EuroTimes Vol 24 Issue 4

SPECIAL FOCUS CORNEA

April 2019 | Vol 24 Issue 4

The Evolution of

CROSS-LINKING

CATARACT & REFRACTIVE | RETINA PAEDIATRIC OPHTHALMOLOGY

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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 Ria Pollock 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

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.

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ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

CORNEA

4 Advances in cross-linking technology provide new options in keratoconus treatments

6 Athens Protocol for

keratoconus shows marked improved visual outcomes

8 Everything you need

to know about new treatments for keratoconus

10 Prevention of herpetic

reactivation essential in at-risk patients undergoing corneal surgery

11 New tools could help

diagnose causes and severity of dry eye disease

12 Donor corneal ring

segments may be safer, more flexible than synthetic implants

13 Adding donor stroma is a new frontier for presbyopia

CATARACT & REFRACTIVE 14 Taking a look back at the

early days of laser vision correction

16 Fluid-driven IOL nearly As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2017 and 31 December 2017 is 45,316.

doubles accommodation of previous designs

17 Optimised calculations can further improve refractive predictability

www.eurotimes.org

RETINA

P.28

20 The fascinating

workings of the eye’s immune system in uveitis

21 We report from the 9th EURETINA Winter Meeting

22 Research supports

feasibility of gene therapies for disabling colour blindness

23 Natural history in cases of retinitis pigmentosa

24 Gene therapy has

a wide window of opportunity in rodcone dystrophy

25 Punctal plugs can

reduce ocular surface discomfort linked with intravitreal injections

PAEDIATRIC OPHTHALMOLOGY 26 Retinopathy of

prematurity “risk clock” starts at birth and runs for the first two months

27 Modifiable risk

factors in childhood could help to reduce high myopia

REGULARS 28 Hospital diary 29 Random thoughts 31 Books 32 Outlook on Industry 33 Practice management 34 Industry news 35 My mentor 37 Travel 39 Calendar

Supplement April 2019

STRATEGIES

for SUCCESS w th

&

Presbyopia

Correcting

I OL s

Included with this issue...

ESCRS Forum Supplement

Clarification In the March 2019 Vol 24 Issue 3 issue of EuroTimes, in the article Errant rhexis we referred to the “little rhexis” technique. This should have been the “Little rhexis”, popularised by Brian C Little.

EUROTIMES | APRIL 2019

2

EDITORIAL A WORD FROM JESPER HJORTDAL MD, PhD

GUEST EDITORIAL

Keeping up to date EuCornea plans exciting programme for 10th EuCornea Congress

Jesper Hjortdal

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-Lamard (France), Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Daniel Kook (Germany), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland) Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)

M

ajor changes in corneal healthcare require corneal specialists to continuously keep updated on new diagnostic methods and new treatment modalities.

The Cornea Day at the ESCRS Winter meeting organised by ESCRS in collaboration with EuCornea and the EuCornea Annual Meeting give us the opportunity to discuss the latest hot topics with our friends and colleagues.

The 2019 Cornea Day was held on Friday 15 February during the ESCRS Winter Meeting in Athens, Greece, and I would like to thank José Güell from EuCornea and Rudy Nuijts from ESCRS who jointly organised the four programme sessions, each composed of a keynote lecture followed by several case-presentations.

The Cornea Day was very well attended and I would like to thank all my colleagues who took part in the sessions and ensured that the day was a big success.

The Board and Programme Committee of EuCornea look forward to welcoming residents and colleagues to Paris where the 10th EuCornea Congress will take place from 13-14 We are also very September at Paris Expo pleased that The Porte de Versailles.

Again, we have a very Cornea Society exciting programme has accepted our planned with Focus invitation to attend Sessions on Ectatic Diseases, Viral Keratitis, and participate in DSAEK and DMEK, the Joint Session – Ocular Allergy, NonUpdate on Ectatic Healing Corneal Ulcers, Diseases...

Complications In Corneal Surgery, Ocular Surface Diseases In Paediatric Patients and Dysfunction of Corneal Homeostasis.

We are also very pleased that The Cornea Society has accepted our invitation to attend and participate in the Joint Session – Update on Ectatic Diseases, and I believe this will be one of the major highlights of the meeting.

This year’s Medal Lecture will be delivered by Sadeer Hannush, and we are looking forward to a stimulating presentation by Dr Hannush who is an Attending Surgeon on the Cornea Service at Wills Eye Hospital and Professor of Ophthalmology at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, US. Dr Hannush is an expert on the subject of corneal and refractive surgery and has earned many distinctions in the field. He has been invited to lecture nationally and internationally on a wide range of subjects including laser vision correction, astigmatism correction, intraocular lens management and corneal transplantation.

I look forward to seeing you in Paris and for further updates visit our website at www.eucornea.org

Jesper Hjortdal is the President of EuCornea EUROTIMES | APRIL 2019

10th EuCornea Congress

13 – 14 September 2019 | Paris Expo Porte de Versailles

Scientific Programme, Registration & Hotel Bookings www.eucornea.org

4

SPECIAL FOCUS: CORNEA

Evolution in CXL Advances in cross-linking technology provide new options in keratoconus treatments. Roibeard Ó hÉineacháin reports

L

essons learned from experience with corneal cross-linking (CXL) and recent advances in technology call for the establishment of new treatment algorithms for keratoconus, according to Miltos Balidis PhD, FeBOphth, ICOphth, Thessaloniki, Greece.

“We should put the new technologies together with what we have learned so far.

Correcting visual acuity, reducing coma, stopping progression, and the thinnest EUROTIMES | APRIL 2019

pachymetry – these are the standards we should always have in mind if we are going to have a new algorithm for these eyes,” Dr Balidis told the 23rd ESCRS winter Meeting in Athens, Greece.

In the past, treatment algorithms have been based on K readings, progression, corneal thickness, visual acuity and the age of the patient. The goal of treatment has been the stabilisation of the cone rather than visual rehabilitation. Meanwhile, there has been an evolution of technique

that provides the surgeon with a broad range of options to consider.

The original CXL procedure was the Dresden protocol, which involved a simple cross-linking procedure using riboflavin 3mW/cm 2 of energy for 30 minutes. There soon followed the Athens/ Cretan protocol in which photorefractive surgery is used to change the shape of the cone and then afterwards freezing the shape of the cornea with cross-linking in order to maintain this change.

SPECIAL FOCUS: CORNEA

Other variations of technique include epi-off CXL, where the cross-linking is performed through the corneal epithelium to provide greater patient comfort and less postoperative pain and a lower risk of infection. However, the procedure appears to have the disadvantage that the crosslinking doesn’t penetrate as deeply, even when the CXL is accelerated. More recent times have seen the advent of customised CXL in which only the weakened cornea undergoes cross-linking.

There has also been an evolution of riboflavin from the standard dextran solution to riboflavin plus hydroxypropyl methylcellulose (HPMC) hypotonic saline solution, which induces much less corneal thinning.

CUSTOMISED CXL Topography-guided PRK plus crosslinking has proved successful in large series of patients; however, it has one inherent flaw in that it makes thin corneas even thinner.

However, a new procedure has recently been developed, which treats only the cone as determined by posterior elevation measured by tomography with the Pentacam. A system now marketed by Avedro combines an eye tracker with an adjustable ultraviolet A light device that irradiates the cornea in customised patterns, delivering greater energy levels to where greater stiffening is required.

Early results with the technique suggest that it produces a greater flattening of the cornea and better improvements in vision than more conventional CXL. Early indications also suggest that, when combined with oxygen supplementation delivered via boost goggles, transepithelial procedures will penetrate to sufficient depth for optimum cross-linking.

“This is a new era – we can translate any type of configuration on to the cornea with the customised cross-linking and I really think this is a game-changer in our armamentarium,” he told the Athens conference.

A NEW ALGORITHM On the basis on what research has shown and the tools now available, Dr Balidis said a new algorithm is necessary to treat keratoconus patients in a more individual way.

So, for example, in eyes with corneas thinner than 400 microns with a good visual acuity and a good RMS, an accelerated cross-linking will produce a satisfactory result. However, a customised procedure will produce better results. In eyes where vision is getting worse, the cone is increasing and the RMS is high, CuRV (Customised Remodeled Vision) procedures will be especially beneficial.

However, when the RMS is 3.1, transepithelial topographically-guided

PRK to normalise the cornea may be a better interventional option. When the visual acuity is less than 0.4 and the RMS is greatly elevated, deep anterior lamellar keratoplasty (DALK) is often the best option, although topographicallyguided PRK or possibly intracorneal ring segments may be considered.

Eyes with very thin corneas are good candidates for epi-on customised CXL with oxygen supplementation. As an illustration Dr Balidis presented a case where this approach flattened the cone by four dioptres.

Dr Balidis noted that in the past hydration has been used to increase the thickness of thin corneas to allow deeper penetration of the cross-linking without compromising the safety of the endothelium.

However, he and his associates have shown in a study that, in fact, that the more hydrated the cornea, the less functional will be the cross-linking. The epi-on customised oxygen-supplemented procedure allows deeper penetration of the cross-linking but with an adequate safety zone without any hydration.

SOME CAVEATS REMAIN In an interview with EuroTimes, Vikentia Katsanevaki MD PhD, Athens, Greece, noted that keratoconus is of major concern in the Mediterranean area and cases are dealt with every day at her institution. Therefore, she has a lot of experience with the classic Dresden protocol, which is known to work.

However, things can always get better.

“It is obvious now that if we deliver the same energy to the cornea we can play a little bit with the time and the fluence and the question to be answered here is, how can we have the results of the Dresden protocol without such a time-consuming therapy, meaning minimising the time by advancing the fluence without having adverse effect to the cornea?” said Dr Katsanevaki.

However, she pointed out that surgeons need to be aware that CXL procedures carry some risks. For example, in epi-off treatments, exposure of the stroma while the epithelium heals leaves it open to a range of complications.

“In most cases the epithelium heals in a few days but there were cases where it could take a longer time. And the longer the epithelium is off the more risk there is. There is the risk of infection, the risk of corneal melt, and the risk of significant scarring to the eye. It is almost necrotic keratitis. Of course these are really, really rare but the risk is there,” she added.

Miltos Balidis: balidis@ophthalmica.gr Vikentia Katsanevaki: vikentia2015@gmail.com EUROTIMES | APRIL 2019

5

SPECIAL FOCUS: CORNEA

CXL plus PRK for keratoconus Athens Protocol for keratoconus shows good long-term results with no keratoconus progression and additionally marked improved visual outcomes.

Roibeard Ó hÉineacháin reports

T

he Athens Protocol for treating progressive keratoconus with partial topographyguided photorefractive keratectomy (PRK) and corneal crosslinking (CXL) appears to provide a safe and stable regularisation of corneal topography, said Anastasios John Kanellopoulos MD, New York University School of Medicine, New York, USA. At the 23rd ESCRS Winter Meeting in Athens Greece, Dr Kanellopoulos presented an observational case series of 144 eyes treated for progressive keratoconus with the Athens Protocol procedure.

The study showed that mean uncorrected distance visual acuity, (UDVA) improved from 0.19 preoperatively to 0.53 at one-year postoperative follow-up, remaining stable at 10 years at 0.55. In addition, corrected distance visual acuity (CDVA) increased from 0.59 preoperatively to 0.8 at one year, remaining stable at 10 years at 0.81.

Dr Kanellopoulos noted that 144 eyes showed no further keratoconic progression, although corneal topography showed progression in three eyes and was associated with persistent eye rubbing against medical advice and five eyes had a hyperopic shift during the 10-year follow-up.

In terms of keratometry, mean K2 decreased from 50.57D preoperatively to 45.87D at one year postoperative (p<0.01), further flattening slightly but significantly more to 44.0D at 10 years (p<0.01). In addition, mean Kmax decreased from 53.43D to 46.17D (p<0.01), and also further decreased slightly but statistically significantly to 44.75D at 10 years (p<0.01).

In addition, mean minimal corneal thickness decreased from 468.74 microns preoperatively to 391 microns at one year. However, by 10 years this had increased to 395.42 microns, most likely as a result of epithelial remodeling.

EUROTIMES | APRIL 2019

54 K1 (flat) K2 (steep)

52

50

48

46

44

42

40

0

2

4

6

8

10

Time Since AP operation (years) Mean anterior K1 flat (blue line) and K2 steep (red line) and maximum keratometry (black line) as measured by the Scheimpflug device (Oculyzer II, WavLight AG, Erlangen, Germany) preoperatively up to 10 years postoperatively.

All units in keratometric dioptres (D)

TOPOGRAPHICALLY GUIDED ABLATION A CLOSER FIT TO CORNEAL OPTICS The Athens Protocol involves first performing a partial topographicallyguided transepithelial photorefractive keratectomy (PRK), followed by a phototherapeutic keratectomy at a depth of maximum 50 microns, the application of mitomycin-C 0.02% for 30 seconds and then finally higher fluence corneal cross-linking at 6mW/ cm2 for 15 minutes.

Clinical refraction can vary considerably from the eye’s topographic refraction, because many keratoconic patients learn to use their irregular topography to achieve a kind of pseudo-accommodative effect, Dr Kanellopoulos said.

Dr Kanellopoulos emphasised that

although some UDVA is commonly restored by the Athens protocol, the purpose of the procedure is to improve the corneal irregularity and thereby make the eye more amenable to correction with spectacles or contact lenses (CDVA).

He noted that the progressive flattening seen in some eyes may be due to earlier techniques that used dextran riboflavin solutions rather than the hydroxypropyl methylcellulose (HPMC) formulations that are currently available.

He added that he has recently adopted a new Athens protocol that incorporates customised CXL and reduces the ablation depth to 30 microns.

Anastasios John Kanellopoulos: ajk@laservision.gr

Courtesy of Anastasios John Kanellopoulos MD

6

8

SPECIAL FOCUS: CORNEA

Everything you need to know about

New treatments for keratoconus Treatment of keratoconus is at an extremely exciting stage, with new developments in cross-linking, reports Soosan Jacob MD

A

s opposed to standard Dresden protocol, accelerated CXL delivers a higher irradiance for a shorter period, keeping total energy constant. It helps decrease treatment time and intraoperative dehydration while maintaining clinical efficacy. The commonly used protocol is 9mW/cm2 for 10 minutes. Higher oxygen usage during accelerated CXL can, however, lead to oxygen depletion and a decrease in the efficiency of CXL. Pulsed CXL applies UV-A light in a pulsed manner to overcome this. Its effect is seen clinically as a deeper demarcation line and greater apoptotic effect. Further studies are required for ideal pulsing duration.

