Vol. 18 - Issue 9 by EUROTIMES

VOLUME 18 ISSUE 9 september 2013

Cover Story

Gene Therapy & Retinal Disease

In a Class of its Own vitreoretinal A new dimension in precision, safety and flexibility: faros™ with Oertli TrueFlowControl®. Now you always have flow and vacuum under complete control, and the faros™ device can demonstrate its superiority – especially with very difficult manoeuvres.

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september 2013 Volume 18 | Issue 9 This ISSUE... Special Focus: Retina 4

Cover Story: Some incurable retinal disorders may be treated with gene therapy

Newsmaker Interview with president-elect of EURETINA, Francesco Bandello

10 Treatment of vitreous floaters not without risks 11 Ireland rolls-out national diabetic screening programme 13 Navigated laser shows promise as added treatment for DME patients

Cataract & Refractive

18 Are some femto-cataract benefits questionable? 20 Intumescent cataracts can be successfully treated with laser technology 21 French study looks at redefining cataract definition 28 The future of IOLs 31 Study looks at advantages of femtosecond laser-assisted cataract surgery

Cornea 33 Characterising endothelial cell loss after DSEK

Glaucoma 34 Third Glaucoma Day to be held at ESCRS congress 37 Corneal transplantation procedures assessed worldwide

Ocular 38 A look at how the recession is affecting French ophthalmology

News 40 ESCRS and charities help to empower communities 42 President of ESASO discusses advantages of institution’s training programmes 45 New ESCRS study to compare femto-phaco outcomes

Features 46 Eye on History 47 Book Review 48 Eye on Travel 49 Ophthalmologica 50 JCRS Highlights

Clarification:

In an article on "Phakic Explants" published in July/August EuroTimes (Vol 18 Issue 7/8, p13) we reported that, "The Alcon Cachet lens was withdrawn from sale in 2012 because of concerns relating to sudden reduction in endothelial cell counts in implanted patients". We have been asked to clarify that in early 2013, Alcon placed a temporary voluntary hold on shipments of the AcrySof® CACHET® Phakic lenses so the company could revise the product’s Direction For Use information to ensure safe and proper use.

53 Practice Development

55 Industry News 57 EU Matters 59 Outlook on Industry 60 Calendar

With this month’s issue... Oraya Therapy – A Significant Advance in the Treatment of Wet AMD

editorial staff

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Published by The European Society of Cataract and Refractive Surgeons Publisher Carol Fitzpatrick

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Advertising Executive Mairin Condon Senior Designer Janice Robb

Assistant Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

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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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As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2012 and 31 December 2012 is 37,563.

EUROTIMES

Editorial

ESCRS

EDITORIAL

Medical Editors

Volume 18 | Issue 9

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

creating the future

EURETINA is proud of its achievements but the challenge is to continue to improve the services to its members and to retinal specialists

by Gisbert Richard

International Editorial Board

am delighted to write this guest editorial for this issue of EuroTimes which coincides with the 13th annual Congress of EURETINA in Hamburg, Germany. The success story of our society is probably unparalleled in European medicine. After starting in Hamburg 13 years ago with 300 attendees, the meeting this year might be the largest retinological meeting worldwide as thousands of delegates will be in attendance. Many have had a part in this achievement, whether through having responsibilities within the society, or through helping with scientific or other contributions. Our task is to preserve what we have achieved, to carry the society forward and to develop it further, without losing sight of the unity of the whole field of ophthalmology.This is a challenge, because the general framework is rapidly changing. Today we are experiencing global changes to the conception of the healthcare system, partly through the demands and expectations of our patients, but particularly also through the great scientific advances that directly benefit our field. It is the task of EURETINA to promote research and to communicate the results. What is important for our society in the future? The first aim is to improve the exchange of ideas between vitreoretinal specialists and to give them a voice in Europe. The progress in our subspecialty in the last few years has been immense. A good example of this is the development of vitreoretinal surgery, the treatment of macular degeneration, inflammation inhibition and many others. Other major advances include the development of the retinal chip, the application of stem cells, gene therapy and the availability of new drugs. It is the responsibility of EURETINA, together with colleagues from other continents, to communicate these developments and to justify the financing of these innovations to the community. One especially vital task is to support young talented and motivated scientists to become well-trained ophthalmologists. We are continuing to meet this challenge by expanding our educational programme and by introducing new courses. This is and will be a central task of EURETINA now and in the coming years.

Securing a balance

How can we strengthen this society? Science does not live in a vacuum, and sometimes it can be a struggle to make sure that scientific results are put into practice for the benefit of patients. Diagnostics and treatment have to be financed. It is EURETINA’s task to back up innovations in diagnoses and therapies, to draw up training curricula and to harmonise these at a European level. At the same time, the healthcare system is facing increasing economic pressures. It is our job to secure a balance between ethics and economics. EURETINA has unquestionably succeeded in profoundly improving European cooperation. Whereas previously scientific advances were primarily presented and discussed at national congresses, today’s stage is a European one. No one here believes that the clock can be turned back.

EUROTIMES | Volume 18 | Issue 9

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Béatrice Cochener france Hiroko Bissen-Miyajima JAPAN John Chang CHINA The problems that we have are similar internationally. This inevitably leads to the necessity to promote international exchange. For this reason, at our meeting this year we are hosting many important societies – not just from Europe, but also from North America, South America and South-East Asia. We have to work together with our international friends in the interests of our patients to make the current medical advances available to all people and to promote our scientific field as a vital specialty and push it forward. For the future we have to be a society in which innovation is continuous, because it is an integral activity. Such a society need never fear the future; it is creating it every day. I hope that you enjoy our congress and I also hope you enjoy your stay in Hamburg. For those of you who are not able to attend the meeting, I would encourage you to read future issues of EuroTimes which will carry reports on all the major presentations.

Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY

* Gisbert Richard is president of EURETINA

Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Special Focus

retina

GENE THERAPY AND RETINAL DISEASE

Gene replacement therapy emerging as a novel approach in the treatment of many retinal disorders once deemed incurable by Dermot McGrath

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The range of corporate, venture and private finance now available to commercialise gene therapy is healthier than at any time before Gearóid Tuohy

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Gene therapy will be a significant contributor to the future armamentarium of therapies for at least some of the hereditary blinding conditions that are currently incurable Artur V Cideciyan PhD

EUROTIMES | Volume 18 | Issue 9

t has been estimated that one in every 4,000 people suffers from an inherited retinal disease and half of those affected have no family history of the pathology. Individuals diagnosed with diseases such as Leber’s congenital amaurosis (LCA), choroideremia, Stargardt's disease, Usher's syndrome, certain forms of retinitis pigmentosa (RP) as well as other inherited dystrophies typically have a poor visual prognosis and treatment options are currently limited. In recent years gene replacement therapy has emerged as a novel approach in the treatment of many retinal disorders once deemed incurable. The principle of gene therapy is based on the transfer of a therapeutic gene or part of a gene administered to the eye by use of viral or non-viral vectors. After a succession of early clinical failures led many to dismiss the technology as over-hyped, that view has been revised due to notable breakthroughs in gene therapy treatments over the past five years. In the field of ophthalmology there is real hope that the eye can showcase the potential of gene therapy to delay, arrest, reverse or ultimately “cure” a range of blinding diseases. As geneticists have long since noted, the eye is a particularly amenable target for gene therapy. It is one of the few immunologically privileged sites in the body and is therefore less likely to provoke a systemic immune response from gene vectors injected subretinally. Moreover, the defined volume of the eye means that minute amounts of viral vectors may be all that are necessary to achieve localised therapeutic effects without the risk of systemic toxicity and absorption that comes with intravenous drug delivery. Furthermore, major advances in ocular imaging and the localised nature of retinal pathologies means that treatment effects can be more readily observed and monitored for efficacy and safety than with systemic conditions.

Courtesy of Gearóid Tuohy

The number of clinical studies (over 1,970) and the range of indications targeted (above) has increased steadily year on year, 28 studies alone in the field of ocular disease to date. With the approval of the first gene therapy product in the EU (Glybera for the treatment of lipoprotein lipase deficiency) gene therapy is set to undergo a further revival of interest as pharmaceutical companies become increasingly aware of the commercial opportunity. Data summarised from statistics compiled by the Wiley Journal of Gene Medicine Clinical Trials Database (http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291521-2254)

Centre stage Hence the guarded optimism among researchers and clinicians that gene therapy is now ready to move centre stage in the battle against inherited retinal pathologies. “All the evidence suggests that gene therapy will be a significant contributor to the future armamentarium of therapies for at least some of the hereditary blinding conditions that are currently incurable,” said Artur V Cideciyan PhD, research professor of ophthalmology at the University of Pennsylvania and one of the researchers involved in the groundbreaking human trials of LCA. Gearóid Tuohy, CEO, Ibla Partners Ltd, a specialty-pharma business advisory group and director, Commercialisation & Technology Transfer, at the Royal College of Surgeons in Dublin, Ireland, pinpoints three areas – vector design, clinical success in LCA and European approval of the first

gene therapy product – which are radically changing perceptions of the field. “The range of corporate, venture and private finance now available to commercialise gene therapy is healthier than at any time before, timing which combines with the availability of considerable expertise and know-how across basic biology, medicine, business and regulation – all key elements required to advance these novel therapies from bench to bedside,” he said. Dr Tuohy stressed the significance of Dutch biotech company uniQure’s achievement in developing the first gene therapy to be approved by the European Medicines Agency (EMA) in July 2012. Its product, Glybera® (alipogene tiparvovec), is designed for the treatment of lipoprotein lipase deficiency (LPL), a rare autosomal recessive disorder affecting about one in a million people.

Tackling retinal degeneration

While the latest findings are undoubtedly a setback, clinicians are already probing possible methods to overcome the issue of ongoing retinal degeneration after successful gene therapy. “We know now that gene expression following AAV mediated gene transfer is efficient and safe. So the technology has reached a point where substantial cure is possible if intervention takes place in tissue that still contains photoreceptors and RPE cells to be cured,” said Knut Stieger DVM, PhD, of the University Eye Clinic in Giessen, Germany. “This point cannot be stressed enough – AAV-mediated gene addition therapy only works if there are target cells remaining. Therefore, identification of patients, or more strictly speaking, treatable retinal tissue by OCT and functional tests is the key to successful gene therapy,” he added. EUROTIMES | Volume 18 | Issue 9

Possible solutions exist, however, to tackle the problem of continued neurodegeneration regardless of the successful reactivation of rods and cones in treated areas. “This could potentially be addressed by a combination treatment of a vector containing the specific gene for correcting the disease, for example RPE65, and a second viral vector or encapsulated cells containing complementary DNAs for neuro-protective or anti-apoptotic proteins,” said Dr Stieger. “Such an approach in non-specific gene therapy has been tested in many animal models and also with the use of ciliary neurotrophic factor in encapsulated holofibres to protect neural cells, including photoreceptor cells, in human patients as developed by Neurotech in the United States,” he said. While promising techniques do exist for gene therapy augmentation with adjuvant treatments, a lot more basic research is needed to assess their safety, cautions Dr Cideciyan. “Such treatments could involve induction of cell-protective pathways or inhibition of cell-death pathways with the use of neurotrophic factors, antioxidants and apoptotic inhibitors. Pre-clinical studies using such approaches will have to demonstrate proof-of-concept and safety before clinical trials can be planned,” he said.

(a) Control retinal section (X400)

(b) affected retina under-going cell death (X400)

(d) affected retina under-going cell death (X1000)

Early results from first choroideremia trials Other positive

news has been emerging from the first clinical trial in humans of a gene therapy for choroideremia, an inherited retinal degenerative disease caused by a defective Rab escort protein-1 (REP1) gene. The disease is X-linked recessive and leads to the degeneration of the choriocapillaris, the retinal pigment epithelium and the photoreceptors of the eye. Starting in October 2011, a team at John Radcliffe Hospital in Oxford led by Prof Robert E MacLaren of the University of Oxford began treatment of the first of six patients using a modified AAV vector to deliver the replacement gene. With the study outcomes currently under review prior to publication, Prof MacLaren told EuroTimes that the six-month data look very promising. “What we discovered was that most choroideremia patients have subtle defects in retinal function that are similar in some ways to a mild form of LCA. It is not obvious at first because most can read 6/6 or better on a Snellen chart, but it is easily seen on microperimetry. This is helpful for a gene therapy trial because improvements in visual function serve as an early indicator of successful gene transfer. Of course we do not know early on if the degeneration has stopped, but with an improvement in vision we can at least assume that the transgene has been activated in the cells. The first six patients have now reached the full sixmonth follow-up and we will be reporting our results in full shortly, however, we can say that there have been no serious adverse events in any of these patients and the gene therapy appears to be very well tolerated,” he said. “What is particularly exciting about this trial is that we can also see for the first time the effects of AAV gene therapy in patients who have a near normal foveal

Courtesy of Gearóid Tuohy

“Aside from demonstrating further clinical proof-of-concept for the AAV delivery system, uniQure's achievement represents a game-changer for the investment community as it heralds the arrival of an entirely new class of therapeutics bringing with it significant medical and business opportunity,” he said. A quick glance at the clinical trials website also confirms the current flurry of activity in gene therapy for retinal diseases, with several trials already started or recruiting for LCA, choroideremia, Stargardt's disease, achromatopsia and certain forms of RP. Of all the retinal degenerations, LCA is one of the most common cause of inherited blindness in childhood, has the earliest age of onset and can be the most severe, leading to retinal dysfunction and visual impairment at an early age. At present, at least 18 different gene mutations known to lead to different forms of LCA have been identified, including the RPE65 gene, which accounts for 5-10 per cent of all LCA cases. Building on successful research in animal models, a major breakthrough in LCA research came in 2008 when three groups, two in the US and one in the UK, reported success in RPE65-associated LCA using the adeno-associated viral (AAV2) vector (Bainbridge et al, 2008; Cideciyan et al, 2008; Maguire et al, 2008). In all three trials, patients recovered functional vision without apparent side-effects, sparking renewed interest worldwide in using gene therapies to treat a host of other retinal diseases. In a follow-up study earlier this year, however, the University of Pennsylvania team involved in the initial trials reported that although gene therapy treatment improved eyesight, the photoreceptor cells crucial for vision continued to degenerate. This new finding suggests a need for a combination therapy that restores vision while also protecting the photoreceptor cells, Dr Cideciyan told EuroTimes. “Our results in human children and adults with RPE65 form of LCA show that substantial improvements in visual function measured within days to weeks following gene augmentation therapy endures for at least as long as three years. However, the underlying retinal degeneration continues to advance in treated retinas at the same rate as untreated retinas. This result is duplicated in RPE65 mutant dogs when the therapy is initiated at a stage of disease that actually models the human condition,” he said.

Normal retina [panel (a) and (c)] and affected retina under-going apoptotic cell death [panel (b) and (d)]. Despite a vast heterogeneity of initial causal factors, a wide range of retinal disorders progress through a process of apoptotic cell death in the retina. The red arrow in (b) indicates disorganised outer segment layers while red arrows in (d) indicate apoptotic cells adjacent to healthy cells. Sections from resin embedded retinal tissues courtesy of Dr Gearóid Tuohy, Trinity College Dublin, Ireland

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Identification of patients, or more strictly speaking, treatable retinal tissue by OCT and functional tests is the key to successful gene therapy Knut Stieger DVM, PhD

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I would urge all clinical retinal specialists to engage with this technology

Robert E MacLaren

Courtesy of Hanno J Bolz

Principles of NGS

NGS underpins gene therapy progress

EUROTIMES | Volume 18 | Issue 9

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In each case, and especially in a diagnostic setting, one has to make sure that interpretation of next-generation sequencing data is sound and to the benefit of the patient Hanno J Bolz

“What we do now is secondgeneration sequencing but thirdgeneration sequencing which denotes single-molecule or nanopore sequencing is already available but needs to be refined in terms of accuracy and cost effectiveness. Technically, it is already possible to sequence individual exomes or even genomes with the current NGS platforms, and it is being done for research in great numbers already,” he said. In each case, and especially in a diagnostic setting, one has to make sure that interpretation is sound and to the benefit of the patient, insists Prof Bolz. “Genetic counselling before sequencing of whole exomes or even genomes will be even more important than before running gene panels for a particular indication. For example, the patient will have to state whether she or he wants to be informed about incidental findings. Before exome/genome sequencing can become a diagnostic routine, frameworks that include appropriate consent forms among other things, for such large-scale NGS applications have to be set up,” he said. With the advent of NGS in diagnostics, the overlap with research is larger than ever before, concludes Prof Bolz. “I think it is crucial that the investigator has a good background knowledge about the genes and diseases analysed in order to get the right conclusion,” he said.

Courtesy of Martin Biel

eciphering DNA sequences is essential for virtually all branches of biological research and ophthalmology is no exception. In recent years, the advent of next-generation sequencing (NGS) has transformed gene therapy research, enabling rapid sequencing of large stretches of DNA base pairs spanning entire genomes, with the latest instruments capable of producing hundreds of gigabases of data in a single sequencing run. Retinal diseases are prime candidates for NGS because of their extensive genetic heterogeneity, explains Prof Hanno J Bolz, deputy medical director at the Bioscientia Centre for Human Genetics, Ingelheim, Germany and adjunct professor to the Institute of Human Genetics at the University Hospital of Cologne. His group has identified several novel genes for Usher’s syndrome, RP, Joubert’s syndrome, ataxia and deafness. NGS also assists in rapidly identifying the remaining unknown disease genes, notes Prof Bolz. “Targeted NGS of panels comprising all known genes for a disease group such as LCA or RP are an excellent first step. In research, those samples that remain mutation-negative in this test are excellent candidates for exome sequencing, enriching and sequencing virtually all exons of all human genes,” he said. Obtaining data, however, is only a small part of the picture, points out Prof Bolz. “Generating the data has become less of a problem but interpretation is now crucial. For macular dystrophies, for instance, one has to differentiate between the monogenic forms of macular disease and choroidal retinal dystrophies, where a single mutation in one gene is sufficient to cause the disease, and polygenic forms like AMD where there are variants rather than mutations that predispose to disease, but not necessarily evoke it in all carriers. The pace of progress in gene sequencing in recent years has been phenomenal, said Prof Bolz.

Image shows AAV-mediated CNGA3 expression (green) in cone photoreceptors of the CNGA3-knockout mouse

structure and in whom vision is not limited by amblyopia. This is the likely scenario for future gene therapy treatments for most retinal diseases, as it will almost certainly be better to intervene to correct the underlying gene defect before the onset of retinal degeneration,” said Prof MacLaren. Another interesting by-product of the choroideremia trial is that it has gone some way towards confirming what Prof MacLaren has advocated for some time – that treatment of the fovea is indeed possible in gene therapy. “These are early days, but we have noted from our study that the human fovea can be detached before the onset of significant degeneration and exposed to therapeutic levels of AAV vector without significant detrimental effect. There will be complications as with all surgery to the retina, but the principle is there – it can be done. When analysing results from all studies, it is important not to confuse surgical complications with those arising due to properties of the vector,” he said. Although this first trial will hopefully answer some of the key questions relating to the safety of gene therapy, many more questions concerning the benefits of early intervention, optimal dosing and surgical technique remain to be elucidated, added Prof MacLaren. “Ideally we would like to treat patients as early as possible to preserve their remaining sight. Although the gene therapy appears to replace the missing REP1 protein effectively, we still do not know how long the effect will last. Of course we hope that humans share the same features of retinal gene therapy in the animal models studied so far in which the effects are long lasting, but we cannot be sure until we follow these patients up for years. We also do not know the optimal

dose of gene therapy and most importantly we need to develop an effective surgical technique that can be used widely in many centres without complications,” he said.

Other trials on the horizon As the most common juvenile degenerative retinal disease, Stargardt's disease is caused by a mutation of the ABCR gene that leads to the degeneration of photoreceptors in the retina and vision loss. Up to 28 people are currently being enrolled in a Phase I/IIa clinical trial to be conducted at Oregon Health and Science University in Portland, Oregon, US and at the Centre Hospitalize Nationale D’Opthalmologie des Quinze-Vingts in Paris, France. The trial will assess the safety and efficacy of StarGen™ gene therapy (Oxford BioMedica), which uses LentiVector® technology, a “stripped-down” version of the equine infectious anaemia virus (EIAV), to deliver a corrected version of the ABCR gene. The same company is also currently recruiting for trials of UshStat®, its gene therapy targeted for the treatment of RP associated with Usher's syndrome type 1B. The first human trials for patients with achromatopsia are also on the horizon. While achromatopsia has often been loosely defined as colour blindness, the disease is actually a lot more debilitating than the term implies, points out Prof Martin Biel, a pharmacologist at Ludwig-Maximilians Universität in Munich, Germany. “Achromatopsia is a lot more than just colour blindness. It is a strictly autosomal recessive or sporadic disease characterised by a loss of cone function and patients lack colour discrimination, have very poor visual acuity, pendular nystagmus and severe photophobia. Its prevalence is about one

Special Focus

retina

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I am very optimistic with many groups now working on improving retinal gene therapy. I feel that a real breakthrough could happen in a few years Martin Biel

in 30,000 and so far at least five genes that have been identified as playing a role in the disease development,” he said. Most cases of achromatopsia are due to a mutation in one or other of the CNGA3 and CNGB3 genes essential for photoreceptive function in cells. Prof Biel in collaboration with Prof Mathias Seeliger of Tübingen University and Dr Tim Gollisch of the Max Planck Institute for Neurobiology showed that it is feasible to rescue fast degenerating cone photoreceptors in mice even though cone degeneration had already started. But will the same treatment work in humans? “What we need now are robust clinical data,” Prof Biel told EuroTimes. “We simply do not know so far to what extent vision can be restored in patients. We also do not know whether vision can be improved in the long term in patients. These questions can be only answered on the basis of the clinical studies which are about to start in several countries,” he said. While not wanting to raise expectations to unsustainable levels, Prof Biel remains “very optimistic” that gene therapy of achromatopsia, and to a lesser extent RP, will also deliver positive results in humans.

“I am particularly optimistic with regard to the treatment of achromatopsia because the functionally impaired cone photoreceptors survive for quite a long time in these patients. Hence there is a large therapeutic window for the application of viral vectors. RP is more complicated however, since depending on the affected gene neurodegeneration can proceed very fast. A lot will depend on the extent to which the neurodegenerative process can be stopped or slowed down,” he said. As research continues to advance on all fronts – gene sequencing, diagnostics, patient selection, delivery methods, surgical techniques and so forth – and the trial data continues to accumulate, there is a real sense that gene therapy may be on the cusp of finally achieving its promise. “I am very optimistic with many groups now working on improving retinal gene therapy. I feel that a real breakthrough could happen in a few years,” said Prof Biel. “These are early days, but we now have a second genetic retinal disease showing a promising response to gene therapy. I would urge all clinical retinal specialists to engage with this technology,” said Prof MacLaren. “We are now into the domain of optimising the surgical approach and defining the clinical observations that are needed to select the most appropriate patients and assess treatment effects,” he concluded.

