EuroTimes Vol. 22 - Issue 3

SPECIAL FOCUS RETINA MEETING REPORT

MAASTRICHT PROVES A GREAT SUCCESS AS HOST CITY OF 21ST ESCRS WINTER MEETING

CORNEA

FINGER-PRICK AUTOLOGOUS BLOOD FOR RELIEVING REFRACTORY DRY EYE March 2017 | Vol 22 Issue 3

GLAUCOMA

MIGS – ADOPTING NEW DEVICES REQUIRES RESEARCH AND PRACTICE

RVO Diagnosis

& Treatment

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

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

SPECIAL FOCUS RETINA

4

Cover Story: A new era in RVO treatment

7 3D printing technology to create personalised surgical instruments

8 Gisbert Richard Lecture: A multi-pronged attack on underlying retinal disease processes

10 ‘Change is coming in AMD therapy’

13 Emixustat fails to slow geographic atrophy in 24-month trial

15 Ophthalmologica Update

FEATURES CATARACT & REFRACTIVE 16 Radner Reading Charts – multilingual test system receives prestigious award

www.eurotimes.org

MEETING REPORT

P.18

24 Maastricht proves a great

success as host city of 21st ESCRS Winter Meeting

CORNEA 26 ‘There is still room for

traditional PK in corneal transplantation’

27 Dry eye after LASIK – neurotrophic epitheliopathy is difficult to treat

28 Finger-prick autologous blood for relieving refractory dry eye

GLAUCOMA 30 MIGS – adopting new

devices and techniques requires research and practice

REGULARS 33 Industry News 35 ESCRS News 37 Book Reviews 38 Exploring Lisbon 39 Calendar

31 Enhanced technical training of non-physicians to improve efficiency for patients

17 Comparison of four

multifocal IOLs shows good patient satisfaction

18 Everything you ever

P.38

wanted to know about posterior polar cataracts

20 Improving ELP prediction – new algorithm using AS-OCT parameters 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.

21 ‘SMILE may be more predictable than LASIK for correcting myopic astigmatism’

22 JCRS Highlights EUROTIMES | MARCH 2017

2

EDITORIAL A WORD FROM ANAT LOEWENSTEIN MD

LISTEN AND LEARN

One of the key functions of EURETINA is to ensure that young retinal specialists are trained to the highest standards

I

t is with great pleasure that I am writing this editorial lose sight of the present. This is especially important when we for the first special retina edition of EuroTimes in 2017. I are training young ophthalmologists. Some of our trainees will was recently in Vienna, where EURETINA hosted its 7th become great surgeons, but before we teach them exciting new Winter Meeting. The Winter Meeting is a smaller techniques, we must ensure that they meeting to our annual congress, but it is very learn the basics.

Sixteen years ago at the important to us as it offers us the chance to meet The most effective surgical in an informal setting and discuss some of the hot topics instruction is hands-on training inception of the society in our subspecialty. with students being coached by in Hamburg, we had a We had some excellent presentations on neovascular experienced surgeons during surgery gathering of only 200 age-related macular degeneration, geographic atrophy and I always urge my students to delegates. Last year we and computational image analyses, and the meeting listen, look and learn. welcomed over 5,000 was a great success.

One of the most important delegates to our 16th As General Secretary of EURETINA, I am especially functions of EURETINA is to ensure privileged to attend our meetings, which continue to that our young ophthalmologists Congress... go from strength to strength. As my colleague Ursula are trained to the highest standards, Schmidt-Erfurth pointed out at last year’s EURETINA and for that reason, I would urge Congress in Copenhagen, the growth of the society has trainees to join the newly formed Young Retina Specialist been remarkable.

Group (YOURS) and to take part in their first programme Sixteen years ago at the inception of the society in Hamburg, in Barcelona. we had a gathering of only 200 delegates. Last year we In conclusion, I would like to again thank EuroTimes for welcomed over 5,000 delegates to our 16th Congress and we giving me this opportunity to share my views, and I encourage are anticipating another big attendance when we hold the 17th you to carefully read the excellent articles in this magazine and EURETINA Congress in Barcelona in September. future editions.

I am glad to see that some of the hot topics we will discuss in Barcelona are covered in this issue of EuroTimes. I took a special interest in the cover story which focuses on retinal vein occlusion. The development of new imaging techniques and novel intravitreal treatment approaches is ushering in a new era in patient management in this area and I look forward to hearing about some of the exciting developments with this when we meet in Barcelona.

‘What does the future hold?’ is a question we frequently ask ourselves when treating our patients, as we look for better drugs and better therapies to give us better outcomes.

Prof Anat Loewenstein is Chairman of the Division However, I would also point out that, while it is important of Ophthalmology, Tel Aviv Medical Center, Israel, and General Secretary of EURETINA to learn from the past and look to the future, we should not

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 | MARCH 2017

17th EURETINA Congress 7–10 September 2017 CCIB, Barcelona, Spain

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

4

COVER STORY: RETINA

RVO

Diagnosis Treatment

&

Retinal vein occlusion – a new era in patient management. Sean Henahan reports

W

hile the traditional approach to treating patients with retinal vein occlusion (RVO) involved watchful waiting, with laser treatment considered when vision worsened, the development of new imaging techniques and novel intravitreal treatment approaches is ushering in a new era in patient management.

“When I was in training, if a person came in with a RVO, and that person had 20/20 vision, you would just watch and wait. If the person was 20/40 or worse, you watch and wait, and some would get better by themselves and some would not.

If not, we might do laser. That is where we were not long ago. But now we understand that there are patients who might come in with 20/20 visual acuity (VA), but they complain bitterly about bad vision. A few years ago we didn't understand what was going on,” Pravin Dugel MD told EuroTimes in an interview.

This is an example of where structural optical coherence tomography (OCT) imaging has advanced the understanding of RVO, said Dr Dugel, Managing Partner EUROTIMES | MARCH 2017

of Retinal Consultants of Arizona, Phoenix, and Clinical Professor at the University of Southern California Keck School of Medicine, Los Angeles, USA. Imaging studies revealed that such a patient might have an abnormal fovea, which would account for the vision complaint. Standard VA exams do not provide the information necessary to make that determination.

“We understand that VA is not an adequate proxy or representation of visual function. Rarely are we in a dark room tunnel with a bright light at the end.

Life has different lighting conditions contrast, shade, glare and so on. Structural OCT gives information on what may affect visual function by causing subtle anatomical changes. In those patients we may choose to treat even though the vision

is 20/20, because we understand that there is oedema there that is affecting visual function,” explained Dr Dugel.

Indeed, OCT imaging studies have shown that there can be a price to be paid for delaying treatment in patients with good VA. While those patients who are treated after vision begins to deteriorate may get better following treatment, it has become clear that their vision will never be as good as it would have been had they been treated earlier, he added.

Many clinicians, but not all, will still do routine fluorescein angiogram as part of the initial work-up of a patient with RVO. Fluorescein angiography is starting to fall out of favour in the management of age-related macular degeneration (AMD).

What role does it have in RVO?

When I was in training, if a person came in with a RVO, and that person had 20/20 vision, you would just watch and wait Pravin Dugel MD

COVER STORY: RETINA “Fluorescein angiography is not crucial for the diagnosis and management of RVO disease, unless you suspect the existence of neovascularisation, and are not sure.

However, I still tend to do fluorescein angiography at baseline mainly for assessing non-perfusion of the macula which has an impact on the prognosis for VA,” notes Anat Loewenstein MD, Chairman of the Division of Ophthalmology, Tel Aviv Medical Center, Israel.

OCT ANGIOGRAPHY – A STRANGE SITUATION OCT-angiography (OCT-A) is one of the most exciting areas of retinal ophthalmic research today. Recent developments in hardware and software allow non-invasive three-dimensional vascular mapping of retinal and choroidal layers, showing structural and flow information. It is quickly finding a place in the diagnosis and management of neovascular AMD. However, its role in RVO is still in the developmental stage.

“We are in a strange situation with OCT-A in general and as it pertains to vein occlusion.

We know it is here to stay, we understand that it will be a paradigm we will be using for many diseases including RVO. We have a lot of studies that have shown very interesting findings, but we haven’t crossed the threshold where we have enough data to say OCT-A should be done. The biomarker data is simply not there yet. I have no doubt that it will be a diagnostic standard in the near future,” commented Dr Dugel.

Indeed, an increasing amount of research appearing in the journals suggests that OCT-A will have an important role in the management of RVO. For example, researchers at the Karolinska Institute in Stockholm used OCT-A to evaluate factors associated with poor visual outcome in central RVO patients without macular oedema treated with anti-vascular endothelial growth factor (anti-VEGF) agents (Epstein et al, IOVS, 2016;57). They observed an association between an enlarged foveal avascular zone and poor VA. Another study, reported at ARVO 2016, compared OCT-A and fluorescein angiography for evaluating collateralisation in acute and chronic RVO. The researchers reported ‘perfect agreement’ between the two imaging systems in all patients (BP Jones et al. IOVS Vol.57, 5473).

ARRAY OF OPTIONS FOR TREATMENT Laser photocoagulation has been a mainstay of therapy for RVO, specifically for macular oedema and for ischemia and neovascularisation. However, the success of anti-VEGF therapy for these indications, and, on the negative side, the destructive nature of the laser has led to much less use of the once traditional approach.

“I only do pan-retinal photocoagulation in the rare cases of neovascularisation or neovascular glaucoma. I don’t think we

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have enough evidence for doing peripheral laser with the aim of controlling the macular oedema. If I treated the patient pharmacologically either with an antiVEGF or steroid and there is no response, then I sometimes consider grid laser,” Dr Lowenstein told EuroTimes.

A series of large clinical studies conducted in recent years confirm the value of anti-VEGF agents for RVO. Ranibizumab (Lucentis, Roche/Genentech) and aflibercept (Eyelea, Regeneron/Bayer) are both approved in the EU and the USA for the treatment of macular oedema following branch and central RVO. Both proved safe and effective in treating the oedema and in maintaining or improving VA. Bevacizumab (Avastin, Roche/ Genentech) has shown similar effects in clinical studies and is used off-label.

Which agent works best, and which regimen provides the best results with the least treatment burden? This is a focus of many clinical trials now under way. The large-scale LEAVO study aims to provide randomised clinical trial evidence on the comparative effectiveness of ranibizumab and aflibercept in central RVO patients.

The results of another comparison study, the SCORE2 study, are expected soon. This was a non-inferiority study comparing aflibercept and bevacizumab in patients with macular oedema associated with central RVO. The primary outcome measure at six months was the mean change from baseline in VA letter score.

Steroids, alone and in conjunctions with anti-VEGF agents also continue to have a

role in RVO treatment. The dexamethasone intravitreal implant (Ozurdex, Allergan) is often used to provide an anti-inflammatory component to treatment.

“I usually start with anti-VEGF treatment, Lucentis or Eylea. If there is a situation where the patient cannot tolerate the treatment burden and there is constant recurrence, or if there is a situation where the patient has reached a plateau and there is still oedema, I consider using Ozurdex.

This does happen in approximately half of patients that I treat. In some cases Ozurdex decreases the treatment burden, and also addresses patients that may have a primarily inflammatory component causing resistance to anti-VEGF monotherapy,” notes Dr Dugel.