Contact lens-assisted CXL (CACXL) for thin corneas was described by the author. A riboflavin-soaked, UV barrierfree soft contact lens is placed on the de-epithelialised, riboflavin-soaked cornea to functionally increase corneal thickness before proceeding with standard/ accelerated CXL (see http://bit.ly/ET-SJ-K14 EUROTIMES | APRIL 2019

for more). CACXL has been shown to have adequate demarcation line and effective results in subsequent publications from various groups. It gives effective crosslinking, especially as thin corneas tend to cross-link more effectively than thicker ones due to higher oxygen bioavailability.

Customised CXL is used to obtain different curvature and flattening responses in different parts of the cornea for improving vision. Treatment can be applied in different patterns â&#x20AC;&#x201C; circular, toric or arcuate. Customisation needs to be adjusted to individual biomechanical properties and would vary depending on the intraocular pressure.

Transepithelial CXL may be performed using epithelial permeability enhancers or iontophoresis to enhance riboflavin penetration through an intact cornea.

CXL combined with PTK/partial topography-guided PRK/wavefrontguided transepithelial PRK includes treatment protocols such as the Athens, Cretan and STARE-X protocols. These subtractive procedures help regularise the cornea. Combining with cross-linking helps prevent progression.

ADDITIVE TECHNOLOGIES Synthetic intrastromal corneal ring segments (ICRS) have played a key role

CAIRS or Corneal Allogeneic Intrastromal Ring Segments uses allogeneic donor corneal stromal tissue segments that are inserted into circular femtosecond dissected channels similar to Intacs

SPECIAL FOCUS: CORNEA in the management of irregular ectatic corneas. Commercially available ones include Intacs/Kerarings/Ferrara rings/ Myorings/Bisantis segments etc. Though effective, being synthetic, they have been reported to have up to 30% rate of complications including sight-threatening issues such as extrusion, migration, erosion, necrosis, corneal melts and infection.

CAIRS or Corneal Allogeneic Intrastromal Ring Segments uses allogeneic donor corneal stromal tissue segments that are inserted into circular femtosecond dissected channels similar to Intacs. This technique was introduced by the author and retains all advantages while avoiding disadvantages of synthetic ICRS (see page 12). It flattens the cornea, regularises topography, centralises the cone, improves uncorrected and corrected distance visual acuity, decreases spherical equivalent, regular and irregular astigmatism and aberrations, improves quality of vision and helps decrease progression by redistributing biomechanical stress forces.

Being composed of donor cornea, it is biocompatible, can be implanted in thinner corneas, has a lower risk of complications than synthetic ICRS and can be implanted more superficially than synthetic ICRS, thus achieving greater corneal-flattening effects. It can therefore make treatment possible in a large spectrum of disease, from early to those otherwise indicated to undergo lamellar keratoplasty. Depending on other parameters, it may or may not be combined with CXL/CACXL.

CORNEAL TRANSPLANTATION Isolated Bowman layer transplantation has been proposed by Melles et al. for strengthening the cornea. Stromal augmentation uses donut-shaped or complete lenticules implanted within the corneal stroma to correct thinning and regularise topography. However, the complexity of possible outcomes and possible further steepening in the ectatic area are disadvantages. Deep anterior lamellar keratoplasty may be needed for advanced cases of keratoconus.

Femtosecond laser-assisted DALK can create side cuts with exact depth, architecture and diameter for better wound apposition, healing and improved visual acuity. Tunnels at desired depth for air injection can facilitate big bubble formation.

A lamellar cut may be created, taking care not to cut through the endothelium at the posterior cone. Intraoperative OCT makes surgery predictable and safer by assessing surgical planes, confirming big bubble, differentiating Types 1 and 2 bubbles and by verifying graft apposition.

A modified technique of pre-Descemetic DALK for primary management of acute corneal hydrops has been described by the author to avoid the scarring that occurs after currently employed management techniques. Surgery is done immediately

A: After removing donor epithelium and endothelium, CAIRS segment is punched from donor cornea using a double-bladed Jacob CAIRS trephine; B: First segment introduced into one side of the femtosecond channel using a Y-rod; C: Segment drawn in using a reverse Sinskey hook; D: Second segment similarly inserted; E: Postoperative slit-lamp appearance; F: Difference map showing flattening and regularisation of topography

and gives good visual, optical, topographic, refractive, structural, pachymetric and biomechanical improvement while decreasing contact lens dependence and avoiding other complications.

Primary surgery is possible by following three basic principles: oedematous stroma above Descemet’s tear should be dissected without stressing the tear; thin layers of pre-Descemetic tissue should be retained over the tear to avoid opening the anterior chamber; and the Descemet’s tear should be air tamponaded from within.

OPTICAL OPTIMISATION Small-aperture IOLs such as the IC-8 AcufocusTM or Trinidade’s XtraFocus IOL (Morcher GmBH) work on the pinhole principle to provide clear vision through aberrated corneal optics. Agarwal et al. have described pinhole pupilloplasty with sutures for this. Complex spectacle lens design softwares have been tried but are challenging and generally not very successful in highly aberrated corneas.

Pinhole glasses are available. Rigid contact

lenses, hybrid lenses and scleral lenses with newer materials are being developed.

MISCELLANEOUS TREATMENTS UNDER RESEARCH

Small and strong carbon nanoparticles, though researched for strengthening the cornea, cause pigmentation. Tear fluid analysis for detecting biomarkers for keratoconus and targeted treatments such as Cyclosporine A to reduce MMP-9 and inflammatory cytokine levels are being researched to decrease progression.

IVMED-80, a copper-based eye drop is also being researched for its effect on increasing lysyl oxidase activity and corneal stiffness.

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com. She has a patent pending for shaped corneal segments and devices and processes used to manufacture them EUROTIMES | APRIL 2019

9

SPECIAL FOCUS: CORNEA

The threat of herpes in

OCULAR SURGERY Prevention of herpetic reactivation essential in at-risk patients undergoing corneal surgery. Roibeard Ó hÉineacháin reports

O

phthalmic surgeons is 0.23% by 30 years, 0.4 % by 50 years but should take precautions 0.94% by 80 years. in eyes with a history of Risk factors for reactivation include herpes simplex keratitis physical factors such as ultraviolet radiation, (HSK) and herpes cold, ocular surgery such as keratoplasty, zoster ophthalmicus (HZO), said refractive and cataract surgery, Marc Labetoulle MD, Bicêtre corneal cross-linking and iris Hospital, Paris France. laser surgery. There are also Speaking at the 23rd biological triggers including ESCRS Winter Meeting immunosuppressive in Athens, Dr Labetoulle treatments, ophthalmic noted that surgery solutions containing involving the cornea steroids, fever and general brings with it several anaesthesia. triggering factors for the He noted that HSKreactivation of HSV and related disease is a major HZO, including nerve trauma, indication for corneal grafting.

Marc Labetoulle steroids, and inflammation.

In a series of 2,962 grafts HSV He noted that almost everyone is a accounted for around 10% of cases. HSV candidate for HSV or varicella zoster virus is also a major cause of graft complications.

(VZV) reactivation, since 90% of 50-yearIn addition, the risk of HSK recurrence old people have antibodies to HSV and following a corneal graft is 25% at one year VZV. The presence of the viruses in the and 45% at two years. trigeminal ganglion is 80% at 20 years of Meanwhile, cataract surgery carries its age and 100% at 60 years, even in a few own set of risk factors for HSV reactivation patients without antibodies. and corneal nerve injuries as it involves The lifetime risk of herpes zoster is 10-toa combination of several risk factors, 20% and that is multiplied 15 times in HIVincluding stress and fatigue from early infected patients, where the recurrence is waking and postoperative inflammation.

25%, versus 4% in immunocompetent Other contributing factors may include patients. As HZO accounts for 10-to-20% preoperative eye drops such as preoperative of all herpes zoster infections, the alpha mimetics and postoperative steroids. lifetime risk of HZO is 1-to-4%.

It is vital, therefore, to check the HSV Concomitantly, the lifetime and VZV status of all patients when risk of herpes simplex keratitis planning corneal or cataract surgery.

Patients at risk should receive prophylactic treatment with antiviral medication such as acyclovir or famciclovir at least two days before the procedure and the treatment should be prolonged at least as long as postoperative steroid treatment.

He added that only systemic treatment is logical in such cases. Research indicates that the recurrence rate, in the case of corneal graft, is only 12% with systemic treatment, compared to over 50% with topical treatment. In addition, the rate of graft rejection is 52% with topical treatment compared to 20% in systemic treatment.

Practical recommendations when dealing Marc Labetoulle MD with patients with a history of herpes

...almost everyone is a candidate for HSV or varicella zoster virus (VZV) reactivation, since 90% of 50-yearold people have antibodies to HSV and VZV

EUROTIMES | APRIL 2019

Courtesy of Marc Labetoulle MD

10

Example of geographic keratitis observed four days after cataract surgery in a patient without previous history of herpes simplex ocular disease

simplex keratitis or HZO include delaying cataract surgery by three-to-six months and using systematic antivirals, starting two days before surgery and as long as risk factors persist and at least as long as the patient is receiving steroids.

Dr Labetoulle cautioned that antiviral prophylaxis is not without risk. For example, in patients with idiopathic thrombopenia the antivirals can decrease platelets to dangerous levels. In patients with preexisting renal failure, the dosage must be adapted to creatinine clearance. They can also disturb liver function. He also noted that they don’t prevent all recurrences as some HSV variants have mutations that result in a selection of resistant viral strains.

In patients with a history of HZO, surgeons should also be on guard against post-viral keratitis. Assessment of corneal sensitivity is therefore mandatory to detect potential neurotrophic keratitis. Corneal perforation can occur in eyes with the condition when NSAIDs are used.

He added that thankfully in the future HZO will probably become less common with the advent of the varicella zoster vaccine. It should reduce the number of cataract candidates who have already had a herpes zoster infection and also reduce the risk of recurrent episodes of recurrent inflammation.

Marc Labetoulle: marc.labetoulle@aphp.fr

SPECIAL FOCUS: CORNEA

Diagnosing dry eye disease New tools for detecting and quantifying inflammation could help with treatment. Howard Larkin reports

D

eveloping new tools that can accurately characterise the types and quantity of inflammatory factors present in the clinic could help diagnose the causes and severity of dry eye disease, Jose Benitez-del-Castillo MD, PhD, told the 2018 Cornea Subspecialty Day at the 36th Congress of the ESCRS in Vienna.

Citing studies showing that dry eye disease has a significant, chronic inflammatory component (Pflugfelder SC et al. Cornea 27(Supple 1):S9-11. Massengale ML et al.

Cornea. 2009;28:1023-7.), he described several tools in clinical and research use that may be helpful.

Fluorescein staining: Cytokines degrade the ocular epithelial barrier, and gaps in this barrier are revealed by fluorescein staining. Severity can be judged using tools such as a modified Oxford scale, said Dr Benitez-del-Castillo, of Clinica Rementeria, Madrid, Spain. However, this is an indirect method that does not provide information on specific inflammatory factors.

Tear osmolarity: Generally, tear osmolarity increases with disease severity, and hyperosmolarity is easily detected clinically with a TearLab or I-pen, Dr Benitez-del-Castillo noted. However, this, too, is an indirect measure of inflammation that is subject to fluctuation. The ocular system reflexively increases tear production to compensate for hyperosmolarity, sometimes resulting in normal or nearnormal readings in eyes with severe disease.

MMP-9: Matrix metalloproteinases (MMPs) are proteolytic enzymes produced by stressed ocular epithelial cells (Chotikavanich S et al. IOVS. 2009;50:3203-9.). Their level in tears varies with dry eye type, with meibomian gland dysfunction evaporative disease generating a mean activity score of nearly 500 and Sjögren’s syndrome aqueous deficiency nearly 700 compared with normal level of 341 (Solomon A et al. IOVS, 2001;42:2283-92.). However, current clinical tests are binary, detecting dry eye disease in patients with more severe disease but missing less severe cases, and fail to distinguish among more severe cases, Dr Benitez-del-Castillo observed.

Confocal microscopy: This can quantify dendritic cells in the corneal epithelium as well as nerve density in the basal corneal plexus, which inversely correlates with dry eye disease – the higher the dendritic cell density the higher dry eye disease symptoms and the lower basal nerve density (Tapelus T et al. Graefes ACEO 2017;255:1 771-8).

HLA-DR: Flow cytometry is a research method that directly quantifies ocular surface cells, which correlates with fluorescein staining but is more precise (Brignole-Baudouin F et al. IOVS. 2017;58:2438-48).

Tear cytokines: Similarly, the level of tear cytokines detected in research assays correlates with ocular surface disease index (OSDI) scores.

“Dry eye is an inflammatory disease and new practical tools for detecting inflammation on the ocular surface are needed.

Dry eye disease should be treated with anti-inflammatory drugs,” Dr Benitez-del-Castillo concluded.

European Union Web-Based Registry The aim of the project is to build a common assessment methodology and establish an EU web-based registry and network for academics, health professionals and authorities to assess and verify the safety quality and efficacy of corneal transplantation.

Join

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Track

your Surgical Results

www.ecctr.org ECCTR is co-funded by Co-funded by the Health Programme of the European Union

Jose Benitez-del-Castillo: josembenitezdelcastillo@clinicovision.com EUROTIMES | APRIL 2019

11

SPECIAL FOCUS: CORNEA

CAIRS for keratoconus Donor corneal ring segments may be safer, more flexible than synthetic implants.

Howard Larkin reports

Courtesy of Soosan Jacob MS, FRCS, DNB

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Post-CAIRS implantation on a previously cross-linked eye.

