EuroTimes Vol. 23 - Issue 2 by EUROTIMES

SPECIAL FOCUS NEW IOLS CATARACT & REFRACTIVE

FLEX AND SMILE VS LASIK â&#x20AC;&#x201C; THE LATEST

CORNEA

TISSUE-ENGINEERED CORNEAS SHOW PROMISE

RETINA

February 2018 | Vol 23 Issue 2

SEARCH CONTINUES FOR EFFECTIVE DRY-AMD TREATMENT

CETUS NANO-LASER

Laser Cataract Surgery

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* J Cataract Refract Surg. 2016 May;42(5):725-30. doi: 10.1016/j.jcrs.2016.02.039. Tanev I, Tanev V, Kanellopoulos AJ. Nanosecond laser-assisted cataract surgery: Endothelial cell study.

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg 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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CATARACT & REFRACTIVE LENS 4 Dr Soosan Jacob covers the wide range of modern lenses

6 Can more accurate results for toric IOL calculations be obtained using mathematical models?

8 An add-on multifocal 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

lens has restored near vision without sacrificing distance

9 One novel IOL has shown

continued success up to 25 months

10 Negative dysphotopsia can be counteracted with a new IOL

FEATURES CATARACT & REFRACTIVE 11 FLEX and SMILE are at least as good as LASIK in terms of visual acuity

12 A new formula has compared favourably to more traditional methods

13 IOL calculations must

take the anterior and posterior surfaces into consideration

www.eurotimes.org

16 Advances in tissue

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engineering lead the way for cornea replacements

18 There is still room for

DSAEK in the era of DMEK

RETINA 19 Early diagnosis is key

in treating emerging infections

20 Hope remains that current trials will lead to drug treatment for dry AMD

21 ‘Time to theatre’ is essential for successful retinal detachment treatment

GLAUCOMA 22 Exercise may prove key in protecting against glaucoma

23 New advances help clinicians to track glaucoma progression

PAEDIATRIC 24 Radiology is helping to advance understanding of strabismus

25 A small study has shown

that atropine is safe and effective in slowing myopia

OCULAR 26 Patient expectation needs to be managed when dealing with prosthetic eyes

RESEARCH 27 EU EYE is advancing the case for further funding in ophthalmology research

REGULARS 29 Congress news WCPOS 31 Industry news 33 Book reviews 34 Hospital diary 35 Travel 36 Outlook on industry 37 ESCRS News 38 Random thoughts 39 Calendar Managing Ocular Surface Disease to Optimise Surgical Outcomes

Sponsored by

14 JCRS highlights 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.

CORNEA 15 DMEK is safe and

effective in the long term

Supplement February 2018

Included with this issue... SIFI and ESCRS/EuCornea Education Forum supplements

Quality of Vision with MINI WELL Extended Depth of Focus IOL: What’s New? XXXV Congress of the ESCRS, Lisbon, Portugal Sunday 8 October 2017

Supported by an unrestricted educational grant from Shire, Novartis & TearLab V. Camps

D. Tognetto

O. Moraru

G. Auffarth

H. Bissen-Miyajima

EUROTIMES | FEBRUARY 2018

EDITORIAL A WORD FROM BORIS MALYUGIN MD, PhD

USEFUL DEVICES Patient demand has had a major effect on the power of the lenses we provide

n the past two decades lens manufacturers were good way to go in order to avoid unhappy patients with being driven by clinicians in the direction of current multifocal technology. decreasing the near add of bifocal lenses from Monofocal implants are the significant part of our +4 to +3, then +2.5 and then even down to 1.5 daily clinical practice. Being able to modify the power dioptres. This is a trend reflecting the changes in of the lens, correct astigmatism or even add and remove the demands of our patients, for whom multifocality to the optic intermediate vision is becoming, at least, no already implanted inside the eye It is now absolutely clear less important than the near vision. This is a very exciting option. This that utilising the complex clinical finding gave birth to the new class can be achieved with various optics we can provide of devices called EDOF. Rather than having technologies, such as applying distinct multiple foci, the optics of these lenses UV light or laser to modify the our patients with high provide the extended focal zone that helps to surface or refractive index of visual functions at various add some intermediate vision. These devices the implant. I do believe that distances with reasonably proved to be useful, and their functionality sooner or later this will be the modest optical side-effects may be further enhanced when combined with routine to enhance outcomes of mini-monovision technology. lens surgery. On the other hand, bifocal IOLs are almost completely Despite multiple efforts, the goal of achieving functional replaced now with trifocal lenses, a concept that was vision with current accommodative IOL technology is yet pioneered about 10 years ago. Trifocal lenses now available to be achieved. Many of us are looking forward to being from different manufacturers provide reasonably good able to use a truly accommodative IOL in the near future. optical compromise matching the demand for vision at And it looks like that moment is close at hand. far, near and intermediate distances. However, the true definition of “intermediate” is still a bit blurry and is a subject for further discussion. It is now absolutely clear that utilising the complex optics we can provide our patients with high visual functions at various distances with reasonably modest optical side-effects. However, I do feel that in spite of multiple options available, we as surgeons are trying to make the selection from what we currently have rather than what the patient really needs. Sometimes the available Boris Malyugin is professor of ophthalmology, Cataract options and patients’ expectations match perfectly. But & Implant Surgery Department, and chief, S Fyodorov Eye in some cases, they do not. Computer simulation of Microsurgery Complex, Moscow, Russia. He is also editor of the visual function to be achieved postoperatively is a the EuroTimes Russia website at www.eurotimesrussia.org

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

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

EUROTIMES | FEBRUARY 2018

VIENNA 2018 36 Congress of the ESCRS TH

22â&#x20AC;&#x201C;26 September Reed Messe, Vienna, Austria

www.escrs.org

Abstract Submission Deadline 15 March 2018

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

There is a huge range of IOLs available to the surgeon of today. Soosan Jacobs MD reports n today’s increasingly demanding world, the perfect cataract surgery needs to be complemented by a suitable IOL. Surgeons can choose from an ever-increasing array of monofocal, multifocal and accommodative IOL options to meet their patients’ needs. Multifocal IOLs have two distinct foci with blurry vision in between. Focusing on one, may cause glare and haloes from the other. The Mplus, Mplus X (Oculentis) and SBL-3 (Lenstec) are rotationally asymmetric segmented bifocal IOLs with sector-shaped near vision segment giving two focus zones for better depth of focus. AT Lisa (Zeiss), FineVision (PhysIOL), PanOptix (Alcon), Alsafit (Alsanza) and Acriva Reviol (VSY Biotech) are available trifocals and most have toric versions. Trifocals provide better intermediate vision with fewer side-effects by using secondorder light diffraction and asymmetric light distribution. These are popular in Europe. “I prefer the AT Lisa Trifocal and the PanOptix IOL for correcting presbyopia. Both of these gave us good visual acuity for all distances and high patient satisfaction,” notes Tomas Kohnen MD, Professor and Chair, Department of Ophthalmology, Goethe University Frankfurt, Germany. Extended depth of focus (EDOF) IOLs EUROTIMES | FEBRUARY 2018

are the latest variation in multifocal lens solutions. An elongated area of focus extends depth. Peak resolution is only minimally affected, thereby giving reasonably clear vision at all distances with lesser glare and haloes or loss of contrast as compared to multifocals. They are preferable over conventional multifocal IOLs in eyes with maculopathy, irregular corneas or glaucoma. An AAO Task Force consensus statement requires EDOF IOLs to be within one line of BCVA of monofocal IOLs; to have 0.5D more of defocus than a monofocal at 20/30 level (therefore, approximately 1.25D defocus), and 50% patients to be better than 20/30. In my experience, EDOF IOLs have generally given good uncorrected distance and intermediate vision: however, near vision from standard multifocals may be better. Therefore, it may be implanted in the dominant eye first followed by a micromonovision strategy with EDOF IOL or a multifocal in the non-dominant eye.

EDOFs like the Tecnis Symfony IOL (AMO) use a biconvex design, anterior aspheric surface, posterior achromatic diffractive surface with an echelette design to give better intermediate vision with less haloes and light scatter. The AT LARA 829MP (Zeiss) is the latest EDOF lens to appear. It has a diffractive aspheric design, chromatic correction and smoother phase zones that optimise contrast sensitivity and minimise light scattering and visual side-effects. In pre-clinical studies, it has shown higher visual acuity over wider range of focus than the Symfony. “Concerning monofocal IOLs, I see many IOLs at a very high standard. I still prefer open-loop IOLs and hydrophobic acrylic that are fully transparent (not blue blocking) and that do not have any reports of significant glistenings. In the arena of presbyopic correcting IOLs, I prefer trifocal IOLs for patients that are hoping for spectacle independence. For myopes and

I still prefer open-loop IOLs and hydrophobic acrylic that are fully transparent (not blue blocking)... Oliver Findl MD

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS less risk-taking patients I prefer classical minimonovision of 1.25D or EDOF IOLs with micromonovision of 0.5D,” said Oliver Findl MD, of the Vienna Institute for Research in Ocular Surgery. Small-aperture IOLs also extend depth of focus. These are especially effective in post LASIK, post RK eyes and in irregular corneal astigmatism. The IC-8 IOL (AcuFocus) is a singlepiece hydrophobic monofocal IOL that works similar to Kamra corneal inlay and uses the pinhole principle to increase depth of focus to about 3D. It has a non-diffractive 3.23mm diameter opaque PVDF mask with 1.36mm central aperture. Results show good distance, intermediate and near vision (especially when targeting -0.75 D myopia) and improvement of up to -1.5D of astigmatism. It is also more forgiving of missing the target refraction. The XtraFocus Pinhole implant (Morcher) designed by Trinidade et al. is another small-aperture sulcus IOL made of black acrylic with a central pinhole. Fundus imaging is possible and vitreoretinal surgery can be performed when required through both these IOLs.

ACCOMMODATIVE IOLS Partially accommodating IOLs rely on changes in axial position of the IOL. Singleoptic IOLs such as Crystalens (B&L), 1CU IOL (HumanOptics), Tetraflex (Lenstec) as well as dual-optic IOLs such as Synchrony (AMO) give antero-posterior movement said to give some degree of both near and distant vision. Synchrony Vu has a central blended aspheric zone to extend depth of focus. Accommodative IOLs remain the holy grail of ophthalmic surgery. Several options now available are getting closer to the goal of restoring accommodative vision. Some of these act by various mechanisms, including changing optic shape, curvature or thickness to change focus. In-the-bag accommodative IOLs are an interesting innovation. The FluidVision (PowerVision) changes accommodative power by increasing and decreasing the quantity of fluid within the optic. The Sapphire IOL (Elenza) is electronically controlled, remotely programmable, customisable and utilises nanotechnology, artificial intelligence and advanced electronics to auto-adjust focus in response to pupillary changes. Speed and amplitude of pupillary responses are used to differentiate between light and accommodation. The

Fig: A: Segmented bifocal; B: EDOF IOL; C: Small aperture IOLs; D: FluidVision in-the-bag accommodative IOL; E: Dynacurve sulcus implanted accommodative IOL; F: Scharioth macula lens

power-cell requires recharging every threeto-four days, has hibernation mode and a fail-safe mechanism that converts it to monofocal status till recharged. Juvene (LensGen) is a two-lens modular IOL made of a monofocal base lens into which a fluid-optic accommodating component that changes curvature is placed. The WIOL-CF (Medicem) accommodative polyfocal IOL has a 9mm optic made of proprietary hydrogel (WIGEL). The hyperbolic posterior optic gives polyfocality, and ciliary body contraction causes lens deformation, pseudoaccommodation and accommodation. Capsular fibrosis and IOL tilt can lead to loss of effect of in-the-bag accommodative IOLs. Sulcus-implanted accommodative IOLs are also making an appearance. These are not affected by capsular bag fibrosis. The Dynacurve IOL (NuLens) changes curvature in response to accommodation by using the collapsed bag-zonular complex as a mobile diaphragm, which activates a piston that modifies a flexible membrane to provide spherical or aspherical dynamic surface, thus giving accommodation. The Lumina lens (Akkolens/Oculentis) has two optical elements shifting in a plane perpendicular to the optical axis producing accommodation.

SPECIAL FUNCTION IOLS Tecnis toric, Symfony toric, Trulign, Lentis toric, enVista, Acrysof IQ and Acrysof IQ ReSTOR multifocal toric are some of the choices available for astigmatism correction. Adjustable IOLS allow postoperative adjustments. Light Adjustable Lens (LAL – Calhoun Vision) is a silicone IOL containing light-sensitive macromers that are modified post-operatively using a digital light delivery device to attain desired refraction. UV-protective glasses are worn till changes

are finally locked in by re-irradiation. Refractive indexing utilises the femtosecond laser to create patterns in the IOL, thereby correcting myopia, hyperopia, astigmatism and higher-order aberrations. It also gives the ability to create specific focal patterns in the IOL. Multi-component IOLs allow adjustability by changing the optic component alone while the base component remains fixed, e.g. Perquisite (IVO) and Harmoni (ClarVista Medical). Piggyback IOLs are available for primary or secondary implantation. Piggyback aspheric, multifocals, torics, negative dysphotopsia (ND) and Age related Macular Degeneration (AMD) IOLs are available. Some examples are Clariflex (AMO), Sulcoflex (Rayner) and AQ5010 (Staar). The Scharioth macula lens for AMD has central 1.5mm diameter with +10D add giving magnification of about 2X. The EyeMax mono, also for AMD, extends usable macula by 10 degrees in all directions. However, progression of AMD can negate the effect. The Masket ND 90S IOL (Morcher) for negative dysphotopsia has a peri-optic groove to capture the rhexis. All of the preceding options notwithstanding, monofocal IOLs remain the most commonly implanted IOLs. The field of monofocal intraocular lenses also continues to evolve. For example, Alcon recently released the Clareon IOL with higher water content, glistening free material and modified anti-glare edge. It comes with an automated lever-based disposable preloaded injector (AutonoMe). Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at dr_soosanj@hotmail.com. EUROTIMES | FEBRUARY 2018

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

MANAGING ASTIGMATISM Advances in power calculation methods enable good results in routine cases. Cheryl Guttman Krader reports

Courtesy of Adi Abulafia MD

hile toric IOL implantation has become a standard of care for correcting regular astigmatism at the time of cataract surgery, the refractive results following their implantation can be unpredictable, Adi Abulafia MD told a session of the XXXV ESCRS Congress in Lisbon. He spoke during a clinical research symposium in which speakers discussed ways to optimise outcomes across a spectrum of cases focused on calculation strategies in routine cases. He told attendees that the available toric IOL calculators are differentiated mainly by two features: 1) use of a fixed ratio versus estimated effective lens position (ELP) to calculate the IOL cylinder power at the corneal plane; and 2) whether or not they incorporate an algorithm to estimate the net corneal astigmatism. His advice was to use a calculator that both takes into account ELP and estimates net corneal astigmatism. “Currently, it appears that more accurate results can be obtained using mathematical models that account for posterior

Currently, it appears that more accurate results can be obtained using mathematical models... Adi Abulafia MD

cornea astigmatism rather than a direct measurement. Hopefully in the near future, however, we can use direct measurements of the posterior cornea,” said Dr Abulafia, Director of Cataract Services, Ophthalmology Department, Shaare Zedek Medical Center, Jerusalem, Israel. Dr Abulafia explained that ELP affects the refractive outcome with a toric IOL because the amount of induced cylinder power at the corneal plane depends on where the lens sits in the eye.