It has become clear that, as good as they are, anti-VEGF treatments reach a physiological ceiling effect in the treatment of retinal vascular disease. There are no studies in neovascular AMD where treatment beyond four years maintains visions better than original baseline levels.

Rather, there is a gradual deterioration associated with atrophy. There are also a small percentage of patients who do not respond well to anti-VEGF therapy.

There is also a logistical ceiling effect where endless intravitreal injections are not feasible. This has driven the search for supportive therapeutic agents that could improve clinical outcomes while reducing the treatment burden of current monotherapy approaches.

“We know we have to have a multimodal approach. We know that suppression of EUROTIMES | MARCH 2017

5

COVER STORY: RETINA

Courtesy of Anat Loewenstein MD

6

Colour picture, red free and fluorescein angiography of a patient with branch retinal vein occlusion with significant non-perfusion

one chemical factor alone is not going to be sufficient. Neovascularisation and macular oedema are complex biological processes.

VEGF is an important component, but it not the only component. Combination treatment is clearly the future,” said Dr Dugel.

FULL PIPELINE Researchers had high hopes that blocking the activity of platelet-derived growth factor (PDGF), which plays a separate role in neovascularisation, could play a supportive role in combination treatment. This led to the development of the PDGF inhibitor Fovista (Ophthotech). However, the results of two international phase 3 studies caused considerable disappointment in the clinical research community. Those trials compared Fovista plus ranibizumab to ranibizumab alone in patients with neovascular AMD. The bottom line was that the combination did not provide additional benefit compared with ranibizumab alone.

The angiopoietin pathway represents another potential front in the battle against retinal neovascularisation. A co-formulation developed by Regeneron (REGN910-3), combines aflibercept with nesvacumab, a novel anti-Ang2 monoclonal antibody. Early clinical research suggested the formulation was safe, with some evidence of benefit. A phase 2 clinical trial is under way in patients with neovascular AMD. Researchers at Roche Genentech have developed another approach seeking to exploit the angiopoietin pathway. The agent RG7716 is a unique bi-specific EUROTIMES | MARCH 2017

molecule with two different arms. One of these arms inhibits angiopoeitin2 while the other targets VEGF-A. The compound is held together with an Fc component engineered specifically for the retina. The Fc component includes one mutation that specifically decreases systemic absorption of the compound, while a second mutation decreases inflammation and effector cell function.

Preliminary results from ongoing clinical studies with RG7716 indicating potential efficacy were presented at the 2016 AAO Annual Meeting in Chicago. Two phase 2 trials are under way, the AVENUE study

for AMD and the BOULEVARD study for diabetic macular oedema (DME).

“There are a lot of drugs in the pipeline.

I think the most exciting are those that target the angiopoietin pathway. Clinical studies are under way with these agents, both for neovascular AMD as well as for DME. It would seem logical that if these agents prove efficacious, then treating vein occlusion would be the next step. This is the sequence we’ve seen with the antiVEGF agents,” noted Dr Dugel.

Anat Loewenstein: anatl@tlvmc.gov.il Pravin Dugel: pdugel@gmail.com

OCT-ANGIOGRAPHY: THE GAME CHANGER Optical coherence tomography (OCT) has proven to be an invaluable tool for retina specialists. More recently, OCT-angiography (OCT-A) has widened the scope of this imaging technology even further. EuroTimes asked Marco Lupidi MD, of University of Perugia, Italy, to provide some context for the rapidly evolving role of OCT in ophthalmology.

The development of algorithms to analyse the contrast generated Marco Lupidi between static and non-static tissue in repeated consecutive B-scans was the basis for OCT-A. This “dramatic” change allows visualisation of retinal and choroidal perfusion in a depth-resolved approach, clearly distinguishing the superficial from the deep retinal capillary plexus, he noted.

He explained that, with the development of OCT-A, it became possible to identify the exact morphology of a type I or II choroidal neovascularisation (CNV) and their anatomical and topographical relationship with outer retinal layers. “When considering retinal vein occlusion, OCT-A allows a precise assessment of the macular perfusion impairment. Not only the superficial capillary plexus, but also, and for the first time, we are able to analyse and quantify the deep capillary plexus and the potential damages induced by the occlusive process,” said Dr Lupidi.

Marco Lupidi: dr.marco.lupidi@gmail.com

SPECIAL FOCUS: RETINA

INNOVATIVE INSTRUMENTS Application of 3D printing to create customised retinal forceps grips. Cheryl Guttman Krader reports

C

ustomised retinal forceps grips created with threedimensional (3D) printing will bring surgeons personalised handheld instrumentation that should translate into better ergonomics and comfort, said David R Chow MD at the 16th EURETINA Congress in Copenhagen, Denmark.

“During the history of retinal surgery, we have been using forceps with a standard design that does not take into account human variation in the size and shape of hands and grips. No doubt surgeons are doing a great job using the available instruments, but I believe we could do better with customisation. 3D printing is changing the manufacturing process and allows customised instrumentation to be created without major production costs,” said Dr Chow, Assistant Professor of Ophthalmology, University of Toronto, Canada.

Dr Chow is working in conjunction with Katalyst Surgical to bring his idea to market. After testing forceps moulds of different sizes and different materials to create a suitable model, Dr Chow imprinted his grip at the desired depth. The impression is scanned using a 3D scanner to create a software file for superimposing the grip onto the forceps that is done using selective laser sintering.

Simultaneously, Dr Chow and colleagues worked to identify the ideal substrate forceps.

David R Chow To validate the idea that, when given the choice, surgeons would prefer different grip designs, Dr Chow sought the cooperation of four prominent retinal surgeons from around the world. The group was comprised of male and female surgeons, with varying heights, in order to recruit individuals with different hand types.

Each surgeon was provided with different moulds from which he or she could choose a preferred mould size and then the preferred depth of the imprint created with their grip.

“It was striking to see the significant differences in the four prototype forceps that were created when just four surgeons were given the opportunity to personalise the grip,” Dr Chow said, adding that additional data were being collected from a larger group of 80 surgeons.

Next, new prototypes that would allow rotation of tips with the customised grips were developed and validated. Looking ahead, Dr Chow said he also has ideas for creating other customised instruments using 3D printing.

Proof that grip personalisation improves surgeon performance may be difficult to obtain. The issue is being explored, however, by reviewing intraoperative videos of surgeons completing different manoeuvres using standard and customised forceps. Nevertheless, considering his experience with ski boots as an analogous situation, Dr Chow is convinced the customisation will deliver a comfort advantage.

“I cannot say for sure that I ski better when wearing my moulded boots versus a rental pair, but I know that when I am wearing the personalised product, I feel much better and am much happier at the end of the day,” he said.

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David R Chow: davidrchow@me.com EUROTIMES | MARCH 2017

7

8

SPECIAL FOCUS: RETINA

DISEASE THERAPY Multi-pronged attack on underlying retinal disease processes drives current research. Leigh Spielberg MD reports

D

r Gisbert Richard’s keynote lecture at the 16th EURETINA Congress in Copenhagen, Denmark, examined the prospects and limitations of artificial vision and stem cell therapy.

“About two million people worldwide suffer from photoreceptor degenerative diseases,” said Dr Richard in his inaugural Gisbert Richard Lecture. “With a prevalence of approximately one in 4,000, these diseases are not so uncommon. It is therefore crucial that research continues, and that we continue trying to solve the primary problems inherent to the treatment of these diseases,” he added.

“The first problem is the interdependence of different layers of the retina. Retinal pigment epithelium (RPE) degeneration leads to both degeneration of the choriocapillaris and focal necrosis of photoreceptor cells. The second problem is the question of timing of a therapeutic intervention. Namely, is it better to intervene early, before the damage has occurred? Or later, when the risks of making it worse have lessened?” he asked.

As it turns out, that depends on which type of therapy is administered. Gene therapy should be administered in an early stage, cell therapy in any stage, and the retinal prosthesis in the late stage.

The third problem is that of additive RPE ageing. This refers to the various ways in which RPE cells degenerate, losing their typical cell morphology and undergoing atrophy and hyperpigmentation. This physiologic ageing also causes secondary alteration of the choriocapillaris and retina.

Dr Richard discussed the treatment options in depth. Broadly speaking, there are three therapeutic categories: cell therapy, gene therapy, and retinal prostheses.

cultivate human adult RPE cells. HLAtyped RPE transplantation has been shown to be a safe procedure, with no rejection of transplanted cells and improvement of visual acuity, albeit limited. However, there remains the problem of progression of geographic atrophy,” said Dr Richard.

Stem cell therapy, which involves undifferentiated, multipotent cells with the capacity for self-renewal, aims to transfer therapeutic gene products to the retina, or to substitute or replace dysfunctional or degenerated retinal cell types.

Grafted primary retinal cells develop the morphology of fully mature photoreceptors when incorporated into an otherwise healthy retina. These cells also express photoreceptor-specific antigens. There is, however, no proof of therapeutic value to date, he noted.

CELL THERAPY

GENE THERAPY

Cell therapy refers to the transplantation of either HLA-typed RPE cells or stem cells, or a more pharmacologic approach to the diseased cells.

“Cell therapy requires the establishment of an RPE cell bank in order to isolate and

Gene therapy focuses on treatment of earlystage disease. Because these diseases are monogenetic, they are ideal candidates for gene therapy. The goals include replacing or knocking down a defective gene, controlling gene expression, delivering a suppressor

Gisbert Richard receives the certificate for the inaugural Gisbert Richard Lecture from EURETINA President Ursula Schmidt-Erfurth at the 16th EURETINA Congress in Copenhagen in September 2016

or correcting a mutation that misdirects splicing. With 204 causative genes identified and 244 retinal dystrophy loci mapped, there is clearly no shortage of targets.

“Ongoing and anticipated gene therapy trials include treatments for Leber’s congenital amaurosis (LCA) Type 2, choroideremia, Leber’s hereditary optic neuropathy (LHON), Stargardt and Usher syndrome Type 1B,” said Dr Richard.

RETINAL IMPLANTS

Cell therapy requires the establishment of an RPE cell bank in order to isolate and cultivate human adult RPE cells

Dr Richard then turned his attention to retinal implant (prosthetic) technology.

This incorporates two primary external components: a camera chip and a retina encoder; and an implanted component: the retinal stimulator, which receives pulse sequences and transmits them to the retina.

“Visual improvement by retinal stimulation is definitely possible. However, high-resolution implants are difficult to achieve,” said Dr Richard.

This was evident in the five-year trial of the Argus II implant, in which patients were clearly able to recognise and use shapes for orientation and environmental information, but do not have any fine resolution.

This is because the current maximum number of electrodes per square millimetre is 37. Each electrode generates one phosphene. However, to obtain normal reading speed, more than 5,000 phosphenes are needed per square millimetre.

Dr Richard remains very optimistic.

“Who knows what the future holds?”

Gisbert Richard MD

Gisbert Richard: richard@uke.de

EUROTIMES | MARCH 2017

SPECIAL FOCUS: RETINA

AMD PIPELINE Extended release, new molecules and combinations coming, though hurdles remain. Howard Larkin reports

L

ike the smell of imminent rain in the desert, change is coming in age-related macular degeneration (AMD) therapy, Pravin Dugel MD told the Ophthalmology Futures European Forum 2016 in Copenhagen, Denmark.