Pre-op and post-op testing (right) shows good results

F

or keratoconus patients treated with intrastromal ring segments, with or without corneal cross-linking (CXL), implants cut from donor corneas may be safer, and can be used in a broader range of cases, than segments of synthetic materials, said Soosan Jacob MS, FRCS, DNB, of Dr Agarwal’s Group of Eye Hospitals and Eye Research Centre, Chennai, India.

Complication rates for synthetic intrastromal ring segments run up to 30% in some studies and include problems such as extrusion, migration, neovascularisation, corneal melt, corneal necrosis and infection, said Dr Jacob. “The cornea does not tolerate synthetic materials well. So, why not use an allogenic substance instead?”

To reduce complications, Dr Jacob developed corneal allogenic intrastromal ring segments (CAIRS). As with synthetic ring segment surgery, CAIRS threads semi-circular inserts into channels cut by femtosecond lasers in the patient’s mid-peripheral stroma to reinforce and reshape the corneal surface, but the inserts themselves are cut from donor cornea tissue.

CAIRS may be done with or without CXL depending on patient age, progression and whether previous CXL has been performed.

In more than 80 CAIRS patients treated through mid-February, Dr Jacob has seen excellent biocompatability, with followup ranging up to nearly three years. She believes this tolerance results from host keratocytes quickly repopulating the small amount of donor stroma, as happens in deep anterior lamellar keratoplasty (DALK) buttons, but quicker due to the much lower volume of tissue transplanted as well as the intrastromal placement. She treats patients EUROTIMES | APRIL 2019

with topical corticosteroids for six weeks after CAIRS, compared with four-to-six months after DALK, and mostly to control post-surgery inflammation rather than to prevent rejection.

MORE EFFECTIVE High tolerance also makes allogenic ring segments more flexible than their synthetic counterparts, Dr Jacob said. Because they are less likely to extrude or cause corneal melt, allogenic implants may be inserted at 50% corneal depth or even more superficially, compared with 80% depth for synthetics. Placing the rings more superficially makes them more effective in reshaping the cornea, she noted. They can also be implanted in corneas thinner than the 450-500-micron limit for synthetic segments, Dr Jacob added.

“We can treat thinner corneas that are also steeper, which is a huge advantage. We have successfully treated many patients, from minimal cases to the most severe cases.

If desired, allogenic segments may also be cut to different thicknesses, arc lengths and optical zone diameter as needed.”

Safety and efficacy has been quite good, Dr Jacob said. In a prospective study involving 24 eyes in 20 young patients undergoing CAIRS and accelerated CXL or accelerated CACXL (contact lens-assisted CXL – another technique described by Dr Jacob for thin corneas), all patients showed significant improvement in corrected and uncorrected visual acuity and corneal topography with no

complications related to the implants.

Mean uncorrected distance visual acuity improved 2.79 lines ± 2.65, and mean corrected distance vision improved 1.29 ± 1.33 lines, and no loss of corrected or uncorrected VA in any eye. No progression was seen in any eye during follow-up, which averaged 11.58 months ranging from sixto-18 months (Jacob S et al. J Refract Surg 2018;34(5):296-303.).

As word spreads about the results she is achieving with CAIRS, many keratoconus patients from all over India are requesting treatment, Dr Jacob said. For those aged 30-to-40 or more with no signs of progression, CAIRS is typically done without CXL. “We are also offering it to our patients who have previously had crosslinking who want to improve their vision.”

In one case, a patient who had similar keratoconus in both eyes had CAIRS in one and CXL in both. The patient came back a year later for CAIRS in the other.

Another patient with previous CXL had CAIRS in one eye and was so impressed he immediately asked for it in the other eye, Dr Jacob said.

Surgeons across India, the Middle East and the US are contacting her for adopting CAIRS. The procedure is easy to perform using a pull-through technique, Dr Jacob said. Next steps include femtosecond lasercut donor segments, modified segments and storage development, she added.

Soosan Jacob: dr_soosanj@hotmail.com

CATARACT & REFRACTIVE

Hyperopia innovations Adding donor stroma is new frontier for hyperopia, presbyopia, keratoconus treatment. Howard Larkin reports

I

n 1949, José I Barraquer MD, the father of modern refractive surgery, formulated a simple, yet profound, law: if tissue subtraction from the centre of the cornea corrects myopia, then equal amounts of tissue addition should correct hyperopia of a similar magnitude.

“So, after 70 years, why are we still removing corneal tissue when treating hyperopia?” asked Ronald R Krueger MD, delivering the Barraquer Lecture at the American Academy of Ophthalmology 2018 Annual Meeting in Chicago, USA. It’s mostly because the precision of excimer lasers simplified hyperopia correction by tissue subtraction, Dr Krueger said. However, the donut-shaped tissue removed leaves the cornea with an uneven surface, which tends to regress as the epithelium thickens to fill in the curves, and creates an extreme hyperprolate corneal shape profile that distorts vision at higher corrections.

Femtosecond lasers are now making possible additive approaches that are as precise as LASIK and may be more suitable for treating higher hyperopia and other conditions, said Dr Krueger, who recently left the Cleveland Clinic to head the Truhlsen Eye Institute at the University of Nebraska Medical Center, Omaha, USA. The techniques involve implanting donor stroma under corneal flaps or in pockets for treating hyperopia, presbyopia and keratoconus.

Combined with new methods for preserving, preparing and banking stromal tissue, these could soon make lenticular implantation practical for routine clinical use.

SMILE CREATES POSSIBILITIES

The rise of small-incision lenticule extraction (SMILE®) over the past decade sparked development of additive refractive surgery by generating a large supply of lenticules, which would otherwise be discarded. More than one million SMILE procedures have been performed since 2009, and the procedure is rapidly gaining in popularity. A method for eye-banking SMILE lenticules, involving

serotyping, infection testing and storage at -198°C, has been developed by Sri Ganesh MD, Jayanagar, Bangalore, India, for later hyperopia correcting implantation.

An early study implanting eye-banked SMILE lenticules into 22 moderate-tohigh hyperopic eyes dropped the mean spherical equivalent refraction from +5.4D to +0.65D, with an average bestcorrected visual acuity of 20/26 at 12 months after the surgery (Ganesh S et al.

Cornea 2014;33:1355-1362). No loss of best-corrected vision or regression was seen at 12 months, likely because adding tissue leaves the corneal surface with a more regular aspheric profile than the steep to flat profile of hyperopic LASIK, thus, leading to a stable, uniform epithelial thickness, Dr Krueger said. The mean corneal Q value did increase from -0.32 to -0.82, but this is less than the extreme hyperprolate shape seen with hyperopic LASIK corrections of this magnitude.

No adverse reactions or rejection was observed after steroids were discontinued three months following the surgery. Dr Krueger believes the risk of immunologic response may be limited in part because the implanted stroma is less responsive to the host immune system. Furthermore, studies have shown that autogenic implants and xenogeneic grafts that have been decellularised generate no inflammatory cell infiltrates or fibrotic reaction in the cornea (Liu YC et al. Sci Rep. 2018 Jan 30;8(1):1831).

Refractive lenticular implantation (RELIMP) is the name of another approach, popularised by Dr Osama Ibraham from Egypt, that cuts a small myopic SMILE crater into the cornea of a hyperopic eye to facilitate centration and refractive targeting of a higher power SMILE lenticule. For example, placing a +13.75 lenticule into a -2.25 sphere -4.00 cyl SMILE crater brings a +12.00 sphere +4.00 cyl aphakic patient to a stable, near plano refraction throughout the first postoperative year, and beyond.

Beyond hyperopia, similar tissue addition techniques have been used to treat keratoconus, inserting a planar or donut-

So, after 70 years, why are we still removing corneal tissue when treating hyperopia?

Ronald R Krueger MD

shaped lenticule into a pocket to thicken and centrally flatten the cornea, and for presbyopia by adding a centrally placed 1.0mm-to-2.0mm lenticule, improving near vision while maintaining distance correction with no haze or inflammatory response, as seen with some synthetic implants, Dr Krueger added.

In a yet unpublished Turkish study of 17 presbyopic eyes and 28 hyperopic eyes, implanting shaped, stromal tissue from a commercial source resulted in a mean central power increase of +2.7D for the correction of presbyopia and a mean uniform power increase of +6.0D for the correction of moderate to high hyperopia (personal communication Aylin Kilic MD and Michael Mrochen PhD). The commercial sources may cut many lenticules from a single donor and sterilise, process, package and store them at room temperature, Dr Krueger said.

The surgeon can later open the packaging and shape them with a compact industrial excimer laser as needed.

LIKE – A NEW TECHNIQUE Dr Krueger and others are beginning clinical investigation of a technique popularised by Dr Theo Seiler, called LIKE (lenticular implantation keratoplasty). This involves shaping donor corneal tissue with Bowman’s layer using a lenticule cavity unit, which defines the precise shape profile and power. The implanted lenticule power is targeted to be greater, and placed under the large LASIK flap of moderate-to-high hyperopia eyes, making it possible to later lift the flap for a myopic or customised ablation enhancement. In the first 12 eyes treated for up to +8.5D in Europe and India, five have so far received a laser ablation one-to-three months after implantation, and one required a replacement implant.

Of the first nine, no eye lost more than one line and three gained two lines at six months. Four had slight, temporary lenticular haze, less than typically seen with LASIK, Dr Krueger said. LIKE-shaped lenticules are also being shaped for treating keratoconus by placing the lenticule in a corneal stromal pocket.

“High hyperopia, presbyopia and keratoconus are just a few of the errors that will implement this technology in the future. Refractive eye-banking will be the emerging, new market and partnership that brings this technology to our field,” Dr Krueger concluded.

EUROTIMES | APRIL 2019

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14

CATARACT & REFRACTIVE

Laser vision correction at 30 How a brave patient and a trash compactor advanced corneal laser surgery. Howard Larkin reports

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or all the dedicated work by brilliant researchers including Marguerite McDonald MD, Stephen L Trokel MD, Charles R Munnerlyn PhD and Stephen D Klyce PhD, the early development of excimer laser vision correction technology also greatly benefited from the bravery of a dying woman, and the recalcitrance of sanitation engineers at Louisiana State University Health Sciences Center in New Orleans.

“It’s a great example of the things that can happen when teamwork and serendipity meet up,” Dr McDonald told the International Society of Refractive Surgery Refractive Subspecialty Day at the American Academy of Ophthalmology 2018 Annual Meeting in Chicago, USA. In her keynote address commemorating the 30th anniversary of the first human photorefractive keratectomy (PRK) procedure, performed by Dr McDonald, she recalled the brave contribution of Alberta H Cassady. Midway through a long series of primate tests under close FDA scrutiny, Mrs Cassady offered for research her normal, healthy, 20/20 eye. It was scheduled for exenteration to treat an advanced orbital tumour with a dire prognosis.

With just 11 days to work with, the development team won emergency FDA permission. On March 25, 1988, Dr McDonald walked Mrs Cassady past cages full of howling and spitting monkeys in the LSU primate vivarium and laid her

“It’s a great example of the things that can happen when teamwork and serendipity meet up Marguerite McDonald MD EUROTIMES | APRIL 2019

Mrs Alberta H Cassady 11 days after the world’s first human PRK procedure, just before her exenteration,

down under the same industrial-based laser used in animal studies to conduct the world’s first human PRK procedure.

By all accounts the operation, which targeted 4.5 dioptres of myopia, was a success. “We nailed the refractive change,” said Dr McDonald, who now holds clinical professorships at New York University, New York City, and Tulane University, New Orleans, USA. “As she was emmetropic, we made her 4.5 dioptres hyperopic.” In 11 days’ follow-up before the globe was removed, the cornea reepithelialised and healed smoothly and remained clear.

Data from this procedure helped convince the FDA to leapfrog to human blind-eye studies, cutting months, if not years, from the development of laser vision correction, Dr McDonald said. In honour of Mrs Cassady’s bravery and selflessness in submitting to an

uncomfortable experimental procedure in the face of a devastating diagnosis, the team named the research lab for her after she died a few months later.

Dr Marguerite McDonald, Dr Stephen D Klyce and a lab tech standing in front of the laser lab named after Mrs Cassady

CATARACT & REFRACTIVE

15

Images courtesy of Marguerite McDonald, MD

VIBRATING OR Human trials meant relocating the research lab from LSU’s vivarium across Lake Pontchartrain to its eye centre on campus in New Orleans. But concerned about the possible release of toxic gases, university officials insisted the laser be installed outdoors in a trailer – and the only available space was next to the trash compactor.

Beyond emitting its own noxious gases, the compactor made the ground shake, Dr McDonald said. The engineers operating it would not shut it down during surgery. So, Dr McDonald pulled paper patient records and a mechanical calculator, and set out to prove that the vibrations were damaging clinical outcomes.

“I crunched the numbers and I was sure I was wrong, and I did it all again. I had to admit the stunning truth that the trash compactor patients were doing better – significantly better,” Dr McDonald said.

The next day she presented to the team.

They, too, were shocked.

The reason quickly became clear. The procedure was being done with a wide-beam laser with a diaphragm stepped down 40 times during the ablation. Vibrations were creating blended zones between the stops that smoothed the surface, Dr McDonald said.

“We started to realise that smoother is better and 40 steps was not enough.”

That led immediately to tripling stops to 120 for wide-beam surgery,

Mrs Alberta H Cassady 11 days after the world’s first human PRK procedure, just before her exenteration,

and spurred development of flyingspot lasers and the trackers needed to make them work, Dr McDonald added.

Improvements followed with increasing rapidity, including LASIK, wavefrontand topography-guided procedures, all the way up to today’s FLEX and SMILE® single-laser procedures, corneal implants and epi-Bowman keratectomy.

Indications expanded just as rapidly from

low myopia to a wide and growing range of myopic, hyperopic, astigmatic and mixed procedures.

Laser vision correction development is far from over, Dr McDonald predicted.

“After 30 years how do I feel about it now? I think we are just getting started.”

Marguerite McDonald: margueritemcdmd@aol.com

Grow Your Practice Through Innovation Win a €1,500 Bursary ESCRS Practice Management and Development Innovation Award Submission Deadline Monday 29 July 2019

ESCRS

For further details visit: www.escrs.org

Practice Management

& Development

EUROTIMES | APRIL 2019

16

CATARACT & REFRACTIVE

IOL gives broader range of focus Fluid-driven IOL nearly doubles accommodation of previous designs.

