FRCS to European and global ophthalmology.

Dr Barry, who served as ESCRS President in 2012 and 2013, died after a short illness in May 2016.

The fellowship of €50,000 will enable a trainee ophthalmologist from Europe to study at a centre of excellence anywhere in the world.

Applicants for the fellowship must meet the following criteria: l Be a European trainee ophthalmologist l Be 35 years of age or under on the closing date for applications (1 May 2017) l Have been an ESCRS member for three years at the time of taking up the fellowship (if successful)

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All completed applications should be sent by email to Danielle Maher at: danielle.maher@escrs.org The deadline for submission of all applications is: 1 May 2017 For further details on the material to be submitted in your application, see: http://www.escrs.org/ about-escrs/ESCRS-PeterBarry-Fellowship.asp

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USIOL Inc | 2500 Sandersville Rd | Lexington KY 40511 USA +1.859.259.4925 | Fax +1.859.259.4926 | info@usiol.com © 2017 USIOL Inc. All rights reserved.

EUROTIMES | FEBRUARY 2017

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BOOK REVIEWS

WSPOS World Society of Paediatric Ophthalmology & Strabismus

SUBSPECIALT Y DAY Friday 6 October 2017 Lisbon, Portugal Preceding the XXXV Congress of the ESCRS 7–11 October 2017

www.wspos.org

EUROTIMES | FEBRUARY 2017

BOOK

REVIEWS

TRUSTWORTHY INFORMATION The importance of research is the focus of Cataract Surgery: Maximizing Outcomes Through Research (Springer), edited by Hiroko BissenMiyajima, Douglas Donald Koch and Mitchell Patrick Weikert.

A great deal of information on cataract surgery is still provided in the form of “expert opinion”, videos presented at conferences and the well-intentioned recommendations of colleagues and mentors.

However, clinical and fundamental PUBLICATION research remains the cornerstone of CATARACT SURGERY: MAXIMIZING OUTCOMES the field’s advancement.

THROUGH RESEARCH “Textbooks on cataract surgery generally focus on either clinical EDITORS issues or basic research,” reads the HIROKO BISSEN-MIYAJIMA, preface. “In this book, we chose DOUGLAS DONALD KOCH & to concentrate on new basic and MITCHELL PATRICK WEIKERT clinical discoveries that provide PUBLISHED BY SPRINGER insight and perspective for the cataract surgeon.”

The topics covered are primarily practical, such as ‘Cataract Wound Size & Astigmatism’ and ‘Fluidics of Phacoemulsification Systems’. These are discussed in a highly scientific fashion, in the manner of a peer-reviewed article, from which the chapters are largely derived. This allows the reader to find trustworthy information that has been properly curated for relevance and interest.

Each chapter is concluded with a detailed discussion, helping the reader to fully understand the material discussed and incorporate it into his or her practice. I found the ‘IOL Lens Power Calculations in Long Eyes’ to be particularly useful. Few refractive outcomes are more frustrating than postoperative hyperopia in a previously myopic patient, due to an insufficiently powered IOL. Another chapter described the simulation of the retinal surgeon’s view through various premium IOLs, which, as a retinal surgeon, I read with great interest.

Other topics include the evaluation of (pseudo) accommodation, image quality with premium IOLs, the relationship between pupil size and postoperative visual function, glistening and femtosecond laser techniques.

This book is intended for general ophthalmologists who wish to update and refine their knowledge, as well as fellows in cataract and/or refractive surgery.

BOOK REVIEWS

CHALLENGING CASES How to handle challenging cases, and what to do when things go wrong, are the subjects of Difficult and Complicated Cases in Refractive Surgery (Springer), edited by Jorge Alió, Dimitri T Azar and colleagues.

The book is divided into 10 sections, each of which covers a specific group of challenges that may be encountered. Part I considers the complications resulting from the surgeons’ refractive laser treatment plan: refractive surprises. The next three parts cover LASIK complications: intraoperative, early postoperative and late postoperative problems such as epithelial ingrowth and corneal ectasia.

