Volume 15_Issue 10 by EUROTIMES

VOLUME 15

Cover Story

What can be learned from the developing world?

ISSUE 10 OCTOBER 2010

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ESCRS

EUROTIMES

OCTOber 2010 Volume 15 | Issue 10 Cover Story

This month...

Learning from the developing world

Special Focus: Astigmatism 8

Getting more from your topographer

Prevalence of astigmatism higher than expected

20 Years of LASIK 10 New consumer LASIK website launched

Cataract Update

More cataract surgeons needed in developing countries

Refractive Lens 13

Potential colour discrimination difficulties with IOLs

Cornea Update 14

Positive results with combination therapy for post-LASIK keratectasia

Treating corneal blindness with biological keratoprosthesis

Glaucoma Update 16

The crystalline lens and open-angle glaucoma

17 New visual field test grid links function to structure

Retina Update 18 New paradigm of care for AMD

Combination treatments in AMD

Are MIOLs suitable for vitreo-retinal surgery?

Global Ophthalmology 22

Greater support needed to fight global blindness

News 25

Istanbul to host 15th ESCRS Winter Meeting

EUREQUO update

ESCRS to expand Young Ophthalmologists’ Programme

Features

JCRS Highlights

Book Review

Henahan Prize Winner

EU Matters

Journal Watch

Practice Development

Product Update

Calendar

Eye on Travel

Industry News

Cover image courtesy of Jack Vekermans

With this month’s issue... Paris supplement WITH highlights from 10th Euretina congress & XXVIII Congress of the escrs

editorial staff

ESCRS

EUROTIMES

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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

Senior Designer Paddy Dunne

Assistant Designer Janice Robb

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

Colour and Print Times Printers

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes.

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2009 and 31 December 2009 is 29,298.

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EUROTIMES

Editorial

ESCRS

EDITORIAL

Medical Editors

Volume 15 | Issue 10

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

A bright future

XXVIII ESCRS Congress shows benefits of collaboration and offers new possibilities by José Güell MD

International Editorial Board

s president of ESCRS, I would like to thank all the ESCRS members and EuroTimes readers who contributed to a very successful and enjoyable XXVIII Congress in Paris last month. The success of the meeting was a tribute to our society but also to the European Society of Retina Specialists (EURETINA) who joined us in Paris for the first ever joint meeting of the two societies. In Paris we had our own programmes but the success of the joint symposia organised by ESCRS and EURETINA emphasised the new possibilities for both societies, working in collaboration for the benefit of all of our members. Our meetings in Paris also offered the opportunity for specialists in cataract and refractive surgery and retinal diseases to meet and discuss common problems and opportunities. Close to 5,900 delegates registered for the ESCRS Congress and over 2,700 for EURETINA this year, making this one of the largest ophthalmological meetings ever held in Europe. In this month’s EuroTimes we have published a special supplement with reports and highlights of the meeting for those readers who were unable to attend. In addition, interested delegates can access presentations and symposia from the congress through ESCRS on demand. Next year we can look forward to a new collaboration when the XXIX ESCRS Congress in Vienna will take place in conjunction with the second EuCornea meeting.

The developing world I would also draw your attention to our Cover Story this month which asks us, “What can be learned from the developing world?” Innovations in cataract surgery in developing countries have reduced the cost of procedures to as little as €12 and greatly increased surgeon productivity. As a result, millions of the world’s poorest citizens have had their sight restored, and the goal of eliminating preventable blindness worldwide may be within reach. Some surgeons have argued that avoiding waste and setting up systems that optimise use of surgeons’ skills could help reduce costs, improve quality and efficiency, and shorten waiting lists in Europe and other developed areas. As I mention in the Cover Story, personally I question the need to increase surgeon productivity and I would caution that safety must remain the primary goal. “The need is not to get cataract surgery times down to eight minutes, the need is for patient safety and this is true, from my point of view, for the developing and for the 'developed' world.” However, needlessly wasting resources, particularly disposable instruments, also should be avoided as it is extremely important in

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN our professional but also personal activities. For example, it may make more sense to sterilise a diamond knife that can be used 200 times than to use 200 disposable knives. I would also argue that it is not enough to address the problems of global blindness simply as surgeons. When we operate on patients with cataracts in the developing world we reach out to those who have survived long enough to develop a cataract. But other help is urgently required, such as food and shelter, and projects to help local communities to sustain themselves.

John Chang CHINA Joseph Colin FRANCE 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 Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM

José Güell is president of the European Society of Cataract and Refractive Surgeons

Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz GERMANY

EUROTIMES | Volume 15 | Issue 10

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Cover Story

Managing eye care resources

A different approach

What can be learned from the developing world?

New approaches could help improve quality and efficiency, and shorten waiting lists in Europe by Howard Larkin

“

There are some who find it controversial and practise as in the west, and others who find it controversial but do something far inferior in actual practice. It takes courage to state what we did; we are putting our heads on the block

Thulasiraj Ravilla, BSc MBA

“

The entire system is geared to maximising productivity from the scarcest resource, which is the cataract surgeon David F Chang MD

EUROTIMES | Volume 15 | Issue 10

ndia’s Aravind Eye Care System is the world’s largest provider of eye surgery. Through its five hospitals and network of clinics in southern India the system manages some 2.5 million outpatient visits and 300,000 eye surgeries annually. Of these about 55 per cent are unpaid or steeply subsidised services to indigent patients. The system also trains about 50 new ophthalmology residents and 600 technicians annually, manages two other hospitals in India, develops hospitals and eye care programmes in other countries in Asia and Africa, operates its own research institute and owns a manufacturing facility that produces about seven per cent of the world’s intraocular lenses. Aravind is a model of efficiency. Its total cost for small-incision manual cataract procedures using non-foldable lenses is about €12. Its surgeons typically operate 12 to 18 cases per hour – with 92 per cent achieving 20/60 or better best corrected vision, and complication rates similar to those reported in developed countries. The total cost of its entire operation is currently about €16m annually. To put that in perspective, Aravind does about 60 per cent as many eye surgeries and trains about 70 per cent as many ophthalmologists as the entire United Kingdom National Health Service – at a cost of about one-tenth of one per cent of the £1.6bn the NHS currently spends on eye care. Such efficiency has allowed millions of the world’s poorest citizens to have their sight restored. It also puts the VISION 2020 goal of eliminating preventable blindness worldwide within reach. “It is simple to say that it’s just because the UK isn’t India, but there is more to it,” says Thulasiraj Ravilla BSc MBA, executive director of the Lions Aravind Institute of Community Ophthalmology in Madurai and a former president of the VISION 2020 India.

Courtesy of Mike Myers

Surgeon being assisted by nurse at an Aravind Eye Hospital

Certainly, vastly differing economic conditions, cultural expectations, oversight standards and the compelling need to reduce the enormous burden of blindness make it less expensive to operate in India. But the system’s success is more the result of rigorously applying industrial process improvement techniques to every aspect of operations, from reducing supply costs to eliminating unnecessary motion in the operating room. David F Chang MD highlighted the Aravind system in his 2009 Binkhorst Lecture at the ASCRS Annual Meeting in San Francisco, which discussed model systems for reducing the backlog of cataract blindness in the developing world. “Although costs are dramatically reduced by using manual, sutureless small incision ECCE with a PMMA IOL, the real paradigm shift is in the entire high volume surgical delivery system which surrounds the surgeon,” he said. Using standardised protocols and two scrub/circulating teams,

the cataract surgeons alternate between two adjacent OR tables, where one patient is prepped while the neighbour is undergoing surgery. “The entire system is geared to maximising productivity from the scarcest resource, which is the cataract surgeon,” Dr Chang explained. “Using this team approach run with military precision, one surgeon is able to do 12-15 cases per hour, and the result of this efficiency is that more charity cataract patients can be cured of blindness.” Mr Ravilla allows that many practices developed to address overwhelming need, including widespread use of manual smallincision procedures and assembly-line processes, are not viable in developed countries. In particular streamlined infection control protocols, such as reusing irrigation tubing and not changing gloves between cases, are controversial even in India. While some large studies suggest these practices are effective (J Cataract Refract Surg 2009; 35:629–636), some researchers question the validity of these

studies and believe such practices risk spreading HIV, hepatitis C, prions and other infective agents. “There are some who find it controversial and practise as in the west, and others who find it controversial but do something far inferior in actual practice. It takes courage to state what we did; we are putting our heads on the block,” Mr Ravilla says. He points out that Aravind developed its surgical practices using data-driven process improvement techniques based on huge case volumes, and closely monitors ongoing outcomes to ensure quality. He also believes the basic principles that make high-volume practice so successful in his organisation can be successfully applied to increase efficiency and reduce costs in Europe and the US. Fundamentally, there are two guiding principles: First, don’t waste or inappropriately use resources, most especially surgeons’ skills. Second, set up the surgical process so the surgeon never has to wait for anything – not a record, or a patient or a set of instruments. “These principles are in use to some degree everywhere there is high-volume practice,” Mr Ravilla says. He points to centres in Germany and the US that use multiple operating beds (though not in the same OR) and have on hand 18 or 20 sterilised phaco hand pieces, allowing surgeons to do 40 or more cases a day. These approaches have the potential to address the rising demand for services and improve quality – and could also increase surgical volume and surgeons’ income.

Finland vs India Just how much adopting best practices from the developing world might benefit European centres has been extensively studied by Anssi Mikola MSc Eng, director of business development for Nordic Healthcare Group, a management consulting firm in Helsinki, Finland. He and his colleagues conducted extensive time-motion studies at six clinics across Finland, including two teaching hospitals and four central cataract referral stations, and at one of Aravind's hospitals. Mr Mikola says that adopting some techniques developed to improve patient flow at Aravind could substantially increase productivity at even the most efficient Finnish facility. He has successfully employed some techniques to reduce waiting lists for cataract surgery at two hospital centres in Finland. Establishing a fast track programme that employs two operating theatres per surgeon nearly doubled productivity at another hospital in Sweden, he says. In all these cases a shortage of surgeons, rather than a lack of operating theatres or staff support, was the bottleneck restricting capacity. When working to streamline the processes we have never touched any safety precautions nor has anybody been asked to operate any faster. The difference is in the length of the changeover, not the operation Mr Mikola emphasises. Mr Mikola’s study broke down the process of cataract surgery into 164 steps in four categories: direct patient care, including exams and operating time; operative preparation; non-value adding activities, such as moving patients around the unit, looking for records, and waiting for colleagues; and other activities including lunch, breaks, meetings and training. Only EUROTIMES | Volume 15 | Issue 10

Courtesy of Mike Myers

Post-op patients at an Aravind Eye Hospital

data on phaco procedures in India were used to ensure a valid comparison with the Finnish data. Overall, the Indian unit spent a total of just under one hour of staff time per case. Of this about 16 minutes were consumed by two nurses and one surgeon during an average procedure time of just over five minutes. By contrast, the most efficient Finnish unit examined spent about three hours of staff time per case while the least efficient spent almost eight hours, of which about 50 minutes was for three nurses and one surgeon in operations that averaged more than 12 minutes. At the Indian facility about 65 per cent of staff time was spent on direct patient care compared to about 45 per cent at the most efficient Finnish facilities, and 25 per cent at the least efficient. Indian surgeons averaged 70 cases a day; Finnish surgeons eight to 10. Mr Mikola also analysed what made the most difference in productivity. Preoperatively, segmenting patients into non-complicated and complicated cases allowed scheduling to achieve maximum surgical productivity. Non-complicated cases can be fast-tracked on one day of surgery, which allows minimal variation in approach, enabling quick turnaround and minimum waiting. About 80 per cent of the Finnish cases fall into this group. The 20 per cent that are more complex can then be operated at a slower pace with just one case on the table at a time. Standardising the cataract procedure also allows efficiencies in other areas, such as assembling surgical trays. Complete standardisation is not necessary, Mr Mikola says. At one facility surgeons were able to agree on all but three instruments. They

found that the cost of including all three instruments in every set was significantly less than trying to assemble, maintain and sterilise a slightly different set for each surgeon. Another key feature of more efficient operations was the use of non-physicians to gather diagnostic data and counsel patients. While the Indian system was set up to efficiently gather this information, it presents a challenge in many European settings, where patients are referred for cataract surgery by ophthalmologists in the community. Coordination with these referring doctors is required to enable referral centres to reliably know in advance if a case is appropriate for a fast-track process, Mr Mikola notes. Training and having control of technicians who do assessments has also been essential for creating an effective referral system in rural Nepal, says Suman S Thapa MD of the Tilganga Eye Centre in Kathmandu. When the centre only trained the technicians, who screen patients in outlying villages, they found they were not reliable. So the practice now employs them as well and constantly works with them to improve their skills. “When they refer a patient to us we can tell them what they missed and they learn what to look for.” In the operating room, having several patients prepared, and only moving those who are ready for surgery to the operating table helped avoid wasting surgeons' time waiting for pupils to dilate, etc. Using two operating tables and minimising the time taken for changeovers between patients was a big factor. In India it averaged 22 seconds – with two tables in the operating room the surgeon rinsed gloves, swung the