Roibeard Ó hÉineacháin reports

2019 Applications are open for the Peter Barry Fellowship 2019. 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 trainee member for 3 years by the time of starting the Fellowship.

The Fellowship will be awarded at the ESCRS Annual Congress in Paris in September 2019, to start in 2020.

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 2019 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org

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new version of the FluidVision accommodating intraocular lens (IOL), the FluidVision 20/20 (PowerVision), can provide a broader range of focus than earlier models, according to the results of a study presented by Louis D. “Skip” Nichamin, MD at the 36th Congress of The ESCRS in Vienna, Austria.

“The next-generation FluidVision accommodating IOL demonstrates excellent and stable monocular visual acuity at distance, intermediate and near,” said Dr Nichamin, Vail, Colorado, USA. In a pilot multi-centre clinical study involving 27 patients who underwent monocular implantation of the new FluidVision IOL, the mean best monocular corrected distance visual acuity in eyes with the lens was stable at logMAR -0.05 at six months’ follow-up. In addition, the average distancecorrected intermediate and near visual acuities were logMAR 0.05 and logMAR 0.14 for the same period.

The mean objective accommodation at six months, measured by autorefractor, was nearly twice that achieved by the earlier FluidVision lens. The average accommodative amplitude was 2.0D, although some eyes achieved objective accommodation up to 4.1D. In addition, the average mesopic contrast sensitivity was equivalent to an age-adjusted reference population and patients were not troubled with the dysphotopsias common to IOLs with light-splitting technologies, he reported.

The trial was conducted at six sites in South Africa and enrolled 28 patients with a mean age of 66 years (range 51-82 years). All underwent implantation with the FluidVision 20/20 AIOL through a 3.5mm incision using the PowerJect injector system.

INCREASED DIOPTRIC POWER

The FluidVision IOL is a hydrophobic acrylic lens with a hollow optic and two hollow haptics that are filled with a refractive index-matched silicone fluid and are connected by fluid-filled channels.

When the ciliary muscle contracts in response to a near stimulus, the resulting relaxation of zonular fibres causes the capsular bag to contract, forcing fluid from the haptics into the optic, making it more convex and thereby increasing its dioptric power.

“FluidVision movement translates into a true shape change for seamless vision from near to distance,” said Dr Nichamin.

In addition to the enhanced near-focusing power, the improved design of the latest version of the IOL makes it easier to implant and to teach how to implant than the earlier model. Two international multi-centre controlled studies are currently under way in several countries and are progressing very well, he said.

“The results of our study were consistent with expectations and predict the ability to meet design objectives and deliver 20/20 vision at all distances,” Dr Nichamin concluded.

Louis D. “Skip” Nichamin: nichamin@laureleye.com

EUROTIMES | APRIL 2019

CATARACT & REFRACTIVE

Increasing predictability Trifocal IOL yields good results in eyes that have had previous laser ablation.

Roibeard Ó hÉineacháin reports

O

ptimised IOL calculations can further improve the refractive predictability of the FineVision trifocal IOL in presbyopic patients who have previously undergone excimer laser corneal refractive surgery, Luis Brenner MD told the 36th Congress of the ESCRS in Vienna, Austria.

Dr Brenner, Oslo, Norway, presented the results of a multicentre retrospective single protocol study involving 241 eyes of 123 patients who had undergone previous PRK, LASIK or LASEK and underwent presbyopic RLE with FineVision trifocal lens implantation during the years 2015-2017 at Memira Clinics in Scandinavia.

The results showed that 85% of patients achieved binocular uncorrected distance and near visual acuities of 0.9 and J3, respectively. In addition, 80.9% were within 0.5D of predicted postoperative refraction and 97.9% of eyes were within 1.0D at the three months, Dr Brenner said.

Dr Brenner noted that from 2016 they Luis Brenner included IOL constant optimisation and a nomogram to correct for prediction errors to the online ASCRS IOL calculator. They found that the mean refractive error was -0.29D for the standard calculation group compared to only -0.14D for the optimised calculation group. In addition, only 76% of eyes were within 0.5D of target refraction in the standard calculation group, compared to 84% of the eyes in the optimised group.

Your Professional Dry Eye Assistant

PREVIOUS ABLATIONS

The study included 155 eyes (64.3%) that had undergone previous myopic ablations. Among those with prior refractive data, the mean manifest refraction spherical equivalent (MRSE) was -3.05D (range: -0.75 to -7.00D). Also included were 86 eyes (35.7%) that had undergone hyperopic ablations.

Among those with previous data, the mean MRSE was +1.99 to 0.84D (range: 0.00 to +4.00D).

All eyes in the study were presbyopic to the point that a 1.50D add for near vision tasks was required. The study’s exclusion criteria were abnormal optics determined by topography, de-centred ablations, high ametropic ablations and corrected distance visual acuity of less than 0.8.

Prior to implantation of the trifocal IOL, the myopic ablation group had a Snellen corrected distance visual acuity CDVA of 1.09, an uncorrected near visual acuity (UNVA, American point type) of 12.42 and an MRSE of -0.06.

Following implantation of the IOL, the group had mean Snellen uncorrected distance visual acuity (UDVA) of 0.88, a UNVA of 5.11 and an MRSE of -0.25D. In the hyperopic ablation group, prior to implantation of the presbyopic IOL the mean corrected distance visual acuity CDVA was 1.05, the mean UNVA was 18.47 and the mean MRSE was +1.05D. Following implantation of the trifocal lens, the mean Snellen UDVA was 0.85, the mean UNVA was 5.25 and the mean MRSE was -0.02D. Luis Brenner MD, Luis.brenner@memira.no

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18

CATARACT & REFRACTIVE

JCRS Symposium Monday, May 6, 2019

Controversies in Anterior Segment Surgery

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS

1:00 pm–2:30 pm

VOL: 45 ISSUE: 2 MONTH: APRIL 2019

MODERATORS

VISUAL QOL WITH TRIFOCAL IOLS

Nick Mamalis u.s. editor Sathish Srinivasan european associate editor

Trifocal IOLs appear to be living up to the expectation that they satisfy patients’ need for intermediate vision in addition to distance and far, a small study suggests. Researchers in Turkey evaluated 48 patients who had received bilateral implantation of a new trifocal IOL (PanOptix). A subgroup of 14 patients received monocular implantation. Patients were asked to complete the National Eye Institute Visual Function Questionnaire-14 (VF-14 QOL questionnaire) three months after the surgery in the second eye. Reading small print, driving at night and doing fine handwork were the most difficult tasks to perform. Mean values obtained with the QOL questionnaire were 0.94 ± 0.81 (SD), 0.89 ± 0.68 and 0.64 ± 0.67. Binocular implantation was associated with improvement in vision-related QOL when compared with monocular implantation, with significant differences in doing fine handwork such as sewing (p=.02) and using a computer (p=.03). Overall, those receiving bilateral trifocal IOL implantation had high satisfaction rates and a high vision-related QOL.A Akman et al., “Evaluation of quality of life after implantation of a new trifocal intraocular lens”, Volume 45, Issue 2, 135-145.

TRIFOCAL IOL COMPARISON TRIAL 1:00 pm IOL Power Calculations Nicole Fram usa Intraoperative Aberrometry Is Here to Stay Douglas Koch usa Modern IOL Formulas Have Superseded Intraoperative Aberrometry

1:30 pm Femtosecond Laser–assisted Cataract Surgery Richard Davidson usa FLACS Is the Best and Safest Surgery for White Cataracts Soon-Phaik Chee singapore Manual Phacoemulsification Surgery Is Still Good and Safe Enough for White Cataracts

2:00 pm Managing Vitreous Loss During Cataract Surgery by the Cataract Surgeon Abhay Vasavada india Pars Plana Anterior Vitrectomy Is the Best Kevin Miller usa Traditional Anterior Vitrectomy Is Good Enough

ASCRS•ASOA ANNUAL MEETING

A prospective, controlled clinical trial enrolled 126 cataractous eyes with a mean age of 62.5 years. Patients underwent bilateral implantation with either a trifocal spherical hydrophilic IOL (FineVision POD F) if corneal astigmatism was 1.0D or less, or with a trifocal toric hydrophilic IOL (FineVision POD FT) if astigmatism was more than 1.0D. The spherical IOL group consisted of 33 bilateral patients and the toric IOL group consisted of 30 bilateral patients.

An analysis at three months showed significant improvement in functional uncorrected visual acuity across all distances in both groups. There was no difference between the groups in contrast sensitivity, defocus curves or cylinder. Satisfaction was high with both IOL types. F Poyales et al., “Comparison of 3-month visual outcomes of a spherical and a toric trifocal intraocular lens”, Volume 45, Issue 2, 135-145.

TORIC IOLS COST-EFFECTIVE? Dutch researchers evaluated the cost-effectiveness of toric versus monofocal intraocular lens implantation in 77 cataract patients with 1.25D or more of bilateral corneal astigmatism. All relevant resources were included in the cost analysis. Although this study confirmed that toric IOLs improve UDVA and spectacle independence compared with monofocal IOLs, no improvement in generic health-related quality of life was found. Furthermore, toric IOLs increased healthcare and societal costs in the short-term. The researchers suggest that based on these findings, co-payment by patients should therefore be considered for toric IOLs. R Simons et al., “Trial-based cost-effectiveness analysis of toric versus monofocal intraocular lenses in cataract patients with bilateral corneal astigmatism in the Netherlands”, Volume 45, Issue 2, 146-152.

May 3–7, 2019 | San Diego, California, USA JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | APRIL 2019

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20

RETINA

The eye fights back!

Immune, inflammatory processes play large, but poorly understood, uveitis role.

Howard Larkin reports

T

he eye’s immune privilege is not passive, but rather a system that tightly regulates inflammation, actively maintaining tissue clarity and integrity using an inner and outer bloodretinal barrier. However, this control can be knocked out of balance resulting in chronic uveitis and other inflammatory diseases, said Janet L Davis MD in the C Stephen and Frances Foster Lecture on Uveitis and Immunology at the 2018 American Academy of Ophthalmology Annual Meeting in Chicago, USA. Regaining the null point of no inflammation after uveitis sets in requires understanding of both inciting events, such as active or past infections, and sustaining mechanisms, including persistent autoimmune and autoinflammatory processes. Better understanding of these mechanisms also could improve treatment for other eye diseases that include an inflammatory component, such as inherited retinal degenerations and age-related macular degeneration, said Dr Davis, of the Bascom Palmer Eye Institute, University of Miami, USA. However, “we are woefully ignorant of that [inflammation null] point”, Dr Davis said. But even without complete knowledge and the specific molecular tests that would be required to precisely diagnose many immune and inflammatory conditions, much can be done to help calm ocular inflammation as the eye fights back against infection and other insults and allergens.

DIVERSE CAUSES Dr Davis started with a case of undifferentiated panuveitis involving blurred vision but no pain or associated disease that persisted for 30 years. The patient had received topical corticosteroids, intraocular triamcinolone, bevacizumab and vitrectomy, as well as methotrexate, azithioprine, chlorambucil and anti-IL17. For eight years she had been mostly stable on infliximab.

So why does she still have uveitis 30 years on? Dr Davis considered the possibilities: Autoimmune uveitis: When the bloodretina barrier is disrupted, T-cells produced to attack self-antigens in response to infection or systemic immunologic disease can enter and may become resident in the eye, where they attack that antigen in ocular tissues, provoking inflammation, Dr Davis said. Inciting causes may be an autoimmune EUROTIMES | APRIL 2019

disease such as Vogt-Koyanagi-Harada, which is treatable with corticosteroids and immunosuppressants; or infiltrating lymphocytes from remote tumours leading to conditions such as melanoma-associated retinopathy that is difficult to treat, but may be partially reversed with reduction of primary tumour burden.

Only a handful of true autoimmune antigens have been identified, though patient serum staining of banked retinal tissue often indicates the presence of antibodies to unknown antigens identified only by molecular weight, and some of these may be stimulated by viruses. This makes it difficult to identify and treat true autoimmune disease, which requires agents addressing specific antigens.

Infection: Herpes viruses, tuberculosis and syphilis are among infections that can persist for 30 years or more, and may often be involved in what appears to be noninfectious uveitis, Davis noted. Tuberculosis with actively replicating organisms is not uncommon and is treatable with antibiotics.

However, antibiotic treatment sometimes provokes the eye to fight back with an excessive inflammatory response known as immune recovery uveitis, which requires anti-inflammatory treatment.

Retinal vasculitis may result when the inner blood-retinal barrier breaks down and can often be treated with antiinflammatories. Choroidopathy that can occur when the outer barrier is breached, stimulating inflammation that destroys the retinal pigment epithelium, may require immune suppression.

Autoinflammatory disease: What looks like autoimmune disease may be autoinflammatory, which does not require a specific antigen to stimulate an innate immune response. Autoinflammation can result from a genetic predisposition, and uveitis may be involved in a multi-system inflammatory response. For example, mutation of the NLRP3 inflammasome is associated with several autoinflammatory syndromes, and

uveitis involving this mutation is the only type that responds to IL-1 beta inhibitors.

Biologic therapy and control of environmental triggers can be effective in treating these. Some uveitis may involve both autoinflammatory and autoimmune processes. These include Behçet’s disease and HLA-B27-associate uveitis.

Protein persistence in macrophages: Proteins from infective agents engulfed by macrophages may persist after the macrophage dies, leading to engulfment and re-presentation by another macrophage in a repeating cycle, perpetually stimulating an immune response that manifests as persistent uveitis. The mechanism may be similar to that of tattoo pigment granules observed in a recent mouse study (Baranska and Malissen. J Exp Med 2018:215(4), Dr Davis said.

Lacking better diagnostics and insights, sorting through the various causes and treatments for persistent uveitis is challenging, Dr Davis said. However, she offered a treatment strategy.

“We don’t go nuclear with bone marrow transplants. We can cut immune and inflammatory supply chains with cytokine inhibitors, lay siege with corticosteroids with local or systemic treatment.

We can broadcast propaganda with immunomodulatory drugs. If macrophages pass antigens from one generation to the next, we can control the myeloid population.