EURETINA Lunch Symposium 13:00-14:00 28th on September 2013 @ Hall C, Congress Center Hamburg

Moderator

Giovanni Staurenghi, MD Eye Clinic, "Luigi Sacco" Hospital, University of Milan, Italy

Introduction of the NIDEK OCT “RS-3000 Advance” Version Upgrade

Speaker

contacts Martin Biel – mbiel@cup.uni-muenchen.de Hanno J Bolz – hanno.bolz@bioscientia.de | hanno.bolz@uk-koeln.de Artur V Cideciyan – cideciya@mail.med.upenn.edu Robert E MacLaren – robert.maclaren @moorfields.nhs.uk Knut Stieger – Knut.Stieger@uniklinikum-giessen.de Gearoid Tuohy – GTUOHY@tcd.ie

Matthias Bolz, MD General Hospital Linz, Austria

The Role of OCT in Diagnosing DME

COMING SOON IN OCTOBER EUROTIMES...

ESCRS builds global links with supraregional and national societies

The ESCRS is continuing to build links with other societies through presenting educational symposia at meetings all around the world. Providing symposia gives supraregional and national societies access to educational initiatives and scientific exchange from ESCRS opinion leaders. In October's Cover Story ESCRS president Dr Peter Barry explains how these meetings benefit both ESCRS and the supraregional and national societies. Successive ESCRS presidents have been ambassadors for the ESCRS around the world, spreading the message that ESCRS stands for progress in education, in technology transfer and in supporting novel techniques. EuroTimes also talks to ophthalmologists from developing regions who explain how co-operation and partnership with ESCRS helps to harmonise education and medicine in Europe and also globally. While national societies are particularly focused on discussing how to introduce new techniques in their own countries, the ESCRS can offer matrices to help them achieve their goals. By travelling to national meetings, ESCRS opinion leaders also get the chance to share their experience with ophthalmologists who cannot afford to attend the annual ESCRS meeting and other international meetings. The ESCRS is also co-operating with these societies in developing new research initiatives. EUROTIMES | Volume 18 | Issue 9

Speaker

Manish Nagpal, MS, DO, FRCS (UK) Retina Foundation & Eye Research Center, India

Diagnosis and Management of Various Macular Pathologies Including DME and AMD Using Retromode Imaging, Multiwavelength Pattern Scanning Laser and Anti-VEGF

Newsmaker Interview - Special Focus

retina

PROPELLED BY PROGRESS

The president-elect of EURETINA says while much progress has been made, there remains many important milestones to be reached by Roibeard O’hEineachain

rancesco Bandello MD, FEBO, is the president-elect of EURETINA. He first became involved with the organisation when his mentor Rosario Brancato MD was working with Gisbert Richard MD to get the EURETINA meetings project started. Dr Bandello was among the very small group of doctors in attendance at the first meeting in Hamburg in 2001. He has since played an active role in every subsequent meeting and has watched as EURETINA became the bestattended retina meeting in the world. In a Newsmaker interview, he spoke with EuroTimes contributing editor Roibeard O’hEineachain, about the advances in diagnosis and treatment that have brought retinal specialists into the spotlight in recent years.

An important factor in EURETINA’s success has been the wise and very fortunate choices made by the people who were managing the society. Mainly thanks to Gisbert Richard’s intuitions, the result has been a series of good, wellorganised meetings, in beautiful places, with interesting scientific programmes, and with interesting speakers. All of these factors were to help make EURETINA the most important retinal society in the world, which I believe it to be today. But the achievement of two important milestones was another of the main reasons behind EURETINA’s success. The first milestone was the success achieved in diagnosing retinal diseases by OCT, which

Francesco Bandello

produces very reliable and quantifiable results and is completely non-invasive. The other milestone, some time after the introduction of OCT, was the advent of intravitreal therapies with steroids and antiVEGF agents for treating retinal diseases. Together these two milestones have totally changed our patients’ prognosis, and this has greatly increased the interest with which ophthalmologists now look at retinal disease. It also means there is now a much greater market for retinal specialists. There can sometimes be a rivalry within the retinal specialty between those taking a medical approach and those taking a surgical approach to the treatment of retinal disease. The medical approaches

4TH EURETINA WINTER MEETING

are typically aimed at intervening in some way in the underlying pathological mechanisms and generally involve repeated administration of therapeutic agents. The surgical approach on the other hand aims to repair the damage to the eye in a much more direct and immediate fashion. The recent introduction of enzymatic vitreolysis as a treatment for vitreomacular traction may require some gymnastics on the part of both subspecialties if they are to work together in harmony, because vitreolysis is a medical treatment which achieves a result that was previously possible only through surgical vitrectomy. We need to encourage medical retinal specialists to work together because we will need the competence and expertise of both subspecialties. This may be less of a concern in countries that have health systems which do not separate the two subspecialties. Meanwhile, the indications for antiVEGF continue to expand and now include diabetic macular oedema, and also prophylaxis against intraoperative bleeding in eyes undergoing surgery for proliferative diabetic retinopathy. However, there is a danger that anti-VEGF agents will be overused and used inappropriately. We have already seen that happen with photodynamic therapy, where some who were not retinal specialists started to do PDT treatments, sometimes very inappropriately, for example, in patients with dry AMD and Stargardt’s disease. This also happened with anti-VEGF and it is still happening.

ROME 25 JANUARY 2014 ROME CAVALIERI WALDORF ASTORIA HOTEL, ITALY

WWW.EURETINA.ORG

EUROTIMES | Volume 18 | Issue 9

Our treatments for retinal disease should be evidence-based and the quality of the evidence will have a bearing on the quality of the treatment. Frequently it is the case when drug companies sponsor large multicentre studies that the indication for the treatment under investigation is defined rather broadly and little attention is initially paid to important subgroups within the patient population that may have a better or worse response to the agent under investigation. For that reason, EURETINA is in the process of developing a standard protocol for conducting trials and reporting results. The aim is that studies conducted according to the guidelines will produce results that are more clinically useful. It may not be easy to engage drug companies in this process since their motives are much more profit-oriented. On the other hand, the Novartis-sponsored Luminous prospective study provides a great example of how physicians and industry can work together on a broad scale for the benefit of patients. There remain many important milestones that we have yet to reach. For example, we need to develop diagnostic techniques that will detect more accurately and consistently the structural changes that correspond with losses and gains in vision. In addition, we need to develop intravitreal agents that will remain effective in the eye for longer than is currently the case. In the not-too-distant future we will most likely see the introduction of intravitreal implants which remain effective for several years. That may well spell the end of the current golden age for retinal specialists since our expertise may be in much less demand. In the meantime, it is among EURETINA’s tasks to convince those in charge of health systems across Europe of the genuine benefit that patients with retinal disease can gain from the vision that modern treatments can restore and preserve.

Across the page. Across the room. Across the years.

THE PRESBYOPIA SOLUTION THEY’VE BEEN WAITING FOR. UNCORRECTED NEAR VISUAL ACUITY (INLAY EYE ONLY)* SNELLEN ACUITY

20/12.5

INLAY EYE

20/20 20/32 20/50

20/80 20/125 20/200

LOSS OVER TIME IN EYE WITHOUT INLAY 0

30 MONTH

The KAMRA inlay provides a full range of vision and long-term performance, while leaving the natural lens in place. ™

Mean near acuity (or near vision) improved 3.2 lines to 20/25 at 1 month and was maintained over the 5 year follow-up. * Data presented by Prof. Dr. Günther Grabner at the 2013 DOC in Nuremberg, Germany.

Special Focus EUROPEAN SOCIETY OF OPHTHALMIC NURSES

retina

& TECHNICIANS

5 -7 O C TOB E R

ESONT Meeting

Go to

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EUROTIMES | Volume 18 | Issue 9

VITREOUS FLOATERS

Despite the evidence, the question for many ophthalmologists is, ‘Are floaters a disease or simply a nuisance?’ by Leigh Spielberg MD

he treatment of vitreous floaters is controversial. Surgical interventions are available, but are only rarely offered to select patients with symptomatic primary floaters, despite several small-scale studies that suggest that good results can be obtained, with great patient satisfaction and relatively low complication rates. “To many vitreoretinal surgeons, floater treatment is somewhat of a taboo,” says Prof Marc de Smet of the University of Amsterdam in the Netherlands, and chief of MIOS sa, a centre specialised in retina and ocular inflammation in Lausanne, Switzerland. “And some surgeons consider floaterectomy unnecessary cosmetic surgery, with all its associated risks.” These risks include retinal breaks, vitreous incarceration and retinal detachment, not to mention intraoperative choroidal haemorrhage and postoperative endophthalmitis. Further, cataract developed within a few years in more than half of the phakic patients, necessitating a second operation. Given the elective nature of the procedure and the scarcity of objective parameters to support the indication for surgery, many vitreoretinal specialists are understandably hesitant to perform a floaterectomy. “However, there are those for whom the position and size of the floater is a major hindrance, and for them a therapeutic solution is needed,” continued Prof de Smet. A large study published in the American Journal of Ophthalmology1 has shown that patients are willing to trade off an average of about one out of every 10 years of their remaining life to get rid of the symptoms associated with floaters. Furthermore, the authors claim that patients are willing to take, on average, an 11 per cent risk of death and a seven per cent risk of blindness to get rid of symptoms relating to floaters. Whether these results reflect a realistic truth is debatable. Does patient personality play a role in the desire for surgery? Does it matter? Some patients are clearly willing to accept the risk of an invasive procedure. Indeed, in contrast with vitrectomy for retinal detachment or macular hole, the indication for floaterectomy is primarily driven by patient demand rather than by a surgeon’s recommendation. A great deal of information regarding treatment options is readily available online, the majority of which comes via non-peer-reviewed medical education websites. Because of this, patients may have a very optimistic impression of the procedure prior to the visit to the ophthalmologist. Ophthalmologists tend to be more cautious. Most patients with primary floaters – those not due to ocular pathology such as uveitis – have objectively “perfect” vision. Snellen acuity, the standard clinical test of visual function, does not detect the visual disability associated with vitreous floaters, and patients’ distress does not correlate with visual acuity. Prof de Smet and his team recently presented data at ARVO which show that light scattering is significantly higher in eyes with floaters. “Surgeons are currently willing to operate a cataract based on increased light scattering rather than decreased

“

However, there are those for whom the position and size of the floater is a major hindrance, and for them a therapeutic solution is needed Marc de Smet

Snellen visual acuity. In time, the same may be true for floaters,” according to Prof de Smet. Further, the status of the posterior vitreous detachment (PVD) seems to be of crucial importance, with a well-developed PVD being associated with less bothersome symptoms. Despite the evidence, the question for many ophthalmologists is, “Are floaters a disease or simply a nuisance?” That depends on whom you ask. “I consider the risks of surgery, particularly in phakic patients, to be excessive,” said Prof Charles Wilkinson of Johns Hopkins University in Baltimore, Maryland at the 2012 Amsterdam Retina Debate. “I have, however, done it,” he admitted. “Selected patients will demand the operation, and it is the patient’s right to undergo surgery.” The traditional management of vitreous floaters usually includes only education and reassurance, but invasive treatments exist, including Nd:YAG laser vitreolysis; cataract surgery combined with deep anterior vitrectomy; and pars plana vitrectomy. Among those surgeons who do treat vitreous floaters, most opt for pars plana vitrectomy. The procedure, primarily utilised for other indications, is routine and sophisticated, with a well-known risk profile and high rates of success. Patient satisfaction is high.2 Nd:YAG laser vitreolysis currently has a limited role. It has not yet been widely accepted, as published data are limited to a small series of highly motivated patients. In the most comprehensive study to date, postoperative patient questionnaires indicated that in no eye was laser treatment 100 per cent successful in eliminating symptoms. Moderate improvement was noted in about one-third of cases, but 7.7 per cent experienced a worsening of symptoms.3 Vitreolytic agents might offer an alternative, although it is too early to say. More research needs to be done.

References: 1. Wagle AM, Lim WY, Yap TP, Neelam K, Au Eong KG. Utility values associated with vitreous floaters. Am J Ophthalmol. 2011 Jul;152(1):60-65. 2. Schiff WM, Chang S, Mandava N, Barile GR. Pars plana vitrectomy for persistent, visually significant vitreous opacities. Retina. 2000;20(6):591-6. 3. Delaney YM, Oyinloye A, Benhamin L. Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye 2002;16:21-6.

contact

Marc de Smet – info@retina-uveitis.eu

20130808 Sept Eurotimes third spread advert Advance PRINT.pdf 1 08/08/2013 13:53

Special Focus

retina

DIABETIC RETINOPATHY

After 20 years of planning, Ireland is ready to roll-out a national diabetic screening programme by Priscilla Lynch in Killarney

rish ophthalmology saw its long-awaited national diabetic screening programme, known as Diabetic Retina Screen, finally began its phased roll-out this year. The programme encountered many issues along the way including the cost of anti-VEGF injections, convincing treatment centres to sign up to a new funding model, and a healthcare staff recruitment embargo. Diarmuid Smith MD, FRCPI, Ireland’s Health Service Executive (HSE) National Clinical Lead for Diabetes, gave a detailed presentation on the development of the programme during the Irish College of Ophthalmologists annual conference. Attempts to set up a national diabetic screening programme in Ireland have been ongoing for more than 20 years, he told delegates. Previous attempts to start a national screening programme in the early 2000s had been turned down by the Department of Health but despite this a number of local screening initiatives started. The success of these local screening initiatives have helped advocate for a national screening programme, Dr Smith told the conference. The programme was finally granted funding to launch in 2011 but its roll-out has proved more difficult than anticipated, largely due to the Irish health service’s recruitment embargo, so the necessary staff could not be recruited, Dr Smith explained. The National Cancer Screening Service (NCSS) is to implement the national retinopathy screening programme. As part of this implementation a procurement process was undertaken and two external providers have been identified to deliver the retinopathy screening programme nationally. In addition, given the costs of the programme in a time of recession and the likely increase in retinopathy treatment demands, it was felt that a phased roll-out would be the best option. There have been significant difficulties in accurately costing the new programme, partly due to the lack of Irish data on the number of people with diabetes, as well as the increasing use of anti-VEGF injections for some retinopathy patients when compared to laser injections, Dr Smith acknowledged. He said current calculations estimate that the programme should cost approximately €14m per year for screening and treatment when it is fully up and running. Some ophthalmologists, speaking during the Q&A session, noted the use of anti-VEGF injections varies across Irish facilities. Dr Smith said a new clinical group involving ophthalmologists and vitreoretinal surgeons would be established to define clinical pathways for the use of antiVEGF injections in patients with diabetic maculopathy and this work will help define in a more robust fashion the cost of treatment of diabetic eye disease for 2014 and in the future. Dr Smith said the new programme offers free, regular diabetic retinopathy screening to all persons with diabetes aged 12 years and older, taken from a newly set-up national diabetes register. EUROTIMES | Volume 18 | Issue 9

Dr Smith said the new programme offers free, regular diabetic retinopathy screening to all persons with diabetes aged 12 years and older, taken from a newly set-up national diabetes register

The programme calculates that about 18 per cent of screened patients will have a diabetes-related pathology; an estimated five per cent will have sight-threatening retinopathy (three per cent macular oedema and two per cent proliferative retinopathy), while a further seven per cent will have a non-diabetes-related eye problem. Dr Smith said he hopes 30 per cent of eligible Irish diabetic patients will be screened in 2013, with the remaining 70 per cent in 2014, and that 100 per cent coverage can be achieved in 2015. The programme expects a 20 per cent ‘do not attend’ rate. About 250 patients were screened earlier this year on a pilot basis with the programme due to ramp up screening numbers to 500-1,000 patients a week shortly, if all goes to plan. In addition, best practice standards for the operation of the programme have been created by a multidisciplinary quality assurance committee, which will be launched later this year. Significant challenges remain to be overcome to ensure the programme is fully rolled out. These include more accurate costings and ensuring those who are screened have immediate access to any necessary treatment. Dr Smith admitted there have been difficulties in convincing all seven treatment centres earmarked under the programme to sign-up, with three centres yet to do so. A Limerick-based ophthalmologist told the conference that the funding stream for the programme, based on Ireland’s new ‘money follows the patient’ funding model, is more difficult to access and is not ring-fenced like cancer screening funds, which is why her centre has not yet signed-up. However, Dr Smith urged the remaining centres to “take a leap of faith” and sign-up so screening can commence in all parts of the country. Dr Smith stressed that Diabetic Retina Screen is the only new project the Irish health service has approved funding for in recent times and has been well supported by health management and policymakers, concluding that it is “fantastic” that the programme has finally been set-up. Y

CMY

contact Diarmuid Smith – dsmithrooms@beaumont.ie

14th EURETINA Congress

LONDON 11-14 September 2014

www.euretina.org

Special Focus

retina

promising data

Navigated laser shows promise as an adjunct to anti-VEGF therapy in DME by Dermot McGrath in Copenhagen

The power of one

avigated laser photocoagulation shows considerable promise as an adjunctive therapy to antiVEGF treatments by significantly reducing the number of intravitreal injections needed to preserve vision in diabetic macular oedema (DME) patients, according to a study presented at the 2013 Congress of the Society of European Ophthalmology (SOE). “We investigated 76 patients with centreinvolving DME for one year and the results of our study clearly showed that additional navigated laser therapy applied after three initial anti-VEGF injections was effective in preserving visual gains comparable to antiVEGF monotherapy. In addition, navigated macular laser significantly reduced the number of injections needed: In the combined treatment group, approximately 70 per cent of patients did not need any reinjection after the initial upload in the first year. It is very clear that while longer follow-up and larger numbers of patients are needed to confirm these initial results, these data are very promising,” Marcus Kernt MD told delegates. Presenting the one-year results of combined ranibizumab and navigated retinal photocoagulation in DME compared to ranibizumab monotherapy, Dr Kernt, Ludwig-Maximilians-University in Munich, said that DME remains a leading cause of visual impairment in the working population in industrialised countries. Recent studies such as RESTORE, DRCR Network, RIDE and RISE have all shown the safety and efficacy of three to four monthly anti-VEGF injections followed by PRN treatment, he said. “There is usually a visual improvement of six to 12 letters from baseline. However, the number of injections is typically around seven to 12 in the first year and there has been no significant reduction reported for combination treatment with conventional laser in most studies that also looked at this question. This high number of injections is a significant treatment burden for the patient and costly also for health systems, so we thought that combination therapy with navigated laser might be able to improve on this,” he added. Unlike traditional laser devices, the Navilas photocoagulation system (OD-OS, GmbH) uses retinal navigation (eye-tracking) and works by integrating imaging and laser delivery into one system and enabling EUROTIMES | Volume 18 | Issue 9

Two types of incisions – one module

“

It is very clear that while longer follow-up and larger numbers of patients are needed to confirm these initial results, these data are very promising Marcus Kernt MD

registration of the fluorescein angiogram and surgical plan onto the live retinal image, noted Dr Kernt. This allows for much greater accuracy and targeted delivery of the laser treatment to affected areas. Dr Kernt’s prospective study included 76 eyes with DME randomised into three groups: group one of 27 patients received ranibizumab monotherapy of three monthly injections followed by a PRN regime; group two of 15 patients received three consecutive monthly ranibizumab injections followed by navigated laser therapy and PRN injections; group three of 34 patients received monthly ranibizumab injections until the central retinal thickness (CRT) was below 300 µm on TD-OCT, at which point they underwent navigated laser therapy followed by PRN injections. After 12 months, the best-corrected visual acuity increased in groups one, two and three by an average of 6.3, 7.1 and 7.4 respectively, although the difference between laser-treated eyes and the monotherapy group was not statistically significant. A major difference was found, however, in the number of injections needed after the initial loading phase. An average of 5.2 injections were required in the 12-month follow-up period for the ranibizumab monotherapy group, compared to just 0.5 and 0.8 for groups two and three that also received laser therapy. Dr Kernt said that his own group’s results were confirmed by a corresponding recent study by Dr Freeman et al at the University of California showing that 14 out of 23 eyes (61 per cent) needed no reinjections after navigated laser and bevacizumab treatment.

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Marcus Kernt – marcus.kernt@med.uni-muenchen.de EuroTimes_sep2013_FEMTO_LDV_Corneal_Inscisions_Ad_120x300mm.indd 1

07.08.13 12:19

13th EURETINA Congress 26– 29 September 2013

SATELLITE EDUCATION PROGRAMME

Thursday 26 September

Friday 27 September

Lunchtime Symposia

Morning Symposia

Boxed lunch included

10.00 – 11.00

13.00 – 14.00 Allergan Satellite Meeting Sponsored by

Iluvien® (Floucinolone Acetonide): New Option in the Management of Chronic Diabetic Macular Edema Moderator: B. Kuppermann

Cutting Through Complexity: Applications of an Innovative New Cutting Technology in Meeting Demands of Complex Cases Moderator: P. Stanga

USA

Y. Yang UK Intravitreal Corticosteroids in diabetic macular edema (DME) – Pharmacokinetic profile, safety and efficacy considerations B. Kuppermann USA Efficacy and safety of floucinolone acetonide (ILUVIEN) in patients with chronic DME

F. Fayyad JORDAN Why is innovation in cutting important? Applications in complex and challenging cases

R. Parrish USA Understanding intra-ocular pressure in DME patients treated with corticosteroid

C. Awh USA Vitesse – redefining vitrectomy cutting P. Stanga UK Q&A, and discussion

A. Augustin GERMANY Options for patients with chronic DME who are insufficiently responsive to conventional therapies

Sponsored by

Friday 27 September

Saturday 28 September

Morning Symposia

Lunchtime Symposia

Morning Symposia

10.00 – 11.00

Boxed lunch included

10.00 – 11.00

13.00 – 14.00 Management of Challenging Surgical Cases with the Latest Technology

Swept Source, the Third Generation of OCT & Advances in Retinal Treatment

Moderator: B. Corcostegui SPAIN

Moderator: P. Stanga

S. Rizzo ITALY Challenging surgical cases with 27 guage

P. Stanga UK Clinical effectiveness of non-damaging laser therapy with PASCAL’s new Endpoint Management treatment modality

C. Claes BELGIUM Capacities and value of the ultra high speed 7500 vitrectomy probes N. Bechrakis AUSTRIA Increased efficiency and safety with the new ultra high speed probe technology R. Tadayoni FRANCE Challenging diabetic retinopathy surgical cases

Sponsored by

Boxed lunch included

Establishing the Role of EYLEA® in the Treatment of Wet AMD Moderator: S. Wolf

SWITZERLAND

S. Wolf SWITZERLAND Introduction

J.M. Ruiz-Moreno SPAIN, J. Montero SPAIN Choroidal thickness study by Swept Source OCT

T. Jackson UK Ocriplasmin pivotal studies: Efficacy, predictors of response and safety profile

Sponsored by

A. Augustin GERMANY First months of experience with Jetrea®: The European perspective

Moderator: S.R. Sadda

USA

P. Stanga UK Assessing retinal non-perfusion on Optomap® ultrawide-field fundus fluorescein angiography in diabetic retinopathy & macular oedema

Sponsored by

S. Wolf SWITZERLAND European experience with EYLEA® – What have we learned?

Evening Symposia

G. Richard GERMANY Translating EYLEA® trials into clinical practice

18.15

A. Chang AUSTRALIA First-year experience with EYLEA®

Vision Loss in Diabetic Patients: Options and Considerations for Restoring Sight

S. Wolf SWITZERLAND Summary

Light: Applications and Advances in Illumination FRANCE

D. Chow CANADA Why filter light? Results of a global illumination study P.B. Henrich SWITZERLAND Amber filter – where are the applications with such a divisive technology? R. Carvalho PORTUGAL Green filter – the most acceptable route to take? Y. Le Mer FRANCE Q&A, and discussion

Sponsored by

P. Stalmans BELGIUM Adoption of Jetrea® in my everyday practice

Sponsored by

Evolving Data, Evolving Perspectives: Myopic CNV and Anti-VEGF Therapies Moderator: T. Lai CHINA T. Lai CHINA Exploring myopic CNV: The disease burden A. Tufail UK Unmet needs and challenges in the treatment of myopic CNV F. Bandello ITALY Anti-VEGF therapy for myopic CNV: What’s the latest evidence?