“

Re-use needs dedicated, trained and disciplined operation theatre staffs who know what is safe and what is not. Given a choice between economy and safety, it is better to err on the side of safety Parikshit Gogate MD

contacts

Cover Story

MANAGING EYE CARE RESOURCES

Is there a need for greater efficiency? ESCRS president José Güell

MD, PhD questions the need to increase surgeon productivity and cautions that safety must remain the primary goal. While the supply of ophthalmic surgeons varies widely, from about two per 100,000 in the UK to about 14 per 100,000 in Greece, there is no shortage overall, he believes. “The need is not to get cataract surgery times down to eight minutes, the need is for patient safety.” However, needlessly wasting resources, particularly disposable instruments, also should be avoided, Dr Güell adds as it is extremely important in our professional but also personal activities. For example, it may make more sense to sterilise a diamond knife that can be used 200 times than to use 200 disposable knives. “We need to know the cost. I know the cost of the single-use knife to me, but what is the cost of sending it to the basket? These numbers need to be studied and we need to reconsider what we are doing locally in every country.” Such re-examinations are taking place. In Germany, for example, protocols for safely sterilising and reusing diamond knives have been developed by the Robert Koch Institute. Parikshit Gogate MD, former medical director of the Desai Eye Hospital, Pune, India, also sees re-using instruments as a way developed countries could improve

EUROTIMES | Volume 15 | Issue 10

efficiency, but emphasises that doing so safely requires a high level of skill and organisation. “Re-use needs dedicated, trained and disciplined operation theatre staffs who know what is safe and what is not. Given a choice between economy and safety, it is better to err on the side of safety.” Emanuel Rosen FRCS, FRCOphth also stresses safety and efficacy as the driving concerns for improving practice in the developed world. But he sees no need to adopt techniques from the developing world. Rather, he sees technology, most especially femtosecond laser technology, as the likely key to both better outcomes and greater efficiency. “The safety and dependability should be much better.” Making optimal use of femtosecond laser technology would require rethinking surgical procedures and staffing practices, Dr Rosen says. He foresees two-person cataract teams in which one specialises in making the laser incisions while the second extracts the lens and implants the IOL. “A properly constructed unit could do 50 to 100 procedures a day,” he says. The laser specialist might be a trained technician under the direct supervision of a surgeon, he suggests. Surgeons must always directly supervise all treatment, from workup to diagnosis and treatment decisions through follow-up, he adds.

The bottom line While some centres Mr Mikola has worked with have successfully reduced waiting times and overtime using these techniques, he sees little pressure overall for greater efficiency. This may be a function of a more-or-less adequate supply of surgeons. But there are also economic disincentives in the Finnish system to increase productivity, he notes. The same surgeons practise in both the public and private system but get paid more by private patients. If the public system, which is much less expensive for the patient, had no waiting list there would be fewer private patients to go around. However, the private market can create its own incentives to increase efficiency. Some of the largest cataract practices in the US are finding that their surgery volumes – and incomes – multiply when they make more use of optometrists and other nonphysicians to screen, prepare and follow-up with patients. It allows practices to identify more surgery candidates and frees surgeons to spend more time doing surgery. Serving private-paying patients is also becoming a bigger factor in India, and phaco is becoming more common, even among non-paying patients, thanks to new low-cost phaco machines, Dr Gogate says. “They are becoming more like the practices in the western world as the patients and the doctors are getting wealthier and the need to economise reduces.” The growing market for paid surgery also

Courtesy of Aravind Eye Care System

microscope over to the other bed for the next patient and resumed operating. By contrast, the most efficient Finnish unit averaged 8.5 minutes and the least efficient nearly 20 minutes between cases. While it would be impossible to duplicate Indian turnaround times in Europe due to stricter infection control procedures, Mr Mikola has found that a change of gloves and gown and a trip to a patient waiting in a second operating suite can be routinely accomplished in 1.5 minutes. Doing so could nearly double patient throughput in most facilities, he says. Minimising movement in the operating room also reduced operating time substantially. In India, nurses handing instruments close enough allowed surgeons to take them without lifting their eyes from the microscope. Structured documentation that allowed nurses to check off standard processes reduced the time taken for writing operative notes. At the Indian facility these notes were entered into the computer in less than one minute by a clerk. By reducing operating times to nine minutes and changeovers to 1.5 minutes, and working seven hours instead of less than six, throughput at the Finnish units could be about quadrupled, Mr Mikola says. “If patient flows were organised according to the most efficient practices, the weekly volume of cataracts could be done in one day.”

Thulasiraj Ravilla - thulsi@aravind.org José Güell - guell@imo.es Emanuel Rosen - ERosen9850@aol.com David F Chang - dceye@earthlink.net Parikshit Gogate - parikshitgogate@hotmail.com Suman S Thapa - ssthapa@tilganga.com.np Anssi Mikola - Anssi.mikola@nhg.fi

Wetlab training in microsurgery

Courtesy of Aravind Eye Care System

Technician performing an OCT

subsidises provision of care to the millions in poverty still in need, Mr Ravilla says. Here again, Aravind’s efficiency makes the system work. Charging no more than the going market rate, Aravind makes enough on paid surgeries to not only cover the 55 per cent of patients who cannot pay the market rates, but also to generate a nearly 40 per cent gross operating margin. “We continue to benefit from market inefficiency,” Mr Ravilla says. But what really drives efficiency at Aravind is commitment to a higher purpose – eliminating avoidable blindness. Despite its amazing capacity the system still only reaches about 10 per cent of those in need in India, where an estimated 12 million of the world’s 45 million blind people are thought to reside. Reaching them requires the will and desire to give away what one can, Mr Ravilla adds.

“

The need is not to get cataract surgery times down to eight minutes, the need is for patient safety José Güell MD, PhD ESCRS president

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Special Focus

astigmatism

utilising topographers

Software tracks astigmatism changes to improve nomograms

by Howard Larkin

orneal topography makes possible precise measurements of astigmatism induced by corneal surface irregularities before and after any type of cataract or refractive surgery. Combined with measures of total astigmatism from aberrometry or manifest refraction, it can also reveal how much astigmatism originates elsewhere in the eye. “This quantitative value of how the eye looks is really very valuable,” says Noel Alpins FRACS, FRCOphth, FACS, Melbourne, Australia. “But just looking at the changes in topographic corneal astigmatism values alone does not use the topographer to its full potential.” While raw data on corneal and noncorneal astigmatism gives insight into the eye’s condition, it can’t tell you how much astigmatism your surgical approach induced. For example, if the patient starts with 3.50 dioptres cylinder at 22 degrees before surgery and ends up with 0.50 dioptres at 160 degrees, did you overcorrect or undercorrect? You know your correction is off axis – but how much and in what direction? And what does it mean for the patient’s vision? Objectively answering these questions is essential for planning re-treatments and adjusting astigmatism correction nomograms, Dr Alpins says. Vector analysis of topographic data can provide the answers. Long used by scientists to model complex interactions in multiple dimensions, Dr Alpins pioneered applying vector analysis to astigmatism correction in the early 1990s. His innovation was distilling the complex mathematics of vector analysis into a few actionable values that surgeons can use to measure outcomes and plan surgery. Dr Alpins has also developed several software packages incorporating what has become known as the Alpins method of astigmatism vector analysis. The latest is iAssort, a program that can be installed on many topographers and aberrometers, including the Pentacam (Oculus) and Scout (Optikon). Unlike raw topographic astigmatism values such as Sim K, vector values correlate well with surgical processes, and can be analysed quantitatively to adjust surgical technique, Dr Alpins says. iAssort automatically quantifies the degree of over- or under-correction as well as the magnitude and angle of offaxis corrections based on preoperative and

EUROTIMES | Volume 15 | Issue 10

Figure 1

Figure 2

Figure 1: The iAssort program displays double angle vector diagrams to better understand astigmatism analysis. Figure 2: The iAssort program enables analyses using topography parameters and displays visual symbols to indicate the success of the sugery

postoperative topography. It also quantifies with an index how much the patient’s astigmatism improved compared with the correction target. Results can be displayed numerically, as expanded expressions or graphically on a doubled angle vector diagram (Figure 1). “This software provides much more clinically useful information than has been available before from topographers,” Dr Alpins says.

Before surgery iAssort imports topographic data in the form of sim-K values and zonal parameters from topographers or second-order astigmatism values from aberrometers. The surgeon can also manually enter astigmatism parameters measured by manifest refraction or they can be imported directly from aberrometry in combined

devices. From these the program calculates ocular residual astigmatism or ORA, a vectorial measure of astigmatism due to non-corneal surface causes (Figure 2). The ORA informs the surgeon of how much total astigmatism potentially can be corrected by reshaping the cornea, as well as the power and axis of surgical correction required to achieve the maximum potential correction. This information can be used before surgery to help manage patient expectations, Dr Alpins says. For the 25 per cent to 30 per cent of patients with ORA values of 1.0 dioptre or more it may not be possible to achieve the degree of astigmatism correction they might expect, he notes. “Before surgery you can take that parameter into account and counsel the patient accordingly.” Pre-op measures also are used to

Noel Alpins - nalpins@unimelb.edu.au

determine a target for corneal astigmatism that minimises total astigmatism after surgery in cases where a zero astigmatism target cannot be achieved. “If everything goes according to plan, this difference between the spectacle astigmatism and the corneal astigmatism will be left on the cornea,” Dr Alpins says. The target is also essential to quantitatively analyse outcomes, he adds. “If you don’t calculate where the target ahead lies, you don’t know how much you missed it by. Remember that zero cornea and/or refractive astigmatism is not always achievable.”

Courtesy of Noel Alpins FRACS, FRCOphth, FACS

After surgery iAssort compares postsurgery topographic data with pre-op values and the target astigmatism treatment. This yields a value for surgically induced astigmatism and a difference vector, which is how much the induced astigmatism differs from the target. Ratios of these values indicate the effectiveness (over or undercorrection and on or off-axis) of the astigmatic surgical intervention, whether incisional or ablative. For example, in the case above the program generates a correction index value of 1.20, indicating a 20 per cent overcorrection, and a magnitude of error of 0.57 dioptres at 6 degrees (in a clockwise direction). The index of success is 0.30, indicating that the treatment corrected 70 per cent of the patient’s astigmatism deficit relative to the treatment. These results suggest that the patient may benefit from an enhancement, and help guide the location and magnitude of the re-treatment based on the patient’s response, Dr Alpins says. “Should you try to fully correct the residual error or peg the treatment back a bit? Given that you overcorrected a bit the first time, you may want to pull it back.” While the iAssort software allows analysis of one patient at a time due to the limitations of the topography systems, data from multiple patients can be analysed with Dr Alpins’ Assort software. Assort also gathers information on incisions and ablations, as well other factors that might affect astigmatism outcomes. This enables identification of under- or over-correction trends for patient groups that can be used to adjust surgical nomograms. Using corneal topography data to assess the success of surgery helps eliminate one significant source of error in measuring astigmatism outcomes – the manifest refraction which is a subjective test. “Of course you want to measure the manifest refraction after surgery. But it is a subjective measure and the person doing the measuring knows the target is zero, so there is a risk of underestimating it. Topographic data it is like a truth drug. You know what the real surgical outcome is because you are measuring it totally objectively with a device that has no bias,” Dr Alpins says.