“We’ve hit the ceiling with monthly anti-VEGF-A injections. We all smell the rain coming,” said Dr Dugel, Managing Partner of Retinal Consultants of Arizona, Phoenix, and Clinical Professor at the University of Southern California Keck School of Medicine, Los Angeles, USA. Drugs targeting non-VEGF biological pathways, combination therapies, extended release devices and formulations that keep AMD drugs at therapeutic levels longer, are all on the horizon, according to a panel of clinical and industry experts led by Dr Dugel. However, to be viable, any new treatment for AMD faces significant hurdles demonstrating efficacy that justifies its extra treatment burden and expense, particularly to insurance companies and other healthcare payers, they said.

BEATING THE CHAMPION Perhaps the biggest hurdle to both regulatory approval and insurance coverage for new AMD drugs is the success of antiVEGF compounds, said Eugene de Juan Jr MD, founder and

Managing Partner of ForSight Labs, Menlo Park, California, and Jean Kelly Stock Distinguished Professor of Ophthalmology at University of California, San Francisco, USA. It’s not likely that a new drug will better the immediate 10 letter+ visual acuity improvement seen in some trials, and demonstrating long-term improvement is expensive and technically challenging.

Still, there is plenty of real-world evidence that current antiVEGF treatment approaches are not enough. “Even though it seems that 95% of patients stabilise, if you look at the long-term in the SEVEN-UP trial and others, after five years there is a significant decline in visual acuity,” said Anat Loewenstein MD, Chairman of the Division of Ophthalmology, Tel Aviv Medical Center, Israel.

The burden on patients and health facilities of frequent intravitreal injections over the typical 10 to 15 years expected lifespan of AMD patients is almost impossible to sustain on a large scale, she added.

Many patients do not reach optimal anti-VEGF treatment levels because monthly monitoring and treatment is difficult and expensive, agreed Andreas Wenzel PhD, of Novartis Institutes for BioMedical Research, Basel, Switzerland. Even treat-and-extend, which lengthens monitoring and treatment intervals to as long as 12 weeks after retinal oedema is initially stabilised, does not work for all patients.

Courtesy of Prof Guna Laganovska, Latvia

10

The device was well tolerated, and the mild irritation two weeks following implantation resolved well in all patients, as can be seen in the six and 12 months follow-up pictures, each taken one month after refill. The refill area can easily be identified. The implant is outside the optical zone and can be seen only after pupillary dilation

EUROTIMES | MARCH 2017

This is an example of a patient who had four refills and there is a good improvement in visual acuity, paralelled by a decrease in centre-field retinal thickness

SPECIAL FOCUS: RETINA “The ceiling has been reached in randomised controlled clinical trials and well controlled patients, but in real life the ceiling is not reached,” said Dr Wenzel.

Long-acting anti-VEGF drugs would help, Dr Wenzel said.

Adding more drug to the eye, increasing the affinity of anti-VEGF, increasing molecule size or making the compound 'sticky' all might increase residence time in the eye. The goal is a drug that lasts three, four months, maybe even longer.

Extended-release devices, such as the port delivery device in clinical trials by Genentech, are another way antiVEGF-A might better fulfil its potential, said Dr de Juan. In addition to reducing treatment intervals, continuous antiVEGF suppression might reduce the need for long-term administration in some patients, he suggested.

“Every once in a while you give a patient one treatment, particularly an early patient, and 5/10% don’t need another injection. What’s going on with that? I think with sustained delivery we will see a lot more of that,” said Dr de Juan, whose ForSight Labs developed the depot device Genentech is testing.

He also emphasised the value of early diagnosis for treatment success, when abnormal blood vessels are most susceptible to anti-VEGF.

EXPANDED TARGET However, as dramatic as anti-VEGF’s impact may be, it actually is more effective in reducing retinal oedema than reversing abnormal blood vessel growth, noted José-Alain Sahel MD,

The vascular component effect is weak.

The vessels are still there José-Alain Sahel MD

Director of The Vision Institute, Paris, France, Professor at Sorbonne Universities Medical School in Paris, and Chairman of Ophthalmology at University of Pittsburgh Medical Center, USA. “The vascular component effect is weak. The vessels are still there,” he said.

Dr Dugel agreed the wound healing process in AMD is very complex and should be attacked in many ways, as with complex oncology targets. Potential broader spectrum treatments include anti-VEGF-A combined with ANG-2 TIE inhibitors, in development by several manufacturers; and pan-VEGF inhibitors that target VEGF-C and D as well as A. However, the recent failure of clinical trials sponsored by two excellent companies (Ophthotech and Regeneron) targeting antiPDGF combination treatment gives us pause, noted Dr Dugel.

This, said Dr Dugel, shows us how formidable anti-VEGF-A monotherapy is, despite its limitations.

However, new compounds must show they add enough benefit to justify the added treatment burden, Dr Lowenstein said. This can be difficulty when they treat later-stage patients, as do antiPDGF and ANG-2 inhibitors.

Demonstrating efficacy to payers is a particular challenge, Dr Wenzel said. While payers may accept an improvement of 5+ letters of visual acuity as a meaningful outcome, he doesn’t think anatomic improvements such as regression of neovascularisation of fibrosis will be enough. This creates huge economic uncertainty that must be addressed to justify the development cost of new AMD treatments.

Anat Loewenstein: anatl@tlvmc.gov.il José-Alain Sahel: j.sahel@gmail.com Pravin Dugel: pdugel@gmail.com Andreas Wenzel: andreas.wenzel@novartis.com Eugene de Juan: edejuan@forsightlabs.com

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

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SPECIAL FOCUS: RETINA

NEGATIVE DRY AMD RESULTS Emixustat fails to slow geographic atrophy in 24-month trial.

Howard Larkin reports

E

mixustat hydrochloride, a small molecule that showed promise for treating dry age-related macular degeneration (AMD) in an early phase 2 study, failed to reach its primary endpoint of slowing progression of geographic atrophy (GA) associated with AMD in a 24-month phase 2b/3 clinical trial, Frank G Holz MD, University of Bonn, Germany, told the 16th EURETINA Congress in Copenhagen, Denmark.

GA lesion growth rates in the three treatment arms of 2.5mg, 5.0mg and 10mg oral emixustat daily did not differ significantly from placebo at any point in the 24-month follow-up period, Dr Holz reported on behalf of the USA-based SEATTLE study group. Changes in best corrected visual acuity were small and similar across the four groups throughout the prospective, randomised, placebo-controlled study involving 508 patients.

While no systemic or non-ocular safety issues were identified, more ocular adverse events were observed in the treatment groups. Most common was delayed dark adaptation, observed in 36% to 77% of patients in the treatment groups compared with 10% in the placebo group.

Chromatopsia was observed in 22% to 50% in the treatment groups compared with 9% in the placebo group. These were likely related to emixustat’s mechanism of action which inhibits retinal pigment epithelium protein 65 (RPE65), a key rate-limiting enzyme in the visual cycle, Dr Holz said.

Unlike most drugs for AMD and other eye diseases, emixustat hydrochloride is taken orally rather than topically or intravitreally, Dr Holz noted. It inhibits RPE65, effectively slowing it down. Early human studies showed emixustat had a measurable pharmacodynamic effect on the retina, Dr Holz said. Among the findings of a phase 2a study were a dose-dependent reduction in rod b-wave amplitude, which inversely relates to visual cycle time. “It showed the oral dose had the desired effect,” he said.

The study randomised 508 patients with clinical diagnoses of GA with AMD in one or both eyes, with visual acuity of 35 or more ETDRS letters, or about 20/200 or better. Total GA area ranged from 1.25mm2 to 18mm2, or about 0.5 to 7 disc diameters in the study eye. In eyes with multifocal lesions, one had to be 1.25mm2 and the aggregate no more than 18mm2. Patients with active (or a history of) exudative AMD in the study eye were excluded.

The primary efficacy endpoint was the mean rate of change from baseline in total GA area in the study eye as imaged by fundus autofluorescence. Patients were examined at baseline, months 1, 2, 3, 6, 9, 12, 15, 18, and 24, with the study exit visit 30 days after the last dose. No statistically significant differences among the three treatment or placebo groups were observed at 6, 12, 18 or 24 months. Rates of loss of visual acuity were also similar for the four groups, with mean losses by group ranging from about five to eight ETDRS letters at the exit visit. “The data from this study are very important to further elucidate the natural history of GA,” Dr Holz said.

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OPHTHALMOLOGICA VOL: 237 ISSUE: 1

THE BLOOD-RETINAL BARRIER REVISITED This issue of Ophthalmologica features the text of Prof José Cunha-Vaz’s EURETINA Medal Lecture, which he presented at the 16th EURETINA Congress in Copenhagen, Denmark. It explores the role of the blood-retinal barrier (BRB) in retinal disease. Prof Cunha-Vaz provides a review from the earliest discovery of the BRB to the modern understanding of the pathological mechanisms underlying conditions such as retinal oedema, and exudative age-related macular degeneration (AMD), which results directly from breakdown of the BRB. He also highlights research showing the potential of spectral-domain optical coherence tomography (SD-OCT) for non-invasively identifying and quantifying sites of OCT-Leakage. J Cunha-Vaz, “The Blood-Retinal Barrier in the Management of Retinal Disease: EURETINA Award Lecture”; Ophthalmologica 2017, Volume 237, Issue 1.

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BETTER CLASSIFICATION REQUIRED FOR GA The term ‘geographic atrophy’ has been rendered imprecise by the advance of the technologies used to diagnose the various conditions it is it has been used to define, according to Steffen Schmitz-Valckenberg MD. In a wide-ranging article, he traces the origin of the term and describes the different forms of retinal atrophy that have become known since the advent of modern imaging technologies and DNA analysis. Noting that the treatment of the conditions has fallen behind that of neovascular AMD, he argues that the time has come to take a closer look different forms of atrophy development, manifestation, and progression in dry AMD, a more rational approach to their nomenclature and classification. S Schmitz-Valckenberg, “The Journey of “Geographic Atrophy” Through Past, Present and Future”; Ophthalmologica 2017, Volume 237, Issue 1.

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EUROTIMES | MARCH 2017

15

CATARACT & REFRACTIVE

AWARD FOR CHARTS Multilingual reading test system for clinical practice and research receives prestigious award. Dermot McGrath reports

A

s long as people read, ophthalmologists will need a test system that provides accurate, reliable and valid reading acuity measures.

That’s the philosophy that has driven Wolfgang Radner MD, PhD, Austrian Academy of Ophthalmology, for a good part of his working life and which is reflected in his prized creation: the Radner Reading Charts, a highly standardised multilingual reading system for clinical practice and research.

Available in 12 languages and developed in collaboration with psychologists, linguists, statisticians and ophthalmologists, Prof Radner’s project has recently received the prestigious PanEuropa Union award for its contribution to pan-European cooperation and advancing the cause of European ophthalmology.