Sponsored by

Moderator: A. Kampik GERMANY

Sponsored by

Moderator: Y. Le Mer

S. Binder AUSTRIA Natural history and pathophysiology of VMA, VMT and macular hole

S.R Sadda USA Peripheral retinal non-perfusion in retinal vein occlusion: Clinical implications

13.00 – 14.00

Moderator: T. Jackson

Z. Michalewska POLAND Swept Source OCT – going deeper, going wider

New Advances in Retinal Imaging

Lunchtime Symposia

Jetrea® (Ocriplasmin) Intravitreal Injection: Pharmacologic Vitreolysis for the Treatment of VMT and Macular Hole with One Single Injection

A. Kampik GERMANY Patients with DME: Key characteristics and common comorbidities G. Lang GERMANY Why treat early in DME? Evidence from recent clinical trials I. Pearce UK What does effective treatment for DME mean for the patient?

Sponsored by

Oraya Satellite Meeting Sponsored by

Saturday 28 September

Lunchtime Symposia

Boxed lunch included

13.00 – 14.00

Expert Experience: Sophisticated Diagnostic Imaging and Treatment for AMD and Diabetic Eyes

EVA, the New Innovation in Vitreoretinal Surgery

Moderator: G. Staurenghi

A. Mohr GERMANY Flow controlled vitrectomy in standard and complex vitreoretinal surgery

ITALY

G. Staurenghi ITALY Introduction of the NIDEK OCT “RS – 3000 Advance” version upgrade M. Bolz AUSTRIA The role of OCT in diagnosing DME M. Nagpal INDIA Diagnosis and SP managemnet of various macular pathologies, including DME and AMD, using retromode imaging, multiwavelength pattern scanning laser and Anti-VEGF

Sponsored by

Insights into CRVO. Including an Update on Clinical Studies with Aﬂibercept Moderator: S. Sivaprasad S. Sivaprasad Introduction

Moderator: C. Eckardt GERMANY

P. Stalsmans BELGIUM DORC EVA, new surgical platform with unique fluidics system C. Eckardt GERMANY How to remove vitreous quickly and safely. New generation high speed twin duty cycle vitrectomes P. Szurman GERMANY Optomised vitrectomy: LED illumination, ultra speed transformer and new generation 23G trocar systems F. Pavlidis GERMANY New 27G instruments – new perspectives G. Pertile ITALY My EVA experience with patch surgery

Sponsored by

S. Sivaprasad UK Management of CRVO patients N. Feltgen GERMANY Galileo and Copernicus – results and implications F. Holz GERMANY Galileo and Copernicus – beyond the first year S. Sivaprasad UK Final Remarks

Argus II Retinal Implant – The First Approved Treatment for RP: 25 Years of Experience Reaching the First 100 Patients Moderator: S. Rizzo

ITALY

T. Wolfensberger SWITZERLAND Historical impact and evolution of retinal prostheses

Sponsored by

M. Mura THE NETHERLANDS Argus II retinal implant: Reaching artificial vision via surgical approach

Anti-VEGF Therapies in Wet AMD – Minimizing Risks and Maximizing Outcomes

F. Arevalo SAUDI ARABIA Argus II system experience in the Middle East

Moderator: P. Dugel USA P. Dugel USA Ranibizumab – Defining desired standards for ocular anti-VEGF therapy

S. Rizzo ITALY Interim results from the largest single site pool of Argus II patients

Sponsored by

F. Holz GERMANY Does less equal more? A comparison of individualized versus fixed-regimen ranibizumab dosing

P. Beaumont AUSTRALIA Anti-VEGF therapies – the link between molecular structure and clinical profile

This is a Preliminary Programme and is subject to change

P. Dugel USA Achieving best practice in wet AMD – typical patient scenarios

Sponsored by

www.euretina.org/hamburg2013/satellite-meetings.asp

Cataract & refractive

contact

Update

Oliver Findl – oliver@findl.at

FEMTO SURGERY

Study calls into question benefit of femto-cataract surgery’s accuracy in capsulorhexis

he supposed advantage of the more predictable capsulorhexis achieved with femtosecond laserassisted cataract surgery may be based on a false assumption about its influence on the stability of an IOL’s position and orientation, according to Oliver Findl MD, Hanusch Hospital, Vienna, Austria and Moorfields Eye Hospital, London, UK. “The rhexis effect is weak, and that brings into question whether femtosecond laser will actually result in a better and more predictable IOL positioning,” Dr Findl told Femto 2013, an international meeting on anterior segment surgery. He reported the results of a study involving 254 eyes undergoing conventional phacoemulsification that compared the IOL position in eyes with ideal capsulorhexes to those of eyes with eccentric or small capsulorhexes. There was no statistical significance between the groups regarding the postoperative shift in anterior chamber depth or tilt. Moreover, although the difference in de-centration was statistically significant, it was too small as to be clinically relevant, Dr Findl said.

Improvised Connections

From a continuous cohort of 635 eyes that underwent cataract surgery by nine surgeons, ranging from experienced to trainees, retro-illumination photographs were taken one hour after surgery. Dr Findl and his associates measured capsulorhexis size and shape. They classified the capsulotomies as “controls” if they had optimal diameters of 4.5 to 5.5mm and overlapped the entire 360 degrees of the IOL’s edge. They classified them as small if they were smaller than 4.5mm, and those with more than 5.5mm or asymmetric overlap were classified as eccentric. All eyes that had small or large or eccentric rhexes were included as well as a randomly selected control (optimal) group of similar number, totaling in 254 eyes included into the study. All underwent implantation of standard IOLs with a good track record regarding postoperative stability. Measurements with the AC-Master (Carl Zeiss Meditec) showed that the mean absolute shift in anterior chamber depth between one hour postoperatively and three months postoperatively was 0.24mm in the optimal capsulorhexis group, 0.25mm in the eccentric capsulorhexis group and 0.25mm in the small capsulorhexis group (p=0.352). Similarly, the mean amount of tilt as tested with a Purkinje-meter at three months’ follow-up was 3.7 degrees in the optimal group, 3.8 degrees in the eccentric group and 3.8 degrees in the small group (p=0.962). And although the Purkinje-meter measurements showed that the mean amount of decentration was statistically greater in the eccentric group (p=0.011) the difference from the control group was only 0.08mm.

Many of femto cataract’s benefits questionable

The Dan Reinstein / Thomas Pfleger Project featuring special guest star

Mo Pleasure

sunday 6 October 7.30pm Bimhuis, Amsterdam, The Netherlands Tickets €10 Limited Capacity Tickets available at The EsCRs Registration Desk, Amsterdam RAi, The Netherlands

EUROTIMES

™

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

EUROTIMES | Volume 18 | Issue 9

Dr Findl noted that the rhexis advantage of femtosecond laser surgery is just one of the predicted benefits of the new technology that does not really stand up to scrutiny. For example, the femtosecond laser’s performance of limbal relaxing incisions to reduce astigmatism may be slightly less variable than that of a surgeon with a diamond knife, but that will have no impact on the differences in elastic properties of the cornea or the healing response of the cornea, which are responsible for most of the variability of refractive outcomes with incisional techniques. Similarly, the reduction in endothelial damage that femtosecond cataract surgery may provide during fragmentation of the nucleus may also be very modest as conventional phacoemulsification is already very safe in that regard, particularly given the low proportion of hard cataracts that surgeons in developed countries encounter nowadays. For those few eyes with cornea guttata or Fuchs’ endothelial dystrophy undergoing cataract surgery, they usually have impeded visual function already before decompensation. With the highly effective lamellar transplantation techniques such as descemet stripping automated endothelial keratoplasty (DSAEK) and descemet’s membrane endothelial keratoplasty (DMEK) at hand today, we are tempted to operate on these eyes before decompensation and, therefore, they would not really benefit when undergoing femtolaser-assisted cataract surgery.

Courtesy of Oliver Findl MD

by Roibeard O’hEineachain in Verona

ESCRS

Example of an eccentric rhexis one hour (upper) and three months (lower) after surgery, showing a relatively small decentration of 0.4mm at three months illustrating that with modern IOLs this must not necessarily result in an off-centre optic

Cataract surgery was at a different juncture when phacoemulsification began replacing extracapsular cataract extraction (ECCE) as the standard method of cataract extraction, Dr Findl said. Part of the motivation for the transition to phaco was the obvious safety advantages it had over ECCE. It remains to be seen whether with femtosecond laser cataract surgery the same will be true regarding comparison to conventional phaco. “At present we have no evidence from large real-world trials showing that femtosecond laser-assisted cataract surgery reduces complications,” Dr Findl emphasised.

Future for younger surgeons The wider adoption and continued evolution of femtosecond laser-assisted cataract surgery will most likely see future generations of cataract surgeons having much less experience with many surgical techniques. Already the adoption of phacoemulsification has meant that trainee surgeons are much less skilled at placing sutures than was the case when surgeons received training primarily for ECCE. Femtosecond laser cataract surgery is likely to reduce the need for a much wider set of surgical skills, Dr Findl said. “We know that femtosecond laser cataract surgery is likely to develop rapidly over the next few years. We will probably be looking at the femtosecond laser doing all of the first parts of surgery. You will probably just need a soft I/A tip to remove these fragments. You may not even need phaco, and then you will put it preloaded IOL into the eye. The trend is already emerging of trainees doing most of the laser part of femtosecond laser cataract surgery leaving only the final part of the procedure to the skilled surgeon. It seems likely that health regulators and politicians will favour the establishment of surgical centres in which trainees and ancillary staff perform the entire procedure while one surgeon supervises several teams and is on hand mainly for dealing with complications.

See your success in the eyes of your patients

Defining the standard of care in wet AMD* LUCENTIS® (ranibizumab) ABBREVIATED UK PRESCRIBING INFORMATION Please refer to the SmPC before prescribing LUCENTIS 10mg/ml solution for injection. Presentation: A glass single-use vial containing 0.23ml solution containing 2.3mg of ranibizumab (10mg/ml). Indications: The treatment in adults of neovascular (wet) age-related macular degeneration (AMD), the treatment of visual impairment due to diabetic macular oedema (DMO), the treatment of visual impairment due to macular oedema secondary to retinal vein occlusion (branch RVO or central RVO), and the treatment of visual impairment due to choroidal neovascularisation (CNV) secondary to pathologic myopia (PM). Administration and Dosage: Single-use vial for intravitreal use only. LUCENTIS must be administered by a qualified ophthalmologist experienced in intravitreal injections under aseptic conditions. The recommended dose is 0.5 mg (0.05ml). For treatment of wet AMD: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. The patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to wet AMD. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. For treatment of visual impairment due to either DMO or macular oedema secondary to RVO: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. the patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab treatment. If there is no improvement in visual acuity over the course of the first three injections, continued treatment is not recommended. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to DMO or to macular oedema secondary to RVO. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. LUCENTIS and laser photocoagulation in DMO and in macular oedema secondary to BRVO: When given on the same day, LUCENTIS should be administered at least 30 minutes after laser photocoagulation. LUCENTIS can be administered in patients who have received previous laser photocoagulation. For treatment of visual impairment due to CNV secondary to PM: Treatment is initiated with a single injection. If monitoring reveals signs of disease activity, e.g. reduced visual acuity and/or signs of lesion activity, further treatment is recommended. Monitoring for disease activity may include clinical examination, optical coherence tomography (OCT) or fluorescein angiography (FA). While many patients may only need one or two injections during the first year, some patients may need more frequent treatment. Therefore, monitoring is recommended monthly for the first two months and at least every three months thereafter during the first year. After the first year, the frequency of monitoring should be determined by the treating physician. The interval between two doses should not be shorter than one month. LUCENTIS and Visudyne photodynamic therapy in CNV secondary to PM: There is no experience of concomitant administration of LUCENTIS and Visudyne. Before treatment, evaluate the patient’s medical history for hypersensitivity. The patient should also be instructed to self-administer antimicrobial drops, 4 times daily for 3 days

before and following each injection. Children and adolescents: Not recommended for use in children and adolescents due to a lack of data. Elderly: No dose adjustment is required in the elderly. There is limited experience in patients older than 75 years with DMO Hepatic and renal impairment: Dose adjustment is not needed in these populations. Contraindications: Hypersensitivity to the active substance or excipients. Patients with active or suspected ocular or periocular infections. Patients with active severe intraocular inflammation. Special warnings and precautions for use: LUCENTIS is for intravitreal injection only. Intravitreal injections have been associated with endophthalmitis, intraocular inflammation, rhegmatogenous retinal detachment, retinal tear and iatrogenic traumatic cataract. Monitor during week following injection for infections. Patients should be instructed to report symptoms suggestive of any of the above without delay. Transient increases in intraocular pressure (IOP) within 1 hour of injection and sustained IOP increases have been identified. Both IOP and perfusion of the optic nerve head should be monitored and managed appropriately. Concurrent use in both eyes has not been studied and could lead to an increased systemic exposure. There is a potential for immunogenicity with LUCENTIS which may be greater in subjects with DMO. Patients should report an increase in severity of intraocular inflammation. LUCENTIS should not be administered concurrently with other anti-VEGF agents (systemic or ocular). Withhold dose and do not resume treatment earlier than the next scheduled treatment in the event of the following: a decrease in best corrected visual acuity (BCVA) of ≥30 letters compared with the last assessment of visual acuity; an intraocular pressure of ≥30 mmHg; a retinal break; a subretinal haemorrhage involving the centre of the fovea, or if the size of the haemorrhage is ≥50% of the total lesion area; performed or planned intraocular surgery within the previous or next 28 days. Risk factors associated with the development of a retinal pigment epithelial (RPE) tear after anti-VEGF therapy for wet AMD include a large and/or high pigment epithelial retinal detachment. When initiating LUCENTIS therapy, caution should be used in patients with these risk factors for RPE tears. Discontinue treatment in cases of rhegmatogenous retinal detachment or stage 3 or 4 macular holes. There is only limited experience in the treatment of subjects with DMO due to type I diabetes. LUCENTIS has not been studied in patients who have previously received intravitreal injections, in patients with active systemic infections, proliferative diabetic retinopathy, or in patients with concurrent eye conditions such as retinal detachment or macular hole. There is also no experience of treatment with LUCENTIS in diabetic patients with an HbA1c over 12% and uncontrolled hypertension. In PM patients there are no data on the use of LUCENTIS in patients with extrafoveal lesions and only limited data on its use in those who have had previous unsuccessful therapy with verteporfin photodynamic therapy. Systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events have been reported following intravitreal injection of VEGF inhibitors. There are limited data on safety in the treatment of DMO, macular oedema due to RVO and CNV secondary to PM patients with prior history of stroke or transient ischaemic attacks. Caution should be exercised when treating such patients. There is limited experience with treatment of patients with prior episodes of RVO and of patients with ischaemic BRVO and CRVO. Treatment is not recommended in RVO patients presenting with clinical signs of irreversible ischaemic visual function loss. Interactions: No formal interaction studies have been performed. In DMO and BRVO adjunctive use of laser therapy and LUCENTIS was not associated with any new ocular or non-ocular safety findings. Pregnancy and lactation: Women of

childbearing potential should use effective contraception during treatment. No clinical data on exposed pregnancies are available. Ranibizumab should not be used during pregnancy unless the expected benefit outweighs the potential risk to the foetus. For women who wish to become pregnant and have been treated with ranibizumab, it is recommended to wait at least 3 months after the last dose of ranibizumab before conceiving. Breast-feeding is not recommended during the use of LUCENTIS. Driving and using machines: The treatment procedure may induce temporary visual disturbances and patients who experience these signs must not drive or use machines until these disturbances subside. Undesirable effects: Most adverse events are related to the injection procedure. Serious adverse events reported include endophthalmitis, blindness, retinal detachment, retinal tear and iatrogenic traumatic cataract. The safety data below include adverse events experienced following the use of LUCENTIS in the entire clinical trial population. Those marked * were only seen in the DMO population. Very Common: Intraocular pressure increased, headache, vitritis, vitreous detachment, retinal haemorrhage, visual disturbance, eye pain, vitreous floaters, conjunctival haemorrhage, eye irritation, foreign body sensation in eyes, lacrimation increased, blepharitis, dry eye, ocular hyperaemia, eye pruritus, arthralgia, nasopharyngitis. Common: Urinary tract infection*, anaemia, retinal degeneration, retinal disorder, retinal detachment, retinal tear, detachment of the retinal pigment epithelium, retinal pigment epithelium tear, visual acuity reduced, vitreous haemorrhage, vitreous disorder, uveitis, iritis, iridocyclitis, cataract, cataract subcapsular, posterior capsule opacification, punctuate keratitis, corneal abrasion, anterior chamber flare, vision blurred, injection site haemorrhage, eye haemorrhage, conjunctivitis, conjunctivitis allergic, eye discharge, photopsia, photophobia, ocular discomfort, eyelid oedema, eyelid pain, conjunctival hyperaemia, cough, nausea, allergic reactions, hypersensitivity, anxiety. Product-class-related adverse reactions: There is a theoretical risk of arterial thromboembolic events, including stroke and myocardial infarction, following intravitreal use of VEGF inhibitors. A low incidence rate of arterial thromboembolic events was observed in the LUCENTIS clinical trials in patients with AMD, DMO, RVO and PM and there were no major differences between the groups treated with ranibizumab compared to control. Please refer to the SmPC for full listing of all undesirable effects.

For UK: Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Novartis Pharmaceuticals UK Ltd on (01276) 698370 or medinfo.uk@novartis.com Legal category: POM, UK Basic NHS cost: £742.17. Marketing authorisation number: EU/1/06/374/001. Marketing authorisation holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Full prescribing information, including SmPC, is available from: Novartis Pharmaceuticals, Frimley Business Park, Frimley, Camberley, Surrey, GU16 7SR. Telephone: 01276 692255. Fax: 01276 692508. Prepared July 2013.

*Neovascular (wet) age-related macular degeneration (AMD)

Lucentis Indications may vary from country to country. Physicians should refer to their National Prescribing Information. Novartis Pharma AG CH-4002 Basel, Switzerland

August 2013

LUC.146879

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Cataract & refractive

FS CATARACT SURGERY

Technology eases management of rock-hard and intumescent cataracts by Howard Larkin in San Francisco

EYE CHAT Exclusive interviews Up to date information Problem solving

How will you manage the future? Dr Oliver Findl talks with Dr Paul Rosen, chairman of the ESCRS Practice Development Committee, about how the society is helping doctors learn about the business of ophthalmology

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EUROTIMES | Volume 18 | Issue 9

Courtesy of Matthias Elling MD

emtosecond laser-assisted cataract surgery can reduce complications in some of the most difficult cases, presenters told the American Society of Cataract and Refractive Surgeons (ASCRS). Reported benefits of the technology include significant reductions in ultrasound energy and associated corneal damage in very hard, dense cataracts, and prevention of radial tearing when opening intumescent capsules. In a series of 27 eyes with intumescent cataracts, complete capsulotomies with no adhesions or tears were achieved in 25, or 93 per cent, using a Catalys femtosecond laser (Optimedica), Matthias Elling MD of the University Eye Clinic, Bochum, Germany reported. The remaining two eyes had tags in the capsulotomy, resulting in small tears. However, these did not damage the capsules enough to prevent implantation of intraocular lenses (IOLs) in the bag without complications. By contrast, manual capsulorhexis in intumescent cataracts often leads to large radial tears, sometimes extending to the posterior, as the pressurised bag tends to burst when punctured, Dr Elling noted. “To prevent capsular tears, safety starts with a precise and fast capsulotomy,” he emphasised. Juan F Batlle MD of the Dominican Republic also reported success treating Morgagnian cataracts with a femtosecond laser. The situation often arises in very elderly patients or those who have received prior surgery for the vitreous or retina where the lens truly becomes a fluid-filled bag as described by Dr Morgagni, he explained. Surgical management in such cases can be difficult, prompting many to opt for an extracapsular technique or manual small incision cataract surgery to avoid posterior capsule rupture, Dr Batlle observed. “The fear is the so-called Argentinean flag syndrome, in which the blue-stained capsule splits when punctured for capsulorhexis, revealing a white band of nucleus across the entire equator. This often occurs even when the anterior chamber is pressurised,” he said. However, confirmation should be made at surgery that a complete 360-degree capsulorhexis has been performed prior to removal of the capsule so as to avoid radial tears produced by tags or incomplete cuts, Dr Batlle added. Femtosecond laser technology also helps manage black or rock-hard nuclei, Dr Batlle said. He presented a case in which he was not able to visualise the posterior capsule at the slit lamp due to a dark cataract, necessitating an immersion A-scan to measure axial length. However, at surgery, the laser’s OCT clearly imaged the posterior capsule, enabling softening of the nucleus while maintaining a safety zone. The bubbles released from behind the nucleus during laser pre-treatment help separate the dense cataract from the capsule, Dr Batlle said. The laser also disrupts the leathery surface typically found on cataract nigrans, making it much easier to crack and remove without major injury. “We began our sojourn with the femtosecond laser in June 2009. I am convinced that the Catalys laser will make