SIMILAR ACCURACY Although in two studies Dr Abulafia and colleagues found similar accuracy when comparing calculators using ELP versus a fixed ratio, he said the results with these two approaches can be very different for the individual, non-average

eye. To illustrate his point, Dr Abulafia presented a theoretical case involving a highly myopic eye with relatively high astigmatism. When choosing the same IOL model, the residual astigmatism predicted with the two types of calculators differed by 0.7D.

ACCOUNTING FOR THE POSTERIOR CORNEA Several mathematical models that calculate net corneal astigmatism from anterior cornea-based measurements have been developed – Barrett Toric calculator, Abulafia-Koch, and Johnson & Johnson (Koch) – and are used by various online and commercial calculators, sometimes as an on/off option. While these models are not perfect – available data show that the predicted residual astigmatism is ≤0.5D in only about 80% of eyes – another study by Dr Abulafia and colleagues indicated more accurate outcomes were achieved when toric IOL calculations were performed with one of the mathematical models (the Barrett Toric calculator) than if Scheimpflugbased direct measurements of the posterior corneal curvature were used. Dr Abulafia said that surgeons should make sure the tear film is normal and that the corneal astigmatism is symmetric and regular when obtaining preoperative measurements. Reiterating the recommendation of Warren Hill MD, he said to use primary and secondary supporting instruments to verify the steep meridian and to repeat the same proses for the power difference between the steep and flat meridians. He also noted that the mathematical models were not built for performing toric IOL calculations in eyes with unusual corneas, such as those with keratoconus or a history of corneal refractive or transplant surgery, and he cautioned that mathematical models should never be used with total corneal measurements. “You will correct the same error twice, and you will be wrong,” Dr Abulafia said. Adi Abulafia: adi.abulafia@gmail.com

EUROTIMES | FEBRUARY 2018

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SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

MULTIFOCAL AMD LENS An injectable add-on IOL is a promising alternative to telescopic implants for some patients. Howard Larkin reports

single-piece, add-on multifocal lens in clinical trials in Europe has restored functional near vision without sacrificing distance vision or field of vision in patients with advanced agerelated macular degeneration (AMD), Sathish Srinivasan MD told the American Academy of Ophthalmology 2017 meeting in New Orleans. Other advantages of the sulcus-supported Scharioth Macula Lens (Medicontur, Zsambek, Hungary) over telescopic implants include insertion through a much smaller incision (2.2mm clear corneal wound), greater tolerance of decentration and complete reversibility, said Dr Srinivasan, of University Hospital Ayr, Ayr, Scotland, UK, and as it is an add-on lens it can be implanted in patients who were previously pseudophakic. Developed by Gabor B Scharioth MD, PhD, Recklinghausen, Germany, this hydrophilic acrylic Scharioth lens consists of a 6.0mm plano optic with a central 1.5mm optical zone with a +10.0 D. This square-shaped IOL has rounded edges and is supported by a four-point haptic for stable fixation in the ciliary sulcus. (Scharioth GB, J Cataract Refract Surg, 2015 Aug;41:1559-63). Implanted uniocularly in the better-seeing eye, this design allows patients to retain a full field of vision as well as good distance vision – distinct advantages over telescopic designs, Dr Srinivasan

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said. The hydrophilic material consists of 25% water and has very low chromatic aberration. The lens is inserted with a standard injection cartridge and placed in the ciliary sulcus through a 2.2mm incision, compared with 6.0mm-to-12.0mm for telescopic devices, Dr Srinivasan noted. As a result, surgery is much easier, and the lens can be explanted much more easily than can a telescopic lens. “A big advantage is if it doesn’t work you just remove it,” he emphasised. Rounded edges of the four haptics keep the lens centred without risk of distorting the iris or causing pigment dispersion, while a concave-convex design keeps it clear of the iris and the primary IOL in the capsular bag. These features make the lens more stable in the eye than multi-piece telescopic alternatives, Dr Srinivasan added.

TRIAL RESULTS In an ongoing prospective European multi-centre clinical trial launched in October 2015, 35 of a planned 60 patients so far have been implanted, of which 25 now have at least one year of followup. All treated patients were aged 55 or older, pseudophakic and had dry or treated wet macular degeneration that had been stable for at least six months before surgery. These patients had preoperative corrected near visual acuity ranging from 20/50 to 20/200. They also showed an improvement of at least three ETDRS lines with a +2.5D add at 40cm, and a +6.0D add at 15cm, indicating they could benefit from the magnification the lens provides, Dr Srinivasan said. Patients with active wet AMD, severe zonulopathy, iris neovascularisation, uveitis, anterior chamber depth of less than 2.8mm or previous complicated cataract surgery were excluded. Three months after surgery, mean corrected distance visual acuity was 0.18 decimal, or about 20/110 – identical with mean preoperative values. Mean uncorrected near vision acuity at 15cm was nearly 0.7, or about 20/30, three months after surgery, up from corrected near acuity values of about 0.25 with a +2.5D add at 40cm, and 0.6 with a +6.0D add at 15cm. These gains were sustained for the 25 patients with 12 months' follow-up. Intraocular pressure remained stable at 12 months in all patients, and no cases of iris capture, chafing or dislocation were reported. However, three patients reported distance vision issues including glare and halos, leading to explantation in two cases. Vitreous loss occurred during implantation in one patient. “The Scharioth Macula Lens seems to increase near vision consistently without affecting distance vision. Patient selection is key, and postoperative visual training for patients to help then to read at 15cm rather than 30 or 40cm seems to really help,” Dr Srinivasan reported. Sathish Srinivasan: sathish.srinivasan@gmail.com

EUROTIMES | FEBRUARY 2018

The Scharioth Macula Lens seems to increase near vision consistently without affecting distance vision Sathish Srinivasan MD

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

NEW LENS GETS RESULTS Dual-element lens retains accommodation up to two years in clinical study. Howard Larkin reports

novel accommodative intraocular lens (AIOL) retained significant objective and subjective accommodative power at 12 and 24 months after surgery, reported Jorge Alió MD, PhD, presenting at the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. The Lumina AIOL (Akkolens, Breda, the Netherlands) consists of two progressive optical elements that change its focal power by moving across each other in a plane perpendicular to the optical axis. Implanted in the sulcus through a 2.8mm incision using a special injector, the lens’ haptics directly contact the ciliary muscles. When the ciliary muscles contract, they move the two elements in opposite directions. The effect can clearly be seen on ultrasound images after implantation. The sulcus placement avoids problems with transferring ciliary muscle movement to the lens often encountered with accommodative lenses placed in the capsular bag. Capsule shrinkage and fibrosis in the weeks after surgery often reduces accommodative amplitude. Data from Dr Alió’s ongoing prospective clinical study suggest that the Lumina design works as intended for at least 25 months. The study compared objective and subjective accommodation of 59 eyes of 43 patients implanted with the Lumina AIOL to 23 eyes of 15 patients implanted with monocular Alcon Acrysof SA60AT IOLs (Alcon) and 25 young phakic subjects. Objective accommodation was measured by the Grand Seiko WAM-5500 autorefractor. At 12 months’ follow-up, the median subjective defocus curve of Lumina patients was above 0.8 decimal visual acuity, or about 20/25, from -2.5D to +0.5D, an accommodative range of about 3.10D, peaking at 1.0 VA over a -2.0D range, 2.0D to 0.0D. By comparison, in monofocal IOL patients, median defocus was above 0.8 VA from -0.5D to +0.5D for an accommodative range of -1.0D, with a sharp peak of 1.2 VA. The young phakic control was above 0.8 VA from -6.0D through +0.5D for an accommodative range of more than 6.5D, peaking at 1.2 VA from -2.0 to 0.0D. Objectively, the Lumina group showed significant accommodation, demonstrating a median refraction of -0.38D±0.39 under -2.0D stimulation and -0.73D±0.53 under -2.5D and -3.0D stimulation. By comparison, the monofocal group showed virtually no accommodation, with a median of 0.17D±0.18 under -2.0D stimulation, 0.22D±0.15 under -2.5D stimulation and 0.17±0.14 under -3.0D stimulation. At 24 months’ follow up, the differences in the defocus curve and the objective accommodative results between the 14 monofocal and the 17 Lumina patients remained unchanged. Dr Alió concluded that both the objective and subjective measures of accommodation showed statistically significant differences between Lumina and monofocal IOL groups. At least 2/3 of the optical power change was explained by the WAM data. Different types of defocus curves were observed in the Lumina patients, which shows variability of outcome, he added.

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Jorge Alió: jlalio@vissum.com EUROTIMES | FEBRUARY 2018

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

CHALLENGING DYSPHOTOPSIA New lens may fix the old problem of negative dysphotopsia. Dermot McGrath reports

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nitial trials of an intraocular lens specifically designed to counteract negative dysphotopsia indicate that the lens is safe, well tolerated and effective at relieving patients of undesired optical complications after cataract surgery, according to Péter Vámosi MD, PhD, Péterfy Sándor Hospital, Budapest, Hungary. “With the latest version of the lens, no patients reported negative dysphotopsia after implantation,” Dr Vámosi told delegates attending the XXXV ESCRS Congress in Lisbon. Post-cataract dysphotopsia typically presents in two principal forms: negative dysphotopsia, with a dark crescent in the temporal field of vision, or positive dysphotopsia, with light streaks, arcs, flashes or starbursts. Although likely multifactorial in cause, experience suggests that negative dysphotopsia occurs only with “in-the bag” IOLs and is prevented, relieved or improved when the IOL optic edge overlaps the anterior capsulotomy, either sulcus placed or with reverse optic capture, said Dr Vámosi. Based on an idea by Samuel Masket MD, the Morcher 90S antidysphotopic IOL, which has received the European CE mark, was designed with a peripheral groove to accept the anterior capsule edge, allowing the bulk of the IOL to remain in the capsule bag with a portion overlying the capsule to avoid negative dysphotopsia. Part of the optic overlies the capsule rather than vice versa, explained Dr Vámosi. The lens simulates reverse optic capture, a technique in which the anterior capsule edge is Péter Vámosi freed from the optic, and the optic is then elevated anterior to the capsulorhexis or capsule edge. While initial results in the first 39 cases showed no incidence of negative dysphotopsia, other complications included capsule block in three patients and optic capture in another two cases. In a design modification, fenestrations in the peripheral optic-haptic junction were created, which solved the problem of capsule block. However, optic capture was still an issue in five out of 48 subsequent implantations of the lens, said Dr Vámosi. Further modifications to the lens design, this time extending the anterior optic from 6.0mm to 6.4mm, seems to have resolved the issue once and for all. “In 13 cases of the latest version of the IOL implanted, there has been no incidence of negative dysphotopsia, no capsule block and no iris-optic capture,” said Dr Vámosi. While the manufacturer recommends using a femtosecond laser to perform an anterior capsulotomy of 4.8-4.9mm, Dr Vámosi said that his own personal experience of more than 50 implantations of the IOL shows that a 4.5-5.5mm manual capsulorhexis also works well. In addition to the absence of negative dysphotopsias, fixation within the anterior capsulotomy confers other advantages such as stable fixation, avoidance of anterior capsule contraction, absence of lens tilt, a stable toric axis, excellent centration, a more predictable effective lens position and decreased higherorder aberrations, he said. Péter Vámosi: vamosipeter@freemail.hu

EUROTIMES | FEBRUARY 2018

CATARACT & REFRACTIVE

LENTICULE EXTRACTION Improved profiles and nomograms leading to improved results in hyperopic FLEX and SMILE. Roibeard Ó hÉineacháin reports

emtosecond laser lenticule extraction (FLEX) and smallincision lenticule extraction (SMILE) for hyperopia have evolved to the point where they are at least as good as LASIK in terms of visual acuity and accuracy and postoperative refractive stability, although some problems with corneal haze remain, reports Walter Sekundo MD, Phillips University of Marburg, Germany “There are many problems to solve but we have been very good at getting ahead with these techniques,” Dr Sekundo told the XXXV ESCRS Congress in Lisbon Portugal. He noted that he and his associates first established the feasibility of correcting hyperopia using FLEX in a series of 47 highly hyperopic eyes as published by Blum et al. in 2012. They found that the refractive results were reasonably predictable initially. At nine months, 64% of eyes were within ±1.0D, and 38% were within 0.5D of intended correction. However, over the follow-up period there was mean of 0.51D regression, and roughly half of the patients had to be re-treated. To address the problem, Dr Sekundo recruited the help of the technicians and engineers from Carl Zeiss Meditec who designed the ablation pattern for treating hyperopia with the Mel 80 Excimer laser. Together they developed a new profile for hyperopia using the FLEX technique.