“As a European ophthalmologist I feel very honoured and privileged to have been recognised by such a prestigious European organisation,” Prof Radner told EuroTimes. “The Radner Reading Chart project shows that foreign languages can link ophthalmologists together in order to establish a homologated standard for measuring reading performance.”

Prof Radner said the award would not have been possible without the generous contribution of over 40 ophthalmologists and academic researchers who helped to realise the project in 12 languages.

INSPIRATION The initial inspiration for the charts came to Prof Radner when he was starting out in his career in ophthalmology. “As a resident, I found a considerable lack of research dealing with reading performance in various pathological conditions that can affect functional vision. However, I also found that the reading acuity obtained with the Jaeger charts could not sufficiently show changes in the patient's reading performance. Since I wanted to do research studies about multifocal intraocular lenses (IOLs) and cataract surgery in age-related macular degeneration patients, there was a need for a well-standardised reading chart system.

Surprisingly, there was none available and that was the initial spark to develop the Radner Reading Charts,” he said.

Prof Radner said it took over two years to develop the first issue of the reading chart in German, and between one to two years for every subsequent language.

“Up to the current day an estimated EUROTIMES | MARCH 2017

Courtesy of Wolfgang Radner MD, PhD

16

The international Radner Reading Charts project (12 languages) received an award of the PanEuropa Union in December 2016 in the European Parliament in Brussels. The award was presented to Prof Radner (left) by the Head of Science and Technology Options Assessment of the European Parliament, Dr Paul Rübig (right)

1,326 volunteers have been examined in order to standardise the test-items for the 12 languages,” he said.

CLEAR INSTRUCTIONS The charts come in the form of a booklet with three reading cards, a card with numbers, and one with Landolt rings. It also includes clear instructions and evaluation sheets. The charts are the first to offer standardised sentence optotypes which are as comparable as possible in terms of the number of words (14 words), word length, number of syllables per word, position of words, number of characters, lexical difficulty, and linguistic aspects such as grammar and syntax, Prof Radner explained.

“These are the only reading charts that provide statistically selected and standardised test items. Only statistical analysis, together with a clear definition of the linguistic aspects of the test sentences, gives users a definite picture about the quality and characteristics of the test items used. The concept of sentence optotypes ensures equal difficulty and accurate geometric proportions of the test sentences at all print sizes,” he said.

Using sophisticated standardisation tests, Prof Radner and co-workers demonstrated that the reading charts provide reliable, reproducible, and comparable measurements of reading performance for research and clinical practice.

After their introduction into clinical use, the charts quickly found favour

among European ophthalmologists who were impressed with their ease of use, accuracy and reliability. Today the Radner Reading Chart bibliography encompasses more than 100 publications in some of the most prestigious research journals in the world. The first study with a standardised reading chart in patients with multifocal IOLs was performed with the Radner Reading Charts and published in JCRS in 2002.

The charts are also currently being used in a number of multicentre trials.

Looking to the future, Prof Radner believes that his charts will stand the test of time and that new technologies to assess near visual performance will still need standardised test items as provided by the chart.

“The standardised sentence optotypes of the Radner Reading Chart can be adopted for any technology and have already been used in a number of electronic devices. However, even the best electronic screens do not have enough resolution to sufficiently measure reading acuity below 0.4 logRAD, whereas the Radner Reading Chart can test reading acuity and speed down to -0.2 logRAD. In addition, a booklet seems to be the quicker solution for daily routine anyway. As an ophthalmologist, I always prefer the quickest and most accurate test in clinical routine and research,” he said.

Wolfgang Radner: wolfgang.radner@inode.at

CATARACT & REFRACTIVE

17

pain irritation burning dry itching MULTIFOCAL redness sore tired ey IOL STUDY dryness gritty pain irritation dry visio

Comparison of four multifocals shows good patient satisfaction.

sensitivity foreign body sensat sorie redness Your LASIK drynes irritation results speak for fatig ijouble vision themselves. rednes dryness redness sore tired ey pain irritation burning dry itching sensitivity foreign body sensat eysandy fatigue Don’t let irritation redness post-op dry eye sore eye tired talk over them. tired pain excess watering gritty san sensitivity foreign body sensat itching burning gritty excess te

Leigh Spielberg MD reports

M

ost patients who receive multifocal intraocular lens (IOL) implants can expect a good visual outcome with few long-term problems, a comparison study of four different multifocals concludes.

Orkun Muftuoglu MD, FEBO, Koç University Medical School, Istanbul, Turkey, shared the results of his study of multifocal IOLs, including three bifocal IOLs with different addition powers as well as one trifocal IOL, in a session of the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

“Multifocal IOLs were introduced to allow spectacle independence after cataract surgery. However, this introduced problems such as decreased contrast sensitivity, unwanted visual phenomena and problems with vision at various distances, particularly intermediate,” he noted.

He commented that a great deal of research has improved the design of IOLs to prevent these problems, leading to the introduction of apodization, hybrid design, aspheric design and smoothened ridges.

Dr Muftuoglu’s non-randomised, comparative, prospective trial compared the clinical outcomes of Alcon’s AcrySof ReSTOR® +2.50 and +3.00D, VSY Biotechnology’s Acriva Reviol +3.75D and Acriva Trifocal Enhanced Depth (ED), which has a +1.50D add for intermediate and a 3.00D add for near tasks.

VISUAL ACUITY

All of the IOLs included in the study were acrylic, aspheric, and single-piece with blue-light filters. “The purpose of our study was to compare the visual acuity at different distances and spherical and astigmatic defocus curves, the quality of vision, and the clinical outcomes,” said Dr Muftuoglu.

Approximately 20 patients were implanted bilaterally with each of the four lenses, for a total of approximately 80 patients with a mean age of 60 years.

Patients were asked to grade their satisfaction of uncorrected vision at distant, intermediate and near, under various lighting conditions, on a scale from one to four. All evaluations were performed at least six months after IOL implantation.

“Patients’ satisfaction with distance vision was very similar across all IOLs. While their satisfaction with near vision was better with the +3.00, +3.75 and the trifocal-ED IOL, the trifocal-ED IOL was superior regarding intermediate vision as well as spectacle independence,” noted Dr Muftuoglu.

He reported no significant difference in photopic and mesopic contrast sensitivity with and without glare between the four IOL groups. “This might be because the +3.75 and trifocal-ED IOLs have smoothened ridges at the diffractive ring transitions, designed to improve retinal image quality.”

Visual disturbances were limited, but there was a relationship between halo size and the add power of near focus, with halos being worse for those with higher power.

The opposite was true regarding glare.

“Overall, patients are satisfied with these IOLs,” he said.

Orkun Muftuoglu: orkun.muftuoglu@gmail.com

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EUROTIMES | MARCH 2017

18

CATARACT & REFRACTIVE

POSTERIOR POLAR CATARACTS Everything you ever wanted to know about posterior polar cataracts. Dr Soosan Jacob reports

P

osterior polar cataract, as the name implies, is located at the posterior pole of the crystalline lens at the nodal point. It is generally bilateral and has a unique, whorl-like appearance. It extends into the subcapsular and posterior cortical regions in the axial zone. It needs to be differentiated from the more anterior and larger, diffuse nature of a posterior subcapsular cataract, as the surgical techniques differ for each.

NODAL POINT The posterior polar cataract may be stationary, associated with hyaloid artery remnants or may be of a progressive variety. Being at the nodal point, patients with the progressive variety present early with symptoms of progressively worsening glare and difficulty in reading.

Interdigitation of the cataract with the posterior capsule causes a weakness in the capsule in the involved area.

In some cases, the capsule may be congenitally deficient. The remaining lens may be clear, associated with riders in the posterior cortex or have associated nuclear sclerosis. With dense nuclear sclerosis, the polar element may be undiagnosed, leading to intraoperative complications. Proper preoperative identification is therefore important to avoid posterior capsular rent and vitreous loss.

patient and an informed consent are important because of the increased risk associated with surgery. Adequate surgical precautions should be taken to decrease the risk of posterior capsular rent and its consequent complications. With better understanding and description of techniques, the rate of posterior capsular rent has decreased from about a third of cases to less than 10%.

WHY, HOW, WHICH? The capsulorhexis should be centred and sized to be suitable for optic capture in the eventuality of a sulcus placement of the intraocular lens (IOL). All surgical manoeuvres should be aimed at negating any stress or pressure on the weakened posterior capsule.

Hydrodissection should never be performed for posterior polar cataracts as it can cause a hydraulic perforation of the posterior capsule or enlargement of a preexisting defect, generally at the border of the cataract. I prefer instead to perform a gentle multi-quadrant, limited viscodissection by

injecting small aliquots of viscoelastic under the anterior capsule in multiple sites limited to a few millimetres beyond the rhexis and not crossing the equator.

This has the benefit of initiating a limited anterior cortical cleavage, while also acting as a barrier preventing accidental hydrodissection. A controlled hydrodelineation is then done to separate the epinucleus and the central nucleus.

The hydro cannula is inserted into the nucleus in a plane away from the height of the polar cataract so that the fluid wave from hydrodelineation does not rupture the posterior capsule.

An inside-out hydrodelineation, as described by Vasavada et al, may also be performed after gently sculpting an initial groove in the nucleus followed by injection of fluid at the desired depth in the groove. A good hydrodelineation allows the generally small and soft nucleus to be lollipopped or speared out gently with the phaco probe. Iris plane or anterior chamber phacoemulsification can then be safely performed.

INFORMED CONSENT Cataract surgery may be planned as soon as there is interference with the patient’s visual requirements. However, proper preoperative counselling of the EUROTIMES | MARCH 2017

Posterior polar cataract

Hydrodissection is contraindicated. Only hydrodelineation is performed and the golden ring is seen

CATARACT & REFRACTIVE The epinuclear shell gives additional protection during nucleus removal. Slowmotion phacoemulsification with low power, flow rate, vaccum and infusion creates a highly stable intraocular environment.

Another technique that has been described for removing soft nuclei is by first performing hydro-free dissection using a blunt spatula that is passed up to the equatorial fornix to free corticocapsular adhesions. The nucleus is then progressively debulked in the inferior half. The remaining superior nucleus is then brought to the centre with a combination of visco-displacement and manual manoeuvring and is then removed.

Though a gentle chop may be attempted for denser nuclei, care should be taken not to apply any posterior pressure.

Femtodelineation using a cylindrical pattern of laser application, as described by Vasavada et al, creates multiple concentric layers that act as shock absorbers and prevent stress transmission to the posterior capsule during surgery.

However, care still needs to be taken that the intra-lenticular gas bubbles created by the femtosecond laser do not increase intra-lenticular pressure and cause a posterior capsular rent. A capsular block syndrome may also similarly occur causing a rent.

CORTEX REMOVAL AND CHAMBER FLUCTUATIONS Chamber fluctuations can cause a dehiscence at the edge of the posterior polar cataract and this should be avoided at all times. Viscoelastic should be injected through the side port before removing the phaco or I/A probe to prevent forward movement of the lensiris diaphragm.