Femtosecond laser-assisted cataract surgery

the average cataract surgery easier and more precise, the difficult cases become average and those that are virtually impossible become possible,” said Dr Batlle, who is a consultant for Optimedica. Femtosecond laser lens fragmentation also reduces ultrasound energy for removal of advanced cataracts, Jonathan Talamo MD of Harvard Medical School reported. In a study of 51 cataracts of LOCS grade 5+, with maximum volume fragmented by laser, mean effective phaco time measured 2.22 +/- 2.95 seconds. That time fell between the average phaco times for grade 2 and grade 3 cataracts observed in a comparison group operated by the same surgeons without laser lens fragmentation. The surgeries were done at Burkhard Dick MDs facility at the University Eye Clinic in Bochum, Germany. So is femtosecond laser energy any better than ultrasound? “Most of us would conclude ‘yes,’” Dr Talamo said. Femtosecond laser softening causes less tissue disruption than phaco, possibly because it produces more but smaller cavitation zones – about 50 microns diameter compared with 600 microns for phaco, Dr Talamo noted. The result is about 1,000 times less collateral damage from cavitation bubbles, and less heat build-up, which reduces thermal damage. This reduces corneal oedema, endothelial cell loss and intraocular inflammation, making laser energy safer than ultrasound for softening advanced cataracts, Dr Talamo said. “As you would expect from this, the peer reviewed literature is starting to show reduced postoperative recovery time.” Reducing phaco time also reduces surgical time in the eye, which in turn stresses zonules and other tissue less, Dr Talamo noted. Laser pretreatment may also reduce suction requirements and with it irrigation volume and pressure needed to maintain anterior chamber stability during surgery. So should replacing ultrasound phaco with femtosecond laser be the goal? “It is probably achievable. Zero phaco for most is okay, but zero for all will not necessarily achieve better outcomes. But trying to get there will help,” he said.

contacts

Matthias Elling – Matthias.Elling@kk-bochum.de Jonathan Talamo – jtalamo@lasikofboston.com Juan Batlle – batlle@codetel.net.do

Update

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DEFINING CATARACTS French study highlights need to integrate quality of vision in cataract assessment by Dermot McGrath in Paris

s technologies evolve and national health systems become increasingly conscious of the need to reduce costs, there is perhaps a real rationale in redefining the current definition of cataract to enable greater account to be taken of quality of vision in its definition and diagnosis, according to Beatrice Cochener MD, PHD. “It is time to look again at how we define cataracts in the French context. The current definition dates back to the conference of consensus in 1989 and stipulates that a loss in visual acuity to below 5/10 is the key parameter to determine whether the cataract operation will be reimbursed by the French social security system,” Prof Cochener told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR). As Prof Cochener pointed out, the present definition of cataract, despite having been adjusted in 2012 to embrace the idea of an “alteration in the crystalline lens of the eye” rather than simply an “opacity”, is not sufficiently precise in this era of premium IOLs and clear lens extraction. “We know now that the loss in visual acuity is the last stage of the process and that the impact on the patient’s qualitative vision is detected or felt earlier, but this has not been measured until now,” she added. Prof Cochener, professor of ophthalmology at the University of Brest, France, said that technologies are available to provide better objective measures of a patient's visual disability due to cataract. These kind of quantifiable values – from light scatter measurements for instance in addition to questionnaire of life – may in future be needed to satisfy government or private insurance requirements for cataract procedures. “A reworked definition would potentially benefit all of the stakeholders. For the patient, it would take account for the first time of complaints concerning their quality of vision. For the surgeon, it would help to define the real limits between cataract and clear lens extraction, and for the social security system, it could potentially change the current reimbursement rules,” she said. To determine the feasibility of integrating more objective quality of vision parameters into the current definition of cataract, Prof Cochener said that SAFIR had commissioned a multicentre study with the support of the EUROTIMES | Volume 18 | Issue 9

French health authority HAS (Haute Autorité de Santé). The prospective study included 10 centres that at that day collected data concerning 1,179 patients who were candidates for cataract surgery (first eye). All patients underwent visual acuity, ophthalmoscope and OCT examinations. Cataracts were graded according to the lens opacities classification system III (LOCs III), and all patients received the VF-14 vision and quality of life questionnaires. In addition, 536 eyes underwent optical scatter index (OSI) measurements using the Optical Quality Analysis System (OQAS, Visiometrics) and evaluation of the ocular surface. The average patient age was 72.6 years with a range from 28 to 93 years and a mean preoperative visual acuity of 0.47 D. The average patient score on the VF-14 chart was 73.90. Almost 67 per cent scored less than 84 on the scale, said Prof Cochener, indicating the presence of pathologic cataract. The results were further analysed using Spearman’s rank correlation method and the Shapiro-Wilk test to examine correlations between visual acuity, patient age, VF-14 outcomes, LOCs III classification and OQAS measurements results. A correlation was found between visual acuity results and patient age, confirming that cataract is an age-related disease. Similarly, OSI scores were correlated with patient age and with visual acuity, said Prof Cochener. While a correlation was found between VF-14 ratings and visual acuity and also between VF-14 results and OSI scores, no correlation was found between VF-14 score and patient age. Summarising the results, Prof Cochener said that while there was clearly a need to integrate some form of objective measurement of quality of vision into the current definition of cataract, further research was required in order to present some clear-cut conclusions. “In the 10 months of the study we obtained a wide variety of results but no correlations that were strong enough to warrant changing the definition for the moment. Hence, we need to continue the study with a wider series of patients and incorporating more OQAS devices to try to establish stronger statistical evidence,” she said.

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Beatrice Cochener – beatrice.cochener-lamard@chu-brest.fr ADV_Eurotimes_260713_O600.indd 1

26.07.2013 13:15:59

Amsterdam

2013

5 -9 O C TOBER

X X X I c o ngress of t he esc r s

This year’s programme not to be missed! Main Symposia

Binkhorst Medal Lecture

Saturday 5 October

Douglas Koch

Refractive Surgery in Risky Corneas: Is it Really Safe for the Patient? ESCRS/EuCornea Symposium

The Ablated Cornea: What Have We Done?

Chairpersons:

Sunday 6 October

B. Cochener FRANCE R. Nuijts THE NETHERLANDS

USA

Sunday 6 October Femtosecond-Assisted Cataract Surgery: Euphoria Amid Skepticism and Financial Restraints Chairpersons:

G. Grabner AUSTRIA Y. Henry THE NETHERLANDS

Monday 7 October Unravelling the Mysteries of Myopia Chairpersons:

D. Epstein SWITZERLAND G. Luyten THE NETHERLANDS

NIOIC/ESCRS Video Symposium of Surgical Complications Sunday 6 October You Make the Call: Real-Time Reactions of Experts to Unseen Videos Chairpersons:

Tuesday 8 October The Management of High Hyperopia Chairpersons:

J. Güell SPAIN R. Lapid-Gortzak THE NETHERLANDS

Wednesday 9 October Treating Astigmatism with Cataract Surgery Chairpersons:

O. Findl AUSTRIA D. Spalton UK

P. Barry IRELAND D. Chang USA R. Nuijts THE NETHERLANDS

NEW

Clinical Research Symposia Saturday 5 October

• Treatment of Macular Edema Chairpersons:

• Effects of Phakic IOLs

P. Barry IRELAND R. Nuijts THE NETHERLANDS

Chairpersons:

• Basic Research on the Crystalline Lens

• Corneal Stem Cells: A Future for Therapy

and IOLs Restoring Accommodation Chairpersons:

M. Knorz GERMANY T. Kohnen GERMANY

of Corneal Disease

G. Auffarth GERMANY M. Tetz GERMANY

Chairpersons:

H. Dua UK F. Majo SWITZERLAND

Other Highlights Saturday 5 October

• Young Ophthalmologists Programme

• Refractive Surgery Didactic Course

Starting Phaco: Learning from the Learners

• Video Symposium on Challenging Cases Chairperson:

Chairpersons:

R. Osher USA

O. Findl AUSTRIA S. Morselli ITALY K. Vannas FINLAND

Sunday 6 October

• Questions for the Cataract and Refractive

• Workshop on Visual Optics

Surgeon in 2013 Journal of Cataract & Refractive Surgery Symposium Chairpersons:

Chairpersons:

I. Pallikaris GREECE M.J. Tassignon BELGIUM

• Young Ophthalmologists Session:

E. Rosen UK (EUROPEAN EDITOR) T. Kohnen GERMANY

NEW

Taking Training into Your Own Hands

(EUROPEAN ASSOCIATE EDITOR)

Chairpersons:

• Video Awards Session Chairperson:

R. Packard UK

O. Findl AUSTRIA N. Hirnschall AUSTRIA T. Rudolph SWEDEN

Monday 7 October

• Clear Lens Extraction: Have we Lost our Way Combined Symposium of Cataract & Refractive Societies Chairperson: Co-chairs:

P. Barry IRELAND (ESCRS) G. Barrett AUSTRALIA (APACRS) C. Carriazo COLOMBIA (LASCRS) E. Holland USA (ASCRS)

Interactive e-Poster Sessions

NEW

Sunday 6 October

Monday 7 October

Refractive

Cataract

Chairpersons:

B. Cochener FRANCE V. Katsanevaki GREECE

Chairpersons:

E. Assia ISRAEL B. Malyugin RUSSIA

94 45

www.escrs.org

Instructional Courses FREE OF CHARGE

WETLABS €100 per course

ESCRS

EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

Saturday 5 October

Lunchtime symposia include boxed lunches

13.00 – 14.00

Leading the Way in New Laser Technology: Bausch + Lomb Technolas Laser Suite

The Toric Solution: Exceeding Expectations in Patients with Astigmatism

Speakers:

Moderator: M. Packer USA

Lunchtime Symposia

R. Ang THE PHILIPPINES R. Bellucci ITALY S. Chee SINGAPORE P. Stodulka CZECH REPUBLIC

M. Packer USA Available options for accurate toric IOL positioning, from markers to latest alignment technology

Sponsored by

D. Black AUSTRALIA Long term performance of toric IOLS in the management of astigmatism

Croma Satellite Meeting

S. Kwitko BRAZIL M-flex® T and patient selection in the management of astigmatism

Sponsored by

Ziemer Satellite Meeting Speakers: F. Ziemer SWITZERLAND M. Tomita JAPAN

D. Kent IRELAND Clinical experience with the Rayner toric IOL platform T. Kohnen GERMANY ‘Why use the T-flex® IOL?’ – A comparison of outcomes, rotational stability and ease of use

Sponsored by

J. Mehta SINGAPORE B. Pajic SWITZERLAND L. Jr. Izqueirdo PERU

Sponsored by

OCULUS Pentacam® and Corvis® ST: Applications of Scheimpflug Technology for Refractive, Cataract and Glaucoma Surgery Sponsored by

Heidelberg Engineering Satellite Meeting Sponsored by

New Technologies for Premium Cataract Surgery: An Interactive Approach Moderator: O. Findl AUSTRIA O. Findl AUSTRIA Key success factors for using toric IOLs S. Beatty IRELAND From advocate to skeptic – why I no longer use blue light filtering IOLs E. Marques PORTUGAL New multifocal options for providing spectacle independence

Sponsored by

Satellite Meeting Schedule

X X X I congress of the escr s

Amsterdam

2013

5 -9 O C TOBE R

Saturday 5 October

Sunday 6 October

Lunchtime symposia include boxed lunches

18.15

Lunchtime symposia include boxed lunches

Premium Outcomes in Refractive Surgery and Preserving the Cornea for the Future

Advancements in the Diagnosis and Treatment of Dry Eye

Lunchtime Symposia 13.00 – 14.00 Advances in Cataract Surgery - Femtosecond cataract surgery: Imaging in LENSAR-assisted cataract surgery - Femtosecond cataract surgery: Experiences with LENSAR - Biometry and topography: Experience with Topcon’s Aladdin system

Sponsored by

Moderator: A. Agarwal INDIA R. Zaldivar ARGENTINA Premium refractive surgery and saving the cornea E. Mertens BELGIUM Premium refractive surgery: What are the key drivers?

Master Your Refractive Outcomes with the LENSTAR LS 900 Moderator: T. Olsen

Evening Symposia

DENMARK

W. Hill USA First experience with the LENSTAR T-Cone topography add-on and toric IOL planning E. Meier USA Excellent refractive outcomes with 5th generation IOL calculation formula: The Olsen vs. Hollady 2 Formula, which road to go H.J. Shammas USA Improved cataract penetration using DCM Mode and Shammas no-history for prior hyperopic post refractive cataract patients with the LENSTAR

Sponsored by

Evening Symposia 18.15 Live Surgery: Advancements in Techniques and Technologies

R. Rivera USA Dry eye: A forgotten hassle post LASIK J.F. Alfonso SPAIN Premium outcomes today and tomorrow J. Aramberri SPAIN Premium innovation: Visian ICL “V5” preloaded A. El-Danasoury SAUDI ARABIA The premium role of ICL in my practice T. Neuhann GERMANY, G. Krommes GERMANY “Visian ICL in my eyes” – a surgeon and patient perspective

Sponsored by

K. Gumus TURKEY Diagnostic approaches and differential diagnosis E. Donnenfeld USA Therapy of ocular surface disease associated with dry eyes J. McCulley USA Expert panel discussion

Sponsored by

Initial Experience with the New Alcon Centurion® Vision System Moderator: D. Allen UK

J. Marshall UK The science of accelerated cross-linking and lasik Xtra

K. Tjia THE NETHERLANDS Transitioning to Balanced Energy™ technology

J. Tan SINGAPORE Lasik Xtra in my practice W.J. Dupps USA Biomechanical modeling and refractive corneal cross-linking D. Muller USA PiXL: photorefractive intrastromal cross-linking A.J. Kanellopoulos GREECE

Sponsored by

J. McCulley USA Definition, ethiopathogensis and physiopathology of dry eye

R. Packard UK Experience with MICS cases

Surgeons:

D. Allen UK, M. Weiser FRANCE, M. Knorz GERMANY R. Kaufer ARGENTINIA

Moderator: J. McCulley USA

The Future of Refractive Surgery

PiXL in clinical practice

Faculty Panel:

13.00 – 14.00

D. Allen UK Overview of Centurion® Vision System

Moderator: D. N. Serafano USA

R. Nuijts THE NETHERLANDS, R. Cionni USA, G. Schairoth GERMANY, O. Moraru ROMANIA

Lunchtime Symposia

C. Johansson SWEDEN Observations using Active Fluidics™ technology Panel Anticipating the future with Centurion® Vision System

Sponsored by

Leading Technology in Refractive Surgery Moderator: J. Marshall

Speakers: M. Tomita JAPAN M. Luger THE NETHERLANDS P. Stodulka CZECH REPUBLIC

Sponsored by

ESCRS

EUROTIMES Satellite Meeting Schedule ™

SATELLITE EDUCATION PROGRAMME

Sunday 6 October

Lunchtime symposia include boxed lunches

13.00 – 14.00

Discover Precise Approaches by Experiencing Latest Zeiss Refractive Laser Technologies

Sophisticated Cataract Surgery: Quantity and Quality of Vision

Redefining Convention: Laser Applications for Vitreolysis and Glaucoma

Moderator: J. Güell SPAIN

D. Spalton UK Phacoemulsification in the 21st century: Meeting patient expectations

Lunchtime Symposia

R. Wiltfang GERMANY Exploring new horizons of refractive surgery with next generation of excimer technology

Lunchtime Symposia

Moderator: D. Spalton UK

O. Findl AUSTRIA Correlating visual outcomes with OCT findings

B. Meyer GERMANY Clinical results with a new MEL® excimer laser ablation algorithm

R. Bellucci ITALY Preventing common complications of cataract surgery

D. Reinstein UK PRESBYOND® laser blended vision with new excimer technology

Sponsored by

M. Nubile ITALY Preserved corneal neural architecture for reduced dry eye symptoms in SMILE refractive treatments J. Dishler USA Initial U.S. Clinical trial results: New SMILE procedure for ReLEx® spherical myopia correction

Sponsored by

Managing Expectations of Cataract Patients with Comorbidities Using ZEISS Retina and Glaucoma Diagnostic Technologies Moderator: P. Koch BELGIUM G. Staurenghi ITALY Tips on how to manage your patients with retinal comorbidities A. Heijl SWEDEN Manage glaucoma patients who need cataract surgery – discover the value of GPA2 P. Koch BELGIUM In your practice, CIRRUS OCT can support you in your daily work with cataract patients with comorbidities

Sponsored by

Complex Cataract Cases: The Simple Truths Moderator: R. Osher USA R. Osher USA Pearls for the challenging situation S. Masket USA Hanging loose: Dealing with loose zonules and malpositioned IOLs B. Malyugin RUSSIA Small pupils: Does size really matter?

Sponsored by

DORC goes Anterior: EVA, a New Dimension in Cataract Surgery and Other Anterior Innovations

www.escrs.org/amsterdam2013/satellite-meetings This is a preliminary programme and is subject to change

Moderator: M.J. Tassignon BELGIUM R. Carassa ITALY SLT in the glaucoma treatment armamentarium M.J. Tassignon BELGIUM Vitreous floaters impeding our vision F. Gerbrandy THE NETHERLANDS YAG Laser Vitreolysis: A breakthrough in the management of floater patients C. van der Windt THE NETHERLANDS A comparison of Nd: YAG Laser Vitreolysis versus Pars Plana Vitrectomy in eyes with vitreous floaters

Sponsored by

New Diagnostic Frontiers in Cataract and Refractive Lens Exchange Moderators: S. Daya UK D. Gatinel FRANCE S. Daya UK A new fast biometer: The AL-Scan technology and comparitive data with Zeiss IOL master D. Gatinel FRANCE Optimizing pre-cataract dignostics: Efficient data collection with NIDEK instruments and IOL-Station Software F. Ekkehard GERMANY The importance of endothelial cell count in cataract surgery: Evaluation of the NIDEK CEM-530 Specular Microscope

Moderator: A. Mohr GERMANY

O. Kermani GERMANY My experience with NIDEK IOL Aktis SP, SZ-1 and pre-cataract WF Aberrometry

R. Lehmann GERMANY EVA, a new dimension in cataract surgery

Sponsored by

I. Dapena THE NETHERLANDS Latest update in DMEK surgery A. Mohr GERMANY Posterior instruments for anterior surgery / my EVA experiences

Lunchtime Symposia

A. Mohr GERMANY New developments in capsular staining K. Klabe GERMANY Glaucolight F. Kerkhoff THE NETHERLANDS My experiences with IOL fixation forceps

Sponsored by

Amsterdam

2013

XXXI c o ng ress o f th e es crs

5 -9 O C TOB E R

Sunday 6 October

Monday 7 October

18.00

Lunchtime symposia include boxed lunches

13.00 – 14.00

Innovations in Cataract and Refractive Surgery

Alcon Visionarium – Cataract and Refractive Innovations in a 3D Video-Symposium

The Cutting Edge of MICS: Introducing INCISE IOL

Moderator: R. Nuijts THE NETHERLANDS

Moderator: A.J. Kanellopoulos GREECE

Evening Symposia Buers Van Berlage

Lunchtime Symposia

(Buses will depart from the Congress Centre at 18.00)

R. Nuijts THE NETHERLANDS Welcome and introduction R. Nuijts THE NETHERLANDS Introducing the VERION™ image guided system R. Cionni USA Precision outcomes with LenSx® Laser System – from the clinic to the OR R. Cionni USA The LuxOR™ microscope experience P. Crozafon FRANCE First step in refractive cataract surgery, Centurion® vision system A.Cummings IRELAND Taking femtosecond lasers to the next level T. Seiler SWITZERLAND Redefining excimer technology

Sponsored by

K. Tjia THE NETHERLANDS INTREPID procedure M. Knorz GERMANY Single femtosecond laser platform for catract and LASIK surgery application A.J. Kanellopoulos GREECE Multi-dimensional performance of WaveLight’s laser technology P. Crozafon FRANCE The Alcon® Refractive Cataract Suite

Sponsored by

Technologies and Techniques for Optimizing Corneal Inlay Outcomes Moderator: F. Carones ITALY F. Carones ITALY Addressing the presbyope

Monday 7 October

G. Grabner AUSTRIA Long-term stability and biocompatibility

Lunchtime symposia include boxed lunches

R. Zaldivar ARGENTINA Advanced diagnostics for patient satisfaction after inlay implantation

Lunchtime Symposia 13.00 – 14.00 IRIDEX MicroPulse for the Ultimate Skeptic: Seeing is Believing Moderator: E. Midena ITALY E. Midena ITALY Clinical efficacy and safety profile of 810 nm and 577 nm subthreshold MicroPulse laser for center involving DME D.D. Gossage USA 532 nm MicroPulse laser for repeatable glaucoma therapy and fovea-friendly therapy for retinal disorders

Sponsored by

J. Machat CANADA Maximizing patient satisfaction after inlay implantation M. Tomita JAPAN Dual-interface for refractive and presbyopic correction

Moderator: R. Bellucci ITALY R. Bellucci ITALY Welcome and introductions D. Spalton UK Introducing INCISE® IOL B. Dick GERMANY INCISE® IOL: Experiences under the trial protocol S. Morselli ITALY Redefining MICS, for every procedure R. Bellucci ITALY Conclusion: The future of MICS All-panel question and answer session

Sponsored by

Prevention of Post-Operative Endophthalmitis: What’s New? Moderators: P. Barry IRELAND R. Nuijts THE NETHERLANDS J. Szaflik POLAND Management of risk factors to prevent POE J. Güell SPAIN European practice concerning intracameral use of cefuroxime A. Behndig SWEDEN Intracameral in capsule rupture?

Sponsored by

F. Carones ITALY Redefining presbyopia correction

The Appliance of Science in the Fight Against Blindness: Affordable New Technology to Treat and Prevent Sight Loss in the Developing World

Sponsored by

Moderator: R.Walters UK

W. Riha AUSTRIA Secondary surgical procedures

NeXt Generation of LENTIS® Premium IOLs Sponsored by

R.Walters UK Introduction and welcome B. Doolan AUSTRALIA Digital imaging techniques M. Maio USA The smart phone in the fight against blindness in the developing world Discussion

Sponsored by

Update

Cataract & refractive

FUTURE IOLS

Accommodating, injectable and customisable lenses are on horizon

The moment you help your patients see the whole picture. This is the moment we work for. AT LISA tri and AT LISA tri toric are not approved for sale in the U.S.

by Howard Larkin in San Francisco

// True Living vision Made By Zeiss

True Living Vision becomes reality with AT LISA® tri and the new AT LISA® tri toric. Excellent near, far and intermediate vision. Under all light conditions. For maximized independency from spectacles.