Special Focus

astigmatism

High prevalence

Largest study of its kind provides new insight into astigmatism by Roibeard O’hEineachain in Dublin

n analysis of what may be the largest selection of biometry datasets reported in the literature has yielded some surprising findings with regard to the incidence of astigmatism among cataract patients and the relationship of the condition to other aspects of ocular anatomy, according to a study published in the September 2010 issue of the Journal of Cataract and Refractive Surgeons. “Corneal astigmatism is far more common than I had expected. About eight per cent of all patients had corneal astigmatism of more than 2.0 D. The sex difference in ocular dimensions also surprised me, the difference between male and female patients in axial length and corneal diameter was bigger than I expected,” said Peter Christian Hoffmann MD, Castrop-Rauxel, who co-authored the study with Werner W Hütz MD, Klinikum Bad Hersfeld, Bad Hersfeld, Germany. The study involved 23,239 data sets of 15,448 patients with a median age of 74 years who attended a high-volume eye surgery centre in Castrop-Rauxel between 2000 and 2006. The researchers used partial coherence interferometry (IOLMaster, Carl Zeiss Meditec) for axial length measurements and they used the device’s built-in automated keratometry and slit-lamp to measure corneal radii, anterior chamber depth and corneal diameter. They found that corneal astigmatism was 2.0 D in eight per cent of eyes, and greater than 3.0 D in 2.6 per cent of eyes. The mean corneal astigmatism was 0.98. Approximately two-thirds of all eyes had corneal astigmatism less than 1.0 D. The difference between the proportion of right eyes and left eyes with corneal astigmatism of 2.0 D or higher was statistically significant (P < 001), at 8.4 per cent and 7.7 per cent, respectively.

Findings could have impact on cataract surgery The study’s authors noted that their findings

regarding the prevalence of corneal astigmatism are of particular interest to the cataract surgeon. For example, if the criterion for a toric IOL was corneal cylinder of 1.5 D or more, 16 per cent of all eyes would be potential candidates. Regarding the axis of astigmatism, 10,876 eyes (46.8 per cent) had with-the-rule astigmatism, with an axis of correcting minus cylinder at 180 degrees, plus or minus 30 degrees, 7,971 eyes (34.3 per cent) had against-the-rule astigmatism, with a correcting minus cylinder at 90 degrees, plus or minus 30 degrees, and 4,392 eyes (18.9 per cent) had oblique astigmatism. “Using temporal clear corneal incisions will reduce pre-existing astigmatism in 34 per cent of cases but will worsen it in 47 per cent because the incision will be near the flattest meridian of the cornea. Temporal incisions do have advantages of course, they are farther away from the centre of the cornea but if the incision is not astigmatically neutral there is a risk of worsening the pre-existing astigmatism,” Dr Hoffmann said. The proportion of eyes having with-the rule astigmatism was higher among eyes with cylinder of 2.00 D or more, EUROTIMES | Volume 15 | Issue 10

Setting the standard.

at 64 per cent. Conversely, among the same eyes the proportion with against the rule astigmatism was lower (24.5 per cent), as was the proportion with oblique astigmatism (10.8 per cent). Another finding of the study was although the prevalence of against the rule astigmatism increased with age, the magnitude of corneal astigmatism did not, Dr Hoffmann said. “Refractive astigmatism is dependent on age. The older the patient, the higher the magnitude of astigmatism and the more frequent is an against-the-rule axis. This is partly due to changes of the crystalline lens. Magnitude of corneal astigmatism has not a clear age dependency, but there is a correlation between axis and age. In older individuals, against-the-rule astigmatism axis is more frequent even in the cornea alone,” he noted.

The long and short of astigmatism Regarding the patients’ general ocular anatomy, their mean axial length was 23.43mm, their mean corneal radius was 7.69mm, their mean white-to white distance was 11.82mm, and their mean anterior chamber depth was 3.11mm. Among the long eyes in the study, high astigmatism occurred more commonly when the cornea was steep, but among the short eyes, high astigmatism occurred more commonly when the cornea was flat. That finding does not appear to have been reported elsewhere in the literature, the study’s authors pointed out. In common with previous studies, female eyes in the present study were shorter than male eyes. Furthermore, female eyes tended to have significantly steeper corneas, shallower anterior chambers, and smaller white-to-white diameters. In normal eyes there were strong statistical correlations between the axial lengths, mean corneal radius, anterior chamber depths and white-to-white diameter. However, those correlations did not hold for eyes with extremely long or short axial lengths, a finding which may be of importance in IOL calculation since most formulae use corneal radius and anterior chamber depth to predict the IOL’s postoperative axial position, Dr Hoffmann said. “In extreme eyes caution must be taken when calculating the IOL power because all models and all formulae don’t take into account that the correlation between some parameters changes a lot with the more extreme axial lengths. Instead, in most models, there is an assumption that the cornea gets bigger the corneal radius gets flatter as axial length increases, but that’s not necessarily true for very long and very short eyes, where the correlations may even be reversed,” he added.

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Peter Christian Hoffmann - ph@augenklinik-castrop-rauxel.de

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Survey shows 98 per cent would have LASIK again, 69 per cent think it is safe, but many still have concerns

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by Howard Larkin in Paris

arking the 20th anniversary of LASIK and the European Year of LASIK, the ESCRS has launched â&#x20AC;&#x153;LASIK Safe in Our Handsâ&#x20AC;? (www.LASIKSafeinOurHands.com), a consumer-oriented website dedicated to getting out the facts about LASIK surgery. The website is the centrepiece of a new campaign to address through education lingering concerns about the procedure held by many who have not had LASIK. European patients who have experienced the benefits of LASIK surgery are nearly unanimous in their enthusiasm for the procedure. A staggering 98 per cent confirmed they would recommend it to someone else, according to an international survey conducted this spring by the wellknown Opinion Health poll. Even so, four out of five respondents who had not had LASIK still had concerns â&#x20AC;&#x201C; even though 69 per cent agreed that eye surgery is a safe and well-established procedure. Of those expressing reservations, the greatest number, 30 per cent, said they needed more information. Another 24 per cent didnâ&#x20AC;&#x2122;t think they could afford it. Potential side effects were the major worry of 17 per cent while 11 per cent said they would not consider the procedure. â&#x20AC;&#x153;LASIK can be a life-changing procedure, but these survey results show that people do not understand just how safe and effective modern LASIK is in the hands of a wellqualified and experienced laser surgeon. We hope that our new campaign will help bridge the information gap so that more people might benefit from good vision without glasses or contact lenses,â&#x20AC;? said ESCRS president Jose Guell MD, Barcelona. In a presentation to the French consumer press, prominent ophthalmic surgeons Jean-Louis ArnĂŠ MD, Joseph Colin MD, Jean-Jacques Saragoussi MD and Beatrice Cochener MD, reviewed two decades of progress in LASIK, including the development of wavefront-guided procedures and femtosecond lasers for cutting flaps. Information on the quality of vision after LASIK and the basics of eye conditions including myopia and hyperopia was also presented. Results from the Opinion Health survey, which queried 1,000 people in five countries in May, 2010, suggest a widespread lack of basic understanding about the eye and eye

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website launched

Jean-Jacques Saragoussi and Joseph Colin speaking at the launch of the new website in Paris

conditions. Eight out of 10 did not know what eye condition they suffer from. The new website, which will also launch in French, provides complete information to help patients understand their eye problems and the potential advantages of laser vision correction, as well as information on who is an appropriate candidate. Dr Colin believes the website will give surgeons another tool to educate the public on LASIK, correcting misperceptions and enabling more to benefit from it. What Europeans think about LASIKâ&#x20AC;Ś n n n

98 per cent of those whoâ&#x20AC;&#x2122;ve had it would recommend it to a friend 69 per cent believe eye surgery is a safe and well-established procedure 82 per cent have reservations â&#x20AC;&#x201C; 30 per cent need more information, 24 per cent donâ&#x20AC;&#x2122;t think they can afford it, 17 per cent worry about side effects, 11 per cent wouldnâ&#x20AC;&#x2122;t consider it

â&#x20AC;Ś and glasses n 71 per cent think they make it difficult to play sports n 73 per cent say theyâ&#x20AC;&#x2122;re difficult or inconvenient in different weather conditions n 84 per cent find replacing them expensive n 33 per cent think laser surgery would be cheaper over 10 years Source: Opinion Health Healthcare Consumer Online Survey, May 2010 N=1,000 (UK 200, France 200, Germany 200, Italy 200, Spain 200)

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40 micrograms/ml eye drops solution-travoprost References: 1. Dubiner HB et al. Clin Ther 2004;26(1):84-91. 2. The AGIS Investigators. Am J Ophthalmol 2000;130(4):429-440. 3. Nordmann JP et al. Clin Drug Investig 2003;23(7):431-438. 4. Kass MA et al. Arch Ophthalmol 2002;120:701-713. 5. Yan DB, Battista RA. Presented at World Glaucoma Congress; July 18-21,2007, Singapore. P 311. 6. Garcia Feijoo J et al. Invest Ophthalmol Vis Sci 2006;47:E-Abstract 444-B179. 7. Sit AJ et al. Am J Ophthalmol 2006;141(6):1131-1133. 8. Netland PA et al. Am J Ophthalmol 2001;132(4):472-484. 9. Maul E et al. Presented at American Glaucoma Society Annual Meeting; March 2-5, 2006, Charleston, SC. P 61. 10. Chew PTK et al. Asian J Ophthalmol 2006;8(1):13-19. 11. Konstas AGP et al. Presented at World Ophthalmology Congress; February 19-24, 2006, Sao Paulo, Brazil. PRESCRIBING INFORMATION: Consult the Summary of Product Characteristics before prescribing, particularly in relation to side-effects, precautions and contraindications. TRAVATAN® (travoprost) Name and Composition: TRAVATAN® 40 micrograms/ml eye drops, solution; 1 ml of solution contains 40 micrograms travoprost, 0.15 mg benzalkonium chloride. Indication: Decrease of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma. Dosage and Administration: Remove protective overwrap before initial use. Adults, including the elderly: One drop in the affected eye(s) once daily, optimally in the evening. Children and adolescents: Not recommended. Hepatic and renal impairment: No dosage adjustment necessary. Contraindications: Hypersensitivity to travoprost or any of the excipients. Precautions: TRAVATAN® may gradually change eye colour. This occurs slowly and may not be noticeable for months to years. Before treatment is instituted, patients must be informed of the possibility of a permanent change in eye colour. Unilateral treatment can result in permanent heterochromia. Long term effects on melanocytes and any consequences are currently unknown. After discontinuation of therapy, no further increase in brown iris pigment has been observed. TRAVATAN® may gradually increase the length, thickness, pigmentation, and/or number of eyelashes in the treated eye(s). Exercise caution in patients with inflammatory ocular conditions and other types of glaucoma, aphakic patients, pseudophakic patients with a torn posterior lens capsule or anterior chamber lenses, and in patients with known risk factors for cystoid macular oedema or iritis/uveitis. Skin contact with TRAVATAN® must be avoided.