The following parts focus on problems arising from PRK, corneal inlays, phakic IOLs, corneal crosslinking and RK surgery. The last section details the management of optical neuropathy and retinal complications after refractive surgery.

This 475-page book is richly illustrated with both clinical and imaging photos. It is intended for the refractive surgeon who has considerable experience but who could still benefit from an organised and well-considered plan when confronted by a difficult case.

Double protection, double safety !

CATARACT SURGICAL SKILLS For those who would like to take their cataract surgical skills to the next level, David F Chang’s Phaco Chop and Advanced Phaco Techniques: Strategies for Complicated Cataracts (Slack) is a good place to get started.

“Like most surgeons, ophthalmologists need a good reason to alter something that they are already comfortable with and which works very well for them,” writes Dr Chang in the introduction. He and his co-authors dedicate the first 15 chapters of this 350-page book to easing the surgeon into the technique of chopping.

This text has a great deal of surgical photographs, which are essential to the learning process. Phaco chop is fundamentally different to the standard divide-and-conquer, and very detailed step-by-step instructions are needed to grasp the concepts and apply them in the operating room.

As a vitreoretinal surgeon, I perform a great deal of cataract surgery in post-traumatic eyes with hard nuclei and unstable zonulae. This book will help me learn this technique.

UNDERSTANDING ENDOPHTHALMITIS Despite our best efforts to prevent it, endophthalmitis still occurs, even after flawless surgery or a perfect intravitreal injection.

Endophthalmitis (Springer), edited by Marlene L Durand, Joan W Miller and Lucy H Young, seeks to help us understand how and why it happens, how to prevent it, and what should be done when an eye succumbs to endophthalmitis.

Because of a lack of large, randomised, controlled trials, a great deal of variability exists in terms of our approach to endophthalmitis. The authors have compiled most of what is known, and have presented it in an organised and highly readable fashion in 280 pages.

Starting with an overview of the disease, the next few chapters discuss the pathogenesis and the microbiologic and molecular diagnosis of endophthalmitis. Thereafter, the infections’ various causes are covered, as well as the differential diagnoses. The last chapter, ’Preventing Endophthalmitis’, is the most important and relevant for most readers.

This book is intended for all ophthalmologists.

Tomography

Biomechanics

Now, measurable biomechanics – Corvis® ST !

And for you that means: twice as much information for twice as much safety in pre-op screening.

With the OCULUS Corvis® ST you can enhance your practice with the world’s first tonometer capable of measuring and interpreting the biomechanical properties of the cornea. In combination with the tomography values from the OCULUS Pentacam®, it gives you maximum safety and efficiency in refractive screening.

OCULUS Corvis® ST – take care of more patients with greater safety !

ESCRS Winter Meeting in Maastricht, booth E14.

TIP: Visit www.corneal-biomechanics.de to learn more about biomechanical properties and how you can benefit in your daily practice.

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

www.oculus.de

EUROTIMES | FEBRUARY 2017

33

WINNER e B2B Magazin 16 20 & ar 2015

of the Ye

0 (more than 5,00 circulation)

THE

TO BE REACH

43,593

*

CUSTOMERS IN OVER 150 COUNTRIES WITH YOUR AD Advertise with the highest audited circulation for any ophthalmic news magazine in Europe 59 per cent of our readers surveyed in an independent research survey have decision-making power when it comes to the purchase of surgical/medical equipment or supplies. A further 20 per cent are usually consulted before a final decision is made**

* Average net circulation for the 10 issues circulated between 1 January 2016 to 31 December 2016. See www.abc.org.uk ** Results from the

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ESASO

17TH RETINA ACADEMY The programme of events includes a range of educational formats

R

egistration is open for the 17th ESASO Retina Academy, to be held in Berlin, Germany, from 29 June-1 July 2017. The venue for this meeting will be the bright and airy dbb forum on Friedrichstraße, situated in the government district close to historic landmarks such as the Brandenburg Gate and the Reichstag building, which is convenient for travel connections.