For now, we realise that genetic causes cannot be modified.”

She also recommended two articles for insight into eye immunity and implications for better treatment of uveitis (Forrester JV, Kuffova L, Dick AD. Autoimmunity, autoinflammation and infection in uveitis.

Am J Ophthalmol 2018;189:77–85; Lee et al. Autoimmune and autoinflammatory mechanisms in uveitis.

Semin Immunopathol. 2014; 36(5): 581–594).

“Keep treating with the expectation that with complete control the eye will stop fighting back,” Dr Davis said.

Keep treating with the expectation that with complete control the eye will stop fighting back Janet L Davis MD

RETINA

9th EURETINA Winter Meeting

Prague 2019

Education under the spotlight Short but intense programme covered fundamental aspects of retinal research. Dermot McGrath reports

B

uilding on the success of last year’s meeting in Budapest, the 9th EURETINA Winter Meeting in Prague provided a timely update on key educational and research topics in the field of retina.

Hundreds of delegates made the trip to the elegant capital of the Czech Republic for a short but intense programme that incorporated main symposia on fundamental aspects of retinal research, quick-fire free papers, interesting case studies and a wide variety of poster presentations.

Welcoming delegates to Prague, Sebastian Wolf, President of EURETINA, said that the society was delighted to be hosting a meeting in Prague for the first time.

“It is a real honour to be here in this beautiful, historic city and to continue our efforts to expand the influence of EURETINA across Europe. My sincere thanks to our local hosts, the Czech Vitreoretinal Society, for all their valuable support and collaboration in bringing this meeting to Prague for the first time,” he said.

Dr Wolf said that the goal of this year’s meeting was to continue to put the spotlight on clinical research and education.

“We introduced a new programme format with an increased clinical and educational focus in Budapest last year and received a lot of positive feedback to this change.

The quality of abstract submissions received for the Prague meeting has been very impressive and we believe our delegates will benefit greatly from the high-quality programme on offer at this year’s meeting,” he said.

In addition to well-attended keynote sessions on topics such as diabetic retinopathy, retinal dystrophies, OCT imaging and AMD, the free paper session on Saturday highlighted the current vibrant state of retinal research and provided a welcome update on a number of pivotal clinical trials currently under way.

In between sessions, delegates also had the opportunity to browse the wide variety of posters on display, covering all aspects of the retinal subspecialty from surgical techniques and experimental science through to ground-breaking research in gene therapy and novel drug delivery systems.

The prize for best poster and a cheque for €2,000 at this year’s meeting went to Giulia Airaghi from Italy for her study of “Inverted internal limited membrane flap peeling technique for large macular holes: 1-year results”. Second and third prize with a cheque of €1,000 each were also awarded to Jong Soo Lee of South Korea for “Perioperative intraretinal fluid observed on optical coherence tomography in epiretinal membrane” and Francisco Javier Diaz-Corralas of Spain for “Gene therapy using RAAV2-HDJ-1 protects the retina of NRF2-/- mice” respectively.

EUROTIMES | APRIL 2019

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RETINA

Colour blindness Research supports feasibility of gene therapies for severely disabling colour blindness. Roibeard Ó hÉineacháin reports

R

esearch begun in the 1990s is now coming to fruition with the initiation of the first retinal gene therapy trial for achromatopsia, and evidence suggests that the prospects for treating blue cone monochromatism is very promising, said Dominik Fischer MD, University Eye Hospital, Tübingen, Germany.

There are three types of cones: the so-called blue cones, which have a peak sensitivity in the shorter visible wavelengths of light; the green cones, with a peak sensitivity at medium wavelengths; and the red cones, with a peak sensitivity in the longer wavelengths range, Dr Fischer told the 18th EURETINA Congress in Vienna, Austria.

Achromatopsia is the dysfunction of all three types of cones and is sometimes called rod monochromacy. When only the blue cones are functional, the condition is called blue cone monochromacy; if only the medium-wave green cones are dysfunctional, it is a condition called deuteranopia, sometimes called Daltonism after the famous chemist who had and researched on the condition.

Absence of the long-wave-sensitive red cones is a condition common to squirrel monkeys of central and south America.

Achromatopsia is a rare autosomal recessive inherited retinal disorder with an incidence of approximately 1/30,000. It presents at birth or early infancy with nystagmus, photophobia, very poor visual acuity and colour vision and relies on luminance levels to distinguish between colours.

The condition commonly (two out of three times) results from mutations in one of the genes for the alpha subunit or the beta subunit of cyclic nucleotide-gated channel (CNG) of the cone version of the cation channel that lies in the membrane of the cone receptors. Without this channel opening and closing, the cone cannot report to the brain when light that hits the cone.

One-third of patients have mutations in other genes that also cause the condition.

Achromatopsia does not appear to worsen with age, Dr Fischer noted. In detailed psychophysical tests using extended electrophysiology, and assessment of morphology by fundus autofluorescence and spectral-domain optical coherence tomography conducted in a population of patients with the condition, Dr Fischer and his associates found no correlation between the severity of morphologic and functional changes of the retina and age (Zobor et al, Invest Ophthalmol Vis Sci. 2017 Feb 1;58(2):821-832. doi: 10.1167/iovs.16-20427).

Therefore, there is a wide window of opportunity for intervention with gene therapy. In knock-out mouse models of the condition, collaborating scientists from Munich developed a mouse model (knockout mice) in which they switched off the CNGA3 gene. Around five years ago, the Tübingen scientists and their colleagues from Munich developed a gene therapy approach that they have used successfully in the mouse model. Experiments with the knock-out mouse model have shown proof of efficacy and proof of principle in gene therapy for the condition.

Dominik Fischer MD

...there is a wide window of opportunity for intervention with gene therapy

EUROTIMES | APRIL 2019

Courtesy of Dominik Fischer MD

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The world’s first gene therapy for achromatopsia: Tübingen on 11.11.2015 by (left to right) Prof Fischer, Prof Karl Ulrich Bartz-Schmidt and Mr Apostolos Bezirgiannidis

In 2015, the scientists received approval from the relevant German authority and the ethics committee to commence the phase I dose-escalating clinical trial. A few weeks later, the first achromatopsia patient underwent the gene therapy treatment at the University Eye Hospital in Tübingen.

BLUE CONE MONOCHROMACY Blue cone monochromacy (BCM), where only the blue cones are functional, is a very rare X-linked recessive inherited retinal disorder with an incidence of approximately 1/100,000. Like achromatopsia, the condition presents at birth or early infancy with nystagmus, photophobia and poor visual acuity.

However, unlike achromatopsia, the condition appears to result in a gradual degeneration of cones over time, suggesting that there is a narrower window of opportunity for gene therapy in such patients.

Nonetheless, a study in which the retinas of patients with blue monochromatism underwent adaptive optics imaging confirmed that human cones in patients with deletions in the red/green opsin gene array can survive in reduced numbers with limited outer segment material, suggesting potential value of gene therapy for BCM (Cideciyan et al, Hum Gene Ther. 2013 1; 24: 993–1006).

Moreover, in an experiment involving adult red-green colourdeficient squirrel monkeys, gene therapy was sufficient to produce trichromatic colour vision behaviour. (Mancuso et al, Nature. 2009 Oct 8; 461(7265): 784–787).

Dominik Fischer: dominik.fischer@med.uni-tuebingen.de

RETINA

RPGR-related retinal dystrophy Link between mutation loci and outcomes revealed in long-term study. Roibeard Ó hÉineacháin reports

R

esearch into the natural history of the RPGRassociated retinal dystrophies such as retinitis pigmentosa (RP) and cone and cone-rod dystrophies (COD/CORD), can provide useful information in selecting candidates and determining clinical endpoints in gene therapy trials for the conditions, said Camiel Boon MD, PhD, FEBO, from Leiden University Medical Centre, and Amsterdam University Medical Centers, the Netherlands.

“It may still seem far away but gene therapy is coming to our clinics and that is why it is important to discuss the genes that are eligible for gene therapy treatment,” Dr Boon told the 18th EURETINA Congress in Vienna, Austria.

He noted that mutations in the RPGR gene are the most common cause of x-linked retinitis pigmentosa, accounting for 45-to-90% of cases. The largest proportion gene’s pathological variants are in its ORF 15 region. Some of the mutations are in exon 1 to 14 and also, though rarely, in exon 16 to 19.

In trials involving the dog model and mouse model of RPGR-related retinal dystrophies, gene therapy appears to have provided improvements in vision. Three phase I trials looking at safety and possible efficacy are now under way.

Prof Boon and associates conducted a retrospective study examining the clinical spectrum of the disease, the long-term outcome and to determine any genotype-phenotype correlations with clinical outcomes. The researchers reviewed the records of 74 patients from 38 families. The diagnosis was retinitis pigmentosa in 52 patients, CORD in 17 and COD in five. They had a median follow-up of 11.6 years (range 0.0-57.1) and median visits: 5 (range 3-55).

Their analysis showed that the onset of symptoms occurred at mean age of five years in the retinitis pigmentosa group and at a mean age of 23 years in the COD/CORD groups. The main first symptom was night blindness in the retinitis pigmentosa group, and loss of visual acuity in the COD/CORD group. The probability of being blind at the age of 40 was 20% in patients with RP and 55% and COD/CORD, respectively.

Two key findings were that high myopia was associated with a faster best-corrected vision decline in patients with RP (p<0.001) and COD/CORD (p=0.03) and that RPGR-ORF 15 mutations were associated with high myopia (p=0.01). In addition, the RP patients with ORF 15 mutations had a faster visual field decline (p=0.01) and a thinner central retina (p=0.03) than patients with mutations in exon 1 to 14.

“The implications for gene therapy are that in an RPGR-associated retinitis pigmentosa there is essentially a wide intervention window, but in the cone and cone-rod dystrophies the window of opportunity might be narrower,” Prof Boon concluded.

Camiel Boon, MD, PhD, FEBO

Mutations in the RPGR gene are the most common cause of x-linked retinitis pigmentosa

5-8 September 2019 Le Palais des Congrès Paris, France

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www.euretina.org EUROTIMES | APRIL 2019

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RETINA

Rod-cone

DYSTROPHY RDH12-related retinal dystrophies are potential candidates for gene therapy.

Roibeard Ó hÉineacháin reports

R

etinopathies resulting from mutations in the gene for the enzyme retinal dehydrogenase (RDH12) mainly include severe, early-onset rod-cone dystrophies. Because this disease progresses gradually and small areas of the retina are retained late into the disease, there is a broad window of opportunity for gene therapy, according to Bart Leroy MD, PhD, Ghent University Hospital, Ghent, Belgium.

“Because of those normal areas, there is a window of opportunity to treat these patients,” Dr Leroy told the 18th EURETINA Congress in Vienna, Austria.

In the process of phototransduction, a photon is converted into an electrical signal when it hits an opsin chromophore. The signal is generated by the isomerisation of 11-cis retinal into all-trans retinal, which changes the opsin protein’s configuration in a way that hyperpolarises the cell membrane.

Following its release of all-trans retinal from the opsin, all-trans retinal is converted by the RDH12 enzyme into all-trans retinol, to be recycled in the retinal pigment epithelium.

Dysfunction of the RDH12 enzyme leads to the accumulation of toxic by-products in the photoreceptor, leading ultimately to its death. The mutations in the RDH12 enzyme gene that give rise to retinal pathologies in humans are primarily autosomal recessive in their expression. There are also rare reports of autosomal dominant mutations.

THE GHENT STUDY To better characterise the RDH12 retinal dystrophy phenotypes, Dr Leroy and his associates have been conducting a prospective natural history study, called the Ghent Study, involving an expanding series of patients.

Their analysis of 23 patients from 14 families with RDH12-related retinal dystrophy showed that the condition generally has an early onset and results EUROTIMES | APRIL 2019

A third common characteristic of RDH12-retinal dystrophies is yellowish discolouration of the macula Bart Leroy MD, PhD

in a severe, progressive rod-cone dystrophy. In addition, some specific characteristics of RDH12-related retinopathies include an early macular atrophy with yellowish colouration and patchy preservation of the peripheral and peripapillary retina.

The findings of a British study, which described the phenotype of RDH12-related retinal dystrophies in 29 families, appeared to support those of the Ghent researchers. The disease characteristics the study identified included an early, severe rod-cone dystrophy with an extensive, generalised atrophy of the retina and the retinal pigment epithelium, progressing to a dense and widespread intraretinal pigment migration.

The British researchers also noted a severe atrophy of the macula, with pigmentation and yellowing with a corresponding loss of fundus autofluorescence and marked retinal thinning and excavation at the macula on OCT by adulthood.

The Ghent team have since expanded their study to now include more than 30 patients from Europe, Africa and Asia, Dr Leroy said. He presented the latest findings in 29 patients from 20 families. All have proven RDH12 mutations, with a total of 23 pathogenic sequence variants.

The mean age of onset of the retinopathy was 3.9 years and all patients had decreased best-corrected visual acuity from early childhood; 25 have night blindness; 10 have moderate photophobia; and 12 have nystagmus.

PATCHY PRESERVATION All eyes had patchy preservation of the peripheral retina, Dr Leroy said.

When viewed by high-resolution optical coherence tomography (OCT) the areas of better-preserved structure corresponded with the more normal areas seen on near-infrared reflectance imaging.

Another common characteristic of the phenotype was peripapillary preservation of the retina, which was present in 18 patients. Again, the fundoscopically normal areas of the peripapillary retina corresponded with structurally normal areas observed with OCT. They also corresponded with areas of visual function as measured with Goldmann visual fields.

A third common characteristic of RDH12-related retinal dystrophies is yellowish discolouration of the macula.

The discolouration may result from a highlighting of the yellow pigment in the macula, caused by atrophy of the retinal pigment epithelium. This causes less absorption of incident light, reflection of it on the inner side of the posterior sclera and highlighting of the yellow pigment due to a second pass of the light rays, Dr Leroy hypothesised.

Dr Leroy noted that among their study’s population was a woman who was diagnosed with macular dystrophy when she was three years of age, yet now, 20 years later although there is atrophy of the fundus in the posterior pole, the remaining retina is seems completely normal. Similar cases were reported in a Chinese study.