Benzalkonium chloride may cause keratopathy and irritation and is known to discolour soft contact lenses. Close monitoring is required in dry eye patients, or where the cornea is compromised. Patients must remove contact lenses prior to application of TRAVATAN® and wait 15 minutes after instillation before reinsertion. TRAVATAN® contains polyoxyethylene hydrogenated castor oil 40 which may cause skin reactions. Interactions: No studies performed. Pregnancy and Lactation: Pregnancy: Do not use unless clearly necessary. Avoid contact with the skin and cleanse area immediately if accidental contact occurs. Women of child-bearing potential: Do not use unless adequate contraceptive measures are in place. Breastfeeding women: Not recommended. Driving: If blurred vision occurs, wait until vision clears before driving or using machinery. Undesirable Effects: Eye disorders: Very common: hyperaemia. Common: punctate keratitis, anterior chamber cells and flare, pain, photophobia, discharge, discomfort, irritation, abnormal or foreign body sensation in the eyes, visual acuity reduced, vision blurred, dry eye, eye pruritus, lacrimation increased; erythaema, oedema and/or itching of eyelid; growth, and/ or discolouration of eyelashes; iris hyperpigmentation. Please refer to SmPC for other eye disorders. Systemic disorders: Common: headache, skin hyperpigmentation (periocular). Please refer to SmPC for other systemic disorders. Overdose: Symptomatic treatment. Incompatibilities: None known. Pharmaceutical Precautions: No special precautions for storage, 3 year shelf life, discard 4 weeks after first opening. Presentation: Plastic bottle containing 2.5 ml eye drops.Cartons containing 1 or 3 bottles. Legal Category: POM.

Pack Size and Basic NHS Price: 2.5ml £9.98. GMS Price: 2.5 ml 17.91. Marketing Authorisation Holder: Alcon Laboratories (UK) Ltd., Boundary Way, Hemel Hempstead, Herts HP2 7UD, United Kingdom. MA Numbers: EU/1/01/199/001-002. Date of preparation of PI: August 2010 (V3).

Adverse events should be reported.Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Alcon Medical Information on 01442 341234 Email gb.adr@alconlabs.com

Alcon Laboratories (UK) Ltd., Pentagon Park, Boundary Way, Hemel Hempstead, Herts. HP2 7UD. Tel: (01442) 341234 Fax: (01442) 341200 Trademarks are the property of the respective owners. Date of Preparation: August 2010

TRA:EU:JA:08/10:LHC

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Update

CATARACT

Cataract blindness

WOC 2010 is told new solutions needed in developing countries by Stefanie Petrou Binder MD in Berlin

ataract remains a major cause of blindness in Africa. This problem needs to be dealt with aggressively and unconventionally, according to Alfred Sommer MD, Johns Hopkins Bloomberg School of Public Health. “Unoperated cataract is the single most important cause of remedial avoidable blindness and visual impairment in developing countries. The relatively small numbers of trained ophthalmologists in Africa are not going to go out to rural areas to work for any long extent of time. Cataract surgeons in Africa ought to take a positive and aggressive attitude toward establishing a programme where they train non-physicians to do high quality and inexpensive cataract surgery, at whatever level feels comfortable and convenient for that country,” Dr Sommer said in a presentation given at the World Ophthalmology Congress (WOC) 2010 in Berlin. He observed that while AMD accounted for 50 per cent of blindness in developed countries, cataract was by far the major cause (50 per cent) in developing counties. To reduce avoidable cataract blindness, cataracts needed to be operated, and to achieve this, surgical efficiency and quality needed to improve, and the number of surgeons needed to increase, he said. Dr Sommer noted that while there was

EUROTIMES | Volume 15 | Issue 10

roughly one eye doctor per 10,000 people in the US, and one in about 100,000 in India, in Africa, one eye doctor served at least one million people or more. Performing more efficient surgery would be one way to overcome the numbers, he said. A notable case in point is India, where in 1980 the cataract surgical rate was roughly 500 operations per year per surgeon per one million population, growing steadily in 1990 to 1,000 operations, in 2000 to 3,000 operations, and in 2005 to 4,500 operations. The tenfold increase in 25 years resulted from an increased efficiency and a government that was committed to making a difference, he said. By contrast, China, which improved its surgical standards between1980-2000 from crude ICCE to phaco plus IOL, resulting in a price jump from $5 to $500+/operation, did not improve its efficiency at operating cataracts. China actually saw an increase in blindness rates, as the increase in quality and price excluded many people from having cataract surgery. The number of blind patients in India dropped from 8.9 million in 1990 to 6.7 million in 2002. By contrast, the blindness rate in China in 1990 was 6.7 million, but increased in 2002 to 6.9 million people. Quality and efficiency need to go hand in hand in order to make a difference, he said.

The strain of the brain drain

In a further comparison, Dr Sommer observed that unlike Asian countries, which have ophthalmologist training programmes, African countries train very few physicians and therefore have very few ophthalmologists. Furthermore, the ophthalmologists that train in Africa often immigrate to countries paying higher salaries and investing more in the ability to carry out ophthalmology. Additionally, the rural areas of sub-Saharan Africa tend to have a low population density and poor transportation, which further complicates the issue. The problems with building a pool of trained health workers in low-density countries are manifold. Thirty per cent of all NHS (UK) doctors come from overseas, according to the Crisp report, an independent evaluation into global health partnerships. There are more Ghanaian doctors in England than in Ghana itself, for instance. This shows that training doctors alone will not necessarily solve the problem, Dr Sommer noted. Dr Sommer believes that training nonophthalmologists for work in rural areas could contribute to solving the problem of cataract blindness in Africa. The trainees need to be trained for high-quality surgery and should be closely supervised by ophthalmologists, he noted. “This has been successfully done before,

Alfred Sommer - asommer@jhsph.edu

and can be done better. Africa needs to invest the resources, whether it comes from the government or from NGOs. They need the facilities, equipment, supplies and a team that operates together to be efficient and effective.” Training includes management for efficiency and involves the whole team, Dr Sommer maintained. The trainees require supervision and assessment as part of a continuous quality improvement process. The ophthalmologist who leads the whole effort must be compensated for his work, because pro bono work may come second to seeing private patients and is not going to be effective, he observed. Without this, Dr Sommer feels there will be little hope for rural cataract patients in our lifetime or, in fact, that of our children’s or of our children’s children. Acquiring adequate numbers of competent cataract surgery delivering services in rural areas of sub-Saharan Africa within the next 30 years will not happen. An ophthalmologist from Rwanda in the audience said that training nonphysician cataract surgeons would not solve the problem that he sees in Rwanda. He said that since the training time is the same, nothing is gained by training non-physicians to do the job. He said that a medical professional was needed for cataract surgery and that his own team increased from two to 10 surgeons over the last years. The problem is the difficulty in getting these trained professionals out to the people, not the paucity of trained surgeons, he said. Dr Sommer agreed that if the professionals were available, they were indeed preferable. His proposal was for areas where physicians were lacking and surgeons were sorely needed. This article does not represent the views of the editors of EuroTimes

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Peter J Cornell - drcornell@cornell-eye.com

Update

REFRACTIVE LENS

Accommodating IOLs

Surgeons should include the possibility of colour discrimination issue in informed consent process by Howard Larkin

small minority of patients implanted with the accommodating Crystalens intraocular lens may be troubled by changes in the appearance of colours, says Peter J Cornell MD, Beverly Hills, California, US. Over a four-year period during which he implanted 347 Crystalens IOLs, five patients spontaneously reported similar colour discrimination difficulties with the lens, including blacks appearing blue and browns appearing purple. Four of the five patients in Dr Cornell’s case series changed their subsequent IOL choices as a result, with implantation of blue filter lenses resolving the symptoms, he told the American Society of Cataract and Refractive Surgery annual meeting. He now discloses the possibility of subjective colour discrimination shifts as part of his informed consent and education process for patients considering the Crystalens. “We know there is often an increase in blue colour perception with cataract removal, but this is out of the usual range,” he said. The problem appears to be more likely in patients who have unusually high colour discrimination abilities and demands, Dr Cornell added. Of the five patients one was an interior designer, another a “corporate colour matcher” and a third asked extensive questions about postoperative colour perception shifts before surgery. Curious

about the phenomenon, he tested two of the five with the Farnsworth-Munsell 100-hue colour discrimination test and found they scored well above the normal range for their age.

20/20, but… Dr Cornell’s first experience involved a 76-year-old female hyperope with visually significant cataracts. “After an extensive preoperative consultation with many, many questions about colour changes, lens options and expected visual results she elected to have a Crystalens implanted in the left eye,” Dr Cornell said. The visual results were excellent on day one, and the patient left the office happy. Then the problems began. “She called me back the same day complaining that there was a ‘purple cast’ to all colours, especially black. I advised her to wait for further healing,” Dr Cornell recalled. The problem persisted with the patient saying she needed to close her left eye to see colours correctly out of her now 20/60 phakic right eye. At nine months a Tecnis ZCB00 aspheric lens with UV block was implanted in her right eye. Once again, the visual result was excellent, but the patient felt the colour was not right. Four years later she continues to be very symptomatic and unhappy, but wants no further surgery, Dr Cornell said. Her F-M 100 test scored total errors of 20 in the right eye and 32 in the left

eye, or 4.4 and 3.8 standard deviations above the mean for this age group, he noted. Dr Cornell ran across a similar issue with a 74-year-old male who listed his occupation as “corporate colour matcher”. He had a Crystalens implanted in his right eye and was initially very happy, with 20/30 distance and J1 near vision, Dr Cornell said. But after six weeks he reported difficulty distinguishing black from blue, and brown objects appearing purple. A blue-blocking Alcon SN60WF was implanted in the left eye. The patient feels colour discrimination is normal out of the left eye and is happy with binocular visual function for distance, near and colour. However, he still sees the problem when he closes the left eye. The third case involved a 67-year-old myopic woman who had a Crystalens HD 520 implanted in the right eye. Day one she had 20/20 uncorrected distance, J5 intermediate and J3 near and was very happy with the visual result. But the day after surgery she reported trouble. “The colour distortions… became immediately apparent in daylight…. Blacks registered as navy, taupes became purple and deep reds were magenta. Moreover, grass, trees and shrubs were washed out,” she wrote in a long letter. A Crystalens and a blue filter Staar AQ-5010 plano piggyback lens were implanted in the left eye with relaxing

incisions for astigmatism, producing 20/30 distance and 1.25 D residual astigmatism resulting in monocular diplopia. Plus, the colour in the right eye wasn’t right, the patient said. So the piggyback and Crystalens were replaced with a toric, blue filter Alcon SN60T3 with a target of -1.00. The patient was now very happy with the left eye, but still very bothered with colour vision disturbances in the right eye despite excellent binocular vision at distance, intermediate and near. So an Alcon MN60MA IOL blue filter lens was also placed in the sulcus of the right eye. While 20/20 distance vision was preserved intermediate vision dropped from J3 to J8, and near vision from J5 to J8, but she prefers vision out of progressive spectacles to the colour distortion, Dr Cornell said. “She is reasonably happy with her vision at this stage.” But not all patients prefer colour discrimination to visual acuity, Dr Cornell noted. A 61-year-old hyperopic female had a Crystalens HD implanted in one eye and subsequently reported colour symptoms, including purplish blacks and “washed out” greens. A blue filter Alcon SN60WF was implanted in the other eye, resulting in normal colour, but a -1.25 D refraction. The patient decided that she preferred the better vision she had with the Crystalens and the colour problems were not intolerable, and so had the blue filter replaced with a second Crystalens. Similarly, a 63-year-old interior designer noted colour issue, but liked the 20/20, J3 near results she got with the Crystalens so well she had a second implanted. “It is a rare problem but I do strongly recommend surgeons include the possibility of colour discrimination issue in the informed consent process. Blue-blocking lenses appear to resolve the problems,” Dr Cornell concluded.