Delivered by an internationally renowned faculty, the programme of events for the Academy includes a range of educational formats, including plenary sessions, poster presentations, case studies, debates, industry sessions and workshops, and vitreoretinal video surgery sessions.

Particular highlights of the programme include ESASO Medical and Surgical Masterclasses, in which participants have the opportunity to interact with expert faculty in small group sessions, an imaging workshop providing handson demonstrations of the most recent ophthalmic imaging equipment, and presentations of pipeline developments by pharmaceutical industry representatives.

A wide variety of topics will cover the newest developments in medical and surgical retina, retinal pathologies, treatment and Francesco Bandello, management, monitoring and imaging, plus Scientific Committee Chair much more, to ensure that participants’ educational needs are met.

Live streaming of sessions will permit the educational content presented at the meeting to be made available to as many participants as possible, including those who are unable to travel to Berlin to attend the meeting in person.

Abstract and case study submissions are open until 10 February, and participants are encouraged to submit their work for consideration. All accepted abstracts will be presented as posters and published in the peer-reviewed and indexed journal Ophthalmic Research, and in addition the Scientific Committee will select five abstracts and up to six case studies for oral presentation and discussion during the scientific sessions.

Participants under the age of 40 can choose to enter their abstracts in the Young Ophthalmologists category, the winners of which will be invited to attend the 18th ESASO Retina Academy meeting in 2018 as special guests.

In addition to the scientific sessions, the 17th ESASO Retina Academy will host a graduation ceremony to honour those students who have successfully completed the requirements of the ESASO Fellowship Programme and the ESASO Graduation Scheme, as well as celebrate the winners of the XOVA Excellence in Ophthalmology Vision Awards.

This programme provides financial support for outstanding initiatives to address unmet needs in eye care worldwide. The winners of this year’s XOVA will be in attendance to receive their awards and share details of the projects that they will be embarking upon with the help of XOVA funding.

For further details of the 17th ESASO Retina Academy, visit: www.esaso.org/17th-esaso-retina-academy-2017

17th ESASO Retina Academy 2017 29 June – 1 July 2017 Berlin , Germany

ESASO Programme 2017 Surgical Retina

06 – 10.02.17, Lugano

Medical Retina

20 – 24.02.17, Rome

Basic Surgical Retina

20 – 24.03.17, Lugano

Glaucoma Course

30.03 – 02.04.17, Singapore

Uveitis Course

18 – 21.05.17, Singapore

Surgical Retina

29.05 – 02.06.17, Lugano

Medical Retina

05 – 09.06.17, Lugano

Medical and Surgical Retina Course

24 – 27.08.17, Singapore

Cornea and Corneal Refractive Surgery

04 – 08.09.17, Lugano

Glaucoma

18 – 22.09.17, Lugano

Cataract and Intraocular 23 – 27.10.17, Lugano Refractive Surgery Cataract and Intraocular 20 – 24.11.17, Lugano Refractive Surgery Medical and Surgical Retina Course

25 – 28.11.17, Beijing

www.esaso.org

EUROTIMES | FEBRUARY 2017

35

Los Angeles 2017 Save the Date

Friday, May 5 – Monday, May 8, 2017 Make the most of your time at the ASCRS•ASOA Symposium & Congress and attend our EyeWorld multi-supported CME, independent education, and Corporate Events.

They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Register online now! www.eyeworld.org

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

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

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

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

www.EyeWorld.org

Topics are subject to change.

HOSPITAL DIARY

IN THE ZONE

When operating isn’t everything – it’s the only thing.

Dr Leigh Spielberg reports

A

Illustration by Eoin Coveney

journalist from The But sometimes I’m ‘in the zone’, New York Times and this might last for an entire recently asked Keith procedure. For me, being 'in the Richards of The zone' means existing in a mental Rolling Stones about state of focused concentration on performing onstage. the performance of an activity, in “I was made to do it,” he replied. which I dissociate myself from “Playing live, that’s the essence of distracting or irrelevant aspects what I do. As I say to (fellow of my environment.