LARGE TRANSITION ZONE The new laser profile requires a larger “M” cone instead of an “S” cone (as was used in the initial study). “The advantage with the M treatment cone is that you can implement a large transition zone, and a large transition zone is a key for a stable correction of hyperopia. However, the disadvantage is that using a large treatment pattern on a small cornea presents a higher risk of suction loss,” Dr Sekundo explained. A pilot study involving nine patients who underwent FLEX for spherical hyperopia with the new profile using a VisuMax femtosecond laser (Carl Zeiss Meditec) showed that the treatment provided larger optical zones than the previous profile and refractive stability similar to that of LASIK, he said. In fact, a mean optic zone of 5.7mm and an adjustable transition zone between 1.9mm and 2.5mm, depending on the range of correction required, was successfully applied.

The advantage with the M treatment cone is that you can implement a large transition zone, and a large transition zone is a key for a stable correction of hyperopia Walter Sekundo MD At nine months’ follow-up, 33% were within ±0.50D and 78% within ±1.00D of intended correction. Regression was minimal, as the mean spherical equivalent changed from +0.14 at one month to +0.17 at nine months. At the same time, the investigators noted a systematic undercorrection of about 0.5D when using the first nomogram of the new profile. Dr Sekundo, Dr Blum and their associates then conducted a second, phase II study involving 40 eyes with hyperopia and astigmatism. The patients had a mean age of 49 years and a mean preoperative spherical equivalent of +1.94D (range, 0.63D to 4.5D). The target refraction was between plano and -1.0D, depending on age. In addition, 0.5D of overcorrection was added to the treatment taking into account the experience of the phase I. At the conclusion of this prospective study, which was nine months postop, 70% were within half a dioptre and roughly 90% were within one dioptre of intended correction. Furthermore, regression was slight and similar to that commonly achieved with hyperopic excimer laser surgery, with the mean spherical equivalent changing from 0.2D to 0.0D when comparing the six- and nine-months follow-up. In terms of safety, best corrected visual acuity remained unchanged in 78% of eyes, 10% gained one line and 13% lost one line. In addition, there were no decentred treatments, no instances of suction loss and no patients reported halos. Dr Sekundo noted that there were a higher proportion of patients with dry eyes than is the case with SMILE for myopia, most likely because of the older age of the patients treated and the FLEX technique requiring flap. In addition, one-in-five patients had trace haze in the interface. That is probably because the lenticule is thinnest in the middle in hyperopic treatments, whereas

in myopia the lenticule is thickest in the centre, he said. Research into the use of SMILE for hyperopia is also under way, he noted. Dr Pradhan, Dr Reinstein and Dr Carp at the Tilganga Institute of Ophthalmology in Kathmandu, Nepal, are carrying out studies using a VisuMax femtosecond laser and a similar profile with an optical zone between 6.3mm and 6.7mm and a 2.0mm transition zone. As part of the study, Dan Reinstein MD in London matched a group of eyes undergoing hyperopic LASIK with the MEL 80 excimer lasers (Carl Zeiss Meditec) and compared both the centration and the optical zone size.

REFRACTIVE ACCURACY The British-Nepalese investigators carried out a study in which 31 eyes underwent hyperopic SMILE and were matched to 93 eyes after LASIK. At nine months of follow-up, UCVA was the same or better than preoperative corrected visual acuity in 47% of those who underwent SMILE and in 50% of those who underwent LASIK, Dr Sekundo said. Refractive accuracy was also similar in the two groups. In the SMILE group, 65% were within half a dioptre and 87% within one dioptre, whereas in the LASIK group 53% were within one half a dioptre and 81% were within one dioptre, he added. The results were recently published in the Journal of Refractive Surgery. The above-mentioned investigations paved the way to a worldwide multicentre prospective study on SMILE for hyperopia that has been initiated very recently. The refractive community can expect the first results of a large cohort in one-to-two years' time. Walter Sekundo: sekundo@med.uni-marburg.de EUROTIMES | FEBRUARY 2018

CATARACT & REFRACTIVE

CALCULATING POSITIONS A new formula for cataract surgery may improve outcomes. Leigh Spielberg reports

T Applications are open for the Peter Barry Fellowship 2018. This Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. The Fellowship of €60,000 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, 40 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 Vienna in September 2018, to start in 2019. To apply, please submit the following:  



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 is 1 May 2018 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org

he Emmetropia Verifying Optical (EVO) formula, a new intraocular lens formula, compares favourably to more conventional formulas now in use, reported Tun Kuan Yeo, Tan Tock Seng Hospital, Singapore, at the XXXV Congress of the ESCRS in Lisbon, Portugal. “EVO is based on the theory of emmetropisation. Cornea growth is mainly completed at infancy, and the majority of eye growth occurs in the posterior segment. For a specific corneal power, there is a specific axial length and effective lens position (ELP) to achieve emmetropia. Thus, as axial length differs from the emmetropic axial length, there should be a corresponding change in ELP,” he explained. Dr Yeo presented the results of a retrospective study conducted in his hospital in which 817 eyes underwent cataract surgery. Parameters were measured with the IOLMaster v5.4. Three types of IOL were used in the study: the ZCB00 (n=471), the Z9000 (n=190) and the AAB00 (n=156). The goal was to evaluate and validate the new EVO IOL formula by comparing it to existing IOL formulas: the Barrett Universal II (BUII), RBF, Haigis, Holladay I, SRK/T and Hoffer Q formulas. The EVO, BUII and RBF used ULIB or recommended lens constants, while lens constant optimisation was performed separately for each IOL for Haigis, Holladay, SRK/T and Hoffer Q formulas. Parameters included axial length, K-value and anterior chamber depth. Lens thickness was not used in this study. The EVO formula works with SRK/T ULIB A constant values. The predicted refraction for each formula was subtracted from the postoperative refraction to obtain the error in prediction. “The EVO formula is suitable for all axial lengths and Ks,” said Dr Yeo. The data indicates that it performs similarly to the BUII and RBF formulas, and is statistically better than the Haigis, Holladay I, SRK/T and Hoffer Q formulas. EVO had the lowest median absolute error (0.239) and mean absolute error (0.298), followed by BUII (0.250 and 0.302) and RBF (0.250 and 0.309). Spherical equivalent refractive outcomes using the EVO formula were as follows: 82.0% within 0.5D of target refraction, 94.7% within 0.75D and 98.0% within 1.00D. The formula stood out in its calculation in long (>26mm; n = 105) and short (<22.5mm; n = 95) eyes. “Highly myopic eyes demonstrated no significant hyperopic error compared to using the older formulas, whereas highly hyperopic eyes showed no significant myopic error,” said Dr Yeo. Tun Kuan Yeo: tun_ kuan_yeo@ttsh.com.sg

EUROTIMES | FEBRUARY 2018

For a specific corneal power, there is a specific axial length and effective lens position to achieve emmetropia Tun Kuan Yeo

CATARACT & REFRACTIVE

ENHANCING BIOMETRY The posterior surface can help improve IOL power calculations. Dermot McGrath reports

he accuracy of intraocular lens power calculations can be enhanced if surgeons take account of both the anterior and posterior surfaces of the cornea in their preoperative biometry workup, according to Oliver Findl MD, MBA. “Research has shown that selecting IOLs based on the measurements of the central and paracentral cornea may result in refractive surprises. It is clear that the posterior surface does play a role and it does improve IOL power calculations,” he told delegates attending the XXXV Congress of the ESCRS in Lisbon. Dr Findl presented results from a single-centre prospective study comparing traditional keratometric measurements to those from True Keratometry (TK), which uses data of both the posterior and anterior corneal surface obtained by swept-source OCT (IOLMaster 700, Carl Zeiss Meditec). “It is important not to confuse this with the True-K formula introduced by Graham Barrett, which measures the anterior surface

and then includes an average value for IOL constants we are using at the moment. the posterior surface. Here we are actually If we had a different result, we would have measuring both the anterior and posterior needed to adapt all our IOL constants for surfaces rather than using average different IOLs. Nevertheless, we can see values,” he explained. from the standard deviation (1.49) Dr Findl’s study included 49 that there is some variability, so eyes of 49 cataract patients clearly there are a few outliers implanted with a plate haptic there,” he said. monofocal lens (CT Asphina Looking at the performance 409M/MP). IOL power of TK overall, Dr Findl said that calculation was performed using it showed greater accuracy for all three well-known and widely three formulas used. tested formulae: Haigis, Holladay “This was most pronounced for II and SRK/T. The measurements Oliver Findl the Haigis formula with an 8% difference obtained were based on keratometry using TK for those patients within 0.5D of (K) readings of the anterior surface and target refraction. While the differences were TK (anterior and posterior surface) and not statistically significant given the small checking the differences between them. sample size, there is nevertheless a slight Mean axial length was 23.16mm, and the improvement in IOL outcomes,” he said. mean astigmatism was 0.93D for both K and Dr Findl added that the real benefit of TK. The difference between the mean K and such technology will probably lie in treating mean TK was actually very small (-0.03). unconventional eyes. “It is close to zero, which is good, because that means that we can use this data with the Oliver Findl: oliver@findl.at

I N V I TAT I O N 1st International

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FACULTY:

E. Donnenfeld, MD, USA

Prof. J. Kanellopoulos, Greece Prof. Ivan Tanev, Bulgaria Dr. J.C. Vryghem, Belgium

Live Surgery: Prof. Gangolf Sauder, Germany

April 28, 2018 Stuttgart, Germany Saturday

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www.arclaser.de nano@arclaser.de 05.12.2017 14:18:05

EUROTIMES | FEBRUARY 2018

CATARACT & REFRACTIVE

JCRS SYMPOSIUM

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Segment

Surgery Monday April 16, 2018 1:00–2:30 pm

JCRS HIGHLIGHTS VOL: 43 ISSUE: 10 MONTH: OCTOBER 2017

CXL INNOVATION Contact lens-assisted corneal crosslinking (CXL), which uses a riboflavin-soaked UV barrier-free contact lens placed on a de-epithelised cornea before UVA exposure, is a relatively new technique. The objective is to artificially increase the functional thickness or to artificially decrease the effective UVA irradiation of the corneal stroma during the crosslinking procedure. The demarcation line is used as a surrogate measure of the depth and effectiveness of crosslinking. Researchers conducted a small clinical study looking at the demarcation line depth after contact lens-assisted CXL for progressive keratoconus comparing dextran-based and hydroxypropyl methylcellulose (HPMC)-based riboflavin solutions. CXL performed using riboflavin 0.1% combined with HPMC as the carrier agent resulted in a significantly deeper demarcation line than when the procedure was performed with dextran 20.0%-based riboflavin. C Malhotra et al., JCRS, “Demarcation line depth after contact lens-assisted corneal crosslinking for progressive keratoconus: Comparison of dextran-based and hydroxypropyl methylcellulose-based riboflavin solutions”, Volume 43, Issue 10, 1263–1270.

PINHOLE IMPLANT FOR ASTIGMATISM

Moderators:

Nick Mamalis, MD Sathish Srinivasan, MD

Presbyopia-Correcting IOLs Surgical Correction of Aphakia in a 60-Year-Old Treating Inflammation After Intraocular Surgery

During the ASCRS Annual Meeting Washington, DC, USA

Irregular corneal astigmatism from causes including keratoconus, post-radial keratotomy, post-penetrating keratoplasty and traumatic corneal laceration impairs visual function. Brazilian researchers report a case series of 21 patients treated with a novel pinhole implant. The device is a black opaque diaphragm with a 1.3mm central opening and no refractive power. It is designed to be implanted in the ciliary sulcus of pseudophakic eyes in a piggyback configuration. Patients receiving the implant had statistically significant improvement in uncorrected and corrected distance visual acuities. No major complications occurred. CC Trindade et al., JCRS, “New pinhole sulcus implant for the correction of irregular corneal astigmatism”, Volume 43, Issue 10, p1297–1306.

POST-OP FALLS AFTER CATARACT SURGERY While cataract surgery has been shown to reduce the incidence of falls in elderly patients, post-op falls still do occur. A prospective cohort study conducted at eight public hospital eye clinics in Australia looked at 196 patients that completed first-eye surgery. First-eye cataract surgery reduced incident falls by 33%. Poorer dominant-eye visual acuity was associated with falls during the study timeline. Patients with larger than a spherical equivalent of ±0.75 dioptre change in the spectacle lens (operated eye) had a twofold greater incidence of falls in the period after first-eye cataract surgery than those with less or no change in lens power. The increased risk linked to major changes in the dioptric power of spectacle correction of the operated eye after surgery suggests that cautious postoperative refractive management is important. A Palagyi et al. JCRS, “Visual and refractive associations with falls after first-eye cataract surgery”, Volume 43, Issue 10, p1313–1321.