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Update

CORNEA

A John Kanellopoulos - ajk@brilliantvision.com Josefina Salgado - josefina.salgado@gmx.net

Post-LASIK keratectasia

Cross-linking, with and without PRK, shows good results by Howard Larkin in Boston

ive years after undergoing LASIK and three years after developing post-LASIK keratectasia, a helicopter pilot on disability leave from a metropolitan city’s Fire Department in the US, was referred to A John Kanellopoulos MD at New York University. With the pilot’s vision at 20/60 and dropping, Dr Kanellopoulos discussed the option – not at the time available in the US – of collagen cross-linking and the “Athens Protocol”. Subsequently, the patient flew to his clinic in Athens for a combined PRK and collagen cross-linking procedure to try to arrest the disease and reduce the distortions in his cornea. Six months later the pilot was back on active duty. Today his vision tests 20/15 and he flies a fighter jet for the US Air Force. “This is a remarkable result in a patient who was originally recommended to have a cornea transplant,” said Dr Kanellopoulos, who presented the case as part of a series on the combined procedure at the American Society of Cataract and Refractive Surgery (ASCRS) annual meeting. Of course not all of the 32 keratectatic eyes Dr Kanellopoulos has treated with this combination therapy have done as well as far as the final visual outcome. But most have improved, with 27 showing better uncorrected visual acuity and best corrected vision of at least 20/45 at their last follow-up visits, which were between six months and 59 months post-treatment, averaging 17 months. “Only one patient was unsatisfied with the results. She is wearing [rigid gas-permeable contacts] and her steepest K was over 58.” All 32 eyes in this consecutive series were suffering progressive post-LASIK ectasia. All underwent a topography guided photorefractive keratectomy procedure designed not to correct refractive errors, but specially designed to “normalise” the shape of the cornea, Dr Kanellopoulos said. The procedure applied a myopic profile ablation to the tip of the cone and a hyperopic profile peripherally, superior to the cone to reduce inferior steepening. Up to 70 per cent of sphere and cylinder were also addressed, with total ablation limited up to 50 microns to minimise potential structural weakening. The results were then locked into place the same day with a riboflavin-UVA-A

EUROTIMES | Volume 15 | Issue 10

collagen cross-linking procedure similar to that developed by Seiler, Spoel and Wollensak in Dresden and then Zurich, though for all patients a different (slightly hypotonic) riboflavin in a sodium phosphate solution was substituted for riboflavin in dextran. Visual rehabilitation typically takes three months or so, with steady improvement at six months. Laservision. gr Institute in Athens was the third centre globally to become involved with CXL clinically, since 2002. It is worth noting that keratoconus is endemic in Greece and Cyprus with unofficial estimates affecting one in 100 young male adults. “The technique is based on seven years of experience with corneal cross-linking for treating keratoconus,” Dr Kanellopoulos said. He believes that for keratoconus, combining cross-linking and PRK in one treatment yields better results than crosslinking first and doing PRK later, a result substantiated in a case report involving 325 eyes published in the September 2009 Journal of Refractive Surgery. This technique was developed by Dr Kanellopoulos, after several years and hundreds of ectasia and keratoconus cases treated with collagen cross-linking and is called the “Athens Protocol”. “The eyes are not perfect if compared to routine LASIK or PRK cases, but they have remarkable symmetry improvement in the cornea and improvement in best spectacle corrected visual acuity. The follow-up we have is quite convincing that we have significant rehabilitative results.”

Cross-linking stabilises keratectatic corneas at 12 months

A study of 22 eyes of 15 patients presented by Josefina P Salgado MD of the Technical University of Munich also showed the promise of corneal collagen cross-linking for treating post-LASIK ectasia. In all subjects the cornea had stabilised 12 months after the procedure. Subjects averaged 38.4 years old, ranging from 27 to 51 years. The mean time between LASIK and the onset of symptoms was 38.7 months, but was highly variable, ranging from 0.5 months to 120 months. All subjects received a corneal crosslinking procedure using the Zurich protocol developed by Prof Seiler. It includes removal of the corneal epithelium

Courtesy of Josefina P Salgado MD

Topography of a cross-linked eye before and 24 months after the procedure (OD) and progression of the non-treated fellow eye (OS)

followed by application of a riboflavin in dextran solution every five minutes for 30 minutes. After that UV radiation at 370 nm was carried out combined with the further application of riboflavin solution for a period of 30 minutes. A soft bandage contact lens was applied until complete epithelial closure was achieved after surgery. Objective and subjective refraction, uncorrected and best corrected vision, corneal pachymetry and corneal topography were measured, and slit lamp biomicroscopy observations performed before the cross-linking procedure and one, three, six and 12 months after the procedure. At one month uncorrected visual acuity declined slightly, then gradually improved to slightly better than preoperative levels at 12 months, as did best corrected vision, Dr Salgado reported. A myopic shift and an increase in astigmatism also were observed in the first months and declined over time. Likewise, keratometry showed a steepening of the cornea in the first month that went back over time. “We think this worsening immediately after cross-linking might be associated with

compaction and changes and remodelling of the stromal collagen,” she said. However, the 12-month results in this study, combined with previous experience with keratoconus patients, suggest that corneal cross-linking may be a viable alternative to spectacles, contact lenses and corneal ring segments, which may correct refractive error, but do not prevent progression of keratectasia condition, Dr Salgado pointed out. Stabilising the cornea with cross-linking may also reduce the need for more invasive approaches, such as lamellar or penetrating keratoplasty, which are not only technically challenging and risky, but there is also a shortage of tissue donors. “It has been proven effective in keratoconus, and we can see in iatrogenic keratectasia that it provides maintenance of visual acuity and sometimes an improvement, though it is not statistically significant. I think we can combine cross-linking with PRK and arrest disease progression and avoid corneal transplantations in these patients. But still we need to know more about safety and efficacy in the long term.”

contact

Giancarlo Falcinelli - falcinellig@tiscalinet.it

Update

CORNEA

Biological keratoprosthesis

Innovator describes unique device properties and personal technique modifications by Cheryl Guttman Krader in Venice

EUROTIMES | Volume 15 | Issue 10

3 1. Tooth removal; 2. Osteo-odonto lamina with hole; 3. Optic acrylic cylinder fixation

Courtesy of Giancarlo Falcinelli MD

mplantation of a keratoprosthesis remains the only option for restoring sight in many cases of corneal blindness, but most of the available devices are either not indicated for or have yielded poor outcomes in eyes with very advanced pathological changes. In his EuCornea Medal Lecture at the 1st EuCornea Congress, Giancarlo Falcinelli MD, told attendees about the advantages of the osteo-odonto keratoprosthesis (OOKP) developed by Strampelli and his own modifications to this approach. The method had produced excellent long-term anatomic and functional outcomes in treating eyes with corneal blindness for which no other therapy has proven benefit. Dr Falcinelli is former director of ophthalmology, San Camillo Hospital, Rome, Italy, scientific director, Osteoodonto-Keratoprosthesis Foundation, and director, Ophthalmic Department, Clinic Pio XI, Rome. He summarised his experience performing “Modified OOKP” (MOOKP) surgery over a period of more than 36 years in a series of 282 eyes of 230 patients. The most common diagnoses were end-stage dry eye due to underlying autoimmune disease, including Steven Johnson Syndrome, Lyell syndrome, ocular pemphigoid, Sjögren syndrome and very severe chemical burns. Of the 282 eyes, 29 per cent had a history of one or more failed corneal transplant procedures, stem cells treatment and/or amniotic membrane transplantation. Although a number of complications were encountered during the surgeries and postoperatively, nearly all were successfully treated or had little impact on the final result. The functional data showed that 90 per cent of the 282 eyes regained useful BCVA, with half achieving BCVA of 20/25 or better. Fewer than three per cent of eyes had no visual improvement. Over the long-term, the best BCVA achieved postoperatively was maintained at last available follow-up in nearly 80 per cent of operated eyes, reported Dr Falcinelli. “We may certainly conclude that with the biological properties of Strampelli’s OOKP, combined with the technical innovations we’ve introduced, and assuming the surgery is performed correctly, the MOOKP can effectively restore sight and provide excellent long-term outcomes in all cases of blindness caused by any scars affecting

Implant of the prosthesis after mucosa detached

the anterior surface of the eye, the adnexae, including the lids, and up to the last stage of dry eye,” he said. Dr Falcinelli explained that based on the type of haptic used for joining the optic to the anterior surface of the eye, keratoprostheses may be classified into three categories: biocompatible, biointegrated, and biological. Strampelli’s OOKP, introduced in 1964, represents the first biological keratoprosthesis. It uses autologous living human tissue for the haptic – dentine, alveolar bone with its ligament and periosteum from an extracted single root tooth, that is covered on the eye with autologous buccal mucosa.

Dr Falcinelli highlighted two properties of the biological OOKP that account for its long-term safety and efficacy. “In the mouth, the epithelium of the gingival mucosa lies close to the alveolar dental ligament, cement and dentine and creates a tight seal protecting the dental root from infection. Similarly, in the MOOKP, the buccal mucosal epithelium covering the prosthesis creates a true epithelial seal to the anterior chamber to prevent leakage of aqueous humour, as well as infection and expulsion.” Other benefits of the material relate the hardness and avascular nature of dentine. “These properties may help to confer

stability to the prosthetic complex, and the absence of vascularised tissue in contact with the cornea may help to limit the development of retroprosthetic membranes,” said Dr Falcinelli. Dr Falcinelli explained that MOOKP surgery is performed as a two-stage operation with an interval of about three months between stages. The first stage involves preparation of both the bulbar anterior surface (including coverage with a buccal mucosal graft) and the osteo-odonto acrylic lamina (OOAL) with its PMMA optical cylinder. Once prepared, the OOAL complex is buried temporarily in a subcutaneous pocket below the orbital rim where it can acquire well vascularised tissues that nourish the prosthesis. In the second stage, excess adherent soft connective tissue is removed from the OOAL complex, and, after further preparation of the eye, it is implanted on the anterior bulbar surface and recovered with the buccal mucosa flap. Dr Falcinelli has introduced a total of 13 modifications to Strampelli’s original surgical technique. However, he considers four of the innovations as substantially changing the procedure and being fundamental for improving functional outcomes and long-term device retention. One of these changes involves increasing the diameter of the PMMA optical cylinder. “Widening the optical cylinder diameter has the obvious advantage of increasing the visual field. However, increasing the posterior diameter greater than 4.5mm requires a larger trephination of the cornea that may lead to tilting of the optical cylinder, retroprosthetic membrane formation, and some difficulties in saving the prosthesis,” said Dr Falcinelli. He also introduced total iris ablation by 360-degrees iridodialysis as a routine step in the surgical procedure with the aims of preventing the development of iridocyclitis, anterior iridal adhesions, pupillary seclusion, and iridal incarcerations in radial cuts that are made in the cornea. Anterior vitrectomy is also now mandatory in MOOKP. It is performed with an opensky technique to remove about 1.5 cc of vitreous, and its rationale is to prevent vitreal adhesions and subsequently vitreoretinal traction. In addition intracapsular cryoextraction of the lens is performed routinely, regardless of lens transparency, during the second stage of the procedure. “In Strampelli’s original technique, lens extraction was performed as a third stage. However, I made it a mandatory part of the second operation because the presence and protrusion of the cylinder’s posterior segment into the anterior chamber could cause inflammation or phacoanaphylactic uveitis,” explained Dr Falcinelli.

Update

GLAUCOMA

Open-angle glaucoma

Ageing lens may close apparently open angles in the dark, and otherwise subtly obstruct aqueous outflow

by Howard Larkin in Boston

patient previously diagnosed with open-angle glaucoma (OAG) complained of not being able to watch movies with his family because he got a headache when they turned off the lights in the room. When he turned the lights on, the headache went away. Sanjay Asrani MD of Duke University, Durham, North Carolina, US, suspected the problem might be an intermittent form of phacomorphic closed-angle glaucoma. The ageing crystalline lens pushes on the iris which in turn compresses the trabecular meshwork, but only when the pupil is enlarged under scotopic conditions. “Sure enough on gonioscopy the angle was wide open. But with anterior segment OCT in the dark the angle was closed. When you turned on the room light, let alone the incident light of the slit lamp, the angle opened,” Dr Asrani told the American Society of Cataract and Refractive Surgery annual meeting. Dr Asrani believes many cases of intermittent angle closure and other forms of phacomorphic glaucoma go undetected because of the inherent limitations of gonioscopy. “Light from the slit lamp and accommodation constrict the pupil and artificially open the angle, leading us to call more glaucomas ‘open angle’ which are actually narrow angle.” While patients with diabetes, a history of central retinal vein occlusion, hyperopes over age 40 and East Asians are known to be at risk for narrow-angle glaucoma, Dr Asrani adds those with large pupils to the list. “For patients with large pupils on scotopic illumination, my gonioscopic findings are going to be highly suspect.” Dr Asrani discovered this intermittent angle closure by performing anterior segment OCT in the dark. For those without such equipment he suggests if the scleral spur is visible on gonioscopy, dim the light to the lowest setting, narrow the beam onto the individual mirror and out of the pupil and see if the spur is still visible. Then reverse the process; widen the beam to see if the iris moves away to reveal scleral spur. If significant movement is detected, the angle may be narrowing or occluding in what appears to be an open angle when the lights are on.