Cortex aspiration completed

A different case showing posterior capsular rent as cortex was attempted to be aspirated with the I/A port facing the posterior capsule

This is especially important at the time of cortex aspiration, as the chamber can shallow, and with most of the lenticular material removed, the bag can move forwards substantially while removing the I/A probe, resulting in a posterior capsular dehiscence. Cortex aspiration should be done gently and by stripping the cortex carefully, and slowly by engaging it from under the rhexis. It is helpful to partially strip and loosen the cortex from all sides before finally removing the posterior polar element, though often the plaque comes loose and can then be aspirated.

Any residual posterior capsular opacity is best left for subsequent YAG capsulotomy. At no point should the cortex be attempted to be directly aspirated from the posterior capsule, even with capsule polishing mode, as this can cause a tear in the weakened capsule.

The IOL is finally implanted into the bag, avoiding direct contact of the leading edge of the IOL on the weakened posterior capsule and taking care that it slides gently into the distal fornix. An IOL that gently unfolds in the bag is preferred.

CAPSULAR TEAR If a capsular tear does occur, a closed system should be maintained before retracting the phaco or I/A probe by injecting viscoelastic to avoid vitreous prolapse. Vitrectomy should be performed and the IOL placed into the ciliary sulcus with optic capture.

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

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EUROTIMES | MARCH 2017

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CATARACT & REFRACTIVE

ELP PREDICTION BOOST

A

New algorithm using AS-OCT parameters shows potential for increasing accuracy. Cheryl Guttman Krader reports

new algorithm incorporating novel preoperative parameters obtained by anterior segment optical coherence tomography (AS-OCT) predicts postoperative effective lens position (ELP) more accurately than established methods, reported Ikko Iehisa MD at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

The new algorithm was developed and validated in a retrospective study using data from 60 eyes. The two parameters it uses to calculate postoperative ELP are angle-to-angle (ATA) depth and the sum of the preoperative anterior chamber depth plus one-half of the crystalline lens thickness (ACD + LT/2). The values for ATA depth, ACD and LT are all measured using a new Fourier domain AS-OCT device (CASIA2, Tomey).

“Fourier domain AS-OCT allows for accurate measurements of ocular anatomical parameters at one time. By improving the prediction of the postoperative ELP, this new algorithm may increase the accuracy of intraocular lens (IOL) power calculations,” said Dr Iehisa, National Hospital Organization, Tokyo Medical Center, Japan.

The 60 eyes included in the study were all operated on by a single surgeon using a standard technique with insertion of an acrylic toric IOL (AcrySof® IQ Toric, Alcon) through a 2.2mm temporal clear corneal incision. Preoperative measurements also

included corneal thickness (CT) determined with AS-OCT, as well as axial length (AL) and corneal curvature (K) obtained with an optical biometer (OA-2000, Tomey). AS-OCT imaging was repeated at one month after surgery to measure ATA depth, CT, ELP and IOL thickness.

Using AS-OCT, ATA depth is measured as the perpendicular distance between the posterior corneal surface and the intersection point of a line joining both angle recesses on the cross-sectional horizontal image with the corneal vertex, Dr Iehisa explained.

The 60 eyes were randomised into two groups of 30 eyes each representing a training set and a validation set. There were no significant differences between the training and validation sets of eyes for any ocular, IOL, or demographic characteristics.

The training set was used to evaluate the performance of various parameters for predicting postoperative ELP and to develop a new regression algorithm for ELP prediction based on multiple linear regression analysis. A simple linear regression analysis considering five parameters – ACD + LT/2, ATA depth, ACD, AL, and LT – showed that ACD + LT/2 had the highest correlation coefficient (R=0.913) followed by ATA depth (R=0.809).

The multiple linear regression analysis showed that the combination of ATA depth and ACD + LT/2 had the strongest correlation with postoperative ELP compared with other combinations tested (ATA depth, ACD; ATA depth, AL; ACD + LT/2, AL; and ACD, AL). The coefficient of determination (R2) was 0.856 for the combination of ATA depth with ACD + LT/2, and it ranged from 0.691 to 0.829 for the four other combinations of variables.

TESTING AND ACCURACY

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The study assessed the performance of the new algorithm for predicting ELP in the validation set by determining the R2 between the measured and predicted postoperative ELP. The analyses showed that the new algorithm predicted the postoperative ELP with a higher R2 than a ray-tracing formula (OKULIX, Tomey) and two modern theoretical formulas – the SRK/T and Haigis (R2=0.830 vs 0.285, 0.379, and 0.510, respectively).

The validation set was also used to calculate the absolute ELP prediction error associated with each of the formulas. The new algorithm had a median absolute prediction error of 0.100mm, and that result was significantly smaller (P<0.001) than for the SRK/T (1.026mm), Haigis (0.336mm), and OKULIX (0.193mm).

In a previous study (Goto S, Ophthalmology.

2016;123(12):2474-2480), Dr Iehisa and colleagues reported that ATA depth was an effective parameter for predicting postoperative ACD. They had hypothesised that it would be useful because ATA depth remains unchanged after phacoemulsification and IOL implantation.

Fourier domain AS-OCT allows for accurate measurements of ocular anatomical parameters at one time Ikko Iehisa MD

EUROTIMES | MARCH 2017

Ikko Iehisa: nekohisa03@gmail.com

CATARACT & REFRACTIVE

ADVANTAGES WITH SMILE

OCULUS Easyfield® C

Small incision procedure may be as stable, more predictable than LASIK. Howard Larkin reports

S

mall incision lenticule extraction (SMILE) may be more predictable and stable for correcting myopic astigmatism than LASIK, with similar visual outcomes, Varintorn Chuckpaiwong MD told the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

In a retrospective study involving 4,881 patients treated from July 2010 through to June 2016, mean cylinder fell from -1.00 ±0.75D for 8,406 eyes before surgery to -0.25 ±0.50D for 7,288 eyes one month after undergoing SMILE for compound myopic astigmatic correction at the TRSC International LASIK Center in Bangkok, Thailand.

Mean cylinder outcomes for this group remained identical at all subsequent measurement points out to three years, including for 4,973 eyes at one year and 743 eyes at three years, reported Dr Chuckpaiwong, of Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

For a much smaller group of eyes undergoing SMILE for simple myopic astigmatism correction, results were similar, though some fluctuation was observed, Dr Chuckpaiwong said. Mean cylinder went from -2.25 ±1.50D for 85 eyes before surgery to -0.25 ±0.50D for 78 eyes one month post-op, 0.00 ±0.50D for 65 eyes at six months, -0.25 ±0.75D for 44 eyes at one year, and -0.75 ±0.00D for two eyes at three years.

Predictability was also excellent, Dr Chuckpaiwong said. At one year, cylinder was within 0.5D of intended for 88% and within 1.0D for 99% of the compound myopic astigmatism group, and 76% and 92% respectively for the simple myopic astigmatism group. These results are similar to or slightly better than SMILE and LASIK results in the literature, she added (Moshirtar M et al. J Cataract Refract Surg 2015; 41:652-665).

As for safety, 13.71% lost one line of best corrected visual acuity at one month and 7.32% lost one line at one year, while 20.38% gained one or more lines at one month, and 35.37% gained one or more lines at one year in the compound myopic astigmatism group, Dr Chuckpaiwong said. These results also are similar to LASIK outcomes.

In comparison to LASIK, SMILE shows better efficacy and predictability and also longterm stability for correcting myopic astigmatism, Dr Chuckpaiwong said. This may be because SMILE does away with the LASIK flap, which one study showed induces an average of 0.12D with-the-rule astigmatism (Huang D. J Refract Surg 2000;16:515518). She plans further analysis of her study to improve SMILE astigmatism correction.

Varintorn Chuckpaiwong: iamjeabs@yahoo.com

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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: 12 MONTH: DECEMBER 2016

ROTATIONALLY ASYMMETRIC MULTIFOCAL IOLS While rotationally asymmetric refractive multifocal intraocular lenses (IOLs) have been found to provide a good range of vision from near to intermediate to distance, there has been no consensus on the best choice for position and power of the near add reading segment. Researchers looked at this question in a retrospective comparative case series that compared the postoperative quality of vision between different bilateral placements of the near segments in these types of IOLs. The study of 180 patients (360 eyes) indicated that a combination of superotemporal placement of the near segment (+2.00D add) in the dominant eye with inferonasal placement of the near segment (+3.00D add) in the fellow eye yielded the most consistent, high overall quality of vision and uncorrected visual acuity. RN McNeely et al, JCRS, “Comparison of the visual performance and quality of vision with combined symmetrical inferonasal near addition versus inferonasal and superotemporal placement of rotationally asymmetric refractive multifocal intraocular lenses”; Volume 42, Issue 12, 1721-1729.

VISUAL FUNCTION AFTER TRIFOCAL IOLS

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 | MARCH 2017

Patients receiving trifocal IOLs report better visual function than those receiving monofocal IOLs, according to data gathered from a new Spanish language version of the Catquest-9SF survey instrument. Some 300 patients completed the questionnaire before and three months after the surgery. Patients were asked about changes in visual function and satisfaction with vision after surgery. Patient-reported improvement in visual function was statistically significantly better for those with trifocal IOLs. M Lundström et al, JCRS, “Validation of the Spanish Catquest-9SF in patients with a monofocal or trifocal intraocular lens”; Volume 42, Issue 12, 1791-1796.

ACCELERATED CXL Corneal crosslinking (CXL) is now widely used to halt the progression of ectatic diseases. Newer protocols attempt to increase the speed of the procedure by reducing the illumination time and increasing the irradiation intensity. In a review article, researchers discuss the new accelerated CXL protocols and compare the efficacy and safety of accelerated CXL with conventional methods. The reviewers report that, although the follow-up is short, accelerated CXL does appear to be a safe and effective method for halting the progression of ectasia.

The shortest exposure time used to halt keratoconus progression was three minutes at 30mW/cm2. Corneal shape responses to accelerated CXL varied considerably, as did the demarcation line at different irradiance settings and elevation changes. They conclude that by altering stroma farthest from the endothelium, accelerated CXL could be a safe option for treating thin corneas. CS Medeiros et al, JCRS, “Accelerated corneal collagen crosslinking: Technique, efficacy, safety, and applications”; Volume 42, Issue 12, 1826-1835.

THOMAS KOHNEN European editor of JCRS

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24

MEETING REPORT

Maastricht 2017 HISTORIC EVENT 21ST ESCRS WINTER MEETING

Maastricht a successful host city for the 21st ESCRS Winter Meeting.

Colin Kerr reports

POSTER AWARD WINNERS

Pictured at a welcome reception for the 21st ESCRS Winter Meeting in Maastricht (left-right): David Spalton, ESCRS president; Mr Janssen, deputy mayor of Maastricht; and Rudy Nuijts, ESCRS treasurer and president of the Netherlands Intra Ocular Implant Club

F

or the first time in its history, the ESCRS convened its Winter Meeting in The Netherlands in February, an event which was attended by close to 1,000 delegates.

While The Hague and Amsterdam had previously hosted the annual ESCRS Congress, Maastricht had the honour of being the first Dutch city to host the Winter Meeting.

“The Netherlands is a country with a particularly important place in cataract and implant surgery, as without the pioneering work of Cornelius Binkhorst, intraocular lens implants may never have got off the ground,” said ESCRS President David Spalton.

Prof Spalton said the ESCRS was very pleased to join colleagues from the Netherlands Intra Ocular Implant Club EUROTIMES | MARCH 2017

and the Belgian Society of Cataract and Refractive Surgeons for the important event.