THOMAS KOHNEN European editor of JCRS

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EUROTIMES | FEBRUARY 2018

CORNEA

DMEK SAFETY IMPORTANCE DMEK is safe and effective in the long term. Dermot McGrath reports

escemet’s membrane endothelial keratoplasty (DMEK) represents a clear advance over penetrating keratoplasty and other endothelial keratoplasty techniques in terms of safety and visual outcomes for certain indications, Friedrich Kruse MD told delegates attending the 8th EuCornea Congress in Lisbon. “As surgeons we can all agree that the safety of the procedure is of the utmost importance for the patient. Studies by Price et al. and others have clearly shown that penetrating grafts and Descemet’s stripping endothelial keratoplasty (DSEK) with thicker grafts have a higher graft rejection rate compared to DMEK for at least up to two years postoperatively and I think this also holds true for a longer period,” he said. Looking at data of 1,090 patients from the Cornea Donor Study (CDS), Dr Kruse said that the 10-year cumulative probability for the first definite rejection event was 15% and for the first definite or probable rejection event was 34%. By contrast, Dr Kruse said that he was aware of just one case of DMEK graft rejection in more than 500 cases at his own clinical centre and other published studies have confirmed a very low rate of immunologic graft rejection up to several years after transplantation. Dr Kruse’s own group recently published a long-term analysis of clinical outcomes after DMEK and concluded that the cumulative probability of five-year graft survival was 95%. “The picture is very different in DMEK. This reduced risk of rejection means that we can now administer steroids for six months and then discontinue it and that also reduces the risk of secondary glaucoma,” he said. Visual rehabilitation is typically rapid with DMEK procedures and the outcomes obtained are excellent, said Dr Kruse. In his own long-term study, corrected distance visual acuity improved from 0.62 logMAR before DMEK to 0.13 logMAR postoperatively, and 57% of eyes without ocular comorbidities attained 20/25 at five years after DMEK. Moreover, the visual acuity and endothelial cell loss remained stable between three months and five years after surgery. One possible explanation for the excellent visual outcomes obtained in DMEK may lie in a reduced incidence of higherorder aberrations compared to penetrating keratoplasty and Descemet's stripping automated endothelial keratoplasty (DSAEK), said Dr Kruse. Interestingly, a study by Tourtas et al. showed that aberrations of the corneal back surface decreased significantly in the first three months after DMEK and correlated with the rapid increase of visual acuity. However, during the third and fourth postoperative year, the aberrations of the corneal back surface increased again and afterwards remained stable through the fifth year, correlating with an increase in corneal thickness. Corneal aberrations might therefore provide a more detailed analysis of optical quality after DMEK, said Dr Kruse.

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Friedrich Kruse: friedrich.kruse@uk-erlangen.de EUROTIMES | FEBRUARY 2018

CORNEA

BIOSYNTHETIC CORNEAS Advances in tissue engineering are reducing obstacles to the manufacturing of cornea replacements. Roibeard Ó hÉineacháin reports

everal teams around the world are bringing biosynthetic corneas closer to a clinically useful stage of development, offering genuine hope in the battle against global corneal blindness, said Isabelle Brunette MD, FRCSC, at the XXXV Congress of the ESCRS in Lisbon, Portugal. “There is a huge need for alternatives to native tissue for corneal replacement. Corneal blindness is the third most common cause of blindness worldwide, affecting 28 million individuals either unilaterally or bilaterally. But there is only one cornea available for every 70 patients that need one,” said Dr Brunette, Maisonneuve-Rosemont Hospital, Québec, Canada. Four categories of tissue-engineered corneas are currently under investigation. These are: Acellular inert materials impermeable to cells, such as the PMMA optical stem of a KPro for instance; biomaterials enhanced with cells at time of production; stromal substitutes entirely engineered from cells; and acellular biomaterials that act as a scaffold to be repopulated by host corneal cells.

BIOMATERIALS The current best example of this type of biosynthetic cornea is probably that of the University of Granada, Spain. Their cornea consists of a fibrin and agarose scaffold containing human corneal fibroblasts and is covered with an epithelial layer. Nanostructuration ensures adequate stiffness and resistance. The researchers have recently reported their research protocol for a randomised, controlled, open-label study comparing these new implants with human amniotic

membranes for ALK in patients with severe trophic corneal ulcers refractory to conventional treatment.

A LIVING GRAFT The basic principle behind stromal substitutes entirely engineered from cells, is that corneal cells in culture maintain their ability to secrete and deposit extracellular matrix in vitro, allowing for the production of thick sheets of cellularised stroma, where the interaction between the cells and their environment is preserved, Dr Brunette explained. She added that she and her collaborators from the LOEX in Québec, Canada, have demonstrated the biocompatibility and functionality of stromal lamellar grafts entirely tissue-engineered from corneal stromal cells and transplanted in vivo in the cornea of a large animal model. Four months after transplantation, these stromal grafts were highly transparent, with no signs of rejection. In addition, all corneal layers were re-innervated and had the multi-layered lamellar structure typical of native stroma. The normal stromal components were also present. This keratocytes-generated stroma, however, remains too soft for full thickness stromal replacement.

ACELLULAR BIOMATERIALS The category furthest advanced towards clinical use is represented by biomaterials that are acellular at the time of implantation and promote repopulation by the host’s cells and nerves once transplanted in the living cornea. A stromal substitute of this type developed by May Griffith PhD and

her associates at the University of Ottawa, Canada, has shown promising short- and long-term results in a small series of patients. The 10 patients who received the implants in a phase I clinical trial conducted by Per Fagerholm MD in Sweden showed a mean gain of best corrected vision of more than five lines, without any sign of rejection at four years' follow-up. Furthermore, confocal microscopy showed that the implants were repopulated by host stromal cells and nerves. Patients with these biosynthetic corneas recovered sensitivity faster than those who underwent penetrating keratoplasty. However, the implants being too soft to be sutured, overlying sutures were necessary, which delayed epithelial healing and contributed to astigmatism. Since then, Dr Griffith and her associates have developed a second recombinant human collagen reinforced with MPC, a synthetic phospholipid with antiinflammatory properties. In the three patients who received the implants for chronic corneal ulcers, chemical burns or graft failure, the biosynthetic grafts relieved pain and discomfort and improved visual acuity from 6/600 to light perception before surgery to 6/38 to 6/200 after surgery. Dr Brunette noted that several groups in the world, including her own, have also conducted research on the viability of a tissue engineered corneal endothelium. Advantages over standard DMEK would include the ability to use one donor cornea for multiple patients and a better control of tissue quality. This technology would also allow to generate endothelium from autologous cells, thus eliminating the risk for immune rejection. Isabelle Brunette: i.brunett@videotron.ca

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CORNEA

KERATOPLASTY ADVANCES There is still room for DSAEK in the new era of endothelial keratoplasty. Dermot McGrath reports

ecent advances in endothelial keratoplasty techniques, and particularly the arrival of Descemet membrane endothelial keratoplasty (DMEK), means that corneal surgeons today have no shortage of options when it comes to selecting the right procedure for particular indications, Sadeer Hannush MD told delegates attending the 8th EuCornea Congress in Lisbon. Dr Hannush, Wills Eye Hospital, Philadelphia, Pennsylvania, United States, said that non-refractive corneal procedures could be broadly divided into five categories: ocular surface reconstruction, anterior lamellar keratoplasty, posterior lamellar keratoplasty (DSAEK and DMEK), penetrating keratoplasty and permanent keratoprosthesis surgery. “The big advantage of endothelial keratoplasty for the indication of endothelial dystrophy and dysfunction, of course, is rapid visual rehabilitation. There are also other benefits, such as the absence of suture-related complications, decreased incidence of allograft rejection, an intact globe with resistance to traumatic wound dehiscence, predictable corneal toricity with minimal topographic change and a predictable small hyperopic refractive shift,” he said.

ALMOST 1,000 CASES Dr Hannush said he has now performed almost 1,000 cases of Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) since his first procedure in October 2005. “About one-third of these are endothelial grafts for endothelial dysfunction, usually in the presence of a posterior chamber implant. Another third are triple procedures (endothelial keratoplasty, cataract removal and IOL implantation). The final third are grafts in the presence of a co-morbidity (e.g. previous filtering surgery or tube shunt placement, ACIOL, or unicameral eye), which includes failed penetrating keratoplasty or even DMEK,” he said. Although DMEK has evolved as the procedure of choice for corneal endothelial replacement in the setting of endothelial dystrophy and/or dysfunction, Dr Hannush believes that DSAEK still has a role to play in modern corneal practices. “In many instances, especially in the presence of severe comorbidities, the surgeon may be able to more easily bring the case to a successful conclusion with DSAEK. This is especially true if the surgeon is not experienced in performing DMEK,” he said. Looking at the outcomes after a decade of DSAEK procedures, Dr Hannush said it became apparent that postoperative visual acuity and graft survival were dependent on the type of surgery and the nature of the comorbidities. “The results in all of our cases ultimately depend on the visual potential that the patient has both from a macula and optic nerve point of view at the time of surgery. Also, for patients with tube shunts, the prospects are not great. Endothelial cell loss tends to be very high in these patients and the five-year graft failure rate is around 75%,” he said. Sadeer Hannush: sbhannush@gmail.com EUROTIMES | FEBRUARY 2018

RETINA

EMERGING INFECTIONS Countering the threat of emerging infectious diseases. Dermot McGrath reports

arly diagnosis is essential for appropriate management to minimise the risk of systemic and ocular morbidity associated with a broad spectrum of emerging infectious diseases, according to Moncef Khairallah MD. At a special symposium on uveitis infections held during the 17th EURETINA Congress in Barcelona, Dr Khairallah of the University of Monastir, Tunisia, discussed the challenge of emerging infectious diseases such as Rickettsial infections, West Nile virus, dengue fever, chikungunya, Zika virus and Ebola virus. “Early diagnosis of these diseases can be achieved based on the association of typical ocular findings with a history of high fever and other systemic symptoms allied to specific epidemiological data,” he said. There are certain criteria to look for when potential emerging infectious posterior uveitis is suspected. “Any patient with specific ocular findings, with a history of recent systemic febrile syndrome, living in or travelling from a specific endemic area should be examined very carefully,” he said. Rickettsial diseases such as Mediterranean spotted fever or Rocky Mountain spotted fever or other variants are usually spread by ticks and should be suspected in patients with typical retinitis, retinal vasculitis or optic neuropathy with the classic triad of high fever, headache and skin rash, said Dr Khairallah. Treatment for Rickettsial disease includes antibiotics, mainly doxycycline, for seven-to-15 days, in combination with systemic corticosteroids, in selected severe cases. Prognosis of systemic and ocular disease is good in most patients, said Dr Khairallah. West Nile virus infections spread by mosquitoes are usually subclinical in about 80% of cases or manifest as febrile illness in 20%, said Dr Khairallah. Severe neurologic disease occurs in less of 1% of patients. Ocular manifestations include typical bilateral multifocal chorioretinitis with linear clustering of lesions, and no or mild vitritis. “Active lesions appear as yellow, deep, round chorioretinal spots, with early hypofluorescence and late staining on angiography. Other findings may include macular oedema, RPE changes, anterior uveitis, subconjunctival haemorrhage, papilloedema, oculomotor nerve palsy and nystagmus,” he said. Ocular manifestations of Dengue fever, which infects about 50 million annually in tropical and subtropical regions, include dengue maculopathy with round foveal lesion, retinal pigment epithelial (RPE) thickening, macular oedema, serous retinal detachment, macular haemorrhages and vasculitis. For the Zika virus, the most serious complications are found in infants who have microcephaly. Ocular involvement may include conjunctivitis and anterior uveitis, gross macular pigment mottling, chorioretinal atrophy, optic nerve abnormalities and lens subluxation. Ocular symptoms for patients with the Ebola virus include conjunctivitis and subconjunctival haemorrhage in early stages, and uveitis for those in recovery, said Dr Khairallah. Prophylaxis remains the mainstay of viral disease control, with public health measures being taken to reduce the number of mosquitoes and improve sanitary conditions, he concluded. Moncef Khairallah: moncef.khairallah@yahoo.fr EUROTIMES | FEBRUARY 2018

RETINA

DRY AMD PIPELINE Effective treatment for dry AMD remains elusive, but many studies are under way. Dermot McGrath reports

hile there is currently no approved treatment for dry age-related macular degeneration (AMD), hope remains that the multiple trials presently under way will ultimately yield an effective drug in terms of prevention and progression of the disease, Francesco Bandello MD told delegates attending the 17th EURETINA Congress in Barcelona. “The failure of the phase III trial of lampalizumab for geographic atrophy that was just announced at this meeting is a big disappointment for all of us and for our patients. However, there are still a number of treatments for dry AMD under investigation with some promising results in preliminary studies. We need evidence-based data that will allow us to use some new approaches for this devastating disease,” said Prof Francesco Bandello, Professor and Chairman at the Department of Ophthalmology, VitaSalute University, San Raffaele Scientific Institute, Milano, Italy. Although anti-VEGF agents have transformed the treatment of wet-AMD, almost 80% of people diagnosed with AMD have the non-neovascular (dry) or atrophic subtypes. AMD has a complex pathogenesis, with oxidative stress, deposits of lipofuscin, chronic inflammation, choroidal blood flow insufficiency, environmental and predisposing genetic factors all potentially playing important roles in the development of the disease, said Prof Bandello. He noted that evidence from the AgeRelated Eye Disease Study (AREDS) suggests that antioxidant vitamin and mineral supplementation may be beneficial to patients with dry AMD. “It is one of the areas where we have more evidence, but unfortunately that evidence is not very strong and it related to patients who were at an advanced stage and intermediate stage of the disease. It is perhaps the case that treatment earlier in the disease course might be beneficial, although we need more studies on that,” he said. In terms of anti-inflammatory therapy, Prof Bandello said that Iluvien (Alimera Sciences), a sustained-release formulation of fluocinolone acetonide, already approved for the treatment of diabetic macular oedema (DME), may have potential to slow the progression of geographic atrophy (GA). A phase II study of 40 patients affected bilaterally by GA has been completed, but the results are not yet available. EUROTIMES | FEBRUARY 2018