Accommodative apparatus Another form of lens associated with glaucoma in what appears to be adequately open angles involves the limited anterior movement of ciliary body under accommodation, Dr Asrani said. Citing research by Paul Kaufmann and colleagues at the University of Wisconsin showing that the ciliary body moves forward less during accommodation in older monkey eyes (Exp Eye Res. 2009 Dec;89(6):824-32), Dr Asrani speculated this may be due to the stiffening of the posterior zonules with age. “If you look in the old monkey eye there is something like a steel cable holding back the ciliary body,” Dr Asrani said. This apparently prevents not only the lens from moving forward, it may also restrict the ciliary body from contracting and pulling open the trabecular meshwork, which Dr Asrani noted is the mechanism by which pilocarpine increases aqueous outflow. “If something is preventing the ciliary body from contracting, EUROTIMES | Volume 15 | Issue 10

as we lose our accommodation we might also be losing our outflow as well.” In other cases, the phacomorphic nature of angle closure or narrowing is more obvious, as when the lens pushes the iris forward or blocks the pupil. “The lens can be so swollen that despite compression gonioscopy, it is difficult to see the trabecular meshwork,” Dr Asrani said. Where gonioscopy reveals iris apposition of the trabecular meshwork, and the meshwork and scleral spur cannot be visualised, but the scleral spur becomes visible under gentle compression, laser peripheral iridotomy may be sufficient treatment, Dr Asrani said. However, following laser iridotomy, eyes should be checked regularly to ensure the angle remains open as the lens will continue to grow in thickness and could eventually close the angle once again. However, if the intraocular pressure is raised and the lens has visually significant cataract, cataract surgery should be considered, he said. Typically, this results in a deeper anterior chamber and lower intraocular pressure. “The lens needs to be viewed as playing a significant contributory role in the mechanism of glaucoma and ocular hypertension development in certain cases,” Dr Asrani said. Thomas W Samuelson MD, Minneapolis, US, also believes that the contribution of the lens should always be considered in surgery decisions for adult-onset glaucoma. “The status of the lens has become an important part of my decision-making process. In part, due to the body of evidence accumulating concerning the impact of cataract surgery on intraocular pressure.” He pointed out that the mechanisms of IOP reduction resulting from cataract surgery differs from the mechanism of traditional filtering surgery, one increasing trabecular outflow and the other bypassing it via trans-scleral outflow. As a result, the effects of one procedure may negate the effect of the other. To increase understanding of involvement of the lens in glaucoma, Dr Samuelson suggested that the definition of phacomorphic glaucoma be expanded. Traditionally the condition has been defined as increased resistance to aqueous outflow resulting from narrowing of the chamber angle related to the lens whereby the iris mechanically impedes access to the angle, which encompasses the obvious cases. Dr Samuelson would include any acquired glaucoma in a phakic eye in which the lens has an adverse effect on outflow facility, whether the angle is closed, narrow or open. While the mechanism is unclear, the enlarging native lens may rotate scleral spur forward resulting in compression of the trabecular meshwork and subsequent reduction in outflow facility. Cataract surgery allows the scleral spur to assume a more posterior location, a more favorable anatomic relationship for the compromised meshwork.

contacts Sanjay Asrani – sanjay.asrani@duke.edu Thomas Samuelson – twsamuelson@mneye.com

contact

Ryo Asaoka - ryoasa0120@mac.com

Update

GLAUCOMA

New visual field test grid

Grid may add ease-of-use to perimetry and improve accuracy of glaucoma diagnosis by Roibeard O’hEineachain in Madrid

NEW visual field test grid based on the correspondences between the retinal ganglion cell distribution in the optic nerve head and points in the visual field may detect glaucomatous structural change more sensitively than the conventional 24-2 test grid, said Ryo Asaoka MD, PhD, Moorfields Eye Hospital, London UK at the 9th Congress of the European Glaucoma Society. Dr Asaoka and his associates developed the new test grid, called the StructureFunction Visual Field (SFVF), by calculating the optimum distribution of test locations established from the combined locations of a novel disccentred field (DCF) and those of the conventional 24-2 field test grid, which maximises the structure-function correlation. “The 24-2 test grid is one of the most frequently used visual field test grids. In the 24-2, test points are located at regular six-degree intervals with no particular relationship to the underlying course of retinal nerve fibre layer. We felt that the visual field test points should be based on

“

the distribution of the neural fibres,” Dr Asaoka told EuroTimes in an interview. The test points of the DCF were based on the structure-function map created by David Garway-Heath (Garway-Heath et al, Ophthalmology. 2000:107(10):180915.), in which visual field defects at specific test points correspond to reduced retinal ganglion cell (RGC) density in specific regions of the ONH, as measured by the Stratus OCT (Carl Zeiss Meditec). The DCF also took into account the distribution of the retinal nerve fibre layer (RNFL). “In a previous study, which we presented at ARVO 2009, we compared the structure-function relationship of the 24-2 with that of the disc-centred visual field; contrary to our hypothesis, they were almost identical. We then looked at which combination of test points (from both grids) optimised the structurefunction relationship. Using these findings we developed a new test grid that had two advantages: a stronger structurefunction relationship, and only 36 test points, which is 16 less than the 24-2 test grid,” Dr Asaoka said.

Fibre Analyzer (GDx ECC, Carl Zeiss Meditec). Regarding structure, they classified each 30-degree sector of the optic disc as `glaucomatous’ if the corresponding sectoral RNFL average thickness as measured by OCT was abnormal or borderline, or, the deviation map of the GDx ECC showed three contiguous abnormal pixels in the given sector (p < .05). In terms of function, they classified sectors on the 24-2 field and the SFVF as abnormal if one of the test points in any given sector had sensitivity below the 90th percentile of the age-matched normal sensitivity. Despite the considerably smaller number of test points in the SFVF, there was no loss of diagnostic precision compared to the 24-2 test grid. The sensitivity and specificity of the two test

grids were similar in the nasal sectors of the visual field (sectors 1-4 and 9-12). In the temporal area (sectors 5-8), the sensitivities of the SFVF tended to be higher than those of 24-2, with only a marginal decrease in specificity. “The new test grid has fewer test points in the nasal sectors of the visual field. Nonetheless, the sensitivity and specificity of the new test grid were no worse than the 24-2. The new test grid has more test points in the temporal area of the visual field and the sensitivity in those sectors were better than the 24-2.” Dr Asaoka said that the results with the new structure-function grid require confirmation with an independent dataset. However, he said the study’s findings were fairly robust having been confirmed by a bootstrapping statistical technique. “In conclusion, in addition to a stronger structure-function relationship, the new test grid has a diagnostic ability that has been shown to be at least equal to the 24-2 test-grid, despite the smaller number of test points. Furthermore, we know that a smaller number of test points is advantageous for accurate measurement because the fatigue effect for patients is less,” he added.

Advanced. Versatile. Different

New grid as accurate as 24-2 and easier to use In a prospective

The new test grid has a diagnostic ability that has been shown to be at least equal to the 24-2 test-grid, despite the smaller number of test points. Furthermore, we know that a smaller number of test points is advantageous for accurate measurement because the fatigue effect for patients is less

study involving 50 patients attending a glaucoma clinic at Moorfields Hospital, the new structure-function visual field test grid performed at least as well as in detecting visual field defects, which corresponded to glaucomatous abnormalities in the optic nerve head. In fact the new test grid appeared to be diagnostically more sensitive in some sectors. The study involved eight patients with ocular hypertension and 42 with open-angle glaucoma in various states of progression. Their MD ranged from +1.6 dB to -25.6dB and had a mean value of -9.4 dB. The researchers programmed the DCF test grid into the Humphrey Field Analyzer using the custom full-threshold mode. They measured RNFL thickness using the Stratus OCT and the Nerve

“

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romising new compounds currently undergoing clinical trials may have the potential to reduce the devastating effects of wet age-related macular degeneration (AMD) and offer patients a new paradigm of care, according to Alexander Brucker MD. â&#x20AC;&#x153;There is a huge amount of research being directed at wet AMD at the moment and some of the latest therapies look very promising,â&#x20AC;? Dr Brucker told the World Ophthalmology Congress (WOC) in Berlin. â&#x20AC;&#x153;In addition to the anti-VEGF drugs currently on the market, there are numerous trials of intravitreal drugs targeting AMD including VEGF Trap-Eye, complement factor inhibitors, and anti-platelet derived growth factor (PDGF) drugs. The next steps will be to see which of these drugs, if any, can improve on the gold standard of ranibizumab treatment, to find the most effective combination therapies and to carry out comparative studies to see which drug will be most effective,â&#x20AC;? he said. Dr Brucker, professor of ophthalmology at the Scheie Eye Institute of the University of Pennsylvania School of Medicine, Philadelphia, US, said there is reasonable evidence to believe that the latest therapies undergoing clinical trials may eventually equal or even exceed the performance of current anti-VEGF drugs, which halt or slow down the progression of AMD in most cases, but which do not cure the underlying pathology. Dr Brucker said that VEGF Trap-Eye (Bayer Healthcare, Regeneron Pharmaceuticals Inc.) is currently in Phase 3 development in the VIEW 1 and VIEW 2 trials for wet AMD. The drug is a fully human, soluble VEGF receptor fusion protein that binds all forms of VEGF-A along with the related placental growth factor (PlGF) and has proved effective in improving visual acuity and reducing choroidal neovascularisation. Patient enrolment has been completed in both VIEW 1 (United States and Canada) and VIEW 2 (Europe, Asia Pacific, Japan, and Latin America) studies with initial yearone primary endpoint data expected in the second half of 2010, said Dr Brucker. The primary endpoint of these noninferiority studies is the proportion of patients treated with VEGF Trap-Eye who maintain vision at the end of one year compared to ranibizumab patients. Turning to the CLEAR-IT 2 trial, a phase 2, doublemasked, multicentre trial of VEGF Trap-Eye, Dr Brucker said that patients with neovascular AMD were randomly assigned to receive monthly intravitreal injections of VEGF Trap-Eye 0.5mg or 2.0mg or quarterly injections of 0.5, 2.0 or 4.0mg for an initial 3-month fixed-dose period, after which they received the same doses on an as-needed basis at monthly visits out to one year. At the one-year follow-up point, there was a significant improvement in BCVA from baseline, with a mean improvement of 5.3 letters in all treated groups combined. Patients who received three monthly doses followed by

as-needed dosing achieved mean improvements in BCVA of 9.0 letters from baseline for the 2.0mg dose and 5.4 letters for the 0.5mg dose at the end of one year. Patients who received initial quarterly dosing followed by as-needed dosing also achieved gains in BCVA, but they were generally not as robust as those achieved with initial monthly dosing. Patients receiving initial monthly doses of VEGF Trap-Eye also achieved mean decreases in retinal thickness and a reduction in the size of the choroidal neovascular membrane (CNV) at one year. â&#x20AC;&#x153;The CLEAR-IT 2 study demonstrated that VEGF Trap-Eye achieved clinically meaningful and durable visual improvement over one year and was generally well tolerated,â&#x20AC;? he said. These positive results were confirmed by the CLEAR-IT extension study in which all 117 patients who elected to enter the extension stage received 2.0mg VEGF Trap-Eye on an as-needed basis, said Dr Brucker. â&#x20AC;&#x153;The conclusions of the extension trial were that it is effective and shows improvement in visual acuity, the PRN dosing is durable, that many of these patients required no additional injections and that the VEGF Trap-Eye is well tolerated,â&#x20AC;? he said. In terms of comparison trials, Dr Brucker said that clinicians are eagerly awaiting the results of the CATT trial, designed to evaluate the relative safety and efficacy of ranibizumab compared to bevacizumab for neovascular AMD and to evaluate how frequently the drugs should be administered. The first results are anticipated in February 2011. Similar head-to-head studies of Lucentis versus Avastin are also being conducted in Australia and Brazil. For combination therapies, Dr Brucker highlighted the phase 1 results of E10030 (Ophthotech Corp.), an antiplatelet derived growth factor (anti-PDGF). He explained that E10030 is an aptamer targeting PDGF, a key molecule involved in the recruitment and maturation of pericytes. In neovascular tissue, pericytes have been shown to be protective and play a major role in anti-VEGF treatment resistance. E10030 works by stripping the pericytes from the neovascular tissue rendering it highly sensitive to an antiVEGF attack. In a Phase I clinical study, 59 per cent of patients treated with E10030 and Lucentis gained significant vision (3-line gain or better) 12 weeks after the start of therapy. Notably, there was a mean decrease of 86 per cent in the area of choroidal neovascularisation (CNV) at 12 weeks. A phase 2 trial of 444 patients is currently recruiting to further test the efficacy and safety of E10030.