Rolling Stone) Ronnie (Wood) It happens when a confluence when we go onstage, ‘Right, now of factors occurs, all of which we can get some peace and quiet.’ are necessary but not, in There nobody can disturb us. themselves, sufficient. For me, We’re invulnerable.” what’s required is thorough This is a feeling I recognise. preoperative preparation for Mind you, I’m not comparing the case, a good night’s rest, an myself to Keith Richards! But I unrushed morning with a good can relate to the feeling of peace breakfast, enough caffeine to stay and quiet, when I do what I was sharp, but not too much, so I “made to do”, or at least trained don’t get 'the shakes', a low-stress to do, which is to operate. operating room preparation Surgery is the one time when with motivated and efficient I can shut out the rest of the nurses; and my assistant, an world and concentrate on what ophthalmology resident, who has I’m doing. No one bothers taken care of the details required me, and no one considers it between the planning of the unreasonable of me when I operation and its execution. refuse to discuss anything I cherish such days in the unrelated to the procedure. operating room, and I try to When I started my current make them happen as frequently job as a vitreoretinal and as possible. I often review the cataract surgeon in the ‘Tips & Tricks’ section of my Being ‘in the zone’ means existing in a university, the nurses in the surgical journal to remind me mental state of focused concentration operating room would ask of ways I’ve discovered to make on the performance of an activity me questions about materials a particular procedure go more needed for tomorrow’s smoothly. This might be silly, procedures. Or they would early-fellowship advice like: pick up my hospital phone “Iris tissue is the vitrectome’s when it rang, which is fine, but then would ask me if I would favourite food, so stay away!” to more advanced, subtle or like to speak to the person on the phone, which I prefer not to. nuanced tips regarding how to avoid the Argentinian flag sign in Interruptions have to be kept to a minimum. an intumescent cataract.

As well as that, during surgery, my own mind doesn’t bother me But I can’t continually exist in a state of splendid isolation. by interrupting itself constantly. In this digitally distracted age, in The mood of an operating room is an important factor in the which there’s always something else I could be doing, or another motivation of everyone present. In order to keep our spirits up, we task I should be doing, surgery time is surgery time and nothing maintain a healthy dose of humour. My assistants know that they else. The rest of the world is, at that moment, secondary. I have can occasionally act as a sort of joking cheerleader for me during no obligation to anything or anyone else. From the moment the particularly easy steps (“Wow, you really injected that OVD like a patient is sterile draped to the moment the eye is finally patched, champ!”) or more difficult ones (“Nice ILM peeling, that was your the eye is my only focus. best so far today.”)

Of course, the ultimate goal is great outcomes for the patients.

All the rest is just details. A patient once asked me to pray for her.

CONCENTRATION, CONFIDENCE AND PERSEVERANCE “Why me?” I asked. “I’m just the surgeon.”

During the procedure, I only hear my assistant next to me, the “Because your prayers are worth more than those of most radio in the distance, and the voices of my surgical mentors, others. Doctors are closer to God,” she replied. repeating their advice inside my mind. This isn’t to say that I don’t know whether that’s true or not, but I told her I would operating is all Zen all the time. My mind is not transported to a make sure to be in the zone when I operated on her. meditative state while I’m struggling to peel a diabetic membrane.

It’s hard work and requires a great deal of concentration, Dr Leigh Spielberg is a vitreoretinal and cataract surgeon confidence and perseverance. It can be dispiriting, sometimes at Ghent University Hospital in Belgium even depressing. Oftentimes I feel the crushing burden of a patient’s hopes upon me. leigh.spielberg@gmail.com EUROTIMES | FEBRUARY 2017

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LISBON

TO NOTE...

LISBON

AVERAGE OCTOBER TEMPERATURES: 14-22°C CURRENCY: EURO INTERNATIONAL AIRPORT: LISBON HUMBERTO DELGADO AIRPORT

TOP TIPS FOR OTHER PARK OF NATIONS SIGHTS The Lisbon Oceanarium, built on a pier in an artificial lagoon in the Park of Nations, is home to 450 marine species.The main exhibit alone showcases 100 varieties of fish. Its largest tank, a 1,000-square metre tank, is seven metres deep.