Francesco Bandello

Some complement system inhibitors are also currently under investigation, said Prof Bandello. The rationale behind these agents is that undesirable activation of the complement system, which forms a vital part of the innate immune system, occurs in connection with a number of diseases. While phase I clinical trials of the C3 inhibitor POT-4 (Potentia Pharmaceuticals) and the anti-C5 aptamer ARC1905 (Ophthotech Corp) have been completed, no phase II clinical trial has yet proven the safety and efficacy of either of these drugs in dry AMD, said Prof Bandello. While hopes had been high for lampalizumab (Genentech/Roche) after phase II trials showed a positive effect in slowing growth of GA through complement inhibition, the phase III trial results failed to meet the primary endpoint of reducing mean change in lesion area. “Unfortunately, we know the results of the lampalizumab phase III trials were not good, and the company has decided to stop its trials in dry AMD. This is disappointing, as we are likely to see less interest around this field as a result of its failure,” he said. Another anti-inflammatory therapy, Sirolimus (MacuSight/Santen), has been shown to be well tolerated in patients with GA, but demonstrated no positive anatomic or functional effects in an openlabel phase II trial of 11 patients. A phase I study of another compound, glatiramer acetate (Reva Pharmaceuticals), demonstrated reduction of the drusen area in patients with drusen after weekly subcutaneous injections over 12 weeks. A phase II/III study is currently under way. Neuroprotection is another interesting

area of research in dry AMD, said Prof Bandello, with promising early results of two neuroprotective therapies: ciliary neurotrophic factor-501 (CNFT) and brimonidine. Using a sustained release implant in a phase II trial of GA patients, CNFT showed a dose-dependent stabilisation of visual acuity, which was related to a retinal thickness increase at structural OCT. A phase II study of brimonidine, administered by an intravitreal biodegradable implant (Allergan), to evaluate the changes of GA area and bestcorrected visual acuity in 119 patients with bilateral GA, did not show reliable data. A second multi-centre trial is ongoing and is expected to be completed in March 2019. Another novel approach to dry AMD treatment comes in the form of lipofuscin and visual cycle inhibitors, said Prof Bandello. Emixustat (Acucela), which works by reducing the accumulation of lipofuscin in the retinal pigment epithelium, has completed a phase II/III study but results are not yet available. Choroidal blood flow restoration agents are also being trialled in dry AMD, with compounds such as Alprostadil (UCB Pharma) and the vasodilator MC-1101 (MacuClear Inc) needing further studies to demonstrate their safety and efficacy, he said. A variety of stem cell therapies using human pluripotent stem cells, embryonic (hESC) or induced (iPSC) are also currently being investigated in clinical trials for AMD, and definitely merit further investigation, concluded Prof Bandello. Francesco Bandello: bandello.francesco@hsr.it

RETINA

RETINAL DETACHMENTS ‘Time to theatre’ is crucial in successful retinal detachment treatment. Priscilla Lynch reports

SPECIAL FOCUS

NEW IOLS

CATARACT & REFRACTIVE

FLEX AND SMILE VS LASIK – THE LATEST

CORNEA

TISSUE-ENGINEERED CORNEAS SHOW PROMISE

RETINA

February 2018 | Vol 23 Issue 2

SEARCH CONTINUES FOR EFFECTIVE DRY-AMD TREATMENT

‘T

ime to theatre’ is crucial in successful retinal detachment treatment, according to Mr Ian Dooley MD, Consultant Ophthalmologist and Vitreoretinal Surgeon, Mater Misericordiae University Hospital, Dublin, who gave the European Society of Ophthalmology (SOE) Lecture 2017 on ‘Retinal Detachment – Past, Present and Future’ at the Irish College of Ophthalmologists 2017 Annual Conference in Cavan, Ireland. Retinal detachment develops in approximately one-in-10,000 people per year, and scleral buckle surgery/vitrectomy, cryotherapy and laser (photocoagulation) remain mainstays of treatment, he said. The sooner the patient is treated, the less invasive treatment can be and the better the visual outcome, as patients lose about a line of vision for every three days a retinal detachment remains untreated, Mr Dooley explained. For primary retinal detachments, the reattachment success rate is about 85-to90%, and in secondary detachments it is about 75%, he said. The key symptoms for retinal detachment are the ‘four Fs’ – floaters, flashes, foggy vision and visual field loss, he explained. Vitreous haemorrhage is relatively common. More than 60% of spontaneous severe vitreous haemorrhage cases would benefit from early vitrectomy, as there may be an underlying retinal tear, detachment or vascular problem – and pain is quite rare. Retinal detachment is more common in older people (often following posterior vitreous detachment complicated by small tears), those who have high myopia, pseudophakes, those with diabetic retinopathy and those with a family history of the condition. It can also be associated with previous cataract surgery and trauma, therefore taking a good patient history is key to correct diagnosis said Mr Dooley. In the past 10 years, there have been noteworthy improvements in treatment (small-gauge surgery, better tamponades, stains and viewing systems) and earlier detection of retinal detachment, Mr Dooley stated. “The earlier patients seek treatment, the less invasive treatment has to be and the higher the success rate, and they are less likely to develop the nastier aspects of retinal detachment, such as proliferative vitreoretinopathy (PVR), re-detachment and permanent loss of vision. It is a very treatable condition and I nearly spend half my time dealing with it, but getting the patient in quickly is the key,” he told EuroTimes. Ian Dooley: donna. kiernan@materprivate.ie

The earlier patients seek treatment, the less invasive treatment has to be and the higher the success rate

SPECIAL FOCUS NEW IOLS CATARACT & REFRACTIVE

FLEX AND SMILE VS LASIK – THE LATEST

CORNEA

TISSUE-ENGINEERED CORNEAS SHOW PROMISE

RETINA

February 2018 | Vol 23 Issue 2

SEARCH CONTINUES FOR EFFECTIVE DRY-AMD TREATMENT

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GLAUCOMA

LIFESTYLE AND GLAUCOMA RISK Practice Management

ESCRS

& Development

22–26 September 2018 Vienna, Austria

CALLING ALL MARKETERS!

WIN A €1000 BURSARY. ESCRS Practice Management and Development Marketing Case Study Competition Submission Deadline Monday 30 July 2018 For further details visit: www.escrs.org

Grow Your Practice

Manage Your Business

New evidence from novel study on mice presented at ICO Conference. Priscilla Lynch reports

xercise and a healthy lifestyle could have a protective effect against glaucoma, according to a presentation to the Irish College of Ophthalmologists 2017 Annual Conference in Cavan, Ireland. New breakthroughs in the battle to protect the optic against glaucoma were presented by internationally renowned glaucoma specialist Prof Jonathan Crowston MD, Head of Ophthalmology at the University of Melbourne and Managing Director at the Centre for Eye Research Australia (CERA). He discussed new evidence from a novel study on mice relating to the impact of lifestyle on glaucoma risk. “Our research is looking at new treatments to make the optic nerve more robust and to protect it against elevated eye pressure. We have recently discovered that exercise may play a key role in protecting this nerve. Retinal ganglion cells (RGCs), the nerve cells that transmit the visual message from the retina to the brain, become increasingly vulnerable to injury with advancing age. While age was traditionally thought to be a nonmodifiable risk factor for disease, emerging evidence suggests this may not be the case. We found that this vulnerability with advancing age in mice can be strongly modified by exercise in the form of daily swimming. “We found that exercise promoted functional recovery and reduced RGC loss when initiated after an acute injury induced by elevation of intraocular pressure. This age-related vulnerability was almost completely reversed by exercising. “We are beginning to unlock some of the mechanisms whereby exercise promotes RGC recovery but we don’t know whether exercise will be as effective in humans. We are keen to see that human tests are done as well, and they are not easy to do – but it is something that I have discussed with Jonathan Crowston MD my patients and comes at very little cost, and I would strongly encourage people to consider it as it confers many benefits to other parts of the body as well.” He also highlighted the importance of getting your eyes properly checked, especially if you have a family history of glaucoma. Prof Crowston stressed that a comprehensive eye test where the optic nerve is examined is crucial, as 80-90% of sufferers have no easily recognisable symptoms and the disease may occur even in the absence of elevate eye pressure. “For most types of glaucoma, you can have moderate to advanced disease and still not be aware you have it. The astounding fact is our brains are very good at filling in the picture, even when a substantial portion of your visual field is lost.”

We found that exercise promoted functional recovery and reduced RGC loss

Jonathan Crowston: crowston@unimelb.edu.au EUROTIMES | FEBRUARY 2018

CLINICAL: GLAUCOMA FEATURE

IMAGING PROGRESSION Imaging is increasingly valuable in detecting progression in early glaucoma. Dermot McGrath reports

ecent advances in imaging technology have given clinicians valuable new tools for tracking glaucoma progression over time and fine-tuning therapy in the early stages of glaucomatous disease, according to Francesco Oddone MD, PhD. “Imaging is expected to be more sensitive than visual field in predicting conversion and detecting progression, especially in early glaucoma. At the moment, however, there is no consensus on the best technique or criteria to detect glaucoma conversion or progression, or to assess what amount of change would be clinically meaningful,” he told delegates attending Glaucoma Day as part of the XXXV Congress of the ESCRS in Lisbon. Dr Oddone, Head of the Glaucoma Unit at Britannic Hospital, Rome, Italy, noted that macular parameters seem to be more consistent than retinal nerve fibre layer (RNFL) parameters in detecting progression across the entire glaucoma severity spectrum, but might also be more affected by ageing. Given the uncertainty in interpreting the results of imaging scans and the cost to perform each examination, clinicians should appraise which tests provide the most useful information for their specific decision, he advised. “Examinations whose results are unlikely to influence clinical decisions should be replaced with more frequent examinations or tests that do influence clinical decisions. Approaches that combine structural and functional measurements will likely improve the detection of glaucoma progression while correlating more with patients’ relevant outcomes,” he said. The goal of glaucoma treatment is to slow down or halt the progression of the disease in order to maintain the patient’s quality of life at a sustainable cost, said Dr Oddone. “Assessing the progression of the disease reliably is thus critical for decision-making in glaucoma. We need to know when to start treatment, change an ongoing medical treatment, switch medical treatment to surgical interventions and assess the individual risk of visual disability. These actions may have consequences on a patient’s well-being and quality of life and must be based on solid clinical information,” he said. Anatomical changes in glaucoma are either preceded, accompanied or followed by clinically detectable functional changes in the form of progressive visual field defects, said Dr Oddone. “Only functional changes are currently considered as relevant endpoints of glaucoma care both by clinicians and by regulatory authorities. Visual field can in fact be considered a validated

surrogate endpoint of quality of life measurements, which are less practical to be measured clinically in a consistent and reliable manner,” he said. The rationale for using structural endpoints derived from OCT images is that they may be more consistent than psycophysical endpoints and are not affected by a learning curve. “But considering the extra costs involved, imaging is expected to provide information that is relevant for glaucoma management in a clinically meaningful way, Francesco Oddone in addition to the information provided by psycophysical testing,” he said. “Nevertheless, regulatory authorities, such as the US FDA, for validation of structural endpoints, request such a strong correlation (R2 of 0.9) to current vision or future vision loss that structural endpoints would never be validated if these criteria will be not revised,” said Dr Oddone. The challenge for the physician, however, is knowing how much of a structural change is clinically significant or what change in vision would be expected to occur, and when, as a result of this structural change, said Dr Oddone. Some recent studies have sought to shed some light on a few of these questions with some measure of success, he said. Zhang et al., for instance, took VF measurements and OCT scans in 417 glaucoma suspect/pre-perimetric glaucoma eyes and 377 perimetric glaucoma eyes every six months for several years. “They showed that baseline reductions in NFL and ganglion cell complex (GCC) thickness can predict the development of VF loss in glaucoma suspects and pre-perimetric glaucoma. Eyes with a borderline or abnormal OCT finding had a five-time greater chance of conversion. Focal GCC and RNFL loss were also found to be the strongest predictors for VF progression in perimetric glaucoma,” he said.

Imaging is expected to provide information that is relevant for glaucoma management

Francesco Oddone: oddonef@gmail.com

Courtesy of Francesco Oddone

MONITORING WITH IMAGING

2006

2011 EUROTIMES | FEBRUARY 2018

PAEDIATRIC OPHTHALMOLOGY

STRABISMUS MANAGEMENT Imaging advances transform strabismus management.

WSPOS R

Dermot McGrath reports

World Society of Paediatric Ophthalmology & Strabismus

s u B s p E C i A l tY d A Y

Friday 21 September 2018, Vienna, Austria

Preceding the 36th Congress of the ESCRS, 22 – 26 September 2018

adiology and other advanced imaging techniques such as magnetic resonance imaging (MRI) have greatly increased understanding of the pathophysiology of many strabismus conditions and transformed the strategies for treating them, according to Lionel Kowal MD. “It is thanks to advances in imaging techniques that we have been able to introduce new treatment paradigms. We need to remember, however, that there are abnormal radiological findings that seem to have no clinical significance and radiological assessment in alphabet patterns can be confusing,” he told delegates attending the European Society of Ophthalmology (SOE) Congress in Barcelona. Above all, Dr Kowal, a Senior Fellow at the Royal Victorian Eye and Ear Hospital, University of Melbourne, Australia, stressed the importance of imaging in avoiding incorrect or incomplete diagnoses. “We need to educate and enthuse ophthalmologists and radiologists of the importance of imaging in strabismus, as the surgical management of many of these conditions is very dependent on the correct classification,” he said. Dr Kowal noted that while radiology is useful for a range of strabismus conditions, it is most relevant in abduction deficits, strabismus in high myopia and superior oblique palsy cases. The optimal means of assessing superior oblique function and to diagnose atrophy is using an MRI scan, and it is vital to distinguish between real and apparent or pseudo-superior oblique palsy (SOP). “SOP is often used as a synonym for a condition that resembles SOP. When SOP is diagnosed by strabismus doctors, it is wrong around 50% of the time. The most accessible technique to reliably diagnose SOP is to demonstrate atrophy on coronal scans,” he said. Dr Kowal said that some ophthalmologists have questioned whether it is actually important to know the most accurate diagnosis. “This is because most of the time we are going to do inferior oblique weakening irrespective of the precise cause. However, I think precise diagnosis is important because some pseudo-SOP causes require different surgery. True SOP has other implications: some are rarely due to tumour and the natural history is probably to get worse,” he said. Imaging is also important in congenital superior oblique palsy, said Dr Kowal. “In a prospective study I showed that 20% of patients with radiologically demonstrated atrophic superior oblique palsy on MRI scans have unequivocally floppy tendons after surgery, probably requiring superior oblique tightening. If the patients did not have an atrophic SOP, none of them had a floppy tendon. Superior oblique tightening is a more difficult and higher morbidity procedure than inferior oblique surgery, so this is one good reason to know the precise diagnosis before surgery,” he said. Lionel Kowal: strabism@netspace.net.au

EUROTIMES | FEBRUARY 2018

PAEDIATRIC OPHTHALMOLOGY

HALTING MYOPIA Atropine halts myopia progression in Israeli study. Dermot McGrath reports

low-dose formulation of atropine slowed the progression of myopia for a majority of treated children over a two-year period with no adverse side-effects, according to a study presented at the European Society of Ophthalmology (SOE) Congress in Barcelona. “Our experience in this small study shows that atropine seems to be safe and effective in preventing myopic progression in children. Before treatment the mean progression was around 0.75D per year compared to 0.32D a year after treatment. Importantly there were no side-effects and no patient discomfort associated with its use,” said Yair Morad MD, Assaf Harofeh Medical Center, Tel Aviv University, Israel. Dr Morad noted that the best responders seemed to be children with myopia less than -6.0D and no family history of the disease. The most difficult children to treat were those with high myopia and with both parents classed as myopic. As the most common eye disorder in the world, myopia affects between 25 and 50% of all adults in the United States and Europe. In Asia, the disease has reached epidemic proportions, said Dr Morad, with 85 to 90% of young adults affected in that region. In Israel, the myopia prevalence increased from 20% in 1990 to 28% in 2002. “This is already before the introduction of smartphones and tablets, so the problem has undoubtedly worsened since then,” he said.