Bart LeRoy: Bart.Leroy@UGent.be

RETINA

Ocular surface disease relief Punctal plugs could help for intravitreal injection-related dry eye problems. Sean Henahan reports

A bright vision on illumination

R

etina specialists could take a page from their refractive surgery colleagues by using punctal plugs to reduce ocular surface discomfort associated with intravitreal injections used to treat age-related macular degeneration, reported researchers at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting in Honolulu.

Anti-VEGF agents administered by the intravitreal route have revolutionised the treatment of age-related macular degeneration and other retinal vascular diseases. However, these patients require regular intravitreal injections for many years. A common side-effect of these injections is discomfort associated with dry eye disease. These side-effects are related to toxic effects of povidone iodine, which is typically used for its antiseptic capabilities to reduce the risk of endophthalmitis, the most feared complication of intravitreal injections.

This problem prompted researchers at the University of New Mexico School of Medicine, Albuquerque, US, to conduct a study based on the idea that punctal plugs could provide some relief to these patients. The observational case series included 27 patients who were seen at a regional tertiary care retina clinic. All of the patients were receiving monthly intravitreal injections for retinal disease and all had signs and symptoms of ocular surface disease at the onset of the study.

The patients were assessed for signs and symptoms of ocular surface disease using the Ocular Surface Disease Index (OSDI) questionnaire. The OSDI is a scale used for the assessment of symptoms related to dry eye disease and their effect on vision.

Patients answer several questions in 12 categories, providing responses on a five-point Likert scale. Categories include actual ocular symptoms such as pain, grittiness and reduced vision, along with questions about daily activities such as reading, watching television and driving at night.

Patients completed questionnaires immediately before an intravitreal injection, and then subsequently after a punctal plug was placed. Study participants completed a series of five questionnaires immediately before and three days after each intravitreal injection. An inferior punctal plug was placed prior to the second questionnaire.

The mean OSDI score at the beginning of study was 34.43. These scores did not change after the first intravitreal injection. However, following punctal plug placement, OSDI scores dropped by nearly 50%, with a mean score of 18.3 points. This highly statistically significant decline was maintained for three-to-five days after anti-VEGF injections.

“We are encouraged by the opportunity to provide an option for patients to ease ocular surface discomfort after intravitreal injections. The OSDI is a validated metric that provides quantitative identification of patients with baseline dry eye, who may have the most irritation following betadine prep. Punctal plug placement, an FDA-approved treatment for dry eye, can reduce post-injection discomfort in patients with a high OSDI. Incorporating this option for patients in a retina practice can improve compliance with recommended injection schedules, and therefore achieve better outcomes from anti-VEGF therapy,” John D. Pitcher III MD, Vision Research Centre, Albuquerque, US, told EuroTimes.

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PAEDIATRIC OPHTHALMOLOGY

Getting to know the signs of ROP New research helps find and protect babies at highest risk of severe disease. Howard Larkin reports

S

evere retinopathy of prematurity (ROP) is caused by multiple factors, many of which, such as gestational age and weight at birth, are beyond clinicians’ control. However, recent research suggests that an ROP “risk clock” starts at birth and runs for the first two months of life regardless of the level of prematurity, Ann Hellström MD, PhD, University of Gothenburg, Sweden, told the 2018 World Society of Paediatric Ophthalmology and Strabismus Subspecialty Day in Vienna.

Infants at high risk of severe ROP may be identified and sometimes their risk substantially reduced by modifying postnatal factors uncovered in recent research, added Dr Hellström, a leading researcher in ROP pathophysiology and treatment.

In screening infants, she recommended looking closely at the following factors during the critical first two weeks of life.

O2 use: Higher levels of oxygen use in premature infants have long been associated with increased ROP risk, leading to reduced oxygen use in many centres. But recent studies linking low levels to increased mortality has reversed this practice, increasing ROP incidence, which doubled in certain regions of Sweden in recent years, Dr Hellström said. However, her research found that babies who developed ROP had lower mean oxygen levels, but higher variation in levels, which correlated with frequency of alarms for high or low oxygen. Ensuring levels remain in the target range may reduce ROP risk.

WSPOS World Society of Paediatric Ophthalmology & Strabismus

S U B S P E C I A LT Y DAY Friday 13th September 2019 Preceding the 37th Congress of the ESCRS, 14 – 18 September 2019

Abstract Submission Deadline 19 April 2019

www.wspos.org EUROTIMES | APRIL 2019

It is extremely important to prevent and address anaemia in the first two weeks of life

Breastfeeding: Milk from a premature infant’s mother contains unique bioactive factors that help pre-term infants adapt to life outside Ann Hellström MD, PhD the uterus, Dr Hellström said. These factors are often destroyed in donor breast milk due to pasteurisation and storage and are often from mothers who have given birth to full-term babies. Premature babies don’t need to be fed their own mother’s milk exclusively, but even a little greatly reduces ROP and associated conditions such as growth, necrotising enterocolitis (NEC), late-onset sepsis and bronco-pulmonary dysplasia.

Any sign of sepsis: Sepsis and associated NEC promote ROP and should be prevented with the infant’s own mother’s milk when possible and treated aggressively.

Anaemia: Blood transfusions and administration of erythropoietin, which stimulates red blood cell production, are associated with ROP. However, Dr Hellström’s research suggests that the underlying anaemia is the culprit, and preventing and treating it in the first two weeks of life reduce ROP risk. In particular, animal studies show that infusing platelets suppresses production of factors in the retina that promote neovascularisation, e.g. VEGF. “It is extremely important to prevent and address anaemia in the first two weeks of life,” Dr Hellström stressed.

Ann Hellström: ann.hellstrom@medfak.gu.se

PAEDIATRIC OPHTHALMOLOGY

Minimising the myopia epidemic Modifiable risk factors in childhood could help to reduce high myopia.

Leigh Spielberg MD reports

P

eople who develop myopia before the age of 13 have a much higher risk of high, pathological myopia later in life, Caroline Klaver MD, PhD, told delegates at an ESCRS clinical research symposium during the 36th Annual Congress of the ESCRS in Vienna.

“This is significant because the risk of bilateral visual impairment and blindness is strongly correlated with the degree of myopia, particularly as represented by axial length.

Nearly 20% of patients in whom myopia begins before age 10 will go on to become highly myopic, said Dr Klaver, Erasmus University Medical Centre, Rotterdam, the Netherlands.

There is a worldwide myopia epidemic, which will have significant consequences for ocular morbidity in the future. It is thus of interest to study the phenomenon to be able to devise plans to minimise its impact. The risk of developing high myopia is multifactorial. Genetic risk is significant.

“Many genes of small effect determine refractive error and myopia, and all cell types in the retina express refractive error genes. But myopia is really all about lifestyle in children, as far as modifiable factors are involved. Those that have both high genetic risk and higher education, or high genetic risk plus high environmental risk, are particularly at risk for pathological myopia,” said Dr Klaver.

Environmental risks include spending too little time pursuing traditional childhood activities, notably playing outdoors. Two hours or more outside per day is protective, she said.

COAXIAL SOFT-TIP I/A SYSTEM

PATCHY According to the Rotterdam Eye Study, myopes spend more time indoors, have lower vitamin D levels (vitamin D is a proxy for time spent outdoors) and spend more hours on near work.

There are significant correlations between a lack of various biomarkers for outdoor exposure and myopia.

What about smartphone use? Is there such a thing as “too much” in terms of development of myopia? There are no good data regarding smartphone use, said Dr Klaver, although studies are currently ongoing.

Dr Klaver encourages paediatric patients to follow the 20-20-2 Rule.

“After 20 minutes of near work, you should take a 20-second ‘accommodation break’ during which you look far ahead into the distance, allowing the accommodation to relax.

And, children should spend two hours per day outside.”

Does the use of sunglasses negate the effects of time spent outdoors? There are no real data about that yet, Caroline Klaver MD, PhD either, she noted.

After 20 minutes of near work, you should take a 20-second ‘accommodation break’ during which you look far ahead into the distance

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EUROTIMES | APRIL 2019

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HOSPITAL DIARY

Taking a fresh look

S

A historical case offers some friends the chance to give a speculative diagnosis. Leigh Spielberg MD reports

o, do we have loss of vision, the irritation and any theories the discharge. But in trachoma, on how he visual loss occurs at the end stage went blind? of the disease, due to corneal No one knows scarring by the conjunctival for sure how it happened. A changes.” A quick search online diagnosis was never made,” I yielded some information that said to everyone but no one in supported this theory: trachoma particular. We were watching was responsible for 10% of the Ray, the biopic about the cases of blindness in a school legendary jazz pianist Ray for the blind nearby where Ray Charles. It’s a spectacularly Charles grew up. moving film in which his Niels Hoevenaars, a struggles as a blind musician strabismus surgeon in South in an unforgiving world are Holland and a jazz pianist given a great deal of attention. himself, recalled a presentation It was a unique moment to he had given when we were have this discussion. The eight all in training. It concerned of us were back in the Alps the extraordinary auditory for our yearly ski-trip reunion faculties of people who lose of Rotterdam Eye Hospital their vision at an early age. ophthalmology graduates.

“The neuronal plasticity With six subspecialists and allows the brain to expand two general ophthalmologists, the capabilities of the auditory it became a lively discussion. cortex in order to expand the We were particularly total sensory capabilities,” a interested in the scene that point which was made clear in depicts the seven-year-old the film. Ray Charles was said Ray Charles suffering rapidly to have had excellent hearing. progressive visual loss.

“Stevie Wonder lost his “The way his disease is sight due to retinopathy of depicted here, it looks like prematurity, but that’s probably Ray Charles not only never had access to congenital glaucoma,” said not the case here,” I said. an ophthalmologist during his childhood, Theo Nieuwendijk, a glaucoma “Late-onset RDs in ROP are specialist in the Rotterdam Eye unlikely, since he was known to but apparently never received a diagnosis Hospital. “The blurry vision, have been able to see in his early later in life, when he could certainly the tearing eyes and the rapid childhood years,” said Yashna visual loss look a lot like the van Kinderen, a VR surgeon in afford such care presentation of high IOP at North Holland. birth. Except he was apparently seven years old by then, and “FEVR is a possibility in a young male with bilateral visual loss,” juvenile glaucoma presents differently. And he didn’t have the said Peter van Etten, VR surgeon in the Rotterdam Eye Hospital. typical buphthalmos appearance that would have made for an easy Retinitis pigmentosa was discounted, considering its rarity and diagnosis, even later in life.”

Charles’s young age at onset, as were bilateral detachments due to “That’s a pretty significant detail. Sudden-onset glaucoma in a Stickler’s syndrome. seven-year-old is pretty rare, certainly if it’s primary glaucoma,” said After considering the combination of the poor, rural setting Gertjan Hoddenbach, also a glaucoma specialist in South Holland. of Charles’s upbringing, the sudden, bilateral loss of vision and “Maybe he had bilateral uveitis? Possibly in combination the irritation and discharge said to have been present, we finally with secondary glaucoma? Like in the context of juvenile settled on trachoma as the most likely cause of his blindness. arthritis?” I wondered. “Juvenile cataract is a possibility, with The next day, we ventured out on to the slopes, where we subsequent amblyopia,” suggested Roger Cals, a phaco specialist encountered a total whiteout, a combination of low-hanging clouds in North Holland. “But he probably would’ve been operated on at and a blizzard that rendered the eight of us effectively blind for several some point thereafter, once he had access to medical care.” hours. The stress caused by low vision was readily apparent in the We all pulled out our smartphones and started searching group. Skiing slowed to a crawl and we stayed together. Visibility was for information, but there was little to be found. As far as we only a few metres, and losing someone from the group could lead to a could determine, Ray Charles not only never had access to an tricky situation. Despite the considerable ophthalmological skill set in ophthalmologist during his childhood, but apparently never the group, we had no solution for this universal epidemic of suddenreceived a diagnosis later in life, when he could certainly afford onset, bilateral blindness. So we did the only thing we could think of: such care. And we decided to not use the clinical presentation in we went inside for lunch and waited for the skies to clear. the film as a necessarily accurate portrayal of his symptomatology.

“How about trachoma?” mused Tom van Goor, a cornea specialist Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at in the Rotterdam Eye Hospital. “That could explain the bilateral Ghent University, Belgium Illustration by Eoin Coveney

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EUROTIMES | APRIL 2019

RANDOM THOUGHTS

To err is human – get used to it All ophthalmologists will have bad days and failures, but that is part of the learning curve, says Colin Kerr

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e all have our bad days. Some days are worse than others.

I am not an ophthalmologist, but I can confidently say that my failures on a daily basis outweigh my successes.

Ophthalmologists pride themselves on their attention to detail and on their ability to deliver the best results to their patients.

Do they ever go home and say to their partners or friends: “Today, I failed.”

I don’t think they do, as failure is usually not an option for high-achieving, highly motivated medical professionals.

That brings me to a recent article by the musician and writer Tracey Thorne who wrote on failure in the New Statesman magazine. “.......failed job interviews, infertility, divorce, illness.

Human frailty, vulnerability, and, ultimately, that one great failure none of us can avoid, mortality – they glue us together, or should do,” said Thorne.

FROM TRAINEE TO SURGEON I immediately recalled Thorne’s article when I listened to a EuroTimes Eye Contact interview with Dr Sorcha Ní Dhubhghaill, who discussed what trainees should look for in a mentor and what mentors can offer in that role.

Dr Ní Dhubhghaill is ideally placed to discuss this role having made the transition from trainee to her current position as Corneal Surgeon at Netherlands Institute for Innovative Ocular Surgery (NIIOS) and Antwerp University Hospital.

“There is a saying ‘The master has failed more than the trainee has tried’,” said Dr Ní Dhubhghaill. “When you see this amazing surgeon doing amazing surgery, so quickly and so elegantly, you may wonder ‘how will I ever get there’.

“You have to remember that the surgeon you are observing did not come out of medical school doing that.

They have had bad days, they’ve had failures.”

Dr Ní Dhubhghaill said that part of her job as a mentor is to try and convince young surgeons not to quit out of the surgical programme. “Every young surgeon, when they have their first complication, sits at home, loses sleep and wonders ‘should I have let somebody else do this procedure?’ You need, as a mentor, to help them over these roadblocks because you have to remember that someone helped you over your roadblocks,” she said.