contact

Alexander Brucker - Alexander.Brucker@uphs.upenn.eduÂ

Update

RETINA A A O • M E A C O J O I N T M E E T I N G, 2 0 1 0

AMD treatments

Different mechanisms of a combination approach may also be synergistic by Dermot McGrath in Berlin

This is the second part of an article which appeared on page 29 in the September issue

urning to combination therapy with VEGF inhibitors and steroids, Dr Loewenstein said that the ERIE trial had shown promising results from combined therapy with ranibizumab (Lucentis, Genentech Inc) and dexamethasone (Ozurdex, Allergan Inc). “One of the key results was that Ozurdex did increase the time to the first PRN Lucentis injection. The mean number of injections was smaller in the Ozurdex and Lucentis treated groups compared to those treated with sham and Lucentis. There was also a group of patients that did not need any Lucentis PRN injections or did not require any after the initial injection and this percentage was higher in the Ozurdex treated groups. Overall, there was no difference in visual acuity between the groups and at each time point less people in the Ozurdex treated group needed another injection. In the subgroup of naïve patients there was a better visual acuity result in the ozurdex treated group. Also, the percentage of patients with a thinner retinal thickness was higher in the Ozurdex group and the safety profile was very good,” she said. In terms of anti-VEGF and irradiation treatments, Dr Loewenstein said that three trials – CABERNET, MERLOT and MERITAGE – are currently assessing the effectiveness of this approach in AMD. Preliminary observations from the MERITAGE trials indicate positive results in reducing the number of needed injections and maintaining good visual acuity without significant safety concerns.

Focusing on triple therapy, Dr Loewenstein said that trials carried out by Albert Augustin MD showed good results from a combination of PDT, bevacizumab and dexamethasone in 146 patients with a mean follow-up of 74 weeks. Of the 146 patients, 11 (eight per cent) required one more course of triple therapy, 46 (32 per cent) required one additional bevacizumab injection and there was a mean visual acuity increase of 9.35 letters and a mean decrease in retinal thickness of 167 microns. These outcomes were supported by the results of the RADICAL trial, which looked at standard, reduced- and very reduced-fluence PDT, ranibizumab and dexamethasone, and which showed a 6.8 letter gain after a mean three injections over one year, with 13 per cent of patients requiring no additional therapy beyond baseline in the standard-fluence PDT group. Dr Loewenstein also cited the CAVE trial, which sought to determine whether treatment with PDT could extend the time between intravitreal injections of bevacizumab. One study arm also received intravitreal triamcinolone acetonide as triple therapy. She said that the results showed that combination therapy of bevacizumab and PDT extended the treatment-free interval over bevacizumab alone, although triamcinolone appeared to have no added benefit. She noted that other treatment approaches such as IGG-directed PDT and diode laser also showed promise as possible combination therapies, but that more long-term results were needed to assess their viability.

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Update

RETINA

Multifocal IOLs

New possibilities for vitreoretinal surgery

by Howard Larkin in Boston

nyone who has done fundus exams on patients with multifocal intraocular lenses knows how difficult it can be to adequately illuminate and visualise the retina through these complex optics. MIOLs also can complicate procedures done at the slit lamp due to light scatter. So the question arises: do multifocal lenses interfere with visualisation so much that they should be removed before attempting delicate vitreoretinal procedures, such as peeling epiretinal and internal limiting membranes, that are difficult to see under the best of circumstances? “Today we are implanting a lot of multifocal IOLs, but is a good candidate patient for MIOLs suitable for a vitreoretinal procedure tomorrow?” Gianluca Rubiolini MD, Como, Italy, asked at the ASCRS annual meeting. According to a case series he presented, the answer is yes – it’s OK to leave the MIOLs in place because they don’t interfere very much. “We could perform the surgeries without a problem. We thought we would have a lot of problems because we didn’t know how the retina would appear [through MIOLs], but it

appeared normal; more or less normal,” Dr Rubiolini said. With Massimo Stefini MD, Lecco, Italy, Dr Rubiolini conducted vitreo-retinal procedures on four patients with different types of MIOLs. They tested two diffractive designs with Fresnel lines, which were a single-piece hydrophobic blue filter and a three-piece UV filter lens; and two refractive designs without Fresnel lines, which were a threepiece hydrophobic acrylic and a one-piece hydrophilic refractive progressive lens, both with standard UV filters. The goal was to determine the influence, if any, of lens design and filters on surgeons’ ability to perform epiretinal or internal limiting membrane peels and other very delicate tasks. All the IOLs were previously implanted during cataract surgery when retinal pathologies were not evident or not diagnosed, and all were referred to Drs Rubiolini and Stefini. The patients suffered from a variety of conditions, including macular pucker, macular holes, vitreal traction and epiretinal membranes. The vitreoretinal procedures were carried out using an M841 Leica microscope,

True COMICS

an Oculus Biom4 binocular indirect ophthalmic microscope system with Oculus disposable lenses, and a D.O.R.C. xenon intraocular light source. In all four cases the surgeons were able to use their standard techniques, including vitrectomy and staining to make membranes more visible, and were able to visualise the retina sufficiently to easily identify and remove membranes. In the first case presented, involving a hydrophobic threepiece diffractive lens with Fresnel lines on the optic, the posterior chamber was clearly visible for a central vitrectomy. Staining of the epiretinal membrane did not change its colour much, but enough to make it easily identifiable with sufficient field of vision to remove it with forceps. Similarly, the internal limiting membrane was stained and clearly visible through a hydrophylic acrylic diffractive lens without lines. “The surgeons can use their own strategies without visual limitations. The four cases could be done and the membranes removed without removing the IOL,” Dr Rubiolini said. But while the presence of MIOLs did not force the surgeons to change their operating technique, they did make the surgeries more difficult, and there were differences among the lenses, he added. “The visual field was similar [to a nonMIOL patient] but not the same. The no-line IOLs have some advantages in surgeon focusing capability.” Stained membranes were also more difficult to see through the blue filter lens than through those with only UV filters, he noted. Observing the video presentations, Martin A Mainster PhD, MD, FRCOphth, Kansas,

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EUROTIMES | Volume 15 | Issue 10

Gianluca Rubiolini - rubiolini@grvision.com Martin Mainster - mmainste@kumc.edu

US, noted that the use of endoillumination improved visibility in these procedures. When using slit lamp or other external illumination, ophthalmoscopic light is scattered back at the surgeon from the MIOL, causing glare and reducing contrast, he noted. “The conclusions are valid for intraocular illumination. You designed these surgeries to eliminate standard office problems created by backscatter of slit lamp or indirect ophthalmoscope light from the MIOLs. The problem goes away with endoillumination. It’s too bad that we can’t eliminate it for routine office examination as well. Of course, endoillumination doesn’t get rid of the vitreoretinal visualisation challenges posed by ophthalmoscopic multifocality.” Prof Mainster suggested a couple of reasons other than multifocality why the presence of MIOLs might make retinal surgery more difficult. One is that the reduced modulation transfer function of MIOLs affects surgeons as well as patients who have them implanted. “As a result of looking through a multifocal IOL, your contrast sensitivity is decreased.” Second, when a blue filter IOL is present, visibility may be reduced even further, Prof Mainster said. He cited a 1977 paper by Francois Delori PhD (Monochromatic ophthalmoscopy and fundus photography. Arch Ophthalmol. 1977;95(5):861-868) that showed that many information subtleties about the inner retina were revealed by ophthalmoscopic light of predominantly blue wavelengths. “Yellow-tinted IOL filters take away about 50 per cent of the light between 400 to 500 nm, which is one-third of the visible spectrum. While you can get the job done, it is harder than with a colourless IOL.”

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Update

global ophthalmology

Fighting global blindness

Indian eye care model may offer template for global blindness battle by Dermot McGrath in Berlin

ISTANBUL 15 th ESCRS Winter Meeting in conjunction with the Turkish Ophthalmological Society Cataract & Refractive Surgery Division

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European Society of Cataract and Refractive Surgeons

EUROTIMES | Volume 15 | Issue 10

dvocacy, resource mobilisation and a coordinated effort from national and international stakeholders are required to make progress in the fight to reduce global blindness in the next decade, according to Gullapalli N Rao MD. In delivering the Bernardo Streiff Lecture at the World Ophthalmology Congress, Dr Rao, chair of V Prasad Eye Institute, Hyderabad, India, told delegates that global blindness is a major public health problem that needs greater support if the goal of eliminating avoidable blindness by the year 2020 is to be achieved. He noted that the “VISION 2020: The Right to Sight” global initiative has made considerable progress since being launched by the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB). “The VISION 2020 strategy is based on several essential activities, including disease control, human resource development and infrastructure and technology development. We need to remember that nearly 75 per cent of blindness is avoidable and 90 per cent of the problem is in developing countries. There is a clear need to identify gaps in eye care delivery and to methodically address them to make the necessary impact,” said Dr Rao. Dr Rao said that advocacy, resource mobilisation and coordinated efforts have already been successfully initiated to some degree at the global level. “A favourable outcome has been the important recognition achieved through the World Health Assembly Resolution making prevention of blindness a priority healthcare area for the WHO. Other progress includes the significant recognition of the VISION 2020 brand globally, a substantial increase in the overall funding for blindness prevention and much better coordination among stakeholder groups. WHO reported a reduction in the number of blind from 45 million in 1995 to 37 million in 2002, an important achievement,” he said. Comparing WHO data from 1995 and 2002, Dr Rao said that some significant changes have taken place in the causes of preventable blindness worldwide. This includes an overall reduction in the number of people who are blind or visually impaired and those who are blind from the effects of infectious disease, but an increase in the number of people who are blind from conditions related to longer lifespans. Unoperated cataract is still the leading cause of blindness (48 per cent), particularly in developing countries where 90 per cent of the world’s visually impaired live. Glaucoma, AMD and diabetic retinopathy have now become major causes of avoidable blindness. By contrast, success has been recorded in reducing the incidence of blindness from onchocerciasis, trachoma, vitamin A deficiency and, in India at least, cataract. “The pattern of blindness varies from region to region, necessitating a more context and geographybased approach to programmes aimed at reducing the incidence,” he said.