Tanks around the large central tank house four different habitats with their native flora and fauna. The largest indoor aquarium in Europe, it is one of the few to exhibit an ocean sunfish.

The Oceanarium was among the most popular attractions at Expo '98 and still counts over a million visitors each year. To avoid the queues, buy a ticket online via the Oceanarium website at: www.oceanario.pt, or by the automated ticket vending machine on the side of the building. The Oceanarium is open 10.00-19.00 daily, with the last entry at 18.00.

The aptly named Telecabine cable car loops between the Oceanarium and the iconic Vasco da Gama Tower, now part of the Myriad Hotel.

Literally a “hop on, hop off” procedure, the Telecabine makes its continuous round trip without halting. It’s a short journey but it offers great views of the Park of Nations far below.

Tickets are available for a return trip or one way and must be purchased at one of the ticket offices on the northern and southern terminals prior to the trip. The cable car functions every day with hours varying by season, but operates from 11.00 until 19.00 at the time of the ESCRS Congress in October.

Website: www.telecabinelisboa.pt The Vasco da Gama Bridge, inaugurated in 1989, is the backdrop to the Park of Nations. At 17.3km in length, it is the longest in Europe, spanning the River Tagus at its widest part, known as the “Mar da Palha”, or Sea of Straw. The structure was designed to last 120 years, to withstand wind speeds of 250km/h and to survive an earthquake 4.5 times stronger than the 1755 Lisbon earthquake – which is estimated to have been 8.7 on the Richter scale.

Environmental pressure to preserve the marshes under the bridge resulted in the left-bank viaducts being extended inland while the lampposts along the bridge are tilted inwards so as not to cast light on the river below.

EUROTIMES | FEBRUARY 2017

A view of the Park of Nations from above

LISBON’S MODERN GEMS Delegates to the XXXV Congress of the ESCRS can discover the Park of Nations. Maryalicia Post reports Few international exhibitions have had as elegant an afterlife as Lisbon’s Expo ’98. Its site – on the northeastern bank of the River Tagus – is now the vibrant city suburb known as ‘Parque das Nações’, or Park of Nations.

The area is home to some 22,000 residents, as well as luxury hotels, restaurants, museums, art galleries, shops and the International Fair of Lisbon.

Buildings designed for Expo ’98 are among the architectural highlights of the area.

Outstanding among those buildings is the Gare do Oriente, a major transportation hub. Elevated train tracks are crowned by a distinctive grove of metal and glass “trees”, dramatically lit at night.

The work of the Spanish architect Santiago Calatrava, Gare do Oriente incorporates a metro station, a high-speed commuter and regional train hub, a local, national, and international bus station, shops and a food hall. During Expo ’98 the station also served as an exhibition venue and is still used for the occasional fair.

An underground passageway links the station to the Vasco da Gama shopping centre opposite, as does a pedestrian road at street level. The entrance to the present day shopping centre was once the main entrance to Expo ’98. A walk through the boat-shaped mall leads out to the reflecting pool that was a highlight of the event, and where flags still fly. The two towers flanking the shopping centre are residential and commercial buildings built in 2000 and 2004. They are named San Gabriel and San Rafael after twin ships in Vasco da Gama’s armada.

The ‘flying saucer’ building to the left of the fringe of flagpoles is the MEO Arena, Portugal’s largest indoor arena. Designed

by Portuguese architect Regino Cruz, it is partially below ground and holds up to 20,000 spectators under its giant dome.

During Expo ’98, the building was called the Pavilion of Utopia and housed the spectacle "Oceans and Utopias”.

Renamed the Atlantic Pavilion and now MEO Arena, it hosts visiting bands and artists, as well as a variety of other major events. To check what’s on, visit the website at: arena.meo.pt A short walk from the MEO, is the Garcia de Orta Garden, named after a 16th Century Portuguese doctor who studied and classified Asian plants. Its vegetation represents the regions of the world explored by the Portuguese during the Age of Discovery.