The annual Cornea Day was organised in conjunction with EuCornea and Prof Spalton thanked EuCornea for their continued participation in the meeting.

The scientific programme included an extended didactic programme, with courses in basic optics, cataract, refractive surgery and cornea. The Young Ophthalmologists Programme was very well attended and the YO Committee also organised an interesting symposium on the topic ‘The Usual Suspects: How to Handle Your First Complications’.

A live surgery session, organised by Prof Rudy Nuijts and his colleagues at the Maastricht University Medical Centre, proved a major highlight of the meeting. There was also an interesting symposium on ‘Contributions of the Low Countries to Ophthalmology’.

The winners of the poster awards at the 21st ESCRS Winter Meeting in Maastricht provided comparisons of newer technologies with older technologies, to test whether they fulfilled in practice the advantages they promised in theory.

First place in the refractive category went to Aashish Kumar Bansal, India, for ‘Comparison of efficacy, safety and visual quality of SMILE and LASIK for myopia and myopic astigmatism’. His presentation described the outcomes in 152 eyes of 76 patients who underwent LASIK, and 204 eyes of 102 patients who underwent small incision lenticule extraction (SMILE).

The study showed that the two groups had similar results with regard to visual acuity, with 90.68% and 92.76% achieving 6/6 (p>0.5). However, only 14.4% of patients in the SMILE group complained of glare at night, compared to 19.6% in the LASIK group (p<0.05).

Tushar Agarwal, India, took the award in the cataract category for ‘Comparison of IOLMaster 500 and Lenstar 900 for IOL power calculation in paediatric cataract surgery’. His study compared the two optical biometers in 67 eyes of 38 paediatric cataract patients aged four to nine years. It showed that there was no significant difference between the axial length and keratometry readings with the two devices.

There was also no significant difference between the devices in terms of the postoperative refractive error in the outcomes with two devices when using the the MAE using SRK II, SRK T, Holladay I and Hoffer Q IL calculation formulas.

Aashish Kumar Bansal, winner in the refractive category

Tushar Agarwal, winner in the cataract category

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25

CORNEA

KERATOPLASTY OPTIONS Despite the transformation in recent years, there is still room for PK in corneal transplantation. Dermot McGrath reports

W

hile the field of corneal transplantation has been transformed in recent years by the introduction of lamellar keratoplasty (LK) techniques, there are still indications where traditional penetrating keratoplasty (PK) may provide better optical or therapeutic results, according to Pierre Fournié MD. “Although LK has gained popularity over the past few years, PK remains a commonly performed transplantation technique in eyes with both anterior and posterior corneal disease, and is now limited to use in diseases where the benefit of replacing all the diseased tissue will provide the best optical or therapeutic results compared with LK,” Dr Fournié told delegates at a joint EuCornea-ESCRS symposium during the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

The advantages of PK include the fact that it is an established standardised technique with a short operation time and a long-term follow-up available in the scientific literature, said Dr Fournié, University Hospital Toulouse, France. The disadvantages of PK include the fact that it involves working on an open eye with the risk of expulsive haemorrhage, suture complications, high and irregular astigmatism, endothelial immune reaction, and idiopathic chronic endothelial cell loss which may result in late graft failure, he added.

These drawbacks help to explain the rise of LK, which offers increased postoperative structural stability, reduced astigmatism, reduced rehabilitation time, reduced immunological graft rejection and increased graft survival time for many indications.

...PK remains a commonly performed transplantation technique in eyes with anterior and posterior corneal disease...

Pierre Fournié MD Nevertheless, PK remains a useful option for certain indications such as full-thickness corneal scars (see Figure 1) because of abnormalities involving all layers of the cornea, severe corneal trauma, or after the resolution of infectious keratitis involving all layers of the cornea, said Dr Fournié.

“Corneal imaging (see Figure 2) is also very useful in some cases to assess corneal thickness and the depth of the diseased cornea to help us choose between different techniques,” he added.

For paediatric keratoplasty, most indications now call for lamellar procedures, said Dr Fournié, with some notable exceptions including Peters anomaly or sclerocornea.

“In such cases PK can be very useful and successfully restore corneal transparency and visual function, even if we still have some concerns about the long-term graft survival,” he said.

He noted that paediatric keratoplasty should be performed as soon as necessary to correct amblyopia but as late as possible to ensure better patient cooperation and reduced complications.

“We know that we have decreased graft survival with young patients and especially for children under the age of five and especially during the first 24 months,” he said.

Beyond paediatric keratoplasty, PK is also the preferred procedure in cases where a temporary keratoprosthesis has been

used for retinal detachment repair. The prosthesis is replaced with a PK graft after completion of the retinal procedure which usually works quite well, he said.

Although lamellar techniques such as Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane endothelial keratoplasty (DMEK) are now preferred for most diseases involving endothelial dysfunction, PK may still be an option for certain indications, said Dr Fournié.

He cited examples such as eyes with long-standing chronic corneal oedema and significant corneal scarring, and particularly cases of diffuse corneal stromal opacity. PK may also be an option in ‘complicated’ eyes such as those with open communication between the anterior and posterior segments (large iridectomy and aphakia).

Although deep anterior lamellar keratoplasty (DALK) is now the preferred technique in keratoconus, some exceptions where PK might be employed include posthydrops cases when Descemet’s membrane cannot be bared, with central corneal scarring or persistent corneal oedema (see Figure 3). PK can also be used in eyes with concomitant keratoconus and endothelial abnormality such as Fuchs’ dystrophy or posterior polymorphous dystrophy, concluded Dr Fournié.

Figure 2: Keratitis scar involving the entire cornea on OCT with corneal thinning

Figure 3: Persistent corneal oedema after hydrops

Pierre Fournié: fournie.p@chu-toulouse.fr

Courtesy of Pierre Fournié MD

26

Figure 1: Full-thickness corneal scar

EUROTIMES | MARCH 2017

CORNEA

DRY EYE AFTER LASIK Neurotrophic epitheliopathy is hard on patients and difficult to treat.

Leigh Spielberg MD reports

E

veryone who performs corneal refractive surgery knows that LASIK-associated dry eye is a major cause of patient dissatisfaction in the early postoperative period. But what about LASIK-induced neurotrophic epitheliopathy (LINE), which can result in a very unhappy patient many months after the surgery?”

This question was posed by Renato Ambrósio Jr MD, PhD, Affiliated Professor of Ophthalmology at the Pontifical Catholic University of Rio de Janeiro and Federal University of São Paulo, Brazil, at a symposium during the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

It has been known since 2000 that the decrease, and subsequent return, of corneal sensation can be objectively measured using an esthesiometer, while regrowth of the nerves’ normal morphology can be documented with confocal microscopy. However, there are cases with long-term corneal sensitivity deficits after LASIK that do not recover for a much longer period. This is the situation in patients suffering from LINE, said Dr Ambrósio.

Because of the challenge that treating LINE may impose, the initial focus should be on the prevention. Proper selection of the refractive procedure according to the patient avoids exacerbating pre-existent dry eye, which can worsen the symptoms of LINE. “Pre-existing tear dysfunction syndrome is a major risk factor for severe postoperative dry eye. This is very common, because patients who have difficulty wearing contact lenses self-select for refractive surgery,” he warned.

The surgeon should be alert to the preoperative examination since the complaint profile and anamnesis. In addition, clinical Renato Ambrósio Jr evaluation should include ocular surface imaging, such as with the OCULUS Keratograph®, which allows for assessing tear film stability, the Meibomian glands and blinking dynamics. “Vital dyes, including fluorescein and Rose bengal or lissamine green, are important. We also found trypan blue to be very effective for examining the corneal and conjunctival surface,” said Dr Ambrósio.

How can we minimise trauma to corneal nerves during refractive surgery? When performing LASIK, a thinner flap with lower diameter and larger hinge will reduce the impact on the corneal nerve fibres, he advised.

The small incision lenticule extraction (SMILE) procedure also has a lower impact on corneal nerves than LASIK, as there is no flap cut. He shared data that showed that corneal sensitivity is less affected and returns to baseline faster after SMILE. But what of the patients in which LINE has been diagnosed? His advice is to approach the condition with a comprehensive strategy, starting with patient education about this frustrating disorder.

“Prescribing BAK-free artificial tears is important. Also, oral Omega-3 EFA supplementation with flaxseed and/or fish oil capsules, topical cyclosporine 0.05% and dexpantenol gel work well. In severe cases, autologous serum is needed,” he said.

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Renato Ambrósio Jr: dr.renatoambrosio@gmail.com EUROTIMES | MARCH 2017

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CORNEA

FAB TREATMENT Finger-prick autologous blood relieves refractory dry eye.

Roibeard O’hEineachain reports

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droplet of blood from a pricked finger applied directly to the eye can relieve the symptoms of dry eye disease and persistent epithelial defects unresponsive to conventional therapy, according to the findings of a pilot study presented by Shafi Balal MD at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

The senior author and supervising consultant for the study is Mr Anant Sharma, of Moorfields Eye Hospital, London, UK. Dr Balal, also of Moorfields Eye Hospital, noted that the finger-prick autologous blood (FAB) treatment probably works by the same mechanisms as other blood-derived products, such as autologous serum and platelet-derived plasma, which have been shown to be effective for the same indications in clinical trials. However, those treatments have not been widely adopted owing to the expense and time involved in producing the blood products.

In contrast, FAB involves almost no expense and simply requires patients to trim their fingernails, wash their hands, sterilise their finger with an alcohol steret and prick it with a diabetic lancet, then apply a drop of blood directly from their fingertip to the lower fornix of each affected eye, he said.

DRAMATIC RELIEF Dr Balal reported a study involving 12 patients with dry eye syndrome and three patients with non-infective persistent epithelial defects. All underwent FAB treatment four times daily for eight EUROTIMES | MARCH 2017

weeks and then were followed for a further four weeks.

Prior to undergoing FAB treatment, the patients with dry eye all had tear breakup time (TBUT) of less than five seconds and Schirmer without local anaesthetic of less than or equal to 5mm, or punctuate fluorescein staining of ocular surface or an ocular comfort index (OCI) score of higher than 80%. In addition, all had tried cyclosporine and punctal plugs or refused the treatments. The patients with non-infective persistent epithelial defects had a duration of at least two weeks and their corneal lesions had failed to decrease in size with conventional therapy, or had not resolved after four weeks of conventional treatment.

After eight weeks FAB treatment, the patients’ mean Oxford corneal staining grade improved from 3.67 to 2.33 (p<0.0001), tear break-up time increased from 5.24 seconds to 7.71 seconds (p<0.001) and OCI score improved from 53.17 to 27 (p<0.001). There were also improvements in mean visual acuity and Schirmer’s scores but these did not reach statistical significance. There were no complications or adverse events.

Four weeks after treatment cessation, mean Oxford staining grade, OCI and TBUT scores all worsened. However, persistent epithelial defects had resolved after one month of treatment in two of three patients, Dr Balal said.

MANY PRACTICAL ADVANTAGES Several peer-reviewed studies have shown autologous serum to be effective in a range of corneal conditions. The treatment’s current indications include

limbal stem cell deficiency, recurrent erosion syndrome, diabetic keratopathy, and graft vs. host disease.