Visit us at ESCRS at hall 1 booth G02 to learn more about True Living Vision. www.meditec.zeiss.com/escrs

Tactical Ad_AT LISA tri_130730_V12_RZ.indd EUROTIMES | Volume 18 | Issue 9

30.07.2013 16:08:28

ccommodating lenses, including dual optics, liquid optics, injectable lenses and even liquid crystal electronic devices, as well as lenses that can be customised after implantation, are becoming a reality, Nick Mamalis MD of the University of Utah, US, told the ASCRS annual symposium. Range of accommodation, and long-term function and biocompatibility are major development questions being examined, said Dr Mamalis, who was awarded the Binkhorst Medal in honour of his contributions to intraocular lens (IOL) research and design. Cataract surgical technique and IOL design have both advanced remarkably since the earliest procedures by Sir Harold Ridley in the early 1950s, Dr Mamalis noted. “Results are very good, but we still lack a good way to give clear near and distance vision.” Most available presbyopia correcting lenses are limited, Dr Mamalis said. Multifocal lenses split incoming images, reducing contrast and inducing dysphotopsias, while single-piece hinged lenses have a limited range of accommodation. Lenses offering a greater range of accommodation will soon be available to solve the problem, he predicted. One such accommodating lens on the market outside the US is the Synchrony (Abbott Medical Optics), Dr Mamalis said. A dual-optic design, Synchrony pairs a high-power positive anterior with a posterior negative lens that matches patient refractive needs. The foldable lens can be injected through a small incision but fills the capsular bag. When the ciliary muscles are relaxed, the lenses are close together for distance vision. Under contraction of the ciliary muscles, the capsular bag rounds, pushing the optics apart for clear near vision. The DynaCurve (NuLens) is based on a different accommodating principle modelled after that found in water birds, such as penguins. Penguins need to see in water. Their eyes have a rigid pupil and a soft lens that pokes through it when they go in the water, allowing them to see up close. The NuLens device accommodates by pushing a silicone gel in the flexible lens optic through an aperture in response to ciliary muscle contraction, changing the optic shape and power. Tests show improved near vision without compromising distance vision one year after implantation. The lens fits in the

ciliary sulcus, potentially enabling placement in front of an existing posterior chamber lens to provide accommodation, Dr Mamalis said. The FluidVision IOL (PowerVision) also accommodates by changing shape, but uses internal hydraulic pressure to do so, Dr Mamalis said. The lens consists of a central optic surrounded by balloon haptics containing silicon oil. With contraction and relaxation of the ciliary muscles, fluid is pushed between the haptics and the flexible optic, which changes the shape and refractive power of the anterior optic surface. In pushdown tests, early versions of the lens have demonstrated up to 5.0 D accommodation. The Sapphire autofocal IOL (Elenza) uses advanced electronics to achieve accommodation, Dr Mamalis said. The lens incorporates a liquid crystal optic array, microprocessor and rechargeable battery into a monofocal optic. The device is programmable to adjust as patient refractive needs change. In the late 1980s, Dr Mamalis predicted that injectable IOLs would be available in five to 10 years. “Obviously that’s now been 25 years, and unfortunately this has been a little bit more difficult to come up with.” Potential advantages include very small incisions and customisation. But cataract extractions still require sizable capsulotomies and coming up with injectable materials with appropriate cure rates is a challenge. Nonetheless, the injectable lens concept is moving closer to reality through the work of Okihiro Nishi MD of Japan, Dr Mamalis noted. His system incorporates an optic with a grooved edge into which the edges of the capsulotomy are inserted much like a bicycle tyre on a rim to seal the capsular bag. Silicon gel is then injected behind the cap, filling the bag. Under pressure from the ciliary muscles, the lens changes shape and thickness, providing accommodation in much the same way as the crystalline lens. The Light Adjustable Lens (Calhoun Vision) is made up of partially polymerised material which can be cross-linked after surgery with ultraviolet light to change the shape and refractive characteristics of the lens. Once a good refraction is achieved, the pattern is locked in, Dr Mamalis added.

contact Nick Mamalis – nick.mamalis@hsc.utah.edu

Alcon in Amsterdam 4-9 October 2013 SAve the dAte fOr theSe SympOSiA during the XXXi COngreSS Of the eSCrS in AmSterdAm

friday, 4 October

Sunday, 6 October

Emerald Room – RAI Congress Centre

Elycium 2 – RAI Congress Centre

12:45 – 13:45 (lunch boxes will be provided)

13:00 – 14:00 (lunch boxes will be provided)

Glaucoma Day Symposium! This symposium will focus on the latest efficacy and safety data of the EX-PRESS® Glaucoma Filtration Device, benefits of lumenal control, and advanced pearls and techniques for optimizing your glaucoma filtering surgery procedures.

Surgeons will share observations, pearls and future possibilities using innovative new Alcon Centurion® Vision System. Discussion will cover Active Fluidics Technology, Balanced Energy Technology and Applied Integration Technology available with this new system.

Glaucoma filtration Surgery: Limiting variables and improving Outcomes

Saturday, 5 October

Live Surgery: advancements in Techniques and Technologies TeLeCaST in high Definition! The Auditorium – RAI Congress Centre

18:00 – 20:30 (refreshments will be provided) Register now to learn from world-acclaimed surgeons demonstrating their techniques using the latest Alcon® technologies in cataract surgery. Featured technologies will include: • The innovative Centurion® Vision System, beginning a new era of cataract removal • VERION™ Image Guided System • LenSx® Laser System • INTREPID® AutoSert® IOL Injector • AcrySof® IQ ReSTOR® family of Multifocal and Multifocal Toric IOLs

Sunday, 6 October

advancements in the Diagnosis and Treatment of Dry eye Elycium 1 – RAI Congress Centre

13:00 – 14:00 (lunch boxes will be provided) Join experts in the field as they discuss the differential diagnosis, treatment, and therapeutic options in the Management of Dry Eye.

http://escrs.org/alconsatellites/

These events are for healthcare professionals only. Please present your ESCRS meeting badge for entry into the meeting. For important safety information about the Alcon products discussed in these programs, please visit the Alcon booth #E03 at ESCRS. © 2013 Novartis

7/13

MIX13442JADi

initial experience with the New alcon Centurion® vision System

Sunday, 6 October

innovations in Cataract and refractive Surgery Buers Van Berlage (Transportation will be provided from RAI)

19:00 – 20:00 (refreshments will be provided) Introducing the Cataract Refractive Suite by Alcon®, a wave of innovation featuring: VERION™ image guided system, LenSx® Laser System, LuxOR™ LX3 Ophthalmic Microscope and the new Centurion® Vision System. Come and learn from top industry opinion leaders’ experiences with the CATARACT REFRACTIVE SUITE by Alcon and see the latest advancements in the WaveLight® Refractive Suite.

monday, 7 October

alcon visionarium – Cataract & refractive innovations in a 3D video Symposium The Forum – RAI Congress Centre

13:00 – 14:00 (lunch boxes will be provided) Join our leading cataract & refractive surgeons in a unique 3D Symposium showcasing Alcon’s newest advanced technologies: the new Centurion® Vision System, VERION™ image guided system, LenSx® Laser System, LuxOR™ LX3 Ophthalmic Microscope & WaveLight® Refractive Suite.

The CaTaraCT refraCTive SuiTe by alcon® The future of cataract surgery is here. Come experience the world premiere of exciting new surgical technologies from global eye care leader, Alcon. Please visit the Alcon Booth #E03.

See your success in the eyes of your patients

Defining the standard of care in DME* LUCENTIS® (ranibizumab) ABBREVIATED UK PRESCRIBING INFORMATION Please refer to the SmPC before prescribing LUCENTIS 10mg/ml solution for injection. Presentation: A glass single-use vial containing 0.23ml solution containing 2.3mg of ranibizumab (10mg/ml). Indications: The treatment in adults of neovascular (wet) age-related macular degeneration (AMD), the treatment of visual impairment due to diabetic macular oedema (DMO), the treatment of visual impairment due to macular oedema secondary to retinal vein occlusion (branch RVO or central RVO), and the treatment of visual impairment due to choroidal neovascularisation (CNV) secondary to pathologic myopia (PM). Administration and Dosage: Single-use vial for intravitreal use only. LUCENTIS must be administered by a qualified ophthalmologist experienced in intravitreal injections under aseptic conditions. The recommended dose is 0.5 mg (0.05ml). For treatment of wet AMD: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. The patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to wet AMD. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. For treatment of visual impairment due to either DMO or macular oedema secondary to RVO: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. the patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab treatment. If there is no improvement in visual acuity over the course of the first three injections, continued treatment is not recommended. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to DMO or to macular oedema secondary to RVO. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. LUCENTIS and laser photocoagulation in DMO and in macular oedema secondary to BRVO: When given on the same day, LUCENTIS should be administered at least 30 minutes after laser photocoagulation. LUCENTIS can be administered in patients who have received previous laser photocoagulation. For treatment of visual impairment due to CNV secondary to PM: Treatment is initiated with a single injection. If monitoring reveals signs of disease activity, e.g. reduced visual acuity and/or signs of lesion activity, further treatment is recommended. Monitoring for disease activity may include clinical examination, optical coherence tomography (OCT) or fluorescein angiography (FA). While many patients may only need one or two injections during the first year, some patients may need more frequent treatment. Therefore, monitoring is recommended monthly for the first two months and at least every three months thereafter during the first year. After the first year, the frequency of monitoring should be determined by the treating physician. The interval between two doses should not be shorter than one month. LUCENTIS and Visudyne photodynamic therapy in CNV secondary to PM: There is no experience of concomitant administration of LUCENTIS and Visudyne. Before treatment, evaluate the patient’s medical history for hypersensitivity. The patient should also be instructed to self-administer antimicrobial drops, 4 times daily for 3 days

*Visual impairment due to diabetic macular edema

Lucentis Indications may vary from country to country. Physicians should refer to their National Prescribing Information. Novartis Pharma AG CH-4002 Basel, Switzerland

August 2013

LUC.146879

add.pdf

Cataract & refractive

FEMCAT STUDY

French study to assess medico-economic benefit of femto-cataract surgery by Dermot McGrath in Paris

EUROTIMES | Volume 18 | Issue 9

8/5/13

5:31 PM

Update

n ambitious French study has been launched with the goal of determining the clinical and medico-economic benefit of femtosecond laser-assisted cataract surgery, according to Cédric Schweitzer MD. Addressing delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR), Dr Schweitzer said the FEMCAT* study represented an important and necessary effort to establish some scientific basis for the theoretical benefits of femto-cataract surgery. “We lack robust data looking at this question, so there is a definite need for studies like FEMCAT. Our goal is to validate the clinical and medico-economic utility of femtosecond laser-assisted cataract surgery compared to standard phacoemulsification,” he said. The controlled, randomised study, which has received funding of €3.1m from the French health ministry, will be coordinated by Dr Schweitzer and co-workers at the University Hospital of Bordeaux, and will also include clinical centres in Paris (Cochin Hospital), Lyon (Croix Rousse Hospital), Brest and Tours. The two-year FEMCAT study will recruit 2,000 patients in total, half of whom will be randomised to undergo femtocataract surgery and the other half classic phacoemulsification surgery. Surveying the scientific literature, Dr Schweitzer said that the case series published to date reported several distinct advantages associated with femtosecond laser use in cataract surgery. “Incisions are more precise, reproducible and watertight than manual incisions. In terms of the capsulorhexis, they are better centred, more circular and allow for better positioning of the IOL. There is also less energy delivered into the eye for the fragmentation process. The refractive results from one study showed better centration of the implant and better spherical equivalent postoperatively compared to results achieved using traditional manual techniques,” he said. Dr Schweitzer noted that while many medico-economic studies have highlighted the role of improved technology in making cataract surgery one of the most beneficial and cost-effective surgeries available today,

the case has not been definitively made yet for femto-cataract surgery. “This is really why we want to validate, in a French context, the benefits of femtocataract procedures such as enhanced surgical safety, reduction in intraoperative and postoperative complications and faster anatomical and visual recovery, and assess its implications for the national health system,” he said. The latest data show that between 660,000 and 680,000 cataract procedures are carried out annually in France, said Dr Schweitzer. “The average patient age is around 74 years, with significant growth expected in the number of cataract procedures needed in the future due to the ageing of the population. The cost to the French health system is currently estimated at €900m annually, although this figure does not take account of cases with complications, so the real figure is much higher in reality,” he said. Summing up, Dr Schweitzer reminded delegates that cataract removal remains one of the most beneficial and cost-effective surgeries from the point of view of the individual and society. “No matter what country or region we look at, the cost-utility ratio of cataract surgery is superior to no intervention. The ratio is also significantly better than other surgical procedures, with only hip surgery coming close in terms of cost-effectiveness,” he said. For femto-cataract surgery, Dr Schweitzer noted that the technology is expensive and the medical and refractive benefit remains to be proven in larger and more robust studies. “We hope at the end of our study to have a clearer idea of the real medical benefit of femtosecond cataract technology on a French population, as well as the additional cost that would be acceptable to society in the event of these benefits being proven,” he said. C

CMY

* “FEMCAT: “impact médico-économique de la chirurgie de la cataracte au laser femtoseconde,” CHU de Bordeaux, supported by a grant from the French ministry of health (PSTIC 2012).

AMSTERDAM 2013

4 EUCORNEA CONGRESS TH

4-5 OCTOBER

2 Days. 12 Symposia. 6 Courses. 12 Free Paper Sessions.

Friday

Saturday

Symposia

     

Infections New Contact Lenses in Irregular Astigmatism What I do differently this year than last year Cicatrizing Ocular Surface Disease Laser Assisted Lamellar Keratoplasty Ocular Surface Reconstruction & Keratoprosthesis



Ocular Tumours



Iatrogenic Corneal Disease



Posterior Lamellar Keratoplasty



Cornea Infections and Inflammatory Disease: An Asian Perspective



Ocular Traumas

Courses



New Research in Cornea

Stem Cell Therapy for Ocular Surface Reconstruction  What Can Go Wrong in Lamellar Surgery  Current State of CXL (Corneal Collagen Cross-linking) Controversies and Hot Topics

Courses



Techniques for Evaluating Dry Eye



Corneal Imaging Update



Eye Banking and Corneal Transplantation

EuCornea Medal Lecture Friday 4 October 17.00 – 18.00 At the Opening Ceremony The Cornea: How Many Endothelial Cells Are Necessary?

www.eucornea.org

Gabriel van Rij THE NETHERLANDS



Satellite Meetings Lunchtime Symposia 12.45 – 13.45 Boxed lunch included

This is preliminary programme and is subject to change

Friday 4 October



Saturday 5 October

Allergan Satellite Meeting

Improving Outcomes with Objective Pre-op Dry Eye Diagnosis and Management

Sponsored by

(Final presentation titles still to be conﬁrmed) M. McDonald USA Impact of DE and tear osmolarity on Refractive Surgery outcomes M.A. Jackson USA Managing pre-op DE to ensure outcomes for Cataract surgery J. Pepose USA Co-morbity and therapeutics effect on DED R.D. Stulting USA The role of osmolarity in corneal surgical outcomes Sponsored by

Update

CORNEA

meet

after DSEK

Mid-term follow-up findings favourable, but longer term data still needed by Cheryl Guttman Krader

Courtesy of Sanjay V Patel MD

escemet’s-stripping endothelial keratoplasty (DSEK) has several advantages compared with penetrating keratoplasty (PK) in eyes requiring corneal transplantation. However, there are limited data on the long-term health of the partial thickness transplant. To address this gap, researchers from Mayo Clinic, Rochester, MN, analysed postoperative endothelial cell loss in prospectively followed cohorts from two consecutive trials evaluating PK (15 eyes) and DSEK (52 eyes) for endothelial disease. While the groups were derived from separate studies, their mean preoperative donor endothelial cell density (ECD) was similar, and all measurements were made using the same analysis technique of confocal microscopy images by the same masked observer. The results, which were reported at the 2013 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO), showed a trend toward higher endothelial cell loss at one month postoperatively after DSEK compared with after PK (25 per cent vs. 19 per cent). Thereafter, endothelial cell loss after DSEK levelled off, and the percentage change from baseline ECD was significantly less after DSEK compared with after PK at two years (38 per cent vs. 47 per cent) and three years (44 per cent vs. 60 per cent).

Nevertheless, initial data from five years after DSEK suggested its advantage at two and three years might only be temporary. Data from 10 eyes showed 60 per cent endothelial cell loss, approaching the cell loss at five years after PK as reported previously from Mayo and in the Cornea Donor Study. EUROTIMES | Volume 18 | Issue 9

“

Early graft failure remains much higher after DSEK than after PK… Sanjay V Patel

Sanjay V Patel MD, professor and chair, Department of Ophthalmology, Mayo Clinic, is the lead author of the study. He told EuroTimes, “Our DSEK data showing a trend toward higher endothelial cell loss immediately post surgery compared with PK followed by a more gradual decline are consistent with results reported in a retrospective study by Price et al. [Ophthalmology 2011;118(4):725-9].” He continued, “Our results from five years post-DSEK suggest that cell loss after DSEK might converge with that after PK over the longer-term. However, with the small number of eyes evaluated, more and longer-term data are needed to determine the long-term survival of DSEK grafts.” The investigators proposed that the benefit of less endothelial cell loss at two and three years after DSEK might be explained by the lowered threshold to operate on younger recipients with healthier peripheral endothelial cells, thus impairing cell migration from the donor. Alternatively, the explanation may relate to the use of a slightly larger graft in DSEK procedures compared with PK (mean 8.2 vs. 7.6mm) since the larger DSEK grafts contain a greater density of cells in the periphery that might buffer the overall cell loss rate versus PK. In addition, differences in host-graft anatomy may also play a role as the better alignment of the posterior surfaces of the donor and host after PK may enable easier and more rapid migration of healthy endothelial cells from graft to host. The researchers also reported that five DSEK grafts and none of the PK grafts failed during three years of follow-up. Four early DSEK graft failures occurred during the surgeons’ learning curve for the procedure. “Early graft failure remains much higher after DSEK than after PK, and elimination of these failed grafts from cell loss analyses will artificially contribute to improved cell loss after DSEK,” Dr Patel said.

Meet DORC at Euretina Visit our booth #H125 DORC Lunch symposium 28th of September 13.00-14.00 “EVA a new dimension in vitreoretinal surgery and other DORC VR innovations” At the heart of EVA is a revolutionary fluid control system called VacuFlow VTi using Valve Timing intelligence technology. It just effortlessly delivers the precise flow and fast vacuum required by you, the surgeon. Put simply, EVA VacuFlow VTi technology puts you in absolute control, all of the time.

www.evabydorc.com

109-1088_ADV_Meet_EVA_tbv_Euretina_120x300.indd 1

02-08-13 15:11

Update

GLAUCOMA

GLAUCOMA day

Exciting series of sessions at ESCRS meeting to provide update on glaucoma management

by Roibeard O’hEineachain

or the third year in a row, the ESCRS Annual Congress will be hosting a “Glaucoma Day” organised by the European Glaucoma Society (EGS). As in previous years, it will bring together some of Europe’s leading glaucoma experts who, in a series of sessions, will provide in-depth discussions on the latest controversies and latest developments in the management of this as yet poorly understood disease. The first session, chaired by Anja Tuulonen MD, Finland, will include presentations examining the burden of glaucoma on patients and society, with up-to-date statistics on the incidence and the direct and indirect costs of the disease. There will also be discussions about the most cost-effective way of improving the detection of glaucoma and about the options available to patients with visual impairment from glaucoma who are nearing the end of their lives. The second session, chaired by Fotis Topouzis MD, Greece, will be concerned with some of the other pathological mechanisms apart from intraocular pressure (IOP) which may play a part in the disease. There will be presentations regarding the ocular and non-ocular risk factors which large studies have revealed, as well as a critical re-evaluation of the ways IOP is measured and interpreted. The following session, chaired by JeanPhilippe Nordmann MD, France, will address some of the controversies that have emerged in recent years regarding the medical treatment of glaucoma. Specifically, the presentations will assess the cost/benefit ratio of preservative-free glaucoma medication, the question of whether generic medication really have the same bioavailability as the original branded products, and the role of informing patients about the nature of their disease to insure adherence to their prescribed regimens. The final two sessions will be concerned with the surgical treatment of glaucoma. The first, chaired by Keith Barton FRCS, UK, will include a presentation concerning such matters as the place of argon laser trabeculoplasty and selective laser trabeculoplasty in the current treatment

Don’t Miss EU Matters, see page 57 ad ET versario 1-2hoch ENG 1301v2 pva RZ.indd EUROTIMES | Volume 18 | Issue 9

07.02.13 11:40

The final two sessions will be concerned with the surgical treatment of glaucoma. The Keith Barton first, chaired by Keith Barton FRCS, UK, will include a presentation concerning such matters as the place of argon laser trabeculoplasty and selective laser trabeculoplasty in the current treatment stepladder, as new treatments with similar indications become available

stepladder, as new treatments with similar indications become available. In addition, there will be presentations examining the prevention and treatment of the common complications of filtration surgery, as well as the relative advantages and disadvantages of alternatives to trabeculectomy, such as drainage devices, minimally invasive glaucoma surgery (MIGS) and cyclodestructive procedures. The second glaucoma surgery session and final session of the day, chaired by Carroll Webers MD, The Netherlands, will include several presentations regarding angle closure glaucoma, including the current prevalence of the disease in Europe, which has undergone considerable changes in the composition of its population over recent decades, and also the diagnosis of the disease. There will also be presentations which will examine the problems that need to be considered when a patient requires surgery for both cataract and glaucoma and whether the procedures should be carried out in combination or separately.

LESS

LESS INVASIVE SURGERY, MORE RAPID VISUAL RECOVERY

ith new w s c i t op o quality nabling you t h g i h mbines plantation, e e: o c E S s m INCI e bag i ICS with ea ct h t n i Viscoje w 1.8mm sub 2mm M e n h rial wit bag and e t a perform m acrylic .8mm in the n when d e c n a • Enh logy allows 1 implantatio pabilities a techno ound assist ed Stellaris c t w v harpes s e 1.4mm d with impro h t h it ne CO w P e combi s i m to mini ble IOL d e n g i o • Des f any injecta igned t s e d o s e c pti edg nced o a v d a eric ity • Asph e visual qual e rapid r o m r fo enhanc urgery s e v i s a less inv g n i r e Deliv covery. e visual r ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. All other brand/product names are trademarks of their respective owners. © Bausch & Lomb Incorporated. SUR/INC/13/001 ENG

Glaucoma Day ESCRS PROGRAMME

Amsterdam, The Netherlands

Friday 4th October

Chairpersons:

08.30 – 17.30

F. Topouzis GREECE I. Stalmans BELGIUM

Scientific Programme organised by

Immediately preceding the XXXI Congress of the ESCRS Scientiﬁc programme organised by European Glaucoma Society The Glaucoma Day registration fee is €150.00 plus 21% VAT 14.00

SURGERY IN GLAUCOMA (PART 1) Chairperson: K. Barton UK Moderators: A. Hommer AUSTRIA, I. Stalmans BELGIUM

08.30

Breakfast and Registration

09.00

C. Traverso ITALY, PRESIDENT OF EGS Welcome and introduction

B. Cvenkel SLOVENIA Place of ALT/SLT

09.05

GLAUCOMA BURDEN Chairperson: A. Tuulonen FINLAND Moderators: J. Jonas GERMANY, J. Garcia Feijoo SPAIN

P. Denis FRANCE Preventing and ﬁxing common complications of ﬁltration surgery K. Barton UK Trabeculectomy vs tube drainage devices

A. Azuara Blanco UK The burden of glaucoma on patients and society: direct and indirect costs

T. Shaarawy SWITZERLAND Minimally invasive glaucoma devices: what is the evidence?

A. Tuulonen FINLAND Optimizing surveillance and treatment of OHT and glaucoma C. Webers THE NETHERLANDS End-of-life visual impairment in glaucoma patients 09.55

A CHALLENGE TO THE IOP CONCEPT Chairperson: F. Topouzis GREECE Moderators: A. Hommer AUSTRIA, I. Stalmans BELGIUM

P. Agrawal UK The role of cyclodestructive procedures 15.30

Break

15.50

SURGERY IN GLAUCOMA (PART II) Chairperson: C. Webers THE NETHERLANDS Moderators: A. Azuara Blanco UK, J. Garcia Feijoo SPAIN

S. Miglior ITALY Ocular risk factors for glaucoma

J. Thygesen DENMARK The prevalence of angle closure in Europe

F. Topouzis GREECE Non-ocular risk factors for glaucoma

G. Gazzard UK The diagnostics of angle closure

J. Jonas GERMANY CSF and glaucoma

K. Tjia THE NETHERLANDS Problems of cataract surgery in glaucoma

M. Iester ITALY How can alternatives to Goldmann tonometry help in understanding and managing glaucoma?

C. Traverso ITALY Clear lens extraction in glaucoma J. Salmon UK Combined vs separate cataract and glaucoma surgery

L. Quaranta ITALY How many IOP measurements do we need to make clinical decisions? 11.20

Break

11.40

MEDICAL TREATMENT Chairperson: J.P. Nordmann FRANCE Moderators: J. Thygesen DENMARK, M. Iester ITALY

J. Garcia Feijoo SPAIN Primary surgeries for secondary glaucomas 17.30

End of session

Available Online: Registration and Hotel Bookings

www.escrs.org

F. Meier-Gibbons SWITZERLAND Beneﬁt and cost of preservative free medications in glaucoma J.P. Nordmann FRANCE Quality of generic drugs: equivalent to originals? H.J. Beckers THE NETHERLANDS Does patients’ knowledge about glaucoma improve care? 12.30

Lunch

12.45 – 13.45 Moderators: K. Barton UK, T. Shaarawy SWITZERLAND

Satellite Meeting

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Update

GLAUCOMA

The moment eye care data management gives you more time for your patients. This is the moment we work for.