ECONOMIC BURDEN The annual economic burden of the disease is estimated at $268 billion worldwide, with high myopes at greater risk for other ocular conditions such as myopic maculopathy, retinal detachment, cataracts, glaucoma and strabismus. While the exact mechanism of how atropine works to delay myopia remains unknown, one hypothesis is that the drug blocks muscarinic receptors in the human ciliary muscle, retina and sclera, thus inhibiting thinning or stretching of the sclera, and thereby eye growth. Dr Morad’s study started in January 2015 and included 83 children with a mean age of 9.2 years and a mean refraction of -4.7D, whose myopia had progressed 0.75D or more in the previous 12 months. All of the children received 0.01% atropine nightly and were examined every six months. After six months, 82 patients progressed between 0 and 0.025D, while one patient who progressed 0.75D was switched to atropine 0.05%. At 12 months, 46 out of 56 children showed very little sign of progression, while eight patients progressed 0.5 D and two patients progressed 0.75D. Dr Morad said that further study was needed to answer questions relating to the optimal time and duration of treatment. He also noted that the high cost of current treatments should be alleviated with the commercialisation of atropine in the near future.

CALL FOR ENTRIES

JOHN HENAHAN

PRIZE 2018

Young ophthalmologists are invited to write an essay on “Do We Need a Randomised Controlled Clinical Trial in Cataract Surgery?”

First prize is a €1,000 travel bursary to the 36th Congress of the ESCRS in Vienna, Austria.

CLOSING DATE FRIDAY 30 MARCH 2018

Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org

Yair Morad: yair.morad@gmail.com EUROTIMES | FEBRUARY 2018

OCULAR

SOCKET SURGERY ISSUES Patient expectations key to socket surgery success. Dermot McGrath reports

hile most prosthetic eyes are cosmetically satisfactory and generally well tolerated, complicated sockets, when they occur, present a real challenge to the ocular prosthetist and the oculoplastic surgeon, according to Geoffrey E Rose FRCS FRCOphth. In a keynote address on the problems of socket surgery given at the European Society of Ophthalmology (SOE) Congress in Barcelona, Prof Rose stressed the role of patient education in ensuring the longterm viability of the implant. “We need to carefully manage patient expectations and emphasise to them that this is not just a once-off procedure but will require ongoing care and monitoring over the course of their lifetime. They need to know the complications and limitations of the prosthesis and accept that all sockets have some discharge of mucus and that the movements of an artificial eye can never be completely normal. The good news, however, is that a socket with good volume and a stable artificial eye can serve them a long time indeed before further surgical intervention may be required,” he said. Prof Rose, Moorfields Eye Hospital, London, United Kingdom, said that socket problems can be broadly divided into three groups: poor appearance sockets, unstable artificial eyes and troublesome sockets. “There is often an overlap between these categories, with patients often experiencing problems in several of the groups. Furthermore, a structural problem EUROTIMES | FEBRUARY 2018

will frequently result in all three of the categories being involved,” he said. Characteristic features associated with poor appearance sockets include misaligned pupils, deep upper sulcus, lower lid contour, crease and displacement, poor movement, and upper eyelid ptosis. Unstable prostheses may occur for a variety of reasons, including poor fit due to orbital fat atrophy and implant migration resulting in recession of the prosthesis with the corresponding narrowing of the palpebral fissure. Issues with troublesome sockets include chronic discharge, itching and burning, painful blinking, lashes adherent to prosthesis and socket ache, noted Prof Rose. One of the most common causes of poor appearance sockets is post-enucleation socket syndrome (PESS). Several pathophysiological mechanisms have been proposed to account for the symptoms of PESS, including enophthalmos, sulcus deformity, upper and lower lid malposition and backward tilt of the prosthesis, said Prof Rose. “Unfortunately, most ocularists will try to compensate for inadequate intraorbital tissues by making a very large, oversized artificial eye, which generates its own range of problems, such as elephant-eye syndrome,” he said. Over time, the heavy, oversized prosthesis will result in poor contouring and a displaced lower lid. Problems with elephant eye syndrome arise from a disparity between the prosthetic surface area and the area of socket lining, said Prof Rose.

“The bigger the prosthesis the worse will be any foreign body reaction and biofilminduced inflammation,” he said. Prevention is the best cure for PESS or elephant eye syndrome advised Prof Rose. “We can achieve this by implanting an adequate size prosthesis, which nearly always means a 22mm orbital implant, unless there is inadequate tissue cover,” he said. In cases of poor movement of the prosthesis, he advised that the ocularist should not try to support the upper lid with the artificial eye unless there is a neurological or structural reason for doing so. “He or she should make a prosthesis centred relative to the lower lid and then levator surgery can be performed later,” he said. For scarred sockets with lining deficiency, Prof Rose suggested relining the socket after volume enhancement. “We should reline dry sockets with skin and moist sockets with mucosa and never mix the two lining types,” he said. For chronic discharge problems, the goal should be to reduce the bacterial load within the socket. Having a properly moulded implant helps and cleaning and polishing regimes are important to reduce biofilm on the prosthesis, said Prof Rose. Blepharitis and atopy should be treated and other sources of organisms such as blocked lacrimal drainage and canaliculitis should be tackled. The inflammatory response may also be reduced with topical steroids, he added. Geoffrey E Rose: geoff.rose@moorfields.nhs.uk

RESEARCH

EXPANDING RESEARCH The EU EYE Alliance is calling for more involvement from experts. Aidan Hanratty reports

he European Alliance for Vision Research and Ophthalmology (EU EYE) is an advocacy group launched in 2015. Its purpose is to raise political and societal awareness of the need for research in vision and ophthalmology on a European level. Its members include the European Association for The Study of Diabetes Eye Complications Study Group, the European Eye Bank Association, the European Glaucoma Society, the European Paediatric Ophthalmology Society, the ESCRS, EuCornea, EURETINA, the European Association for Vision and Eye Research and the European Vision Institute. The Alliance believes that the political focus on preventing mortality as a desired health outcome creates a disease bias towards fatal diseases. This does not do justice to sufferers of sensory impairment and other non-fatal conditions who, although they do not die from their diseases, nevertheless experience an enormous impact on quality of life and well-being with high costs in health and social care. The main causes of preventable blindness in Europe are glaucoma, agerelated macular degeneration, diabetic retinopathy and cataract. The Alliance believes that current health policies do not sufficiently take into account the increasing burden of eye diseases and vision impairment on European societies due to an ageing population and the growing prevalence of chronic diseases in Europe. Only research on identifying cost-effective preventive measures and treatment protocols will address such a burden.

PROACTIVE ENGAGEMENT At the helm of the ambitious proactive engagement of the EU EYE with the EU Institutions is its President Prof Einar Stefánsson. At the 17th EURETINA Congress in September 2017, Prof Stefánsson called on the ophthalmology community to work together and combine the interests of sub-specialty eye care societies to increase capacity to shape research directions and public health efforts in a complex political space. This year the EU EYE has focused its efforts on policy and legislation. A recent consultation regarding the Directive on Blood, Tissues and Cells gave the Alliance an opportunity to voice the concerns of its members involved with transplants. A

follow-up report shows agreement on a need for further flexibility and for revised legislation in terms of current scientific and technological trends, the variety of different tissue sectors, as well the different levels of effort and risk for tissue donors. The Alliance has been involved in high-level meetings with the EU’s Expert Panel for Investment in Health regarding benchmarking access to healthcare and the Health Policy Platform on final priorities for Horizon2020, the EU Framework Programme for Research and Innovation. The EU EYE has also emerged as a supportive advocacy partner as indicated by its recent endorsement of the statements on medical training and employment for people with chronic diseases of the European Society of Radiology and the European Chronic Disease Alliance respectively. Believing that policy knowledge is key in successful proactive engagement with the EU institutions, the EU EYE has invested in dissemination tools (email alerts and a regular newsletter) for improving membership awareness on developments in EU policies and directions in research, training and public health. The EU EYE has welcomed: the recent strengthening of research in the area of sensory impairment in the Human Brain Project of the European Commission, a project that seeks to accelerate the fields of neuroscience, computing and brain-related medicine through strategic alignment of scientific research programmes and the construction of research Infrastructure; and the recent showcasing of EU funded projects for vision such as devices providing a sense of vision through acoustics and touch or potential treatments

for X-linked retinitis pigmentosa (Nº 66, October 2017, research*eu, the monthly EU publication on thematic European research and innovation). Although such efforts show that there is some political attention being paid to vision impairment, the EU EYE believes that more can be done at prevention level. Plans for future EU EYE work therefore include promoting awareness across the EU regarding the value for a comprehensive strategy on diabetic eye screening, a key part of diabetes care.

FUTURE SUCCESS Looking into 2018 the Alliance aims to bolster its reputation and legitimacy when making recommendations in key areas of health and research. Ongoing work is focusing on establishing regular communication with various EU institutions, and at present the organisation is mapping out its internal knowledge capacity with a view to matching individual interests with broader directions in health and research. The future success depends on the organisation being able to provide technical expertise of the highest quality expertise to various panels, often at short notice.

Would you like to be involved in the efforts of the EU EYE? Anyone with interests in training, research, prevention, clinical care and public health in general is welcome please email: info@eueye.org EUROTIMES | FEBRUARY 2018

CME Educational Symposium

Washington, D.C. 2018

Save the date Friday, April 13– Monday, April 16, 2018 Make the most of your time at the ASCRS•ASOA Annual Meeting and attend our EyeWorld multi-supported CME, independent education, and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Among the topics to be covered in these sessions are:

• Updates on diagnosing and treating the ocular surface, including dry eye disease and meibomian gland disease • New developments in glaucoma medical and surgical treatment options • LACS: Tips and pearls for current users • Maximizing presbyopia-correcting outcomes • Successfully integrating toric IOLs and improving results and patient satisfaction • Mastering phaco dynamics, fluidics, power, and nuclear disassembly • Modern laser vision correction • A discussion on recent developments in anti-inflammatory therapeutic treatments

ASCRS-Authorized Education These non-CME, ASCRS-authorized educational programs will provide timely and important information on:

• Minimally Invasive Glaucoma Surgery

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

• • • • • • •

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

meetings.eyeworld.org

Topics are subject to change.

CONGRESS NEWS

WCPOS IV

4th World Congress of Paediatric Ophthalmology and Strabismus

AN ACADEMIC FEAST The 4th WCPOS was marked by the desire of the delegates to contribute, learn and help shape future vision of the children of this world. Dr Soosan Jacob reports

hange will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek.” That was the rousing message from Dr Ken Nischal at the end of a very successful 4th World Congress of Paediatric Ophthalmology and Strabismus, in Hyderabad, India. Almost 1,200 attendees from more than 60 countries converged to make this the most successful WCPOS to date. With founding co-chairs Drs Ken Nischal and David Granet and other members of the executive committee coordinating internationally and Dr Ramesh Kekunnaya locally, this was an academic feast. The entire conference was marked by the desire and enthusiasm of the delegates to contribute, learn and help shape future vision of the children of this world. Professor Harminder Dua, UK, delivered the Kanski Medal Lecture on Posterior Corneal Anatomy: Context, Controversy, Corroboration and Clinical Considerations. For the first time he shared notification that the corneal layer he had recently described would be officially called the ‘Dua-Fine Layer’. The Strabismus Lecture was delivered by Professor Richard Hertle, USA, on How and What We Learned From Studying

Nystagmus in Infancy and Childhood. Professor Lea Hyvarinen of Finland delivered the Non-Strabismus Lecture on Non-Strabismus The Important First Year. Several awards were also presented for outstanding contributions. These were: Best Paper – Jyoti Matalia; Vimal Rajput; Marcia Tartarella Best Poster – Simon Welsh; Sujata Sharma Best Video – Bhanunathi Madhavrao Workshops were conducted on lid and orbital disorders, lacrimal surgery, practical strabismus, orthoptics and ocular brachytherapy. Live surgery sessions demonstrated techniques of minimally invasive strabismus surgery, trabeculotomy with trabeculectomy and zepto for paediatric rhexis. Cross-linking in children, Paediatric Dry Eye Workshop (PeDEWS), low vision treatment in children, ocular genetics, paediatric glaucoma, ocular trauma, nystagmus, electrodiagnostics and use of newer imaging techniques such as ASOCT, UBM and OCT angiography in strabismus were other informative sessions. There was huge interest in paediatric myopia, with talks on epidemiology, causes, prevention, atropine treatment, role of increased outdoor time for children, use of dopamine as a biomarker for paediatric myopia and refractive surgery. Major symposia focused on amblyopia, strabismus resurgeries, cerebral/cortical visual impairments, paediatric uveitis and