Barriers to wider adoption of autologous serum include the initial cost of €1,900 and then €450 per month. There is a delay in obtaining funding and there can be a delay in production of drops, since not all laboratories perform the necessary processes on blood products. Moreover, patients have to store the product in the refrigerator at home.

“Fingertip autologous blood possesses several theoretical advantages over autologous serum. Its costs are limited to the purchase of alcohol sterets and diabetic lancets and it requires no storage whatsoever,” Dr Balal said.

He noted that, although the treatment must be maintained over the long-term in dry eye, patients using FAB for the indication are highly motivated to continue their therapy by the relief it provides.

He added that he and his associates are researching the possibility of using less painful lancets.

In addition, plans are under way for a randomised controlled trial recruiting patients from several centres across the UK and also extending their recruitment indication to patients with Meibomian gland dysfunction, Dr Balal said.

“FAB is an alternative low-cost, readily accessible treatment for dry eye syndrome, and also for persistent epithelial defects,” Dr Balal concluded.

Correspondence to Anant Sharma: anant.sharma@bedfordhospital.nhs.uk The authors also acknowledged Moorfields NIHR BRC for support

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GLAUCOMA

ADOPTING MIGS DEVICES Research and practice are keys to successfully adding new devices and techniques. Howard Larkin reports

Corn

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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

W

ith new minimally invasive glaucoma surgery (MIGS) devices emerging every year, prospects for better serving patients have never been better. But successfully adding a new procedure to your practice requires homework, Juan F Batlle MD told Glaucoma Day at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. “The first thing to do is to read about it,” said Dr Batlle, of the Dominican Republic, who was the international guest speaker at the meeting. One of the best information sources is the US FDA. “The FDA is being very cooperative in development of the new MIGS technologies. So we have data that is very accurate in terms of complications, adverse events and things that can go wrong,” Dr Battle said.

Secondly, Dr Batlle recommends watching videos. “YouTube and Eyetube are great. You can see videos from Ike Ahmed or Doug Rhee or Davinder (Grover) or (Steven) Sarkisian, who are actually using these techniques now.”

Implanting MIGS devices such as microshunts or even Schlemm’s canal stents is generally not as complex as cataract surgery, but proper technique is critical, Dr Batlle noted.

“Usually it’s creating a channel through which you introduce the device. If you have the right optics and illumination you will be able to succeed every time, but you have to be knowledgeable,” he said.

Finally, Dr Batlle recommends getting a mentor and practising. “There are tricks to everything, and unless you have someone there with you to observe what you are doing and say, ‘No, don’t do it there’, you can run into trouble.”

For example, in cannulating Schlemm’s canal, Dr Batlle has seen even glaucoma experts have problems. “Things all look the same - the pigment in front of Schwalbe’s looks like Schlemm’s, or it’s behind Schwalbe’s so you end up going higher, higher, higher because people want to put it way back in the trabecular meshwork. So have someone coach you,” he said.

Fortunately, mistakes with MIGS devices usually are not serious, Dr Batlle added. “We have never lost an eye, we have always succeeded in Schlemmʼs canal. The worst that can happen is you don’t lower the intraocular pressure and you have to do it again.”

Still, even a world-class surgeon like Dr Batlle needs practice. He recalls an Ivantis wetlab in Amsterdam introducing the Hydrus Microstent. “I was the only one there… I did 95 insertions of the Hydrus into cadaver eyes before I got it down.”

Juan F Batlle: jbatlle55@gmail.com

EUROTIMES | MARCH 2017

We have data that is very accurate in terms of complications, adverse events and things that can go wrong Juan F Batlle MD

GLAUCOMA

IMPROVING EFFICIENCY Shared care can optimise management of glaucoma patients.

Roibeard O’hEineachain reports

S

trategies involving enhanced EVIDENCE-BASED MANAGEMENT technical training of nonBased on evidence from the literature physicians can improve efficiency and the European Glaucoma Society’s and reduce waiting times for guidelines, Dr Stalmans and her associates patients with glaucoma, according designed an approach to optimising to Ingeborg Stalmans MD, PhD, care delivery for glaucoma patients that University of Leuven (KU Leuven), Belgium. involved training and certifying non“Shared care can improve quality and physician personnel, such as optometric increase capacity, and provides a better costtechnicians, who then run the Glaucoma benefit ratio. It also improves satisfaction at Post, a parallel consultation they all the levels, from patient to employee to introduced in 2012. the specialist,” Dr Stalmans told the 12th “The aim is to focus the expertise European Glaucoma Society Congress in of glaucoma specialists on the newly Prague, Czech Republic. diagnosed and unstable patients to reduce She noted that efforts she and her waiting times for appointments for associates have undertaken to streamline newly referred patients and research the triage process in apportioning the optimal medical treatment care in glaucoma have resulted sooner,” she said. in shorter waiting times and The examinations they more patients being treated. perform include visual She added that optimising acuity testing, intraocular care for glaucoma is taking pressure measurement, visual on increasing importance field examination, optic as the world’s population disc and nerve fibre layer grows and ages. The estimated imaging (Heidelberg Retinal number of glaucoma patients Tomography/HRT), optical worldwide will rise to 76 million Ingeborg Stalmans coherence tomography and optic in 2020 and to 112 million in 2040. disc photographs. Based on preThat, in turn, will lead to capacity set criteria, the specially trained saturation, which could in turn result in personnel make a decision of whether they patients being diagnosed and treated too warrant further examination. late to prevent the risk of blindness during “They don’t need to do subjective their lifetime. interpretations of these tests, they just The task is therefore not only to ensure have to check whether the patients that patients get the treatment they require pass these objective criteria or not,” Dr but also to ensure that resources are not Stalmans said. wasted on patients who are not yet diagnosed If a patient fails in any of the preset and may not be at risk of blindness during parameters, their chart is sent to the their lifetime, Dr Stalmans emphasised.

ESCRS

Glaucom� Day 2017

specialist who then decides whether it is necessary to see the patient at that point.

The glaucoma specialist gives feedback to the person at the Glaucoma Post, helping them to improve their expertise, she noted.

“It is very important that these people get a continuous learning process and this is very well appreciated by them as well,” she said.

They validated the system based on some key performance indicators in a review of the charts since the introduction of the Glaucoma Posts in 2012. For example, they found that after just one year the number of patients they saw at their outpatient clinics rose from 6,000 to 8,000.

In addition, the waiting time for first appointments fell from four-and-a-half months to two-and-a-half months. The number of glaucoma surgeries also increased.

SHARING IDEAS She noted that many centres have mobilised in this way to improve the efficiency of glaucoma care. In addition, several members of the World Association of Eye Hospitals (WAEH) convened to compare their approaches.

Their analysis revealed many similarities and many differences in their approaches. However, based on the evidence, they reached a consensus that the availability of specific training is really crucial to success. The sharing of ideas and experience should also be continuous, Dr Stalmans said.

Ingeborg Stalmans: ingeborg.stalmans@mac.com

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EUROTIMES | MARCH 2017

31

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INDUSTRY NEWS

INDUSTRY

NEWS

WAVEFRONT ANALYSIS NIDEK has announced the launch of the OPD-Scan III VS Refractive Power/Corneal Analyzer.

“The OPD-Scan III VS is an aberrometer providing optimal and facilitated eyeglass prescription with detailed measurement data,” said a company spokesman. “This device mainly measures corneal shape (topographer) and refractive error (refractometer). It clarifies causes of vision difficulties through wavefront analysis of information measured over a wide area,” he added.

The three kinds of easy-to-understand reports displayed on a tablet allow simple explanation of examination results. The Basic Information Report is useful for a general overview of patients’ eye conditions.The Simulation Report offers visual performance simulations and MTF graphs for a variety of conditions. The Eye Diagram Image Report helps to visually understand eye conditions ranging from eye fundus to cornea with the eye model.

The NIDEK spokesman also pointed out that the tablet is not included or sold with the OPD-Scan III VS. www.nidek-intl.com

JOINT VENTURE

Jyoti Gupta

NEW PRESIDENT Volk Optical has appointed Jyoti Gupta PhD to the position of president, following the move of long-time Volk president Pete Mastores to the position of chief commercial officer on Volk’s board.

“In her new role, Dr Gupta will be responsible for leading Volk Optical, providing strategic and tactical direction to support the future growth of Volk’s global sales and operations,” said a company statement announcing the appointment. www.volk.com

Heidelberg Engineering and its long-time distribution partner in China, Gauss Medical Corporation, have established a joint venture for the supply of healthcare IT solutions to the Chinese ophthalmology market.

The joint venture company will offer picture archiving and communication systems (PACS) and electronic medical record (EMR) software.

“The establishment of this joint venture with Heidelberg Engineering comes at a time of growing demand for advanced ophthalmic IT solutions in China,” said Mr Liu Xidong, chairman and CEO of Gauss Infomed. www.heidelberg engineering.com

€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

EUROTIMES | MARCH 2017

33

ESCRS NEWS

Manish Mahabir receives the John Henahan Prize from ESCRS President David Spalton at the XXXIV Congress in Copenhagen, Denmark

ESCRS

NEWS

JOHN HENAHAN PRIZE CALL FOR ENTRIES Entries are now being invited for the 2017 John Henahan Writing Prize. The topic for the essay is ‘How does commercial interest affect my career?’

The judges will draw up an initial shortlist of the five best essays submitted and will then decide on the winning essay.

The competition is open to ophthalmologists who are members of the ESCRS and aged 40 years or under on 1 January 2017. The winner of the prize will receive a €1,000 travel bursary to the XXXV Congress of the ESCRS in Lisbon, Portugal.

Entries should be 850 words and should be sent to Colin Kerr, EuroTimes Executive Editor, in Microsoft Word document format to: henprize@eurotimes.org. The closing date for entries is Friday, 31 March 2017. For further information visit: www.escrs.org

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) 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

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

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

For further details on the material to be submitted in your application, see: http://www.escrs.org/ about-escrs/ESCRS-PeterBarry-Fellowship.asp

EUROTIMES | MARCH 2017

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ASCRS

BOOK REVIEWS

RETINA: CONCISE, PRACTICAL ANSWERS

BOOK

REVIEWS

MANAGING DIABETIC RETINOPATHY New books about the retina offer comprehensive insights for general clinicians and specialist researchers alike.

Clinical Strategies in the Management of Diabetic Retinopathy is a little gem of a book. Published

by Springer and edited

by Francesco Bandello PUBLICATION and colleagues, it is a CLINICAL STRATEGIES IN practical and informative THE MANAGEMENT OF text intended to guide DIABETIC RETINOPATHY the clinician in day-toEDITORS day decision-making.

FRANCESCO BANDELLO, This is not a theoryMARCO ATTILIO ZARBIN, dense textbook, so don’t ROSANGELA LATTANZIO, expect long treatises on ILARIA ZUCCHIATTI the disease’s pathogenesis.

PUBLISHED BY SPRINGER Instead, it is a distillation of what’s currently known about the evaluation and management of diabetic retinopathy (DR) and diabetic macular oedema (DME). Each chapter includes proposed therapeutic algorithms as a simple overview.