One idea is to combine a tour of the Park of Nations with a one-hour jog. Run in Portugal offers a “Modern Lisbon City Run” with a runner-guide. Tours leave from the Vasco da Gama shopping centre at 9.00, 10.00, 19.00 and 20.00, or you can book one to suit your own schedule. For details, see: www.runinportugal.com

Gare do Oriente train station

CALENDAR

MARCH

↙

MediterRetina Club International Meeting

NEW Leuven Retina Meeting 2017

30th APACRS Annual Meeting

9–11 March Leuven, Belgium www.leuvenretinameeting.eu

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

3rd OCT San Raffaele Forum

SOE 2017

2–5 March Athens, Greece www.hsioirs.org/index.php/en

LAST CALL

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

21st ESCRS Winter Meeting 10–12 February Maastricht, The Netherlands www.escrs.org

Retina World Congress

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

MAY

31st International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery

17–18 March Milan, Italy www.octforum2017.eu

8th World Congress on Controversies in Ophthalmology (COPHy)

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

APRIL

AAPOS Annual Meeting

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

FLOREtina 2017 27–30 April Florence, Italy www.floretina.it

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

JUNE

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

World Glaucoma Congress

28 June–1 July Helsinki, Finland www.worldglaucoma.org

JULY

MaculArt Meeting

2–4 July Paris, France www.maculart-meeting.com

AUGUST

ASRS Annual Meeting 2017 12–16 August Boston, USA www.asrs.org/ annual-meeting

MAY

ASCRS 2017

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

SFO 2017

6–9 May Paris, France www.sfo.asso.fr

ARVO Annual Meeting 2017 7–11 May Baltimore, USA www.arvo.org

Athens, host city of the 31st International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery

EUROTIMES | FEBRUARY 2017

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40

CALENDAR

SEPTEMBER

Lisbon, host city of the XXXV Congress of the ESCRS

17th EURETINA Congress 7–10 September Barcelona, Spain www.euretina.org

EVER – European Association for Vision and Eye Research Congress 2017 27–30 September Nice, France www.ever.be

DOG 2017

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

OCTOBER

8th EuCornea Congress 6–7 October Lisbon, Portugal www.eucornea.org

XXXV Congress of the ESCRS 7–11 October Lisbon, Portugal www.escrs.org

NOVEMBER

AAO 2017

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

NEW 3rd European Congress on Ophthalmic Imaging: From Theory to Current Practice

13 October Paris, France http://www.vuexplorer.fr/media/ document/201612221657-2017-congressannouncement.pdf

DECEMBER

4th World Congress of Paediatric Ophthalmology and Strabismus 1–3 December Hyderabad, India wspos.org/india-2017

2018

SEPTEMBER

9th EuCornea Congress

JUNE

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

WOC 2018

16–19 June Barcelona, Spain www.icoph.org

XXXVI Congress of the ESCRS

SEPTEMBER

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

18th EURETINA Congress 20–23 September Vienna, Austria www.euretina.org

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EUROTIMES | FEBRUARY 2017

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European Society of Cornea and Ocular Surface Disease Specialists

8th EuCornea Congress 2017

LISBON 6–7 October FIL – International Fair of Lisbon, Portugal

Abstract Submission Deadline: 15 March 2017

www.eucornea.org

Advancing Advancing PanOptix Toric CATARACT CATARACTSURGERY SURGERY NEW! AcrySof IQ ®

®

Presbyopia-Correcting IOL

Demand more: A multifocal toric IOL that can bring more to astigmatic patients* The proven astigmatism management of AcrySof® IQ Toric IOLs1-11 meets innovative ENLIGHTEN™ Optical Technology12 in a presbyopia-correcting lens that is designed to offer enhanced visual performance12-15 and optimized refractive outcomes.4-11 • Optimized light utilization in a presbyopia-correcting IOL14,16 • More comfortable near to intermediate range of vision12,17,18 • Less dependence on pupil size than previous generations of multifocal IOLs12,19 • Proven toric platform maintains refractive targets over time**,4-11

To learn more about the AcrySof® IQ PanOptix® Toric Presbyopia-Correcting IOL, talk to your Alcon representative.