WSPOS founding co-director Ken Nischal addresses attendees at the 4th WCPOS

Attendees at the 4th WCPOS

tumours of the lid and orbit, gliomas and CNS tumours, intraocular tumours and retinoblastoma. Interesting debates were conducted on the use of multifocal IOLs in children, limbal vs pars plicata approach for posterior capsulorhexis, and surgical vs non-surgical approach to high AC:A ratio accommodative esotropia. The Retinopathy of Prematurity debate regarding surgery vs antiVEGF for advanced disease saw many supporters for anti-VEGFs, but with plenty of discussion and unresolved issues regarding drug, dosage, recurrence, follow-up post-op injections, retreatment, long term safety etc. A mock trial, court-room drama enacted on non-accidental paediatric ocular injuries demonstrated and gave advice to delegates on handling the duties of being an expert witness. Other interesting talks included a debate on whether paediatric ophthalmology was viable in private practice and on how to raise interest in this sub-speciality among residents. Dr Nischal reminded everyone of Goethe’s famous quote: “Ideas are like pawns in a game of chess: they may get wiped out but they may be the beginning of a winning game.” WSPOS wants everyone to keep those ideas of innovative learning to keep coming. See you in Amsterdam October 3-5, 2020, for WCPOS 5! EUROTIMES | FEBRUARY 2018

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INDUSTRY NEWS

INDUSTRY

NEWS

IMPROVED QUALITY Heidelberg Engineering presented the latest features of the SPECTRALIS OCT Angiography Module at the 5th International Congress on OCT Angiography in Rome, Italy. “OCT angiography fully integrated in a multimodal imaging workflow is surely one of the most promising diagnostic tools in modern ophthalmic imaging. However, for clinicians to enjoy its benefits they need a device with resolution that is high enough to see capillary networks in detail and the ability to track eye movement and remove projection artifacts in a reliable manner”, said Dr Kester Nahen, Managing Director of Heidelberg Engineering. The new features of the SPECTRALIS OCT Angiography Module include an improved image quality for the precise visualisation of pathology and structures in the deep vascular complex, a refined retinal layer segmentation and a unique projection artifact removal (PAR) tool. www.HeidelbergEngineering.com

FDA CLEARANCE

RECORD REVENUE

Topcon Medical Systems has announced that its PASCAL Laser has received FDA clearance (K171488) to offer Pattern Scanning Laser Trabeculoplasty (PSLT) for the reduction of intraocular pressure (IOP) associated with glaucoma. PSLT is an advanced tissue-sparing laser treatment for reducing intraocular pressure in open-angle glaucoma. “The availability of PSLT, offers now a clinicallyproven glaucoma treatment technology to ophthalmologists in the US,” said Robert Gibson, Vice President, Eye Care Global Marketing, Topcon Corporation. “Globally, we’ve seen success with the Streamline PSLT application and believe glaucoma specialists and comprehensive ophthalmologists in the United States will find this technology a useful addition to their treatment armamentarium.” http:// global.topcon.com

Zeiss has announced that in the past fiscal year, it increased both revenue and earnings to a record level. Revenue rose by 10% to €5.348 billion. At €770 million, earnings before interest and tax were significantly above the level of the previous year, the company said. “All four segments – Research & Quality Technology, Medical Technology, Vision Care/ Consumer Products and Semiconductor Manufacturing Technology – are either at or above their target returns,” said Professor Michael Kaschke, President and CEO of Carl Zeiss AG. “This development was not and is not just a matter of course. Rather, it is the result of the tremendous efforts made by all employees and partners over a long period of time,” said Prof Kaschke. www.zeiss.com

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

Eye Contact Interviews



Video of the Month

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

player.escrs.org EUROTIMES | FEBRUARY 2018

ATTEND THE LARGEST U. S. MEETING DEDICATED EXCLUSIVELY TO THE NEEDS OF THE ANTERIOR SEGMENT PR ACTICE.

Learn directly from the world’s thought leaders

Broaden your networking connections

Return with the practical tools needed to improve your practice

ADDITIONAL PROGRAMS ASCRS REFRACTIVE DAY • APRIL 13 ASCRS GLAUCOMA DAY • APRIL 13 CORNEA DAY • APRIL 13 ASOA WORKSHOPS • APRIL 13 T&N TECH TALKS • APRIL 13

AnnualMeeting.ascrs.org Programming will be held in the Walter E. Washington Convention Center.

TECHNICIANS & NURSES PROGRAM • APRIL 14–16

BOOK REVIEWS

EASING ANXIETY Intraocular Inflammation (Springer) is an incredible reference work. Edited by Manfred Zierhut, Carlos Pavesio, Shigeaki Ohno, Fernando Oréfice and Narsing A. Rao, the editors declare that the textbook “presents the subject of intraocular inflammation in an PUBLICATION encyclopedic style”. INTRAOCULAR INFLAMMATION In the sense of EDITORS comprehensiveness, this is MANFRED ZIERHUT, CARLOS PAVESIO, true. But they have done SHIGEAKI OHNO, FERNANDO ORÉFICE more than simply compile AND NARSING A. RAO encyclopedic knowledge. PUBLISHED BY SPRINGER They have managed to present this information in a manner that eases the acute anxiety experienced by most ophthalmologists when confronted with inflammation of uncertain origin. This isn’t to say that diagnosing, treating and following up patients with uveitis will instantly become a simple task. No, the 155 chapters cover entities that we have all likely seen (varicella-zoster, HLA-B27-associated acute anterior uveitis), diseases we’re unlikely to ever encounter (rift valley fever virus) and some we all hope never to have to confront (sympathetic ophthalmia), at least for the sake of our patients. Part I, “General Aspects of Uveitis”, is a good introduction, but where it starts getting interesting is in Part II, “Diagnostics”. How does one use serology and taps of the anterior chamber and vitreous to best arrive at answers? What is the role of vitrectomy? Electrodiagnostics? Laser flare photometry? With the recent expansion of therapeutic possibilities, now is also the time to delve into these options: The differences between TNFα-blockers INFα and the immunoglobulins are clearly described. Readers can refer to part IV: “Complications & Their Therapy”, for advice on how to deal with the unexpected.

BOOK

REVIEWS

MEDICINAL TREATMENT Pharmacologic Therapy of Ocular Disease (Springer), edited by Scott M. Whitcup and Dimitri T. Azar, approaches medicinal treatment of ocular pathology anatomically. After Part I’s discourse on ocular pharmacokinetics and drug delivery, Part II focuses on treatment of the anterior segment and tear film. Those interested in corneal pathology will enjoy reading the authors’ predictions regarding the future therapy of keratoconus. Part III is entitled Trabecular Meshwork & Uvea, an interesting way to approach the problems of glaucoma and uveitis. Most interesting here is the chapter on translational pharmacology in glaucoma neuroprotection. Part IV covers treatment of the posterior segment and optic nerve, including the usual antiinflammatory and anti-angiogenic drugs but also treatment of hereditary retinal dystrophy and dry age-related macular degeneration.

Are you ready for the next step? Belong to something energetic. Join us.

www.escrs.org

LEIGH SPIELBERG MD 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 | FEBRUARY 2018

HOSPITAL DIARY

PRIDE AND FEAR The voice inside my head helps keep me alert when the going gets tough, says Leigh Spielberg MD

e was going blind But the voice inside my head in both eyes, and I was not impressed. “So what? had only a few days You chose vitreoretinal surgery, to help him before big deal. This isn’t even VR, it’s the light slipped glaucoma and lens. You’re about away forever. But to pierce a little marble of an eye how to proceed? Each plan I with a 23G incision and you’re came up with had a significant going to see the vitreous squeeze chance of at least one serious through the trocar, pop off the complication. valve and drag the retina right The patient was a on out. The pressure will drop 60-something male with and you’ll have effusion until the 60-something IOP bilaterally. choroids kiss. Good luck,” it said, The cause: angle closure and then it was gone. in the context of extreme The voice inside my head helps hypermetropia. +11 dioptres. keep me alert when the going The anterior chambers had gets tough. But I don’t always disappeared: 100% of the appreciate its presence in my corneal endothelium had mind, especially when I’ve made contact with either lens or iris. the decision to go for it. I walked The eyes didn’t look like eyes, into the operating room and tried but rather like poorly made glass to think only happy thoughts. prosthetics, with too little glass The sharp tip of the bevelled to make an anterior chamber. trocar inserter cut through the He had been referred to us pressurised sclera like butter. after peripheral laser iridotomies I placed the inferotemporal and intravenous mannitol had trocar and then immediately been unsuccessful. Now it was inserted the vitrector for a core my turn to try, but what should vitrectomy. It was too dangerous I do? There’s no consensus on to remove the valve to place the how to treat this problem. infusion line. My devil’s advocate Something needed to be was right: the vitreous would Now it was my turn to try, but what removed from the eye, but what come right out. should I do? There’s no consensus on was the safest option? Simple I removed some vitreous lens removal would be the bestand got the IOP down to a how to treat this problem. case scenario. However, there reasonable level before placing was no safe way to enter the the infusion line and the two virtual space of what used to superior trocars. There was of be the anterior chamber. There course no PVD, and I didn’t was far too much posterior pressure. Under these conditions, I have much room to manoeuvre, so I shifted my attention to the wouldn’t be able to get any viscoelastic into the anterior chamber, anterior chamber. It was time. never mind a phaco tip. And once inside, how would I prevent One option was lensectomy with the vitrector via the pars plana, the iris from popping out of the incisions? A capsulorhexis leaving the anterior face of the lens capsule intact. But I didn’t like would be impossible the idea of placing a sulcus lens – especially a thick, 35-diopter lens Neither my own knowledge, my books nor PubMed offered – into the sulcus of a 19.5mm eye. So, I started creating some space any clear solution. So, I did what I do when I want to discuss between the cornea and the iris without allowing the iris to dance a case: I pitched the problem into our colleague group on on out of the eye. Despite the reduction of posterior segment WhatsApp. I described the situation, and then added: “The pressure, the anterior chamber still didn’t exist, so I injected a solution will be surgical: either regular phaco or vitrectomy with dispersive viscoelastic using a 27G needle, which creates a hole lensectomy.” I specifically directed the question to our glaucoma that’s too small for any tissue to creep through. specialist, Koen Vermorgen. This worked well. As I filled the anterior chamber, the posterior “I’d suggest a core vitrectomy + phaco,” he replied within segment’s pressure rapidly increased, so I went back and removed minutes. The core vitrectomy, he elaborated, would decrease the more vitreous before proceeding. The cornea started to clear a bit posterior pressure and allow activity in the anterior chamber. and I carefully proceeded with phaco, always mindful of the iris, I walked to the operating room with a sense of pride for taking which had suffered ischemia due to the high IOP, and could not on such a challenging case. I had, in collaboration with my be trusted… colleagues, come up with a legitimate plan that had a reasonable To be continued… chance of success. However, this sense of pride was tinged by a Dr Leigh Spielberg is a vitreoretinal and cataract surgeon sense of fear of the consequences of my intervention. And yet, at Ghent University Hospital in Belgium as I scrubbed in, I told myself that this was the reason that I had leigh.spielberg@gmail.com chosen this subspecialty. Illustration by Eoin Coveney

EUROTIMES | FEBRUARY 2018

EXPLORING VIENNA

Vienna University

VIENNA

FOR A STROLL

THE HUNDERTWASSER-KRAWINAHAUS A look at Viennese architect Friedensreich Hundertwasser’s eccentric work. The metro station Landstrasse puts you in the neighbourhood. The HundertwasserKrawinahaus, a 52-unit apartment house that opened in 1986, is at Kegelgasse 36-38. Trees grow out of the facade, grass sprouts on the roof and rooms feature undulating floors, “a divine melody for the feet” according to the architect. The interior can’t be visited but nearby you’ll find a museum and cafe also designed by Hundertwasser, where your own feet can experience the melody. (Careful!) Open year round, free admission. Then stop at nearby Hundertwasser Village, for a coffee and a souvenir. From here it’s a 10-minute walk to KunstHaus Wien, a museum hosting a permanent exhibit of Hundertwasser’s work. www.hundertwasser-haus.info/en

JEWISH DISTRICT After playing an important role in the life of Vienna for 800 years, the Jewish community was almost obliterated after Austria’s annexation by Hitler’s Germany. A one-kilometre walk in Vienna’s 1st district provides insights into this tragic history. Begin at Albertinaplatz with the Memorial against War and Fascism. Follow Dorotheergasse to the Jewish Museum in Palais Eskeles. Take a break in their cafe. Continue to Judenplatz for the poignant Holocaust memorial and to visit a branch of the Jewish museum that focuses on Jewish life in the Middle Ages. Note: both branches of the Museum are closed Friday afternoon, Saturday and high holidays. www.jmw.at

WIENER MODERNE A walk off-the-beaten-track, fine art, plus great shopping… that’s the Wiener Moderne – Beauty and the Abyss tour. Commissioned by the Vienna Tourist Board, it was inspired by the 100th Anniversary of the passing of four of Austria’s most important artists and designers – Gustav Klimt, Egon Schiele, Otto Wagner and Koloman Moser – all of whom died in 1918. In the course of a leisurely three-hour stroll you visit design boutiques with actual works by these men, or with works inspired by them, as well as shops that were around during their lifetime. Maximum number of participants is eight; private tours possible. For further information, visit ShoppingwithLucie.com.