With so many studies being published on DR and DME, it’s almost impossible to keep up with the most recent advances. At just over 150 pages,

the book brings it all together. Although Chapter 1 spends 18 pages covering the epidemiology, risk factors and pathophysiology, Chapters 2 through 5 get to the core of what we might have forgotten but nevertheless need to know.

Chapter 2, on non-proliferative diabetic retinopathy, is most interesting when discussing the ever-evolving algorithms for screening and treatment. Chapter 3, on DME, reviews the well-known classification criteria, but then moves on to more recent advances in treatment, citing the most substantial studies to date and serving as a refresher on topics such as differences between vasogenic and non-vasogenic DME. The sub-heading ‘Factors associated with favourable response to the therapy’ was particularly enlightening.

Chapter 4 covers proliferative DR, doing so in a highly illustrated fashion and instructing the reader primarily by means of imaging examples.

These are designed to show the typical appearance of correctly applied laser treatments. In case of late presentation or treatment failure, Chapter 5 moves on neovascular glaucoma, tractional retinal detachment and other clinical nightmares, generally advising referral to a vitreoretinal surgeon.

This book is intended for ophthalmology residents, medical and surgical retina fellows, and general ophthalmologists who treat DR and DME.

OCT-ANGIOGRAPHY – A HOT TOPIC Optical coherence tomography-angiography is a hot topic right now. To see what all the fuss is about, consider picking up a copy of the Clinical OCT Angiography Atlas, which is published by Jaypee and edited by Bruno Lumbroso and colleagues. As its name implies, this is a true atlas, with a wealth of high-quality images forming the focus of one’s attention.

The images are properly annotated, allowing the reader to progress step-by-step through the process of learning to use this new imaging technique. The first section is essential to the newcomer, as it covers the technology behind the device as well as the methods used to interpret the images.

The rest of the atlas goes straight to the clinical images of the most common diseases, with the most attention given to age-related macular degeneration (AMD) and other choroidal neovascular membranes, central serous chorioretinopathy, macular telangiectasia, vascular occlusions, diabetic retinopathy, pathologic myopia and various others.

This book is recommended for the curious minds within the ophthalmology community and anyone whose practice has been lucky enough to acquire an angio-OCT.

“Are you looking for concise, practical answers to those questions that are often left unanswered by traditional references of the retina?” asks the back cover of Curbside Consultation in Retina: 49 Clinical Questions. If so, this book – published by Slack and edited by Sharon Fekrat and colleagues – is the book for you.

The book is structured in question-answer form, and actually, the questions resemble those that the residents in my university hospital ask my colleagues and me on a daily basis. Examples include: ‘What are some tips to differentiate visual loss from retinal disease versus cataract?’; ‘How do I manage lattice degeneration?’; and ‘How do I follow a patient with a presumed choroidal nevus?’

These are questions whose answers would require an entire evening to find in traditional texts, and here they are, 49 of them fully answered in four pages or less.

This book is intended for residents, general ophthalmologists and those who, like me, need to know the answers to questions that the residents ask us every day.

RESEARCH ON RETINAL DEGENERATIVE DISEASES For researchers, Retinal Degenerative Diseases: Mechanisms and Experimental Therapy, published by Springer, is an 800page tome containing the proceedings of the XVI International Symposium on Retinal Degeneration. Edited by half a dozen experts, this scientific compendium covers experimental and research topics that happen behind the scenes in the ophthalmology world.

Although most clinicians have never heard of most of the molecules, genes and mutations covered in this book, several chapters caught my attention, primarily because I could understand their titles: ‘Therapeutic approach of nanotechnology for oxidative stress induced ocular neurodegenerative diseases’, for example.

Most of the sections cover specific disease types, such AMD, macular dystrophies and inherited retinal degenerations, while others focus on the research conducted into specific therapeutic modalities. Others have grouped the most recent research into specific retinal cell layers such as the retinal pigment epithelium.

This book is intended for full-time retinal researchers, or clinicians participating in clinical trials who want more insight into retinal research.

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

EUROTIMES | MARCH 2017

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38

EXPLORING LISBON

The Tagus River from the MAAT entrance

LISBON

3

TO NOTE...

LISBON

LANGUAGE: PORTUGUESE, ENGLISH WIDELY SPOKEN COUNTRY CODE: +351 TIME ZONE: GMT (NO GMT OFFSET) The Calouste Gulbenkian Museum is the undisputed star of Lisbon’s museums. It’s home to a treasure trove of some 6,000 works of art collected by the Armenian billionaire whose motto was ‘only the best’. The collection ranges through time and across borders - some of the work was acquired during the Soviet sale of Hermitage paintings.The museum’s landscaped park, main building and the neighbouring but lesser-known Modern Art Centre were designated a national monument in 2010.

English language guided tours of works in the ‘Founder’s Collection’ are included in the price of a ticket and do not have to be pre-booked.

Tickets can be bought online. São Sebastião is the most convenient metro station.

Website: gulbenkian.pt/museu/en In the early 1900s, the ophthalmologist Anastacio Gonçalves, influenced by his friend and patient Calouste Gulbenkian, began acquiring fine art. In 1935 he bought a neoromantic house from the artist José Malhoa in which to exhibit his finds. On his death in 1964, his extraordinary collection and the house in which it is displayed were bequeathed to the Portuguese state and became the present ‘house-museum’. In addition to paintings

by Portuguese artists including Malhoa, the museum showcases Chinese ceramics from the Ming and Qing dynasties. Casa-Museu Dr. Anastacio Gonçalves (www.blogdacmag. blogspot.pt) is at Av. 5 de Outubro, 6-8, near the Saldanha Metro Station. Open on Tuesday 14.00-18.00, Wednesday to Sunday 10.00-18.00.

The Pavilion of Knowledge is a happy legacy of Expo ’98. An interactive science museum near the Oceanarium in the Park of Nations, it enchants and intrigues people of all ages.

Many of the world’s major scientific institutes contribute to the thematic presentations which change from time to time. On a recent visit options included riding a counterweighted bike on a high wire suspended over a gallery (full disclosure: there was a net), confronting challenging optical illusions and solving brain-teasing puzzles.

Website: www.pavconhecimento.pt

EUROTIMES | MARCH 2017

LISBON’S MUSEUMS

Delegates to the XXXV ESCRS Congress will find some great museums in the city. Maryalicia Post reports Lisbon’s newest museum, the Museum of Art, Architecture and Technology (MAAT), sits on the shore of the Tagus River like a giant half-opened clam. The work of Amanda Levete, a Stirling Prizewinning British architect, the building is partially underground, and its roof is an upwardly sloping piazza from which to enjoy marvellous river views.

Sharing the riverside campus, and now part of the MAAT, is the old Tejo Power Station. Its historic electricity-generating machinery remains, joined by four new white-box galleries. Under the curatorship of artistic director Pedro Gadanho, formerly with New York’s Museum of Modern Art, MAAT’s ‘soft opening’ was in October 2016.

The museum will be fully functioning by mid-2017. Plans for the future include a footbridge over the highway to link the MAAT to downtown Belém, as well as a restaurant and a park. The MAAT is closed on Tuesdays. For further details check the MAAT website: www.maat.pt/en A 10-minute walk inland from the MAAT are the new premises of Lisbon’s famed National Coach Museum. In May 2015, after more than 100 years in the royal riding school, the collection moved diagonally across the street to a starkly modern concrete structure designed by Pritzker Prize winner Paulo Mendes da Rocha.

The collection includes elaborate vehicles, dress uniforms, harnesses and cavalry accessories that were principally for the use of the Portuguese royal family, but the standout is the Coche dos Oceanos (Oceans Coach) which King João V sent to the Pope in 1716. Follow your visit with a drink or a light meal on the terrace or indoors at the museum’s cafe.

Browse the museum shop and then cross over to the old riding school. Although all

but a few of the exhibitions have been moved to their new accommodation, the old, highly decorated hall and portrait gallery are open.

A combination ticket admits you to both.

Website: museudoscoches.pt The Museu Coleção Berardo, inaugurated in 2007, is located at the Exhibition Centre of the Centro Cultural de Belém, next to the cathedral. The superb collection of over 1,800 works of modern and contemporary art was amassed by Joe Berardo, a Portuguese businessman and one of the wealthiest people in Portugal.

Some 250 artworks are exhibited at any one time, over two floors of galleries.

The collection includes paintings by artistic giants such as Marcel Duchamp, Salvador Dalí, Andy Warhol and Francis Bacon along with two Picassos. Open every day, 10.00-19.00. General admission is free, though temporary exhibits may require a ticket. Website: www.museuberardo.pt

A bike on a wire at the science museum

CALENDAR

↙

LAST CALL

MARCH 2017 31st International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 2–5 March Athens, Greece www.hsioirs.org/index.php/en

Leuven Retina Meeting 2017 9–11 March Leuven, Belgium www.leuvenretinameeting.eu

3rd OCT San Raffaele Forum 17–18 March Milan, Italy www.octforum2017.eu

8th World Congress on Controversies in Ophthalmology (COPHy)

Paris, which will host SFO 2017 in May

APRIL

AAPOS Annual Meeting

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

NEW 3rd ESASO Anterior Segment Academy

21–22 April Barcelona, Spain http://www.esaso.org/ 3rd-anterior-segment-academy-2017

JUNE

SOE 2017

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

World Glaucoma Congress

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

JULY

MaculArt Meeting

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

FLOREtina 2017

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

NEW

MAY

ASRS Annual Meeting 2017

31 March–1 April Barcelona, Spain www.imo.es/BOC

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

↙

3rd Barcelona Oculoplastics, Trends in Eyelid Surgery

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

MediterRetina Club International Meeting 11–13 May Parma, Italy www.mediterretina.com

JUNE

30th APACRS Annual Meeting

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

AUGUST

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

SEPTEMBER

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

NEW Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 11–15 September Vienna, Austria www.echography.com

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

EUROTIMES | MARCH 2017

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40

CALENDAR

SEPTEMBER

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

3rd European Congress on Ophthalmic Imaging: From Theory to Current Practice 13 October Paris, France http://www.vuexplorer.fr/media/ document/201612221657-2017congress-announcement.pdf

Barcelona, host city of the 17th EURETINA Congress later this year, as well as WOC 2018

NOVEMBER

2018

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

WOC 2018

AAO 2017

JUNE

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

DECEMBER

4th World Congress of Paediatric Ophthalmology and Strabismus

SEPTEMBER

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

1–3 December Hyderabad, India wspos.org/india-2017

Hyderabad, host city of the 4th WCPOS

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

Eye Contact Interviews

l

Video of the Month

l

Video Journal of Cataract & Refractive Surgery

l

Young Ophthalmologists Videos: “My Early Surgeries”

l

Online Museum

player.escrs.org EUROTIMES | MARCH 2017

SEPTEMBER

9th EuCornea Congress

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

XXXVI Congress of the ESCRS 22–26 September Vienna, Austria www.escrs.org

LISBON2017 7–11 OCTOBER XXXV CONGRESS of the ESCRS

FIL – Feira Internacional de Lisboa, Portugal

Scientific Programme, Registration & Hotel Bookings

www.escrs.org