*Enlighten technology, AcrySof Platform and new Calculator (1-11). **Studied over a one-year period.

1. Leydolt et al. Posterior Capsule Opacification with the iMics1 NY-60 and AcrySof SN60WF 1-Piece Hydrophobic Acrylic Intraocular Lenses: 3-Year Results of a Randomized Trial. Am J Ophthalmol 2013;156:375–381. 2. Linnola RJ, Sund M, Ylonen R, et al. Adhesion of soluble fibronectin, laminin, collagen type IV to intraocular lens materials. J Cataract Refract Surg. 1999;1486-1491. 3. Boureau C, et al. Incidence of Nd:YAG laser capsulotomies after cataract surgery: comparison of 3 square edge lenses of different composition. Can J Ophthalmol. 2009;44:165-170. 4. Clinical Evaluation Report for: AcrySof® IQ ReSTOR® Multifocal Toric IOLs. TDOC-0016076. Effective date 05 Jul 2013. 5. Mechanical equivalency rationale for AcrySof® Toric Models. TDOC-0050786. Effective date 11 Aug 2015. 6. Lane SS, Burgi P, Milios GS, Orchowski MW, Vaughan M, Schwarte E. Comparison of the biomechanical behavior of foldable intraocular lenses. J Cataract Refract Surg. 2004;30:2397-2402. 7.

Lane SS, Ernest P, Miller KM, Hileman KS, Harris B, Waycaster CR. Comparison of clinical and patient reported outcomes with bilateral AcrySof® Toric or spherical control intraocular lenses. J Refract Surg. 2009;25(10):899-901. 8. Wirtitsch MG, Findl O, Menapace R, et al. Effect of haptic design on change in axial lens position after cataract surgery. J Cataract Refract Surg. 2004;30(1):45-51. 9. Nejima R, Miyai T, Kataoka Y, et al. Prospective intrapatient comparison of 6.0-millimeter optic single-piece and 3-piece hydrophobic acrylic foldable intraocular lenses. Ophthalmology. 2006;113(4):585-590. 10. Potvin R, Kramer BA, Hardten DR, Berdahl JP. Toric intraocular lens orientation and residual refractive astigmatism: an analysis. Clin Ophthalmol.

2016;10:1829-1836. 11. Koshy JJ, Nishi Y, Hirnschall N, et al. Rotational stability of a single-piece toric acrylic intraocular lens. J Cataract Refract Surg. 2010;36(10):1665-1670. 12. PanOptix™ Diffractive Optical Design. Alcon internal technical report: TDOC-0018723. Effective date 19 Dec 2014. 13. Defocus Visual Acuity Estimation of Trifocal IOLs Using Neural Network Algorithm. TDOC-0050480. Effective date June 12, 2015. 14. Alcon Laboratory Notebook. 14073:77-78. 15. Hayashi K et al. Effect of astigmatism on visual acuity in eyes with a diffractive multifocal intraocular lens. J Cataract Refract Surg. 2010;36:1323-1329. 16. AcrySof® IQ PanOptix® IOL Directions for Use. 17. Charness N, Dijkstra K, Jastrzembski T, et al. Monitor viewing distance for younger and older workers. Proceedings of the Human Factors and Ergonomics Society 52nd Annual Meeting, 2008. http://www.academia.edu/477435/Monitor_Viewing_Distance_for_Younger_and_Older_Workers. Accessed April 9, 2015.

18. Average of American OSHA, Canadian OSHA and American Optometric Association Recommendations for Computer Monitor Distances. 19. AcrySof® IQ ReSTOR® 2.5 IOL Directions for use.

AcrySof IQ PanOptix Toric ®

PRE S BY OPI A- C ORRE C TI N G I OL

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CATARACT SURGERY