Dr Ní Dhubhghaill says she was very lucky to have great mentors including Peter Barry and Marie-José Tassignon.

“They both helped me over these hurdles when I didn’t want to continue, and now I love it.”

In one of his last works, Worstward Ho (1983), the great Irish writer and Nobel laureate Samuel Beckett wrote: “All of old. Nothing else ever. Ever tried. Ever failed. No matter. Try again. Fail again. Fail better.”

Beckett’s work is often misinterpreted, but it is possible to argue that what he is suggesting here is that there is no such thing as absolute success or failure.

And that is why ophthalmologists should always remember that to err is human.

Colin Kerr is Executive Editor of EuroTimes

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CME Educational Symposium

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Save the date Friday, May 3 – Monday, May 6, 2019

Make the most of your time at the ASCRS•ASOA Annual Meeting and attend our EyeWorld multi-supported CME and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Registration is now open!

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 • 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

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: • • • • • • •

New developments in surgical instrumentation 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

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Reviews EDITORS HUA YAN PUBLISHED BY SPRINGER

Practical guidance in the face of emergency

Providing emergency eye care is one of the greatest challenges the ophthalmologist encounters. Some “emergencies”, like viral conjunctivitis, can wait. Others, like postoperative endophthalmitis, require extremely rapid, invasive treatment. Ocular Emergency (Springer), edited by Hua Yan, aims to help provide the reader develop the modes of clinical thinking that will lead to the most accurate diagnosis and correct treatment within the boundaries of time that acute disorders require.

The publisher describes Ocular Emergency as “a systematic, symptom-based reference book for clinical practice guidance”. This is true. The first three chapters cover the general guidelines of ophthalmic emergency, the organisation of an ocular emergency room (ER) and the patient care process. The final seven chapters are organised by presenting symptom, sign or injury, from “Acute Redness of the Eye,” through “OpenGlobe Injuries”.

This 240-page book is ideal for junior ophthalmology trainees who are expected to help manage an ophthalmology ER or who will be the first point of contact for patients presenting with acute ocular pathology after regular office hours. More senior trainees could use this text to brush up on the basics, and ambitious nurses and clinical support staff could certainly deepen their knowledge of pathology by reading this book.

A CONCISE, FOCUSED INSTRUCTIONAL GUIDE

PUBLICATION EMERGENCY, ACUTE AND RAPID ACCESS OPHTHALMOLOGY EDITORS JOSEPHINE DUVALL-YOUNG PUBLISHED BY SPRINGER

EUROTIMES | MONTH YEAR

PUBLISHED BY SPRINGER

NEW POSSIBILITIES IN DRUG DELIVERY

BOOK PUBLICATION OCULAR EMERGENCY

EDITORS JAYVADAN K. PATEL, VIJAYKUMAR SUTUARIYA, JAGAT RAKESH KANWAR AND YASHWANT V. PATHAK

Emergency, Acute & Rapid-Access Ophthalmology: Practical, Clinical & Managerial Aspects (also from Springer) is a shorter, 130-page text dedicated to providing an even more concise, focused instructional guide than Ocular Emergency.

Edited by Josephine Duvall-Young, it is also organised differently from the previous book. There are two parts: “Clinical Aspects” and “Leading an Emergency & Rapid-Access Service”.

Part I, which comprises the bulk of the text, is purely medical and assumes sufficient knowledge to make a diagnosis. As such, it is organised by diagnosis. Work-up and treatment per clinical condition are described. The diagnoses are very specific: examples include central retinal artery occlusion, Bell’s palsy, choroidal hemangioma and paediatric nystagmus.

Part II is a shorter section on how to establish and manage an ophthalmic ER or rapid-access service. This takes into account the organisation of the workforce, patient triage, equipment needed and the development of protocols and standard operating procedures.

This book is intended for trainee ophthalmologists, who will appreciate the medically focused Part I. Part II is ideal for the physician responsible for managing the flow of patients with acute pathology.

Eye hospital administrators would also benefit from reading Part II, as it gives them insight into what we as ophthalmologists are confronted with on a daily basis.

“Drug delivery systems are in the forefront of research,” starts the foreword of this 500-page research compilation. Drug Delivery for the Retina & Posterior Segment Disease assembles and analyses recent advances in the research and development of these delivery systems, with an emphasis on implantable devices, iontophoresis and micro- and nanoparticles.

This is a highly detailed text. The average chapters have between 50 and 100 references to recent publications. “Penetration Routes to Retina and Posterior Segment” provides a nifty introduction to the possibilities, while chapters on liposomes, colloidal carrier systems, lipid prodrugs and thermoresponsive gel systems open a new world of possibilities.

This text is intended for researchers working on drug delivery routes and systems for the posterior segment and retina. Retinal specialists interested in keeping abreast of the most recent developments might also consider keeping this book handy as a reference work.

PUBLICATION OCT-ANGIOGRAPHY EDITORS SANJA SEFIĆ KASUMOVIĆ PUBLISHED BY JAYPEE

COMMON PATHOLOGIES SEEN IN A NEW LIGHT OCT angiography (OCT-A) continues to draw the attention of retinal specialists, with its promise of a non-invasive, highly digitalised and differentiated version of the tried-and-true fluorescein angiography. OCT Angiography is a 180-page atlas-like text on the most commonly encountered retinal pathologies, as seen with OCTA. Chapter 1 offers a basic introduction to OCT-A. Each of the following 23 chapters covers a single pathology: introduction, epidemiology and aetiology, symptoms and signs, differential diagnosis, diagnostics, therapy and, most crucially, extensive series of images, not only the OCT-A images but also fundus photography, “regular” OCT and any other relevant imaging modalities that are currently used in the management of these disorders.

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 | APRIL 2019

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OUTLOOK ON INDUSTRY

Monofocal innovation

J

J&J Vision sees new cataract standard of care with intermediate vision-improving IOL. Howard Larkin reports

ohnson & Johnson Vision believe cataract patients should get more than just excellent distance vision with monofocal intraocular lenses (IOLs). The new Tecnis Eyhance monofocal IOL delivers, says JeanClaude Dubacher, the firm’s regional vice president for surgical vision in Europe, the Middle East and Africa.

Eyhance provides the clear distance vision and high contrast sensitivity of a traditional monofocal IOL while extending depth of focus for functional intermediate vision. This enables many patients to perform daily tasks such as walking on uneven surfaces, driving and even reading price tags while shopping.

“It’s really about changing the standard of care. Since the introduction of the foldable lens and aspheric lenses in the early 2000s there hasn’t really been much innovation on the monofocal side. This lens really makes a difference for the patient,” Dubacher said.

Launched this year across Europe, Eyhance is covered by many health plans, making it easily affordable for patients, though arrangements vary, Dubacher added. “This is not a lens in the privatepay, premium IOL space. It is a monofocal innovation targeting the vast majority of cataract patients.”

EASY ADOPTION, ENHANCED OUTCOMES Eyhance extends depth of focus using a higher-order asphere in the optic centre that blends into the optic zone and periphery without rings. Data has shown low incidence of glare, halo or starbursts comparable to what has been reported with the Tecnis 1-piece IOL on which it is based.

As a result, Eyhance can be easily substituted for a traditional monofocal Tecnis lens, requiring no change in biometry, power calculation or surgical technique, said Oliver Findl MD, of Hanusch Hospital, Vienna, Austria.

Courtesy of Johnson & Johnson Vision

32

The Tecnis Eyhance monofocal IOL

If anything, Eyhance gives better results in cases with minor refractive misses due to biometry errors or healing variation than traditional monofocal IOLs, said Dr Findl, who has implanted the lens in about 30 patients. “We have noticed the lens has a larger sweet spot and a higher probability of achieving good visual acuity.”

Indeed, many of Dr Findl’s early patients have achieved 20/16 distance vision uncorrected, he reported. Most also have good intermediate vision, with intermediate vision outcomes generally better in patients who precisely hit the distance refractive target. Glare, haloes and night vision results are similar to standard monofocal IOLs. So far, patients have been very satisfied with visual outcomes, with many pleasantly surprised at the quality of intermediate vision, Dr Findl said. To further enhance unaided vision, he is experimenting with combining Eyhance

For the next generation we want to change the standard of care. We want to lead with innovations that really change outcomes...

Jean-Claude Dubacher EUROTIMES | APRIL 2019

with micro-monovision, targeting emmetropia dominant and about -0.5D non-dominant. “I would expect these people to have good intermediate vision and even some near vision with good lighting, holding the reading card a little farther away.”

Dr Findl finds the advantages of Eyhance compelling enough that he is adopting it as his standard monofocal lens. “It is a more forgiving monofocal lens if you use it as such and don’t promise the patient too much.”

MOVING THE REFRACTIVE MARKET Eyhance is just the first in a range of innovations that Johnson & Johnson Vision intends to elevate the standard of eye care, Dubacher said. In keeping with a statement of purpose adopted when it acquired its surgical vision operations two years ago, the firm has a rich pipeline of products that are intended to protect and improve eye health, he added.

“For the next generation we want to change the standard of care. We want to lead with innovations that really change outcomes, that make a difference in patients’ and surgeons’ lives. Having an innovation in monofocal IOLs is exciting; the market is very different than that for premium IOLs. Think of the millions of people you can reach. We are very excited about that,” Dubacher added.

PRACTICE MANAGEMENT

ESCRS focuses on innovation ESCRS Practice Management and Development Committee launches two new initiatives. Colin Kerr reports

T

WCPOS V | 2020 5th World Congress of Paediatric Ophthalmology and Strabismus

he ESCRS Practice Management and Development Innovation Award 2019 is a new award that will focus on innovations from ophthalmologists and their practice staff that enhance patient services.

The competition enables ophthalmologists to demonstrate what they have achieved with their entrepreneurial skills and show colleagues what they may be able to do in their own businesses.

Entries should be based on a recent innovation introduced into a practice, clinic or hospital by an ophthalmologist. The innovation may be business- and/or customer- and/or societyfocused, and its impact should be proven and measurable in qualitative and quantitative terms. There is no fee to enter and the competition is open to all ophthalmologists.

A shortlist of entries will be selected by of the Practice Management and Development Committee, with the shortlisted entrants invited to give a presentation on their projects at the 37th Congress of the ESCRS in Paris, France during the Practice Management and Development Programme.

The winner will be decided by an audience vote, which will take place after the presentations.

The winning entrant will receive a €1,500 bursary to attend the 38th Congress of the ESCRS in Amsterdam, The Netherlands in October 2020.

Further details are available at http://www.escrs.org/ paris2019/programme/ESCRS-Practice-Management-andDevelopment-Innovation-Award.asp

LINKEDIN PRACTICE MANAGERS GROUP Practice Managers are also invited to join the European Society of Cataract and Refractive Surgeons Practice Managers Group on LinkedIn at https://www.linkedin.com/ groups/12179696/. This group is for Practice Managers who want to share their experiences of working in an ophthalmological practice.

Paul Rosen, chairman of the ESCRS Practice and Management Development Committee, said he hoped the new group would encourage practice managers to talk about the challenges they face on a daily basis.

“How do you attract and retain patients to your practice? What innovations have you introduced that has enhanced your practice, for practice staff and patients?

These are some of the topics we hope to discuss in the coming months,” said Dr Rosen.

Dr Rosen told EuroTimes that although the major focus of the ESCRS Practice Management and Development Committee was to produce exciting and innovative programmes for the annual ESCRS congresses, they were conscious of the need to enhance the programme on an annual basis.

“The principal focus of the ESCRS is education and research but there are other aspects to our professional lives that we need to develop. To advance and introduce new technologies, we have to maximise the efficiency of our practices and work in a more business-like way.

“We hope that the Innovation Award and the LinkedIn Practice Managers Group will encourage ophthalmologists and their practice staff to share their knowledge and enhance their development,” he said.

2–4 October 2020 RAI Amsterdam, The Netherlands www.wspos.org

EUROTIMES | APRIL 2019

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34

INDUSTRY NEWS

NEWS IN BRIEF IMAGING IN SPACE

INDUSTRY

NEWS

Pre- and post-surgery eye drops

Rayner has launched AEON, which the company describes as the first family of pre- and postsurgery eye drops, to help patients manage their condition and improve their visual outcomes.

Rayner say AEON Protect Plus has a unique cross-linked sodium hyaluronate (HA) formulation to provide an artificial tear for relief of moderate-to-severe dry eye.

AEON REPAIR is purposely designed for use in the weeks after surgery and combines sodium HA with vitamins A and E to lubricate, soothe and aid the repair of the surface of eyes.

Both AEON REPAIR and AEON PROTECT PLUS are stored in multi-dose dropper devices, which allow the solutions to stay sterile, without the need of preservatives, say the company.

Tim Clover, CEO of Rayner, said: “As recent research shows, almost two-thirds of patients suffer from dry eye disease prior to cataract surgery and this can significantly hinder recovery and long-term visual results. That’s why we created AEON, because at Rayner, we are passionate about improving patient care and that’s why AEON eye drops are being made available with every Rayner intraocular lens (IOL).” www.rayner.com/AEON

PRE-LOADED CAPSULAR TENSION RING OPHTEC has been granted CFDA approval for the pre-loaded capsular tension ring (CTR) “Ringject” in China.

CTRs were originally introduced to strengthen the zonule in eyes with zonular dehiscence (ZD) in cataract and lens surgery. They also prevent capsular phimosis in eyes at risk for postoperative capsular shrinkage.

“The main indication for the use of CTRs is still the management of ZD but we see surgeons using CTRs for other purposes too,” said Tiago Guerreiro, Global Marketing Director at OPHTEC BV. “We see a clear trend in the use of the pre-loaded Ringject with multifocal IOLs. It started a few years ago in Europe and other countries are following as surgeons see the advantages of (multifocal) IOL stabilisation in the capsular bag,” Mr Guerreiro continued.