KERATOPLASTY

Global trend is towards EK and ALK, but PK will remain a force by Howard Larkin in San Francisco

orneal transplantation worldwide is shifting from conventional penetrating keratoplasty (PK) to emerging selective lamellar procedures including anterior lamellar keratoplasty (ALK) and endothelial keratoplasty (EK). However, PK will continue to play a major role, especially in developing countries, Donald Tan MBBS, FRCSE, FRCSG, FRCOphth, FAMS told a Cornea Day session at the 2013 American Society of Cataract and Refractive Surgery (ASCRS) annual symposium. “Major centres around the world are embracing EK and ALK surgery, and lead the way to the future of corneal transplantation. The lamellar revolution holds great promise,” said Dr Tan, medical director of the Singapore National Eye Centre, chairman of the Singapore Eye Research Institute and president of the Asia Cornea Society. He noted, though, that adoption rates vary significantly by region and country. Differing clinical indications, procedure difficulty, outcomes questions, cost, reimbursement policies and availability of suitable donor tissue all appear to influence selective lamellar keratoplasty adoption. Dr Tan based his assessment on a comprehensive review of peer-reviewed literature as well as data from national registries, eye banks and major corneal transplant centres around the world. While the data are spotty due to inconsistent reporting, and in some cases ambiguous due to lack of uniform diagnosis definitions, they show a clear trend towards greater reliance on both EK and ALK. Some of the more complete data come from developed countries, Dr Tan said. “What is really taking the US and other developed countries by storm is endothelial keratoplasty.” In 2011, EK, including Descemet’s stripping automated endothelial keratoplasty (DSAEK), and Descemet’s membrane endothelial keratoplasty (DMEK), already accounted for 40 to 50 per cent of corneal transplants in Europe, the US and Singapore. Data from larger centres in Japan, Russia Saudi Arabia and elsewhere reflected similar adoption trends. Advantages of EK include better vision with less astigmatism, shorter recovery time, less rejection, potentially longer graft survival and potentially less endothelial cell EUROTIMES | Volume 18 | Issue 9

loss. However, significant challenges exist to global adoption of EK, particularly in developing countries, Dr Tan said. It is still a new procedure, requiring training and simply overcoming inertia. Cost is an issue. As a result, PK remains the predominant transplant procedure in developing Asian countries, ranging from 96 per cent in the Philippines to 89 per cent in India and 68 per cent in China’s Tongren Prefecture, though procedure volume is growing, Dr Tan noted. “In the industrialised countries we are at about 50 per cent adoption and the developing countries are at a slightly lower aspect of the [adoption] curve.” Also, developing countries see more endstage severe disease unsuitable for DSAEK, meaning PK is likely to continue playing a larger role, he added. Overall, ALK adoption lags that of EK, in part because indications for ALK are less common, Dr Tan noted. But while developed countries clearly lead the way in EK adoption, ALK is gaining ground quicker in some developing countries. Nationally, Singapore, Brazil and Italy stand out as mature adopters, with ALK at about 25 per cent of all corneal transplants. Major centres in China and Saudi report similar rates, Dr Tan said. UK, Australia, Hong Kong and India are in the seven per cent to 12 per cent range, while most other countries, including the US, Italy and Germany, are further behind at two per cent to five per cent. ALK benefits include lower graft rejection rates, a stronger eye after surgery, donor advantage in that high density endothelium is not needed, better graft survival, and good visual results with big-bubble and other procedures that leave minimal stoma behind. Challenges to ALK adoption include difficulty of the procedure, Dr Tan said. The procedure takes longer and there are reimbursement issues that may be limiting uptake in the US. Dr Tan noted that in Singapore, PK dropped from about 87 per cent of corneal transplants in 2003 to just 27 per cent in 2012, with DSAEK/DMEK growing to 44 per cent and ALK/DALK to 28 per cent. Similar progressions can be observed globally in eye bank data, and he expects the trend towards selective lamellar keratoplasty will continue as procedures mature and practice catches up with the evidence.

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Update

OCULAR

DIFFICULT CHOICES

In the first of a new series looking at how the recession is affecting European eye care, EuroTimes looks at the present state of French ophthalmology by Dermot McGrath in Paris

n international research centre recently concluded that, “no European country is becoming more dispirited and disillusioned faster than France.” High unemployment, non-existent growth and crippling public debt levels have all contributed to a mood of doom and gloom in Europe’s second-largest economy. France’s 5,500 ophthalmologists have been feeling the impact of this crisis, albeit less drastically than many other industries and professions. As Richard Gold MD, an ophthalmologist in Le Raincy notes, the shortage of ophthalmologists in France has helped to cushion the profession from the worst effects of the economic crisis. “Despite the fact that the situation is getting undoubtedly worse for doctors, with less income per patient, rising costs, increasing workload and excessive

interference from the government, ophthalmology is still a profession where there is no unemployment,” he said. This relative stability in a volatile job market is reflected in the annual survey of French cataract and refractive surgeons that Dr Gold has conducted for the past 16 years. Interestingly, the percentage of respondents who said that they would opt to study medicine again, and in particular ophthalmology, has remained consistently high over the past five years. Similarly, the percentage of ophthalmologists who would advise their children to study medicine has actually increased in recent years, perhaps reflecting the sense that medicine represents a refuge or safe bet in times of economic precarity.

Urgent action Less positive, however, is the progressive ‘greying’ of French ophthalmologists reflected in Dr Gold’s

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survey, with a large percentage heading towards retirement age in the next 10 years. As far back as 2004, ophthalmologists such as Jean-Luc Seegmuller, then president of the National Union of French Ophthalmologists (SNOF), warned authorities that ophthalmology in France was reaching a “critical moment in its history” and that “urgent action” was needed to avert a looming crisis. Almost a decade later, the predicted crisis has now taken concrete form, with waiting times of up to six months or longer to see an ophthalmologist in some regions. “Half of the current crop of ophthalmologists are over 55 years of age, and for Paris alone we will see around 800 ophthalmologists taking retirement in the next 10 years,” Jean-Bernard Rottier MD, current president of SNOF, told EuroTimes. Part of the demographic problem stems from a decision by the French government in 1986 to put a ceiling on the number of medical specialists emerging from training colleges each year. With regular pleas to increase the quota for ophthalmology ignored, the restrictions will result in a drastic culling of the ranks of French ophthalmologists from 5,500 today to around 4,000 in 2020. For Dr Rottier, the inaction of successive governments stems from a deliberate policy to undermine ophthalmologists’ traditionally dominant position in the French health system. “There seems to be a mindset which thinks that it would be a good thing to have fewer doctors, because that would force the profession to delegate more of their tasks to the paramedical professions, as has happened in the United Kingdom and Switzerland,” he said. Furthermore, as Dr Rottier sees it, the profession of ophthalmology is not well understood by the authorities. “We are typically perceived as specialists who just prescribe glasses or contact lenses, which is not particularly glorious, and hence can be readily replaced by opticians which will cost less money to the State. The other predominant image is that of the technical ophthalmologist who performs LASIK, but which represents only a fraction of our profession. Unfortunately, the medical aspect of our work, which is on the increase, is not sufficiently highlighted and this serves

“

There seems to be a mindset which thinks that it would be a good thing to have fewer doctors… Jean-Bernard Rottier

to downplay our critical role in the ocular health of the population,” he said.

Twofold solution To tackle the shortage of ophthalmologists, SNOF proposes a twofold solution: first, increasing the number of ophthalmologists trained in French medical schools, and secondly, delegating more tasks to orthoptists, the “natural collaborator” of ophthalmologists in France. In the French medical system, ophthalmologists traditionally work closely with orthoptists who can provide additional examinations, such as visual field tests, strabismus or low vision aid rehabilitation, and also opticians who provide glasses and contact lenses upon medical prescription. The proposal to delegate more tasks to orthoptists comes at a time when the French Minister of Health, Marisol Touraine, is considering the increasingly vocal claims of optometrists to formally recognise their own profession. Optometry currently has no official status under French health regulations and ophthalmologists believe that optometrists should not be allowed to operate as quasimedical practitioners. “Recognising optometry will be a catastrophe,” argues Dr Rottier. “Our concern is that it will upset the current system of ocular care to such a degree that patients will be confused by the change. Where will this new profession fit in with the current place of orthoptists and ophthalmologists who have worked successfully hand-in-hand for generations with no problems?” he asked.

contacts Richard Gold – rg@ophtalmo.net Jean-Bernard Rottier – jbr@ophtalmo.net

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News

charities

COMMUNITIES By making a donation to the ESCRS-sponsored

Beautifully crafted T

charities, ESCRS members are supporting healthcare projects in the developing world he ESCRS continues to support its charities Oxfam and ORBIS with two projects that will empower local communities. The initiative, first launched by the then ESCRS president Jose Guell in 2011 has been continued during the presidency of Dr Peter Barry. Thanks to the generosity of ESCRS members and delegates attending the ESCRS congresses and winter meetings, more than €70,000 has been donated by the society to ORBIS and Oxfam.

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EUROTIMES | Volume 18 | Issue 9

ORBIS Gondar Project ORBIS has worked in Ethiopia for over 14 years to implement a model for comprehensive rural eye care. Since 2011 ESCRS has supported ORBIS to develop a Paediatric Eye-Care Centre in Gondar Hospital. ESCRS funds have gone towards training resident ophthalmologists in sub-specialties such as paediatric cataract and glaucoma in order to be able to treat a wide range of paediatric eye conditions. The latest installment of this training took place in October 2012 when ORBIS conducted a week-long hospital-based programme in Gondar. In a video which was recently posted on the ESCRS website, ORBIS volunteer and paediatric ophthalmologist Dr Donny Suh can be seen giving hands-on training to Dr Mulusew Asferaw, the head of the Paediatric Eye Care Unit at Gondar. Dr Suh said that the trainees in Ethiopia would have access to videos and the Internet, but this did not compare with the trainees and their teachers working together in a close hands-on setting. On the first day of training, Dr Suh screened and selected some of the complicated cases that Dr Asferaw would not be able to manage himself. On the following four days, Dr Asferaw carried out surgeries on the patients under Dr Suh’s supervision. Dr Asferaw said hands-on training was very important. “It is not theoretical, it is a skill transfer and I can observe, assist and carry out some of the steps.” The video, which is three minutes long, was photographed and produced by Geoff Oliver Bugbee for ORBIS International. The ORBIS video is available at: http:// www.escrs.org/charitable-donations/newsupdates.asp.

Oxfam Congo Project ESCRS has helped to prevent the spread of diseases such as cholera, trachoma and conjunctivitis in the North Kivu area of the Democratic Republic of Congo (DRC) by donating to an Oxfam project which is developing new sustainable water supplies and empowering communities to manage these resources through training schemes and public health initiatives. The devastating impact of 20 years of conflict between armed rebels and the government in DRC is largely forgotten by the world. The brutal conflict has claimed the lives of millions and has caused countless mass movements of people within the country and across its borders. The lives of these displaced people have been impacted on an ongoing basis – children have been unable to attend school, food shortages and malnutrition are widespread and healthcare, water and sanitation facilities are widely insufficient leading to many deaths from preventable diseases. Families living in safer areas take in large numbers of people, placing additional strain on their own resources. The coverage of clean drinking water in the DRC is estimated at 24 per cent, while sanitation is estimated at only nine per cent. Thanks to ESCRS, Oxfam and its WASH partners can improve the health of women, men and children forced to flee their homes to live in camps, and of host communities with limited access to clean drinking water. Oxfam Ireland’s chief executive Jim Clarken said: “The generosity of ESCRS members and the ESCRS Board has helped to deliver real change to the communities in the Lubero and Beni territories of North Kivu. By supporting Oxfam and our partners in the Water, Sanitation and Hygiene Promotion (WASH) project, ESCRS has provided effective and sustainable water sources for communities affected by conflict”. * To support ORBIS and Oxfam visit www.escrs.org/charitable-donations

18TH

ESCRS Winter Meeting In conjunction with the Slovenian Society of Cataract & Refractive Surgery

Ljubljana, Slovenia

14-16 February 2014 More information coming soon

www.escrs.org

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS

News

ESASO

PLAN YOUR CAREER ESASO provides continuing training for ophthalmologists to help develop their careers

he European School for Advanced Studies in Ophthalmology (ESASO) was founded in 2008 to offer master’s programmes to European ophthalmologists and provide them with specific continuing training to develop their careers and personal networks. This unique institution is supported by various prestigious universities and hospitals. Through its teaching model, it seeks to impart ophthalmic knowledge effectively with a combination of didactical classes and practice where internationally recognised surgeons show participants how to deal with practical situations and real problems. EuroTimes spoke with the president of the ESASO Foundation, Giuseppe Guarnaccia, MC, Italy. How is an ophthalmologist’s training structured at ESASO? ESASO’s training programme consists of various modules covering all ophthalmic specialities: retina, cornea and refractive surgery, glaucoma, oculoplastics, strabismus and paediatric ophthalmology. At the end of the training, the participants receive their Diploma Specialist Superior in Ophthalmology (DiSSO). Participants can also apply for a master’s programme, the Fellowship, at one of ESASO’s collaborating centres. What does it mean for Fellows to be selected for the ESASO Fellowship’s programme? Firstly, not only is it an opportunity for the participants to learn at a leading ophthalmology centre, but ESASO also funds the Fellowships to cover the costs of their year-long studies. Secondly, it is a strong career indicator to leverage themselves on an international level and among competing colleagues. Thirdly, the expansion of the personal professional network is key to advancement.

Which are the ophthalmology centres that collaborate on ESASO’s Fellowships? In cornea and refractive surgery, we have the support of the University of Barcelona. In retina, our graduates can choose to study a master’s at IMO (Spain), The San Raffaele University Hospital in Milan (Italy), the Ludwig-Maximilians University (LMU) 08_1307_12 ESASO_Anz_EUT_120x300_Sept_RZ.indd EUROTIMES | Volume 18 | Issue 9

04.07.13 22:27

in Munich (Germany), the University Clinic at Vienna General Hospital (Austria), the Tel Aviv Medical Center (TLVMC) & Sackler Faculty of Medicine in Israel, or the Institute of Ophthalmology & Visual Science, UMDNJ-New Jersey, USA. Recently we have introduced a Clinical Product Development Fellowship that will be available at various institutions and will take two years. Last but not least ESASO offers a Visiting Fellowship, a four-week hands-on training in cataract surgery at the L V Prasad Eye Institute in Hyderabad, India.

“

Our objective and aim is to build our own high-quality laboratory, wet lab and robotics department... Giuseppe Guarnaccia

ESASO certainly seems to be getting itself an international reputation. Is the programme accredited yet? ESASO works closely with a number of high-level ophthalmic institutions, and is supported by Europe’s major ophthalmological societies: the European Society of Cataract and Refractive Surgeons, EURETINA, the European Glaucoma Society and the Association for Research in Vision and Ophthalmology. Further, ESASO is in the process to gain accreditation for its training programme from the Bologna convention. We expect to have further information by the end of the year. What are ESASO’s plans for the future? Our objective and aim is to build our own high-quality laboratory, wet lab and robotics department among other things. We are working towards achieving this goal within the next two years.

E R IP FR EA SH ES 3 Y BER INE A EM R M RT FO

ESCRS

Meet the experts From Concept to Commercial Product – An Entrepreneur’s Story John Marshall

Building your own practice

Assumptions and truths

Growing a Small Ophthalmological Practice Arthur Cummings

Re-Inventing a Large Eye Clinic Thomas Kohnen

Medicine, Marriage and Motherhood Eva-Maria Kohnen (pictured right) & Ina Conrad-Hengerer

Measuring performance

From Small to Big – A Personal Voyage Manfred Tetz

What they Don’t Teach you in Medical Training About the Business of Healthcare

ESCRS

Practice Management

Weekend 2013

1–3 November

Paul Ursell

The Perfect/Imperfect Boss Kris Morrill

Analyse Your Practice Position by Setting Clear Targets Eckhard Weingaertner

Frankfurt, Germany

Managing a Directorate Paul Rosen

How Medical Marketing Can Help Build a Thriving Clinic Rod Solar

€300 Registration fee Discounts available for additional practice members

News

registry

FLACS STUDY

New registry-based study to compare femto cataract surgery with conventional phaco by Roibeard O’hEineachain in Verona

he ESCRS has launched the first study to directly compare the outcomes of femtosecond laserassisted cataract surgery (FLACS) with the outcomes achieved in standard phacoemulsification, Paul Rosen FRCS, Oxford, UK told Femto 2013, an international meeting on anterior segment surgery. “This study will provide the first opportunity to evaluate the outcomes of femto-phaco in a coordinated, multinational study and provide comparison with matched patients undergoing routine phaco,” Dr Rosen said. The study will utilise the EUREQUO platform (www.eurequo.org) which was developed by the ESCRS and co-financed by the EU in 2008. The FLACS study is being funded entirely by the ESCRS without the participation of industry. Dr Rosen emphasised that this study is not a clinical trial. The study will compare the outcomes of two different treatment groups in terms of visual acuity, surgically induced astigmatism, complications and biometric error. Individual surgeons, clinics and patients are anonymous in the database to facilitate honest reporting. The outcomes of FLACS will be compared with control cases from the EUREQUO database. “There has been a gradual development of the use of lasers in cataract surgery and we now have a platform, a principal way of delivering the laser which looks like it's here to stay, and the question we want to answer is, ‘is it better for our patients?’” Dr Rosen said. The control cases in the FLACS study will be randomly selected and will have undergone cataract extractions using conventional ultrasound phacoemulsification technique. They will include twice the number of cases as those undergoing FLACS and will be matched regarding age, gender, preoperative visual acuity and preoperative risk factors. The EUREQUO system has been expanded to include parameters related to FLACS. The FLACS study’s protocol will include mandatory variables in preoperative, surgical and follow-up forms. Each registered case must be saved and completed in the system when all data of the case has been entered. Each participating clinic will provide a registry manager to supervise the study in that clinic and collect the data online. The ESCRS will train the registry manager for this study.

EUROTIMES | Volume 18 | Issue 9

The outcomes data to be entered into the registry will include unaided and bestcorrected visual outcomes at six to 60 days, the difference between target refraction and final refraction, the achieved spherical and cylinder refraction, and complications that occur during surgery and/or within 30 days after surgery. “It is important to remember that all patient and clinic data is anonymous. Each surgeon can have access to their own data, each clinic can have access to its own data, but you can’t see my data and I can’t see your data. The whole of the data can be accessed by the ESCRS but again it’s anonymous,” Dr Rosen said. To avoid bias from a learning curve, all contributing surgeons must have previously completed 50 FLACS. The study will include all available platforms for FLACS but will not identify the platform in the database. “Any femtosecond laser platform can be used but we will not be comparing different platforms, we are comparing the processes of using femto versus ultrasound phaco,” Dr Rosen said. He noted that the ESCRS pioneered the collection of surgical outcome data through its EUREQUO platform. To date, 1,195,998 patient data has been entered into the EUREQUO system from 16 countries and there have been several publications that have appeared in the literature in recent years. “The idea was to improve treatment and standards of care for cataract refractive surgery. We wanted to develop evidencebased guidelines for cataract and refractive surgery across Europe and make a significant impact on the exchange of best practice in relation to patient safety,” Dr Rosen said. The FLACS study will start as soon as all arrangements are finalised. A preliminary report will be released at the XXXII Congress of the ESCRS in London in September 2014. “The invitation is extended to everyone who wishes to participate and be a co-author on the project so we need your help. This will be a unique project using a unique data collection system for what is going to be very exciting,” Dr Rosen added. Those wishing to participate in the FLACS study should contact Carol Fitzpatrick by email: carol.fitzpatrick@escrs.org. ad-half page vertical-Eurotimes-ENG EyeCeeO PRL-1306v03 pva RZ.indd 1

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aser photocoagulation is a crucial therapy for numerous retinal diseases. Photocoagulation involves protein denaturation and is the result of tissue absorption of radiant energy with conversion to heat. The effect of solar light on the retina has been known for centuries. Thus, the history of retinal photocoagulation dates to 400 BC, when Plato described the dangers of viewing the sun directly during an eclipse. The first description of a central scotoma following solar burn of the macula dates back to Theophilus Bonetus, who practised in Geneva during the 17th century. It was the observation of this phenomenon that inspired the earliest experimental research on fundus photocoagulation. Both Czerny and Deutschmann, in 1867 and 1882, respectively, used a concave mirror and a convex lens to focus sunlight through dilated pupils of rabbits, creating thermal burns in the animals’ retinas. In 1927, Maggiore performed the first experimental photocoagulation of the human retina focusing sunlight for 10 minutes into an eye that was to be enucleated because of a malignant tumour. In 1945, the Spanish ophthalmologist José Morón had the idea to close retinal tears using a light source through the pupil to produce a retinal burn similar to that of diathermy. However, although this first known experience of retinal therapeutic photocoagulation appeared in his doctoral dissertation (Madrid 1946), the results were not published until 1949. In the meantime, the German ophthalmologist Gerd Meyer-Schwickerath (1920-1992) conceived the idea of using photocoagulation to make burns in the retina to seal holes and prevent retinal detachment. He was developing a diathermy machine to treat retinal detachment while he was supervising a medical student who had received a macular burn from the 1945 solar eclipse. These circumstances inspired him to develop, in 1947, a sunlight photocoagulator, an instrument of mirrors and lenses that used sunlight. He later included a heliostat so the sun would remain within the optical axis of the tool despite the earth’s movement. He had to bring the patient on the roof of the Hamburg Hospital, where the sun shines early. In 1949 he presented his essays about the resolution

of three cases of retinal detachment successfully treated with photocoagulation. Because the system was so weatherdependent, Meyer-Schwickerath began working with other light sources such as a high-intensity carbon arc. This carbon arc photocoagulator was used clinically on several hundred patients between 1950 and 1956. That system was far from perfect, and Meyer-Schwickerath and Littman in conjunction with Zeiss, assembled the first xenon-arc coagulator in 1956. This was used to treat anterior and posterior segment tumours, retinal tears and macular holes, as well as retinal vascular diseases. Since then, Meyer-Schwickerath is considered the father of modern photocoagulation. Although incandescent light utilised by the first photocoagulators was effective and came into widespread use, it lacked precision, required long duration of exposure, was painful and resulted in multiple complications. Therefore, this light source would later be replaced by the invention of the first ophthalmic lasers, which instigated the widespread use of photocoagulation for treatment of retinal diseases. As the first photocoagulators produced light comprised of various wavelengths within the visible and infrared spectrum, full-thickness retinal burns were achieved rather than tissue-specific burns that were later made possible by laser (single wavelength) photocoagulators. The first functioning laser, whose active laser material was a ruby, was invented by Maimann in 1960. It became clear that the laser could be an excellent source for photocoagulation. The first clinical ophthalmic use of a laser in humans was reported by Campbell in 1963 and Zweng in 1964. The ruby laser they employed operated in a pulsed mode because the thermal characteristics of the ruby crystal prohibited continuous operation at the power levels required for retinal photocoagulation. Use of the pulsed laser often led to the formation of retinal haemorrhages and was poorly absorbed by hemoglobin. The argon laser, developed in 1964, provided an emission spectrum that is absorbed well by hemoglobin when it is used in a continuous mode. Later, in 1968, L’Esperance introduced the argon laser which led to the worldwide use of ophthalmic laser photocoagulation.