VIENNA’S VISION

Delegates to the 36th ESCRS Congress can enjoy some architectural gems. Maryalicia Post reports. Modern architecture isn’t the first thing to come to mind when you think about Vienna. And indeed, that’s the way they want it. Vienna’s inner city, with its Baroque buildings, gardens and monuments, was designated a UN Heritage Site in 2011; as recently as early 2017 the UN reminded Vienna that an intrusion of modern buildings would jeopardise its standing. UNESCO was reacting to a project, planned to break ground in 2019, that proposes a new conference centre, hotel, fitness facilities and high-rise apartment on the south side of the 19th-Century Stadtpark. It’s the height of the high-rise that causes the problem. The proposed tower is 66.3 metres, reduced, following protests, from 75 metres. Forty-three metres is the appropriate height limit in Vienna’s city centre, according to UNESCO. Back in 1990, when Haas House appeared in the old town, it wasn’t the modest height of the building but its stone and glass frontage that caused the most controversy. The building stands eye to eye with the iconic St Stephen’s Cathedral, which is reflected in the glass structure. The Viennese architect, Hans Hollein, explained that his building referenced the Roman watch tower that once stood on this site. Today, however, it’s largely accepted, like an inoffensive old man with spectacles in conversation with his neighbour, the 12th-Century cathedral. Since then, modern developments have been kept away from the inner city. In 2016, a start was made on Aspern Lakeside City in Vienna (about a 20-minute taxi ride from Reed International Conference Centre) for what will be the cheerfully named ‘HoHo Building’, the ‘tallest wooden skyscraper in the world’ according to its developers. The 84-metre tower is due for completion in 2018 and will comprise 24 floors of timber-based

hybrid construction. It was designed by the Viennese architects RLP Rüdiger Lainer + Partner. (At the moment, the world’s tallest wooden building is a 14-storey apartment block in Bergen, Norway.) Also well away from the old town, in fact just a five-minute walk from the Conference Centre, is a newly developed area any modern architecture enthusiast would enjoy visiting. Still settling into its landscape, criss-crossed with bike tracks and walking paths, the new campus of the Vienna University of Economics and Business Administration caters for 25,000 students in a cluster of buildings, each designed by a world-renowned architect. The centrepiece, and centre of attraction, is the imposing Library and Learning Centre designed by Hamburg’s Zaha Hadid. The Architekturzentrum Wien offers two-hour guided tours of the campus. Registration required: contact essl@azw.at, Minimum number of participants: 15 people, Meeting place: U2 station Messe-Prater (Messe exit), Price per Person: €18. Haas House and St Stephen’s Cathedral

EUROTIMES | FEBRUARY 2018

OUTLOOK ON INDUSTRY

GLOBAL FRANCHISE Shire Pharmaceuticals is helping to tackle dry eye and is aiming to become an international ophthalmic player. Howard Larkin reports.

ollowing a successful USA launch of Xiidra (lifitegrast) in 2016, Robert Dempsey, the head of the Global Ophthalmics Franchise at Shire, is working to bring the blockbuster dry eye drug to a number of countries around the world, including several in Europe. Shire is a leading biotechnology company focused on bringing novel therapeutics to address unmet medical needs. Shire filed for European marketing authorisation for lifitegrast in August 2017 with a clinical evidence package similar to the one that won FDA approval a year earlier. In clinical trials it demonstrated repeatable improvement in both dry eye signs as measured by corneal staining and symptoms measured by a patient-reported eye dryness scale. “We solved the puzzle. We were the first company to get an indication for both the signs and the symptoms of dry eye disease, the high hurdle that the US FDA has asked for,” Dempsey said.

EUROTIMES | FEBRUARY 2018

been supporting presentations, educational The European application was submitted supplements and sponsored CME to Denmark, Norway, Sweden, Finland, the programmes. UK, Germany, the Netherlands, France, “It is critical as a new entrant in the space Italy, Portugal, Spain and Greece, with the to share with these organisations our UK leading as the reference member mission and goal of becoming an state. While Shire awaits word on international ophthalmic player.” the filing, they are building out Dry eye is a multifactorial medical and commercial teams disease, so Shire is pursuing throughout Europe. at least one additional dry Marketing applications have eye treatment targeting nonalso been filed in six other inflammatory causes of dry eye countries around the world. disease. “In China alone there are In May 2017, Shire entered into a more people with dry eye than the Bob Dempsey collaborative agreement with Parion population of the US and Canada Sciences in North Carolina, USA, combined,” Dempsey said. He to develop a compound that blocks the estimates there are 30 million people with endothelial sodium channel, slowing tear symptomatic dry eye in the USA, another reabsorption. This helps maintain surface 30 million in Europe and more than 350 hydration and osmolarity, preventing the million globally. inflammatory cascade that leads to dry eye, which could help repair the ocular surface. RAISING AWARENESS The compound is in phase II clinical trials. In the USA, Shire complemented its Other drugs in Shire's ophthalmic pipeline lifitegrast launch with a national public include a combination antiseptic and awareness campaign on television, in antibiotic for treating bacterial and adenoviral print and online, featuring actress Jennifer infectious keratitis in phase III trials, and a Aniston, who said she suffers from dry eye glaucoma medication in phase I. Together almost every day. with lifitegrast, these products are making Dempsey credits Shire’s activities in the a major player out of a company that only space with helping to grow the overall entered the ophthalmic field in 2014. USA dry eye market, including eye drops, “When I started I was in an office all by pharmaceuticals and other treatments, myself, and people didn’t know anything by about 30%. Xiidra revenues were $54 about ophthalmology or optometry, so we million in 2016, accelerating to $96 million built a great team. The goal was to build the in the first half of 2017. ophthalmic franchise, launch Xiidra in the Dempsey sees potential in Europe and US, hire and deploy an international team, says Shire is working with clinical societies, and build a strong pipeline,” Dempsey said. leading institutions and key opinion leaders to familiarise them with Shire, and has The journey continues.

ESCRS NEWS

ESCRS

NEWS

ESCRS PETER BARRY FELLOWSHIP 2018 Applications are open for the Peter Barry Fellowship 2018. This Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. The Fellowship of €60,000 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 one year. The 2017 winners of the inaugural Peter Barry Fellowship were Luis Fernández-Vega, Nino Hirnschall and Myriam Böhm (pictured above with outgoing ESCRS President David Spalton and Carmel Barry, wife of the late Dr Barry). Applicants must be European trainee ophthalmologists, 40 years of age or under on the closing date for applications and have been ESCRS members for three years by the time of starting the Fellowship. The Fellowship will be awarded at the ESCRS Annual Congress in Vienna in September 2018, to start in 2019.

Keep learning. Stay relevant.

To apply, please submit the following: ∙ 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 The closing date for applications is 1 May 2018. Applications and queries should be sent to Danielle Maher at Danielle.Maher@escrs.org

Ready when you are: online, interactive courses from leading surgeons.

VISIT THE ONLINE ESCRS PRESENTATIONS LIBRARY ESCRS On Demand is an online library of presentations from ESCRS Congresses. This library offers ESCRS members the opportunity to view the scientific content of all ESCRS Congresses at

their leisure. This includes all presentations, videos and eposters. Access is free for ESCRS members. Full information is available at http://escrs. conference2web.com

Over 30 hours of content covering the latest techniques and technology. CME accredited and free for ESCRS members

Learn more at http://elearning.escrs.org EUROTIMES | FEBRUARY 2018

RANDOM THOUGHTS

HENAHAN WRITING PRIZE Entries are now being invited for the 2018 John Henahan writing competition for young ophthalmologists. Colin Kerr reports

“Start writing, no matter what. The water does not flow until the faucet is turned on.” – Louis L’Amour 1908-1988 In 2008, the ESCRS decided to introduce a writing competition for young ophthalmologists. The John Henahan Prize was named in honour of John Henahan, who edited EuroTimes, the official news magazine of the ESCRS, from 1996 to 2001. The chairman of the judging panel is Dr Emanuel Rosen, founder of EuroTimes and former president of the ESCRS. The purpose of the competition was to encourage young ophthalmologists to develop their writing skills, not only for professional purposes, but also to showcase their talents outside of ophthalmology. Since the competition was launched 10 years ago, ophthalmologists from all over the world have submitted essays in the hope of winning the prize. Some of them have gone on to become regular contributors to EuroTimes, including Drs Soosan Jacob, Leigh Spielberg, Sorcha Ni Dhubhghaill and Clare Quigley. All of them are gifted ophthalmologists and through their writing they are sharing their knowledge with the 46,000 ophthalmologists who read EuroTimes every month.

JOHN HENAHAN

PRIZE WINNERS

2008 – 2017 EUROTIMES | FEBRUARY 2018

WHY WRITE? Some doctors may argue that they do not have time to write and that their sole focus must be on treating patients and developing their surgical skills. But without writers, where would we get the textbooks that are essential to the training of our young surgeons? Even those who do not have their work published should consider the healing power of writing and how it can make us not only better doctors but better human beings.

CALL FOR ENTRIES That is why we are encouraging all ophthalmologists to consider entering the 2018 John Henahan Prize. The topic for this year’s essay is ‘Do We Need A Randomised Controlled Clinical Trial In Cataract Surgery?’ The judges will draw up an initial shortlist of the five best essays submitted and will then decide on the winning essay. The shortlisted essays and the winning essay will be published in EuroTimes The competition is open to ophthalmologists who are members of the ESCRS and aged 40 years or under on 1 January, 2018. The winner of the prize will receive a €1,000 travel bursary to the 36th

2017 Dr Clare Quigley, Ireland How Does Commercial Interest Affect My Career? 2016 Dr Manish Mahabir, India Why Should I Publish? 2015 Dr Sidath Liyanage, UK How Do I Learn Surgery? 2014 Dr Lampros Lamprogiannis, Greece How Do I See Cataract Surgery In 20 Years? 2013 Dr Nicole Tsim, Hong Kong Recollections Of My First Intraocular Surgery

Congress of the ESCRS in Vienna, Austria, and will be presented with a speciallycommissioned trophy during the ESCRS Video Competition Awards ceremony. The essays will be judged by Thomas Kohnen, chairman, ESCRS Publications Committee; Emanuel Rosen, chief medical editor, EuroTimes; José Güell, former president, ESCRS; Oliver Findl, chairman, ESCRS Young Ophthalmologists Committee; Sean Henahan, editor, EuroTimes; Paul McGinn, editor, EuroTimes; and Robert Henahan, contributing editor, EuroTimes. The punctuation, syntax and grammar should reflect the high standard of material published in EuroTimes. Entries should be 750 words in length 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 30 March 2018. So get writing and consider these words from the American physicist, historian and philosopher Thomas Kuhn (1922-1996). “No language thus restricted to reporting a world fully known in advance can produce mere neutral and objective reports on ‘the given’. Philosophical investigation has not yet provided even a hint of what a language able to do that would be like.”

2012 Dr Sorcha Ni Dhubhghaill, Ireland The Trials and Tribulations Of A Young Opthalmologist 2011 Dr Soosan Jacob, India My Best Teacher 2010 Dr Leigh Spielberg, USA The Outstanding Memory Of My Residency 2009 Dr Kaladevi Ranganathan, India My Best Patient, My Worst Patient 2008 Dr Shiu Ting Mak, Hong Kong Why I Became An Ophthalmologist

CALENDAR

↙

LAST CALL

FEBRUARY 2018

22nd ESCRS Winter Meeting

APAO 2018

8–11 February Hong Kong http://2018.apaophth.org/

2nd International Swept Source OCT & Angiography Conference 16–17 February Paris, France https://www.issoct.com/

8th EURETINA Winter Meeting 16–17 February Budapest, Hungary www.euretina.org

MARCH

14th ISOPT Clinical: The International Symposium on Ocular Pharmacology & Therapeutics 1–3 March Tel Aviv, Israel https://www.isoptclinical.com/

↙

9–11 February Belgrade, Serbia www.escrs.org

The 2018 ASCRS•ASOA Annual Meeting will take place in Washington DC, USA

32nd International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 1–4 March Athens, Greece www.hsioirs.org/index.php/en/

Frankfurt Retina Meeting 2018

24–25 March Mainz, Germany www.eckardt-frankfurt.de

APRIL

2018 ASCRS•ASOA Annual Meeting

13–17 April Washington DC, USA http://annualmeeting.ascrs.org/

4th ESASO Anterior Segment Academy

26–28 April Milan, Italy www.esasoasa2018.org

MAY

15th Congress of the South-East European Ophthalmological Society 31 May – 2 June Szeged, Hungary http://www.seeos.eu

The 4th ESASO Anterior Segment Academy will take place in Milan, Italy

EUROTIMES | FEBRUARY 2018

CALENDAR

JUNE

The 3rd World Eye Bank Symposium will take place in Barcelona, Spain

World Congress on Clinical, Pediatric and Neuro Ophthalmology

4–5 June Osaka, Japan https://neuro.ophthalmologyconferences.com

31st International Congress of German Ophthalmic Surgeons

14–16 June Nuremberg, Germany http://www.doc-nuernberg.de/index-e.php

3rd World Eye Bank Symposium

15 June Barcelona, Spain http://www.gaeba.org/events/ 3rd-world-eye-bank-symposium-gaeba/

WOC 2018

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

SEPTEMBER

20–23 September Vienna, Austria www.euretina.org

SEPTEMBER

↙

18th EURETINA Congress

9th EuCornea Congress

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

2018 WSPOS Subspecialty Day 21 September Vienna, Austria www.wspos.org

36th Congress of the ESCRS

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

OCTOBER

Ophthalmic Imaging: from Theory to Current Practice

12 October Paris, France http://www.vuexplorer.com/en/congres

AAO Annual Meeting 2018 27–30 October Chicago, USA https://www.aao.org/

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Cataract, Refractive and Patient Reported Outcomes in One Platform The patient-reported outcome is linked to clinical data in EUREQUO. This enables better knowledge of indications for surgery and offers a tool for clinical improvement work based on the patients’ outcome.

EUROTIMES | FEBRUARY 2018

EUREQUO is free of charge for all ESCRS members

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18TH EURETINA

CONGRESS

VIENNA 20-23 SEPTEMBER

2018 www.euretina.org

Abstract submission deadline

16 March 2018

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