“We foresee a significant growth on the pre-loaded CTRs demand in China as the product offers easy handling. The CFDA approval of Ringject is another step forward on OPHTEC’s commitment to the Chinese ophthalmic community.” www.ophtec.com

EUROTIMES | APRIL 2019

OPTICAL COHERENCE TOMOGRAPHY NIDEK has launched AngioScan, an upgraded OCT-Angiography software, that enables visualisation of retinal and choroidal microvasculature and blood flow using the RS-3000 Advance 2 Optical Coherence Tomography.

“The new analysis function quantifies vessels in each layer providing metrics to assess disease progression and the effects of treatment. The NIDEK AngioScan [also] presents a vessel density map and a perfusion density map. Additionally, the foveal avascular zone (FAZ) is automatically detected and shape metrics are provided for rapid assessment,” said a company spokesman.

“A newly designed interface displays seven slabs for each layer on one screen.

The interface is intuitive and summary charts facilitate quick evaluation of the most relevant clinical features.”

Improved image-processing algorithms enable visualisation of sub-clinical neovascularisation. New projection artifact removal algorithms provide an accurate representation of vasculature by reducing artifacts for better OCTangiography image interpretation, say Nidek. www.nidek-intl.com

Heidelberg Engineering has announced that its SPECTRALIS imaging platform with the company’s next-generation OCT2 Module has been successfully installed at the International Space Station (ISS) and is now fully operational. NASA launched the SPECTRALIS to the ISS aboard the Antares 230 Cygnus CRS OA-9, also known as Orbital Sciences CRS Flight 9E, from Wallops Island, Virginia, last May. “With this advanced OCT technology, it is easier for the astronauts to capture high-quality images in even less time.

Working in such an environment, there is significant value placed on efficiency that doesn’t compromise quality,” said Arianna Schoess Vargas, CEO. www.spectralis-platform.com

BRAND CHANGE Following Topcon Healthcare Solutions’ acquisition of KIDE Systems in April 2018, KIDE Systems has announced that it will take on the branding of its parent company Topcon Healthcare Solutions Inc., part of Topcon Corporation. The brand change includes the change of KIDE Systems’ corporate name to Topcon Healthcare Solutions EMEA (THS EMEA).

KIDE Systems (now THS EMEA) will take on the responsibility of distributing and supporting the complete suite of Topcon Healthcare Solutions’ software within Europe, the Middle East and Africa (EMEA). Topcon Healthcare Solutions Inc. is a wholly owned subsidiary of Topcon America Corporation.

“The brand change is a natural step towards becoming a true member of the Topcon family,” said Mr Anssi Ylimaula, CEO of KIDE Systems and new Managing Director of THS EMEA. “The brand change will allow us to provide our customers with even better solutions and services,” Mr Ylimaula continued. www.topconhealth.eu

NEW GENERATION OF IOLS OPHTEC has been was granted a patent by the USA patent office for its Continuous Transitional Focus (CTF) optical design of the new aspheric presbyopia-correcting IOL. This new generation of multifocal IOLs for the treatment of cataracts, called Precizon Presbyopic, allows patients to experience a more “natural vision” at all distances after surgery.

Precizon Presbyopic, has European CE Mark approval and is commercially available across Europe, including the Netherlands, Spain, Portugal, Germany and the UK. South Korea and South Africa also have access to Precizon Presbyopic lenses.

The new IOL is not available in the USA. www.ophtec.com

MY MENTOR

Handing down pearls of wisdom Andreas Frings, winner of the 2018 Peter Barry Fellowship, talks about his mentor Navid Ardjomand

M

entor is a figure from Greek mythology.

He is the son of Alkimos from Ithaca in Homer’s Odyssey. When Odysseus sets off for the Trojan War, he hands over his son Telemachus and his household to Mentor, his friend and peer.

Derived from the role of Mentor to Telemachus, the term mentor indicates an older, wise and benevolent adviser to a younger person. For me, this role was taken by Navid Ardjomand from Graz in Austria.

Navid has 25 years of experience in eye surgery. He is one of the leading ophthalmic surgeons in Austria, carrying out about 1,500 surgeries per year. He is also the secretary of the Commission For Refractive Surgery of the Austrian Society of Ophthalmology.

I met Navid late into my medical studies. Unlike most other instructors, Navid was entertaining, knowledgeable and always helpful. I was, and still am, fascinated by Navid’s intellect and great knowledge, especially about refractive surgery and eye surgery in general. Navid is selfless and always interested in passing on his knowledge to make me better. I am proud that I know Navid.

Without him, I would never have become an ophthalmologist.

I thought of Navid when I had the honour of being presented with the Peter Barry Fellowship at the 36th Congress of the ESCRS in Vienna, Austria. I started my Peter Barry Fellowship in August 2018 at Moorfields Eye Hospital, Refractive Surgery Service, under the supervision of Mr Bruce Allan.

My project involves the psychometric evaluation and calibration of a novel patient-reported outcome (PRO) measure for refractive surgery patients developed for use as part of the National Dataset in Refractive Surgery.

Peter Barry was among the pioneers who laid the foundation of the ESCRS and served there for more than 25 years as a board member, treasurer and president. He also had a major role in bringing ESCRS academies around the world and like Navid Ardjomand he was a mentor and friend to many young ophthalmologists.

It is our duty as ophthalmologists to hand down the pearls of wisdom that we are are given by our mentors.

Since my MD thesis in 2011, I have been focusing on issues related to cataract and refractive surgery, including topics dealing with biometry, astigmatism treatment and vector analysis, laser refractive surgery and interdisciplinary topics related to corneal biomechanics.

I am happy to serve as a supervisor of many younger colleagues and students doing their MD theses and will continue to do so in the future.

I first met Navid late into my medical studies.

Unlike most other instructors, Navid was entertaining, very knowledgeable and always helpful

A new eye drop family focused on patients before and after eye surgery

Why let dry eye affect patients’ surgical outcomes?

Up to 63% of patients suffer from dry eye disease prior to cataract surgery.1

NEW

The solution? AEON, a new surgery-specific eye drop family designed to improve visual acuity and patient satisfaction.

PROTECT PLUS with 2nd generation cross-linked sodium hyaluronate REPAIR Sodium hyaluronate with added vitamins A and E

1. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Dove Pres 7 August 2017.

Rayner has been focused on providing the best visual outcomes for patients and surgeons since 1910. ©2019 Rayner. AEON is a proprietary mark of Rayner.

Rayner Intraocular Lenses Limited, 10 Dominion Way, Worthing, West Sussex, BN14 8AQ. Registered in England: 615539. EC2019-30 03/19

rayner.com/AEON

EUROTIMES | APRIL 2019

35

PARIS

3

TO TASTE ...

FAMILY FEUD LEADS TO A NEW TWIST ON A PARISIAN STAPLE For eight decades the word ‘Poilâne’ has meant ‘bread’ to French connoisseurs; they are referring to a two-kilo ‘miche’, a rustic sourdough bread first produced by Pierre Poilâne in 1932. There’s a Poilâne at 49 boulevard de Grenelle (closed Monday). Or discover the lesser-known miche sold by Max Poilâne. A feud between Pierre Poilâne’s two sons, Lionel and Max, following the death of the founder, resulted in Max setting out on his own to produce a miche with a slightly different taste and texture. The shop he established in 1976 is open daily at 87 rue Brancion near Parc Brassens. Closes 20.00.

ENJOY A LEGENDARY CHOCOLAT CHAUD THAT TRULY SETS THE STANDARD One of the pleasures of visiting Paris is having the opportunity to visit the legendary Angelina’s on rue Rivoli. Angelina’s version of hot chocolate sets the standard against which all others are measured. Look for le chocolat chaud à l’ancienne l’Africain. You’ll get a pitcher of hot, creamy chocolate so thick it barely pours. To this you add spoonfuls of the whipped cream served alongside. There are six branches across the city, and the adjacent gourmet shop at the Palais des Congrès branch is good for souvenirs. See http://www. angelina-paris.fr/en/magasins for addresses and opening hours.

700 HIVES KEPT BY URBAN BEEKEEPERS MAKE THE PUREST HONEY IN FRANCE If I had been asked to guess where one could find the purest honey in France, I would have said the hills outside Nice. I would have been wrong. It seems the answer is Paris, which is virtually pesticide free, while pesticides were only banned a year ago in rural parts of the country. And not only is Parisian honey purer, but it is said to taste better too, thanks to the diversity of plants in the city. To keep up with demand, urban beekeepers have been as busy as, well, bees – with 700 hives on the tops of the city’s buildings. Visit La Grande Épicerie 38 rue de Sèvres (in the Bon Marché department store) for a fine selection of the resultant Parisian honeys. Open daily until 21.00, Sunday until 20.00.

Max Poilâne

Timeless favourites

ESCRS Congress delegates won’t have to go far to enjoy a fine evening meal. Maryalicia Post points the way.

A restaurant tip I picked up in a casual conversation turned out to be a surprising find. It’s a modern, bright restaurant with a modern, bright menu and a strange name: 750g La Table. It developed from a website of wine and food pairings created by JeanBaptiste Duquesne (the ‘750g’ refers to the weight of the contents of a bottle of wine).

Two years later his brother Damien, a chef, joined him to present recipes. Considering the immense popularity of the website (www.750g.com), establishing a restaurant was the logical next step.

La Table is a relaxed place with a welcoming staff. You feel as comfortable simply ordering a platter of cheese and a glass of wine, which will come with a basket of homemade bread, as you do treating yourself to a substantial meal. There are interesting vegetarian dishes on the menu, too.

Finish up with ‘cafe gourmand’, a sampling of homemade desserts served with your after-dinner coffee. 750g La Table is at 397, rue de Vaugirard and is open every day of the week.

Once upon a time there were plenty of Parisian restaurants where you’d expect to find a casual atmosphere, minimal decor and the owner in the kitchen turning out simple food, served in generous portions.

A warm welcome was standard, too, and a kiss on each cheek for the regulars.

Time’s moved on, and finding a restaurant like that with plain brown tables and chairs squeezed into a room ornamented with rugby paraphernalia seems like a time warp. La Petite Auberge, at 13 rue Hameau in the 15th arrondissement, is that restaurant.

I chose a timeless bistro favourite, steak and its companion, crispy hand-cut deepfried potatoes. Following that, a slice of homemade fruit tart and coffee. The bill,

including a glass of wine and service, came to €22. No wonder the restaurant fills up early. Booking advised, Open noon to 14.00 and 19.00 to 22.00. Closed Sunday.

Le Grand Pan, an unassuming-looking bistro at 20 rue Rosenwald, is not only recommended by the Lonely Planet guide book but has been unequivocally praised by the New York Times food critic. It’s near Parc Brassens, and George Brassens is said to have eaten here often. Hearty portions of beef, pork or veal accompanied by homemade French fries are a mainstay of the menu. There’s a five-course tasting menu too and a tempting variety of other dishes listed on the blackboard. Closed Saturday and Sunday.

Those with smaller appetites might try Le Petit Pan just across the street. It serves a simple bistro lunch or, in the evening, French-style tapas. Open noon to 14.30 and from 19.30 to 22.30. Closed Sunday and Monday.

750g La Table

EUROTIMES | APRIL 2019

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EXPLORING PARIS

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CALENDAR

The 37th Congress of the ESCRS, 19th EURETINA Congress and 10th EuCornea Congress will each take place in Paris, France

↙

LAST CALL

APRIL 2019 International Meeting of the Egyptian Vitreoretinal Society (EGVRS) 10–12 April Cairo, Egypt www.egvrs.org

8th INCCA Meeting

11–13 April Lima, Peru www.inccameeting2019.com/

MAY

MAY

ASCRS•ASOA Symposium and Congress

The 45th Annual Meeting of the European Paediatric Ophthalmological Society

17th Congress of the Black Sea Ophthalmological Society

3–7 May San Diego, USA www.ascrs.org

46th EFCLIN Congress Exhibition

NEW Bulgarian Society of Cataract and Refractive Surgeons Traditional Conference

19–21 April Istanbul, Turkey http://bsos-istanbul2019.org 25–27 April Brussels, Belgium www.efclin.com

May 18 Varna, Bulgaria

17th SOI International Congress

23–25 May Rome, Italy https://www.congressisoi.com

NEW BSCRS-SOBEVECO Spring 2019 Meeting

25 May 2019 Liège, Belgium https://bscrs.be/events/in-belgium/jointspring-meeting-2019/

May 30–June 1 Riga, Latvia https://www.epos-focus.org

16th South East European Congress of Ophthalmology May 31–June 2 Prishtina, Kosovo http://www.shofk.org

JUNE SOE Congress 2019 13–16 June Nice, France www.soevision.org

MaculArt 2019

June 23–25, Paris, France www.maculart-meeting.com

SEPTEMBER 19th EURETINA Congress

↙

5–8 September Paris, France www.euretina.org

10th EuCornea Congress

13–14 September Paris, France www.eucornea.org

WSPOS Subspecialty Day 13 September Paris, France www.wspos.org 17th Congress of the Black Sea Ophthalmological Society will be held in Istanbul, Turkey

EUROTIMES | APRIL 2019

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40

CALENDAR

SEPTEMBER

ASCRS•ASOA Symposium and Congress will take place in Boston, USA in 2020

37th Congress of the ESCRS

14–18 September Paris, France www.escrs.org

OCTOBER 32nd APACRS Annual Meeting 3–5 October Kyoto, Japan apacrs2019.org

AAO Annual Meeting 12–15 October San Francisco, USA www.aao.org

Ophthalmic Imaging: from Theory to Current Practice

4 October Paris, France https://www.vuexplorer.com /en/congres

2020 ASCRS•ASOA Symposium and Congress 15–19 May Boston, USA www.ascrs.org

OCTOBER 38th Congress of the ESCRS

1– 4 October Amsterdam, The Netherlands www.euretina.org

11th EuCornea Congress 2–3 October Amsterdam, The Netherlands www.eucornea.org

JUNE World Ophthalmology Congress (WOC) 26–29 June Cape Town, South Africa http://woc2020.icoph.org

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus 2– 4 October Amsterdam, The Netherlands www.wspos.org

↙

MAY

OCTOBER 20th EURETINA Congress

3–7 October Amsterdam, The Netherlands www.escrs.org

NOVEMBER AAO Annual Meeting 2020

14–17 November Las Vegas, USA www.aao.org

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