Review

Book REVIEW

DSAEK with caution

Occasionally, a new technique is developed that forever changes the landscape of a particular subspecialty. For retinal surgery, it was vitrectomy. For cataract surgery, it was phacoemulsification. And for corneal surgery, it can be convincingly argued that Descemet’s stripping automated endothelial keratoplasty (DSAEK) serves that role. DSAEK offers the patient faster visual rehabilitation than penetrating keratoplasty, with limited astigmatism and postoperative complications. Within the 15 years since Gerrit Melles first developed posterior lamellar keratoplasty, DSAEK has come to account for nearly half of all corneal grafts performed in the US. When considered together, bullous keratopathy and Fuchs’ endothelial dystrophy currently form the largest indication for corneal transplantation. Indeed, over the period 2005 to 2008, the Eye Bank Association of America reported a massive increase in the number of endothelial transplants from around 1,400 to over 17,000, while the number of penetrating keratoplasties has decreased from nearly 46,000 to less than 33,000 over the same period. This point has not been lost on the editors of a new text by Jaypee Highlights entitled “Descemet’s Stripping Automated Endothelial Keratoplasty: Different Strokes.” Drs D Cassidy, N Sharma, V Jhanji and R Vajpayee have compiled a thorough guide to the procedure. The text is divided into five sections that proceed chronologically and with increasing complexity from beginning to end. Section 1, “Evolution, Indications, Preoperative Evaluation and Eye Banking” begins with the history of corneal transplantation, which started in 1905 when the Czech Eduard Zirm performed the world’s first successful human corneal transplant. What this first section makes clear, however, is that despite the authors’ assertion that DSAEK is an “easy-toperform, safe, effective and reproducible technique,” the (contra)-indications are of crucial importance, and a detailed preoperative examination is essential. Section 2, “Surgical Techniques and Modifications,” discusses the standard procedure, the instruments needed and the various modifications implemented in particular situations. Chapter 8 is a particularly interesting starting point for the surgeon interested in a proper explanation of the entire procedure. Surgical photographs illustrate every step, including donor preparation. The section continues with discussions of the hitch suture EUROTIMES | Volume 18 | Issue 9

technique; sutureless DSAEK using the Busin Glide; the Tan EndoGlide technique; the Sheet Glide; and ultra-thin DSAEK, which might result in better visual outcomes than standard DSAEK. Once the basic procedure and its common variants have been mastered, the reader can progress to Section 3, “DSAEK in Special Situations.” These include a DSAEK triple procedure as well as DSAEK in aphakic eyes, in eyes with intraoperative floppy iris syndrome (IFIS), in glaucomatous eyes, in paediatric eyes and in eyes that have suffered failed grafts. Section 4, “Outcomes & Complications of DSAEK” describes what the surgeon can expect if the procedure has been performed correctly, as well as what to do when it hasn’t. Chapter 24 covers intraoperative complications such as perforation of the donor cornea by the microkeratome blade and iris prolapse through the corneoscleral tunnel. Chapter 25 covers the most common postoperative complication, early graft dislocation, among others. The last section delineates the future of endothelial keratoplasty, including DMEK. This book is most appropriate for cornea fellows who are learning to perform DSAEK, as well as residents during their cornea rotation. General ophthalmologists, who might see patients with endothelial disease who need a referral to a cornea specialist or who present with postoperative complications, will also benefit from having access to this text.

OCULUS SDI® 4 / BIOM® 5

5 Reasons for the new BIOM® 5 •

Reliability Titanium and stainless steel ensure highest mechanical stability

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Function Short and long versions of the BIOM® 5 support the working distance of choice

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Made to last Excellent resistance to today‘s rigorous sterilization methods

BOOKS EDITOR Leigh Spielberg PUBLICATION PUBLICATION: DESCEMET’S STRIPPING AUTOMATED ENDOTHELIAL KERATOPLASTY EDITORS Dermot Cassidy, Namatra Sharma, Vishal Jhanji, Rasik Vajpayee

Visit us at Euretina, booth H108

PUBLISHED BY JAYPEE HIGHLIGHTS If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

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25.07.2013 18:58:40

Feature

EYE ON TRAVEL

THREE WITH ONE STROKE

With the restoration of Rijksmuseum, all three of Amsterdam’s top museums are open for the first time in a decade by Maryalicia Post

s her last public duty, Queen Beatrix officially opened the restored Rijksmuseum in April of this year. “Restored” is a lame description of what was accomplished in the 10 years it took to do the job. Anyone who remembers Amsterdam's most famous museum from over a decade ago will recall a confused jumble of whitewashed rooms divided on the ground floor into left and right, the museum itself a sort of brick arch astride a public road. So visitors to Amsterdam for the XXXI ESCRS Congress which takes place from 5-9 October can look forward to a special treat. The road still runs through the Rijksmuseum; excavating under the road accounted for a large chunk of the €375m budget and much of the time. The new entrance is now below ground level where a dramatic concourse links the two sides of the building into an impressive whole. The whitewash is gone too, the rooms painted in a rich charcoal that sets off the old masters that are the museum's strong suit. The ceilings and architectural details are again polychrome as they were in 1885 when the building was new. In an innovative presentation, furniture and decorative items are displayed in conjunction with the paintings. Some 30 of the 80 galleries are devoted to Netherlands’ Golden Age – the 17th century – while a new pavilion traces the links between the Netherlands and the Far East. Rembrandt's Night Watch is still the museum's chief treasure (it now has its own trapdoor fire escape). A “Gallery of Honour,” including iconic paintings by Vermeer, lead you to it, a 30-minute immersion in fine art. Following the restoring, rehanging, and reworking, the

Amsterdam film museum, ‘The Eye’

museum expects to double its visitors from one to two million annually. Judging by the queue on the day I visited I believe that's a modest estimate. An e-ticket, Museum Card or ticket bought from a concierge spares you from queuing at the ticket desk, but not from queuing for admission. If time is short, book yourself on one of the Museum tours. Tour ticket holders go right in. Book a tour online at: www.rijksmuseum.nl. The queue for the cloakroom can be daunting; don't carry anything bulky, you will be asked to check it.

VINCENT The Van Gogh museum was closed for seven months and reopened two weeks after the Rijksmuseum. Its opening exhibition, “Vincent at Work,” introduces a Van Gogh we never knew – not the manic artist of legend, but a meticulous craftsman who enjoyed discussions with contemporaries like Lautrec and Gauguin, who worried about achieving correct perspective. We also learn that Van Gogh – who only sold two paintings in his lifetime – took the time to explore ideas about how to best frame and display his work. The museum maps out the artist's way of working in a thoughtful presentation of 140 of his paintings, along with his

Refurbished Van Gogh museum

EUROTIMES | Volume 18 | Issue 9

letters and notebooks. Always on the edge of poverty, Van Gogh carried on in spite of it, sometimes painting on both sides of the canvas. The artist's last palette and the accompanying tubes of paint – crumpled by the artist’s own hand – seem to bring him right into the room. Van Gogh's paintings are displayed against walls of blue, yellow or grey on the ground and first floors, along with 50 works by his contemporaries. The top floors present sketches, drawings and some of the scientific analysis that has, over eight years, revealed that the colours we associate with Vincent today are no more accurate than the character we attribute to him. Most importantly, the unstable red paint he used has faded; the white blossoms Van Gogh painted against the sky for his newborn nephew were originally pink. A new exhibit to be mounted in September hangs two versions of Vincent's Bedroom at Arles with its familiar pale blue walls. An accompanying digital reconstruction will reveal the composition with violet walls – as Van Gogh painted it. For direct entry to the museum at a time of your choosing, buy your ticket online at: www.vangoghmuseum.nl.

The Stedelijk ‘bathtub’ museum

THE STEDELIJK Following a nineyear-long makeover, Amsterdam's redbrick contemporary museum has an inviting new entrance on the Museumplein. The glassfronted entry is tucked under a 100-metrelong overhang, a white fibre composite construction promptly and aptly nicknamed “the bathtub.” And why not? Duchamp's Fountain, a urinal, is one of the most influential pieces of modern art of all time. Above ground, the new addition has a cafe at one end and huge bookshop at the other. Underground, the addition provides “Amsterdam's largest black box space” and room for video installations; upstairs there's expanded gallery capacity. The walls behind modern Masters like Matisse, Picasso, Mondrian and Chagall, are painted white. Compared to the warm-hued walls in the Rijksmuseum and the Van Gogh, this seems oddly old-fashioned. The Beanery, a large-scale installation by Edward Kienholz, was meticulously restored while the museum was closed. Visitors enter this life-sized recreation of a celebrated Los Angeles eatery one at a time, to spend a moment with customers and barman, jukebox and menus, frozen in time one day in 1964. For details, visit: www.stedelijk.nl. THE EYE Amsterdam's newest museum, dedicated to films, seems to float on the water behind Central Station like a mammoth folded paper airplane. To reach The Eye, take a three-minute ride on a free ferry from the station followed by a threeminute walk. Once there, have a meal, watch a film, or simply enjoy the view of Amsterdam’s skyline from the bar/cafe/ restaurant. It’s open late, and the ferry runs around the clock seven days a week. Find out what’s on and more information about tickets at: www.eyefilm.nl.

Rijksmuseum – a road runs through it

Review

OPHTHALMOLOGICA

Protein deposits a factor in visual loss The thickness of subfoveal protein deposits in eyes with acute central serous retinopathy (CSR) appears to have a significant impact on patients' vision, according to a new study. In 38 patients with CSR, highresolution spectral domain optical coherence tomography (SD-OCT) showed a significant correlation between the subfoveal thickness of the Protein deposit layer and visual acuity at baseline (r = 0.60, p ≤ 0.001) and upon resolution of the condition (r = 0.45, p = 0.008). n G

Landa et al, “Ophthalmologica, Quantitative and Qualitative Spectral Domain Optical Coherence Tomography Analysis of Subretinal Deposits in Patients with Acute Central Serous Retinopathy”, 2013 (DOI:10.1159/000350231)

AMD patients maintain good social functionality and mental health Elderly patients with bilateral age-related macular degeneration (AMD) tend to have a considerable disability in their day-to-day life but are nonetheless able to maintain a good social functionality and good mental health, according to the findings of a patient-reported outcome survey of affected patients. In their responses to the 25-item National Eye Institute Visual Function Questionnaire (NEIVFQ-25), their overall mean score was 57.89. In addition, in the NEIVFQ-25 subscales there were significant correlations (p ≤ 0.05) between corrected distance visual acuity and role limitations (r = -0.40), social function (r = -0.48) and mental health (r = -0.38).

according to the results of a trial involving 20 patients. The technique involves suctioning the outer margin of the precortical vitreous pocket with a vitreous cutter. That, in turn, creates a small break in the posterior hyaloid membrane which rapidly enlarges, resulting in a posterior vitreous detachment. In addition, a wideangle viewing system and intravitreal injection of triamcinolone acetate are used to enhance visualisation of the vitreous cavity. The study’s authors noted that the technique enabled them to induce posterior vitreous detachments in the patients' eyes while maintaining a good distance from the optic disc and macula. n T.

Sato et al, Ophthalmologica, “Modified Technique for Inducing Posterior Vitreous Detachment through the Posterior Precortical Vitreous Pocket during Microincision Vitreous Surgery with a Wide-Angle Viewing System”, 2013, DOI:10.1159/000351655

Staining with brilliant blue G facilitates macular hole surgery Using the stain brilliant blue G (BBG) to enhance visualisation of vitreoretinal anatomy during limiting membrane peeling in macular hole surgery may increase safety and improve the visual outcome in eyes undergoing macular hole surgery, according to the results of a retrospective study. It showed that in 20 eyes that underwent BBG-assisted macular hole surgery, there was primary macular hole closure after a single surgery in 17 and, at six months' follow-up, mean logMAR visual acuity improved from a baseline value of 0.7 to 0.2 (p < 0.01). n J Lüke

et al, Ophthalmologica, “Morphological and Functional Outcome after Brilliant Blue G-Assisted Macular Hole Surgery”, 2013, DOI:10.1159/000351658).

n A

López-Miguel et al, “Patient-Reported Outcomes in Spanish Patients Diagnosed with Bilateral Age-Related Macular Degeneration” Ophthalmologica 2013 (DOI:10.1159/000351652)

A new technique to induce posterior vitreous detachment A simple 25-gauge microincision technique for inducing vitreous detachment in patients with macular holes appears to be effective and is possibly safer than the conventional vitrectomy approach, EUROTIMES | Volume 18 | Issue 9

José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA ad-Eurotimes-1/2 hoch-1301v2-pva RZ.indd 1

10.01.13 10:05

Review

JCRS Symposium Questions for the Cataract–Refractive Surgeon in 2013 Sunday, October 6, 2013 14:00–16:00

Chairs:

Emanuel S. Rosen, MD, FRCSEd Thomas Kohnen, MD, PhD, FEBO Will Femtosecond Laser–Assisted Cataract Surgery Represent a Real Paradigm Shift in Future Cataract Surgery? H. Burkhard Dick, MD, PhD, David F. Chang, MD Is Excimer Laser Treatment of Suspected Keratoconic Eyes Justified? Noel Alpins, MD, FACS, David R. Hardten, MD What Is the Best Solution for Presbyopic Cataract or RLE Eyes? Hiroko Bissen-Miyajima, MD, Graham Barrett, MD

During the XXXI Congress of the ESCRS, Amsterdam, The Netherlands

EUROTIMES | Volume 18 | Issue 9

JCRS Highlights Journal of Cataract and Refractive Surgery

PC phakic IOLs Phakic intraocular lenses (IOLs) provide a method to correct moderate to high myopia for patients who may not be appropriate candidates for keratorefractive procedures. Each of the three types of phakic IOL – angle-supported, iris-claw anterior chamber and posterior chamber (PC) – comes with its own problems. How well do PC phakic IOLs do in the longer term? German researchers conducted a retrospective cohort study of 53 eyes with a mean SE of −12.17 D looking at the safety and efficacy of these lenses. The mean age of patients was 34.6 years and the mean follow-up was 86 months. The mean UDVA improved from 1.37 ± 0.28 logMAR preoperatively to 0.14 ± 0.19 logMAR at the last postoperative visit (P<.05). The mean CDVA improved from 0.10 ± 0.18 logMAR to −0.01 ± 0.09 logMAR (P<.05). The overall mean efficacy index and mean safety index were 0.9 and 1.21, respectively, at the last follow-up visit. The mean endothelial cell loss at the last follow-up was 6.4 per cent. The complications were slight posterior chamber decentration (five eyes, 9.4 per cent), severe decentration resulting in phakic IOL removal (one eye, 1.8 per cent), glaucoma (four eyes, 7.5 per cent), clinically significant cortical lens opacification resulting in cataract surgery (four eyes, 7.5 per cent), clinically asymptomatic anterior subcapsular cataract formation (six eyes, 11.3 per cent), and retinal detachment (two eyes, 3.8 per cent). n Torun

et al., JCRS, Posterior chamber phakic intraocular lens to correct myopia: long-term follow-up Volume 39, No. 7, 1023-1028.

Diffractive multifocal toric IOL series The presence of preoperative astigmatism in eyes with diffractive multifocal IOLs compromises visual acuity outcomes. Techniques to correct corneal astigmatism include limbal relaxing incisions, opposite clear corneal incisions, corneal photoablative refractive procedures, femtosecond laser–assisted astigmatic keratotomy and toric IOL implantation. Portuguese researchers conducted a study of the latter option in 19 patients with cataract and corneal astigmatism between 0.75 D and 2.50 D who had phacoemulsification with implantation of an AcrySof IQ ReSTOR toric IOL. Predictability of refractive results was good, with an SE refraction within ±0.50 D of the attempted spherical correction in 33 eyes (87 per cent). Results were good for distance, intermediate and near. The mean toric IOL axis rotation was 2.97 ± 2.33 degrees. One eye required a second surgery to align the IOL axis. Ocular aberrometry and dysphotopic phenomena

results were similar to those published for the non-toric version of the toric IOL. All patients were able to achieve complete spectacle independence. n TB

Ferreira et al., JCRS, “Visual and optical outcomes of a diffractive multifocal toric intraocular lens”, Volume 39, No. 7 10291035.

Multifocals compared As the number of multifocal IOLs on the market continues to increase, so does the difficulty in conducting meaningful comparisons. Researchers compared nine IOL types (AcrySof ReSTOR +3.0 D SN6AD1, AcrySof ReSTOR +4.0 D SN60D3, AcrySof aspheric monofocal SN60WF, Acri.Lisa 366D, Finevision Micro F, Tecnis ZM900, and ReZoom, Diffractiva Diff-s, and Lentis Mplus +3.0 D) using the same optical bench that complies with International Organization for Standardization standard 11979 requirements. The through-focus modulation transfer functions (MTFs) were compared, and the image of the United States Air Force (USAF) target was taken while each IOL was at far, intermediate and near focal points. The through-focus MTF of the trifocal IOL showed a peak in the intermediate range that was not present with monofocal and bifocal IOLs. The USAF target images showed similar resolution with all IOLs for far focal points. Diffractive IOLs showed better resolution for near focal points, and the only sharp image in the intermediate range was obtained using the trifocal IOL. The researchers noted a significant difference in the degree of near, intermediate and distance quality of the image with the various types of multifocal IOLs in vitro. n D

Gatinel et al, JCRS, “Comparison of bifocal and trifocal diffractive and refractive intraocular lenses using an optical bench”, Volume 39, No. 7,1093-1099.

Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

EPOS/WSPOS European Paediatric Ophthalmological Society / World Society of Paediatric Ophthalmology & Strabismus

PAEDIATRIC SUB-SPECIALTY DAY Organisers: Nicoline Schalij-Delfos, Marije Sminia, David Granet, Ken K Nischal

WEDNESDAY 9 OCTOBER 2013 08.30 – 17.15

During XXXI Congress of the ESCRS 5–9 October 2013 Amsterdam RAI, Amsterdam, The Netherlands

Immediately preceding The 39th Meeting of EPOS in Leiden, The Netherlands from 11–12 October 2013

www.wspos.org for Registration and Hotel Bookings

A View Through the Child’s Eyes SESSION I: Paediatric ocular surface disease

SESSION II: Visual rehabilitation of the aphakic child

SESSION III: Novel therapies in glaucoma: can we use them in children?

D. Bremond-Gignac FRANCE

Chr. Lloyd UK

L.J. van Rijn THE NETHERLANDS

Incidence and management of BKC in children? N. Schaeken BELGIUM

My choice for a secondary IOL in the presence of capsular support

The role of axial length in the decision to operate on paediatric glaucoma

The use of steam goggles in BKC in children

N. Schalij-Delfos THE NETHERLANDS

K.K. Nischal UK/USA

A. Mataftsi GREECE

Trabectome

Punctal plugs in children: are they safe?

Choices for IOL implantation when there is inadequate capsular support

M. Fernandes INDIA

M. Sminia THE NETHERLANDS

An illuminated microcatheter for 360 trabeculotomy

The use of the iris claw IOL for the correction of aphakia

M. Tekavčič Pompe SLOVENIA

N. Ziakas GREECE

S. Biswas UK

Microsporidia and exotic infections in children W. Moore UK

Keratitis: common and not so common causes P. Nucci ITALY

Limbal vernal kerato-conjunctivitis S. Jones UK

What is the normal tear break up time in children? S. Hamada UK

Can we use Avastin in children with corneal NV’s? A. van der Lelij THE NETHERLANDS

Cross-linking in children

Retroplacement of the secondary IOL in children

C. Eggink THE NETHERLANDS

Aphakic and pseudophakic glaucoma

J. Murta PORTUGAL

Endoscopic cyclophotocoagulation vs high frequency ultrasound guided cyclophotocoagulation

Can we implant infants safely?

E. Gajdosova UK

J. Tjeerd de Faber THE NETHERLANDS

Goniotomy for aphakic glaucoma

Clear visual axis after surgery for Pseudo-Peters / PHPV

E. da Silva PORTUGAL

D. Granet USA

V. Sturm SWITZERLAND

Visual rehabilitation of the child with JIA and aphakia

The role of nanoparticles in paediatric glaucoma Hints and tricks about OCT use in paediatric glaucoma

C. Vervaet THE NETHERLANDS

10 Essentials about the paediatric CL

VIDEO VENTURE

C. Luchansky USA

10 videos of 5 minutes each showing a sign or surgical experience of a classical or unusual nature. The audience will be asked to vote on best video.

Using BIFOCAL CL’s in the aphakic child C. Frambach THE NETHERLANDS

Paediatric CL’s: how to handle the parents

SYMPOSIUM & CONGRESS

2014

APRIL 25–29 BOSTON

Additional Programming Cornea Day ASCRS Glaucoma Day ASOA Workshops Technicians & Nurses Program

Call for Submissions

August 15–September 25, 2013 www.ascrs.org

Feature

PRACTICE DEVELOPMENT

new dimension

LOOKING FOR A NEW PREMIUM OFFER?

ESCRS Booth K05 Hall 1

ALSANZA, German manufacturer of medical and pharmaceutical liquids, extends its activities to Surgical Ophthalmology, focusing on:

The ESCRS Practice Development Committee will host two major meetings this year by Colin Kerr

IOLs

his is the sixth year of the ESCRS Practice Development programme and as Kris Morrill of medeuronet points out, the programme has gone from strength to strength. As well as presenting at the practice development workshops, Ms Morrill has worked as a consultant for the ESCRS Practice Development Committee, helping to select speakers and advise on topics of interest to ophthalmologists who want to improve their business skills. “Going into the first practice development workshop at the ESCRS in 2008 in Berlin, what was foremost in my mind was if we would be presenting to an empty room,” said Ms Morrill. “We knew that there was a need for providing European ophthalmologists with practice and business development advice, but the question remained as to whether attendees would show up. They did – packing the room over the course of the programme – and that has continued to this day.” Over the last six years, the Practice Development Committee, chaired by Paul Rosen, has evolved the content to reflect how medical practice is changing and how healthcare is delivered, while also emphasising the need for ophthalmologists to be thinking in management and business terms. The addition three years ago of the Practice Development weekends, held outside the main ESCRS Congress, has also provided a new dimension.

International dialogue

“Perhaps the thing that has surprised me most over the past five years is how the attendance has become very international,” said Ms Morrill. “In 2012 in Milan, we had ophthalmologists from India and Australia sitting alongside ophthalmologists from eastern and western Europe, as well as North and South America. The dialogue that goes on between the attendees and the exchange of ideas that takes place is one of the most rewarding aspects of the workshops,” she said. “In addition, there are the attendees who return a year later to talk about changes that they have implemented in their practices since we last met – eager to share their experience with colleagues,” said Ms Morrill.

ESCRS Amsterdam

The sixth ESCRS

EUROTIMES | Volume 18 | Issue 9

Practice Development programme takes place at the XXXI ESCRS Congress in Amsterdam, The Netherlands. The programme begins on Sunday October 6 and concludes on Monday October 7. Among the topics to be discussed are Establishing Quality Processes in Your Practice, Basic Business Skills for Young Ophthalmologists, Employers and Employees Rights. The keynote lecture on the first day will come from Carroll Webers and Rudy Nuijts, The Netherlands, who will tell delegates how building and designing a new office for their ophthalmological practice helped them improve efficiency and attract new patients. On Monday October 7, the programme continues with advice on Marketing Pearls for Ophthalmologists, Getting the Right Marketing Mix for your Practice and Internet Marketing. Full details of the programme are available at: http://escrs.org/ amsterdam2013/programme/practicedevelopment.asp

Frankfurt programme

Ophthalmologists and their staff who were unable to attend the Amsterdam programme or who wish to develop their practice management skills further are invited to attend the Practice Management meeting in Frankfurt, Germany from Friday November 1 to Sunday November 3. Unlike the Amsterdam programme, which is held as part of the XXXI ESCRS Congress, this is a standalone meeting with excellent speakers and the opportunity to network in an informal and relaxed setting. The theme of this year’s meeting is “Building your own Practice – Assumptions and Truths” and it is hoped that the programme will allow delegates a unique opportunity to get advice from top ophthalmologists and also marketing and management consultants on how to grow and improve their practices. Full details of the Frankfurt programme are available at http://pmfrankfurt.escrs.org.

OVDs

Knives

BSS

ALSANZA family of IOLs:

LSIOL 3D toric LSIOL 3D

LSIOL TORIC LSIOL

Phaco

Multifocal Toric

Multifocal

Monofocal Toric

Monofocal

www.alsatoriscan.com

Address: Hermann-Burkhardt-Straße 3 72793 Pfullingen • Germany Tel: +49 (0) 7121-69 065-20 Email: info@alsanza.com www.alsanza.com

* Colin Kerr is executive editor of EuroTimes and project manager for the ESCRS Practice Development Programme.

contact Kris Morrill – kmorrill@medeuronet.com alsanza_uk_120_300_mm 2.indd 1

08/07/13 17:43

REACH

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customers in over150 countries with your ad

ESCRS

Advertise with EUROTIMES Europe’s number one with the highest audited circulation for any ophthalmic news magazine in Europe

™

59 per cent of our readers surveyed in an independent research survey have decision-making power when it comes to the purchase of surgical/medical equipment or supplies. A further 20 per cent are usually consulted before a final decision is made**

ESCRS

EUROTIMES

* Average net circulation for the 10 issues circulated between 1 January 2012 and 31 December 2012. See www.abc.org.uk ** Results from the EuroTimes

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Feature

industry news

I am quality

Recent developments in the vision care industry

I am durable I am reusable I am innovative I am effective

Digital medical scope

VersaCam

NIDEK has introduced the VersaCam digital medical scope for rapid digital video and still image capture of retinal and anterior segment pathology. "The camera with a 40° angle-of-view, provides high-quality retinal images. Dual white and blue lights are included to evaluate fluorescein staining. The ability to immediately show patients their pathology facilitates easier patient education and informed consent," said a company spokesman. "As well as capturing and showing an image, VersaCamTM can record the captured image," said the spokesman. About 80,000 images can be saved on a micro SD memory card. Also captured images can be imported to image filing software," he said. n www.nidek.com

Automated cutting process

Gebauer Medizintechnik GmbH has introduced the Doc Assistant. The company says this will enable users to experience a distinct hands-free cutting process. "The Gebauer SLc Doc Assistant eliminates the possibility of any complications caused by irregular hand movements that may occur during the cutting process from a downward pressure or rotational pressure on the donated cornea," said a company spokeswoman. "The Doc Assistant is connected to the Artificial Anterior Chamber (AAC) and serves as a solid base for the Gebauer SLc Handpiece during the pass. This new safeguard feature ensures a precise and repeatable result on every pass, and makes the process truly user independent," she said. n www.gebauermedical.com

Doc Assistant

EUROTIMES | Volume 18 | Issue 9

I am unique

Silicone oil

Geuder has introduced Siluron Xtra Geuder, a new-generation silicone oil, on the market. “Due to its special molecular structure Siluron Xtra has in vitro, in comparison to the standard silicone oils, a high resistance to emulsification,” said a company spokeswoman. “The oil consists of a mixture of extremely long molecular chains and of short molecular chains. Because of the innovative molecular design the oil can change its viscous characteristics according to the high shearing forces which are to be found in the eye,” said the spokeswoman. “A further advantage of the product is its excellent long-term tolerance,” she said. n www.geuder.com

I am cost-efficient I am modern I am steel & composite made I am made by Moria

I am... by

Siluron Xtra

Corneal inlay

AcuFocus has announced that Günther Grabner, professor of ophthalmology at the Paracelsus University of Salzburg, Austria, presented data on the five-year postoperative performance of the KAMRA inlay at the recent 26th International Congress of German Ophthalmic Surgeons (DOC) meeting. According to Dr Grabner’s data, at five years following implantation, patients with the inlay continue to have great vision. He reported, on average in the inlay eye patients achieve J2 uncorrected near visual acuity and 20/25 for both uncorrected intermediate and distance visual acuities. Over this same timeframe the fellow, non-implanted eye, in this same cohort of patients lost lines of near, intermediate and distance visual acuity. “This data underscores that the KAMRA inlay is effective over the long-term, delivering a full range of vision and patient satisfaction,” noted Dr Grabner. “The safety profile for a corneal procedure is much greater than for a lens-based procedure, making the inlay an ideal ‘first choice’ for presbyopic patients. Since the inlay is removable, should it require removal – a rare occurrence at <2 per cent commercially – the patients still have all options available for presbyopia correction.” n www.AcuFocus.com

Moria is pleased to introduce coMposites! Composites by Moria is an innovative range of reusable instruments set to push the boundaries of ophthalmic instrumentation. This new generation of instruments offers the quality and precision you would expect from Moria, at a competitive price that will surprise the market. www.moria-surgical.com

NEW SURGICAL VIDEOS, SESSIONS, AND COURSES AVAILABLE ONLINE

Free access to surgical education from the 2013 ASCRS Symposium on your smartphone, tablet, and laptop.

www.MediaCenter.ascrs.org American Society of Cataract and Refractive Surgery

contacts

Rudy Nuijts – rudy.nuijts@mumc.nl Carla Schoonderbeek – schoonderbeekc@hoyngmonegier.com

Feature

EU MATTERS

LENS REIMBURSEMENT

National policies, EU directive, may pave way for co-payments across Europe by Howard Larkin

ecause of recent decisions by national insurance authorities, European ophthalmic surgeons may be able to charge their patients directly for the additional cost of multifocal, toric and other premium intraocular lenses (IOLs) implanted during insurance-covered cataract procedures. Some legal experts also believe the European Union’s Cross-Border Healthcare Directive may also allow residents of countries that do not allow such co-payments the option of having their operation and in a country that does allow the co-payment practice. “You can get the multifocal lens elsewhere, but the reimbursement of the country of origin will apply,” explained lawyer Carla Schoonderbeek, a partner in the law firm Hoyng Monegier LLP, Amsterdam, The Netherlands. “Allowing for co-payment of the incremental difference between the different treatment options while providing reimbursement of the basic treatment gives patients the possibility to make an informed choice on whether they prefer multifocal lenses or monofocal lenses combined with glasses.” However, these policies have not been well tested, and co-payment rules vary considerably by country, noted Schoonderbeek, who specialises in medical products and pharmaceuticals reimbursement. Therefore, surgeons in countries where co-payments are allowed should check with their own insurers and lawyers to ensure they follow any special requirements for billing insurers and patients outside their home country.

EU directive The cross-border healthcare directive, “Directive on the Application of Patients’ Rights in CrossBorder Healthcare,” was adopted in March of 2011. The directive generally allows a resident of an EU country to travel to any other EU country for medical services, be reimbursed for the cost of those services up to the level allowed in their home country. Countries may limit cross-border patient in-flow and out-flow for purposes including planning, maintaining access to services and quality assurance, though these exceptions are generally limited to hospital-based or services requiring costly infrastructure or equipment. Under the terms of the directive, each EU country has until 25 October of this year to adopt the necessary laws to implement the directive within its borders. By allowing reimbursement up to the limits in one’s own country, the healthcare directive potentially allows co-payments for all EU residents, Ms Schoonderbeek said. And because cataract surgery is usually an ambulatory procedure, in principle it should not be subject to cross-border limits under the directive, she explained. The EU directive also requires EU countries to provide residents with information on cross-border policies, including coverage and quality information on healthcare providers, Ms Schoonderbeek noted. In theory, this requires insurance plans to tell patients how much they will pay for cataract surgery, and providers to disclose how much they charge for surgery and any additional amount for premium lenses and services.

“They have to give you an answer upfront as to what the coverage is,” Ms Schoonderbeek said. In practice, however, service and coverage details may not be clear for premium lenses or other emerging technologies such as femtosecond lasers for cataract surgery and astigmatism correction. Coverage may also be subject to specific insurance company terms.

Co-payment trend Over the past few years, the European trend has been toward allowing co-payments for premium lenses and other advanced technologies while maintaining coverage for basic cataract surgery, Ms Schoonderbeek observed. In 2011, The Netherlands adopted new rules allowing patients to pay extra for multifocal lenses while the Czech Republic introduced co-payments for advanced technologies. Similar options were introduced in Germany and Turkey in 2012; co-payments have been allowed in some circumstances in France and Sweden for some time, she added. However, the services eligible for co-payment with cataract surgery may be quite specific and limited. For example, the decision of 2011 in the Netherlands specifically permits co-payments, and in some cases even full insurance coverage, for implanting multifocal lenses at cataract surgery, but not toric lenses, said Rudy MMA Nuijts MD, PhD, who heads the cornea service and cataract and refractive surgery at Academic Hospital Maastricht. That is because insurance coverage in the Netherlands, while provided by private firms, is determined by what regulators in

From the Archive New device creates alcohol-free epithelial flaps to improve healing and reduce haze

new technique combining LASIK and LASEK characteristics may create a healthier epithelial flap, improve postoperative healing and reduce the risk of haze, according to its developer Ioannis Pallikaris MD.

EUROTIMES | Volume 18 | Issue 9

The technique involves the mechanical separation of the epithelium from the Bowman's membrane with a specially designed epithelial separator device. Since it does not involve the use of alcohol it has no toxic effects on the

epithelium, said Dr Pallikaris, who will be presenting his findings here at the XXI Congress of the ESCRS.

n From EuroTimes, Volume 8, Issue 9, September 2003

the College van Zorgverzekeringen, or CVZ, consider “standard of care.” Decisions on specific technologies are taken on a caseby-case basis and the CVZ is not necessarily bound by published studies or general clinical opinion, Dr Nuijts explained. Before its 2011 decision, the CVZ did not consider multifocal lenses “standard of care.” Their opinion cited a lack of evidence that multifocals were better than monofocal lenses with glasses, and their more-extensive side-effect profile, Dr Nuijts said. As a result, cataract surgery with monofocal lenses was fully covered, but if patients opted for multifocal lenses, they had to pay for both the surgery and the lenses. The Netherlands intra-ocular implant club (NIOIC) worked with the CVZ to accept multifocal lenses for several years, Dr Nuijts said. Based on evidence, the CVZ reversed itself, allowing full coverage for multifocal lenses in cases where there is a medical need for them, such as intolerance of contact lenses and inability to use spectacles. The CVZ’s granting multifocal lenses “standard of care” also allowed coverage of cataract surgery with co-payments to cover multifocal lens costs for patients without a clear medical need. However, the CVZ still does not regard toric IOLs as “standard of care,” even though they are much more widely used around the world, Dr Nuijts said. The reason: only one randomised clinical trial comparing toric lenses to other astigmatism procedures or to no astigmatism correction existed at the time the evidence was examined. This leaves coverage for cataract surgery with toric lenses in doubt in The Netherlands, he added. To address the issue, Dr Nuijts and colleagues began a randomised controlled study of toric lens outcomes in 2010. The results strongly favour toric lenses over alternatives, he said. “We are doing the analysis. Hopefully this will give us the ammunition we need to have toric IOLs included.”

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Feature

OUTLOOK ON INDUSTRY

SUSTAINED RELEASE

Implant for chronic diabetic macular edema approved in six European countries by Howard Larkin

LUVIEN®, a sustained release corticosteroid intravitreal implant for treating chronic diabetic macular edema (DME) that is insufficiently responsive to other therapies has been approved for marketing in six European countries. ILUVIEN (190 micrograms fluocinolone acetonide, or FAc, insert in applicator) has been launched by Alimera Sciences, a biopharmaceutical company specialising in the research, development and commercialisation of prescription ophthalmic pharmaceuticals, headquartered in Alpharetta, Georgia, US. Injected with a 25-gauge needle through a self-sealing wound, ILUVIEN delivers a sub-microgram dose of FAc in the eye, providing an anti-inflammatory effect for up to 36 months, said Dr Philip Ashman, Alimera’s senior vice-president and EU managing director. It is intended for patients with chronic DME who respond insufficiently despite available treatments such as laser photocoagulation or antiVEGF treatment, he added.

Iluvien device

In two Phase 3 clinical trials, known together as FAME, 34 per cent of patients that were treated with ILUVIEN who had chronic DME at study entry gained 15 or more letters of best corrected visual acuity at 36 months. The improvement was statistically significant (p<0.001) compared with the 13.4 per cent seen in the control group, receiving standard of care, which included use of laser and other intravitreal therapies (IVTA and anti-VEGF antibody treatments). These therapies were prescribed by a masked, assessing retina specialist. ILUVIEN is now available in Germany and the UK. Marketing authorisations have been granted in Austria, France, Portugal EUROTIMES | Volume 18 | Issue 9

and Spain, and is pending in Italy, though the drug is not yet commercially available in those markets. Even so, ophthalmologists across the continent are enthusiastic about the introduction of ILUVIEN, which offers hope for preserving or improving vision in patients with no other real options for halting advanced DME, Dr Ashman said. “It is very evident from our day-to-day interactions that ILUVIEN meets a real need for many patients and demand is building.”

Indications and payment In support of ILUVIEN’s launch, Alimera has deployed teams across Europe that provide ophthalmologists with information, answer questions and give instructions for inserting the implant, Dr Ashman said. A model eye is used to help surgeons get a feel for using the applicator. “It works very well and we have had great feedback.” As with many new technologies, though, obtaining reimbursement is a challenge, Dr Ashman said. Even though six countries have granted ILUVIEN national licenses through a marketing authorisation process led by the UK Medicines and Healthcare products Regulatory Agency, achieving universal reimbursement within a country such as Germany, the UK or France is another matter. For example, in Germany, privately insured and self-pay patients had access to ILUVIEN from the day it became commercially available. In contrast, patients using statutory health insurance are typically dealt with on a case-by-case basis until reimbursement contracts are in place, Dr Ashman said. History shows that achieving inclusion of new ophthalmology products in reimbursement contracts can take a number of months, however, the process of contracting is well established and Dr Ashman is optimistic about progress. “It is in everyone’s interests to get contracts in place to enable patients to get the treatment they need.” In the UK, privately insured and self-pay patients have also had access from the day ILUVIEN was made commercially available, and recent events suggest that coverage through the National Health Service appears likely for a subgroup of patients in the near future. In June, a UK National Institute for

Health and Care Excellence advisory panel recommended coverage for pseudophakic, but not phakic, patients with chronic DME insufficiently responsive to available therapy. The ruling reversed a January recommendation that ILUVIEN not be approved because it did not meet NHS costeffectiveness standards. The subgroup was proposed by Alimera, supported by a simplified patient access scheme, or PAS, designed to address the cost-effectiveness issues noted in NICE’s original guidance on ILUVIEN, Dr Ashman said. “We have provided the NHS the opportunity of a simple scheme, not dissimilar to others that have worked well.” While ILUVIEN demonstrated a protective effect on subjects with chronic DME undergoing cataract surgery, narrowing ILUVIEN coverage to pseudophakic patients removes the financial impact of accelerated cataract formation that was seen in the FAME studies. Of the chronic DME patients who were phakic at the start of the FAME trials, 80 per cent of those in the ILUVIEN group developed cataracts and 75 per cent had cataract surgery, compared with 45 per cent and 23 per cent respectively for the control group at 24 months. At 36 months, 85 per cent of them had cataract surgery compared with about half in the control group. In France, the transparency commission of the French National Health Authority issued an opinion favoring ILUVIEN for National reimbursement. Alimera is now working with the economic committee to determine the price and any reimbursement conditions. Dr Ashman expects a final coverage decision by year’s end. While ILUVIEN has achieved approval in six European countries, the evaluation of the registration dossier continues in the US. The approval of ILUVIEN by the EU Health Authorities demonstrates that, in terms of benefit to risk ratio, the discovery of the significant and reproducible treatment effect of ILUVIEN in the chronic DME population offsets the known steroid classeffects of cataract formation and elevation of IOP. These Health Authorities reviewed the same dossier and information that has been submitted in the US. “ILUVIEN is not a therapy for the treatment of naïve patients, but is positioned in the treatment algorithm

“

ILUVIEN offers a sight-saving option for a group of patients who do not gain sufficient response from available therapies. We believe it will bring benefit to very many patients in the future Philip Ashman

in accordance with the label, where available therapies are not providing sufficient benefit,” Dr Ashman said. “We continue to work with the US FDA and hope they will approve the use of ILUVIEN in patients with chronic DME in the US.” Alimera expects to further expand operations in Europe in 2014, Dr Ashman said. He expects growing demand for ILUVIEN as the burden of diabetes continues to increase and more patients develop chronic DME. “ILUVIEN offers a sight-saving option for a group of patients who do not gain sufficient response from available therapies. We believe it will bring benefit to very many patients in the future.”

Iluvien implant

Trials of ILUVIEN are under way in other indications, including dry age-related macular edema and retinal vein occlusion. Alimera also is investigating NADPH oxidase inhibitors to treat dry AMD.

Reference

Calendar of events

.e w w

.org s r c s

www.eu roti me

Dates for your Diary s.o rg

2013 september november 14th International Paediatric Ophthalmology Meeting

12-13 September – Dublin, Ireland Email: hmurphy@materprivate.ie

EVER 2013 Congress

18-21 September – Nice, France www.ever.be

13th EURETINA Congress

Share Learn Connect. Interact with the ESCRS Join Us On Social Media • Be sure to check out our social networking sites and like or follow us to join the conversation • Get real time access to the latest congress updates, society news and event information • Our social media sites are a great way to communicate and share your congress experiences, connect with members of our team and others in the ophthalmic community www.facebook.com/ESCRS www.facebook.com/eurotimesnews @ESCRSofficial @eurotimestweets www.linkedin.com/company/eurotimes www.linkedin.com/company/escrs

93rd SOI National Congress

27-30 November – Rome, Italy www.congressisoi.com

The MCLOSA 20th Annual Scientific Meeting 29 November – London, UK www.mclosa.org.uk

26-29 September – Hamburg, Germany www.euretina.org

2014

october

january

ESCRS Glaucoma Day

5th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

4 October – Amsterdam, The Netherlands www.escrs.org

4th EuCornea Congress

4-5 October – Amsterdam, The Netherlands www.eucornea.org

XXXI Congress of the ESCRS

5-9 October – Amsterdam, The Netherlands www.escrs.org

EPOS/WSPOS Paediatric Sub Speciality Day

8-10 January – Vienna, Austria www.ophthalmictrainings.com

4th EURETINA Winter Meeting 25 January – Rome, Italy www.euretina.org

february 18th ESCRS Winter Meeting

9 October – Amsterdam, The Netherlands www.wspos.org

14-16 February – Ljubljana, Slovenia www.escrs.org

43rd ECLSO Congress

march

25-26 October – Munich, Germany www.eclso.eu

november Queen Victoria Hospital NHS Foundation Trust - Corneoplastic Professional Education Meeting 1 November – Lingfield, UK www.qvh.nhs.uk

Practice Management Weekend

1-3 November – Frankfurt, Germany http://pmfrankfurt.escrs.org/

AAO Annual Meeting

16-19 November – New Orleans, USA www.aao.org

New ENTRY Frankfurt Retina Meeting 2014 15-16 March – Mainz, Germany www.eckardt-frankfurt.de

New ENTRY The 5th World Congress on Controversies in Ophthalmology (COPHy) 20-23 March – Lisbon, Portugal http://www.comtecmed.com/cophy

april ASCRS•ASOA Symposium and Congress 20-23 March – Lisbon, Portugal http://www.comtecmed.com/cophy

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