Dr Rao pointed out that the WHO statistics do not include an estimated 314 million people who are visually impaired, defined as a visual acuity less than 6/18, either due to uncorrected refractive error or eye diseases. He stressed that while VISION 2020’s focus should continue on controlling the major causes of avoidable blindness it was also important to pay attention to the wider context within which these causes lead to blindness. “This means that we need to translate advocacy gains into action in order to get the ‘buy in’ of governments and systems of governance, from the national level down to community level. We need greater mobilisation of resources in more creative ways and from a wider network of stakeholders. This involves bringing into VISION 2020 more corporate partners to share resources, on the one hand and community level organisations, to share local knowledge and create connections, on the other,” he said. One suggested strategy developed by the LV Prasad Eye Institute, and which has worked very well in India, is to develop an infrastructure model that seeks to enhance the delivery of eye care to target populations, said Dr Rao. The system is based on a tiered pyramidal model that envisions the creation of permanent and collaborative infrastructure at every level of eye care service delivery. The base of the pyramid represents crucial community involvement. At this level, “vision guardians” from the community are trained to monitor the eye health of a population of around 5,000 people. At the next level are “vision technicians”, who work at vision centres operating independently or attached to specialised primary health centres. They are trained to perform refraction and to screen for vision-threatening conditions. One such centre is developed for every 50,000 people. The next level of secondary care, the “service centre” is staffed by ophthalmologists, ophthalmic technicians, ophthalmic nurses, rehabilitation professionals and management personnel. The focus here is on comprehensive eye care. These centres typically serve a population of 500,000 to one million people. The next level on the pyramid, the training centre, serves a population of five million people and combines service delivery at tertiary level with training and research. Beyond this is the “centre of excellence” which serves as a “feeder” and “receiver” performing the entire spectrum of eye healthcare functions. The emphasis here is on providing a model of excellence in all respects, and active participation in formulating eye care policy. Dr Rao pointed out that the LVPEI model does not depend on external funding or expertise in the long term, as the vision centres have the potential to grow into community hubs that address other health needs beyond ophthalmic needs. The cost of providing care, from base to apex, is just US$1 per person served.

contact

Gullapalli N Rao – gnrao@lvpei.org

Don’t Miss... ASCRS Glaucoma Day 2011 Friday, March 25 www.ASCRSGlaucomaDay.org

Cornea Day 2011 Friday, March 25 www.CorneaDay.org

ASOA Specialty Forums March 26−29 www.ASOAForums.org

G N I S HOU ATION 1 1 20 TR S I G RE OPEN! D N A NOW rg o . s r sc a . w ww

Technicians & Nurses Program March 26−28 www.ASCRS.org

ISTANBUL 15 th ESCRS Winter Meeting in conjunction with the Turkish Ophthalmological Society Cataract & Refractive Surgery Division

act r t s b A on i s s i Submdline: Dea tober c 31 O

18 â&#x20AC;&#x201C; 20 February 2011

Hilton Hotel, Istanbul, Turkey

www.escrs.org

European Society of Cataract and Refractive Surgeons

Preview

winter meeting

Patients are individuals – the solution is unique: AT LISA® multifocal IOLs

Istanbul 2011 ESCRS looks to the future, to support new generations of ophthalmologists by Dr Bekir Sıtkı Aslan

n February 2011, the 15th ESCRS Winter Meeting will be held in İstanbul, together with the Turkish Ophthalmological Society Cataract and Refractive Surgery Division. On behalf of the organisers and my Turkish colleagues, I would like to invite you to this great event and to İstanbul, one of the most fascinating cities in the world. The 21st century will see the explosion into the post-modern age. Enormous technical, social and cultural transformations have taken place. ESCRS looks to the future, to support future generations of ophthalmologists and to help them to cope with these changes. In this meeting, we will have a mixture of eminent speakers giving updates on a variety of subjects, as well as healthy contributions in the form of free papers. An affiliation with MEACO will certainly convey an enormous strength to our meeting. Four main symposia will cover the most needed aspects of cataract and refractive topics. “Management of unexpected complications,” “Cataract surgery in the diseased eye,” “Premium Lenses” and “Current Options in Presbyopia” are the main symposia topics which I am sure will be highly appreciated by the attendants. Live surgery will be transmitted from Cerrahpasa Medical Faculty Eye Clinic, and as the local organisers we look forward to making it a surgical presentation of great scientific interest. Other educational events will be presented on the podium for the benefit of young ophthalmologists with even more improved programmes. We are also expecting an exciting industry exhibition which will feature some of the newest innovative products. Turkey is a country with a long and very respectable history in the treatment of eye disease that dates back to the 1800s. Having largely conquered most of the leading causes of blindness and visual impairments, Turkish ophthalmologists are now rising to meet the challenges and controversies of the new millennium. With its 3,600 ophthalmologists, the Turkish Ophthalmological Society schedules five annual scientific meetings. Ophthalmology has long held a prominent position in Turkish Medicine. In the early 1900s a general hospital should have had three specialists: an internist, a surgeon and an ophthalmologist. Training in ophthalmology has undergone some

EUROTIMES | Volume 15 | Issue 10

evolutionary changes. In the early years of the last century professors in ophthalmology came mainly from France. In 1934, the German approach to the science became prominent when Prof Josef Ingersheimer became the director of the Department of Ophthalmology at the İstanbul University. The Turkish Ophthalmological Society was founded by a small group of ophthalmologists in İstanbul in 1928. The society started to publish the first Turkish Journal of Ophthalmology appearing quarterly in 1931. This journal is still being published on a monthly basis by the Turkish Society. Sokrates Alexiadis, Nuri Fehmi Aybek, Niyazi İsmet Gözcü, Misakyan and İrfan Başar were some of the great role models of ophthalmology in the first half of the 20th century. Esat Işık invented light ophthalmoscopy, a simple but brilliant idea. In 1951 Naci Bengisu implanted the first Ridley lenses in the eyes of three patients. The venue of the congress is The Hilton İstanbul, with a dominating view of Bosphorus, a channel dividing two continents or joining east and west with the two most elegant necklace-like bridges. The hotel is located centrally surrounded by many other quality but affordable hotels. I would like to extend our gratitude to the Board Members of ESCRS who kindly asserted their wish to join east and west with the words of science to help humanity. This meeting will fulfill the needs of every fellow ophthalmologist scientifically and socially, since this meeting has the purpose “to improve communication between the scientific community and society; to promote contacts among various associations and among ophthalmologists engaged in producing science and technology.” I would like to take this opportunity to invite you to participate in the 15th ESCRS 2011 Winter Meeting. I wish all of you a successful and most memorable congress. * On Behalf of Turkish Ophthalmological Society Cataract and Refractive Surgery Division Dr Bekir Sıtkı Aslan, Head of Eye Clinic, TOBB Economy and Technology University Hospital

AT LISA family of multifocal IOLs Providing a very high level of satisfaction to more astigmatic, cataract and presbyopic patients. Find out more on www.meditec.zeiss.com/lisa

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contact Bekir Sıtkı Aslan – bekirsitkiaslan@gmail.com AT_LISA_Anzeige_120x300_100908.indd 1

10.09.2010 11:39:32

News

eurequo

patient focus

Surgeons in 15 European countries may compare cataract and refractive outcomes by Howard Larkin

urgical outcomes registries operated by 10 national ophthalmology societies serving 15 European countries are beginning to share data through EUREQUO, the online European Registry of Quality Outcomes for Cataract and Refractive Surgery. National registry managers and representatives of their sponsoring societies are meeting regularly to make the programme more accessible to surgeons. The goal is to share data and best practices across borders to improve care standards across the continent. â&#x20AC;&#x153;We hope that presentations from different participants will help to spread information about variations in technique and outcomes that will help all surgeons improve,â&#x20AC;? says Mats LundstrĂśm MD, who oversees the Swedish national cataract registry, and conducted EUREQUOâ&#x20AC;&#x2122;s forerunner, the annual European Cataract Outcomes Study from 1995 to 2008. Piloted last year in Scandinavia, the Netherlands and Spain, EUREQUO has successfully integrated the existing Swedish and Netherlands databases, making available outcomes data on more than 200,000 cataract and refractive procedures. The database grows every day as surgeons from 15 countries contribute outcomes data through their national registries via webbased portals. The scale of data collection makes EUREQUO especially valuable for improving patient safety because it makes it possible to systematically identify and examine unusual events, such as clusters of endophthalmitis or capsule complications, Prof LundstrĂśm notes. â&#x20AC;&#x153;Patient safety means among other things to minimise major complications. A large database will enable risk analyses for severe and rare complications.â&#x20AC;? Large data volumes may also make it possible to more quickly assess new technologies and products, Prof LundstrĂśm adds. â&#x20AC;&#x153;There are possibilities to compare use and results of different premium IOLs or in refractive surgery the outcomes based on the type of flap used in LASIK, whetherÂ created by laser or mechanically.â&#x20AC;? Most important, EUREQUO will give surgeons objective feedback on their own performance in real time, enabling them to make corrections when problems occur.

DG [ ;FHOHQV Y MPR (8527,0(6 LQGG EUROTIMES | Volume 15 | Issue 10

â&#x20AC;&#x153;

If the results are below average or distinctly worse than what other surgeons achieve, this will be a strong incentive to improve performance Mats LundstrĂśm MD

â&#x20AC;&#x153;The project means that single surgeons and clinics can collect outcomes data for comparison and judgement of their own work,â&#x20AC;? Prof LundstrĂśm says. â&#x20AC;&#x153;If the results are below average or distinctly worse than what other surgeons achieve, this will be a strong incentive to improve performance. Poor outcomes will be very obvious for a participating surgeon or clinic and will certainly initiate changes in behaviour.â&#x20AC;? Sponsored by ESCRS, EUREQUO is also supported by a grant from the European Union as well as its partner national societies. While EUREQUO establishes standards for data collection for participants in all countries, and is available via web browser from anywhere, individual national societies determine data collection and audit standards within each country. All data is reported anonymously. Only the surgeons submitting data have access to their own data. Individual results can be compared with aggregate results for similar procedures overall, by country or region, or by patient characteristics, including demographics, preoperative visual acuity and co-morbidities. Participating national societies also provide first-line technical support for surgeons and physicians. EyeNet Sweden supports the national registry managers. The software was developed by ifa systems AG, and integration systems AG, Germany, which also provide second-line technical support and maintain the central database.

contact Mats LundstrĂśm - mats.lundstrom@ltblekinge.se

News

young ophthalmologists

expansion plans

Goal is to better meet training needs, and encourage research and knowledge exchange by Howard Larkin

21( 67(3 $+($' ,1 3(5)(&7 35(&,6,21 )2&86 21 7+( $1' *$8*( 75$16&21-81&7,9$/ 6<67(06 ' 2 5 & WKH LQYHQWRU DQG LQQRYDWRU RI WKH *DXJH YLWUHFWRP\ V\VWHP RIIHUV D QHZ JHQHUDWLRQ DQG *DXJH FDQQXOD V\VWHPV ZKLFK DOORZV D VPRRWK LQFLVLRQ DQG WKH EHVW ZRXQG DUFKLWHFWXUH 7KH XQLTXH YDOYH V\VWHP FUHDWHV D Â´FORVHGÂľ VXUJLFDO ILHOG DQG WKH PRVW VWDELOH LQWUDRFXODU SUHVVXUH )XUWKHU QR QHHG IRU LQVHUWLRQ DQG UHPRYDO RI FORVXUH SOXJV

Oliver Findl, chairman of the Young Ophthalmologistsâ&#x20AC;&#x2122; Forum, Maja Bohac and Nikica Gabric, ESCRS Board member, pictured at a reception for young ophthalmologists at the XXVIII ESCRS Congress in Paris

ith cataract surgery becoming more of a refractive procedure, this yearâ&#x20AC;&#x2122;s Young Ophthalmologists Programme featured a symposium on the refractive aspects of lens exchange in addition to basic and advanced cataract surgery courses. â&#x20AC;&#x153;The talk on IOL calculation was very good,â&#x20AC;? says Rizwana Khan MD of Ireland, who has been a consultant for two years and has attended the Young Ophthalmologists Programme at the ESCRS annual congress for several years. â&#x20AC;&#x153;Anything on cataracts is very useful for me.â&#x20AC;? Maja Bohac MD, a third-year resident from Croatia who has been focusing on refractive surgery, agreed. â&#x20AC;&#x153;The instructional programmes are good for beginners and experts. You can always find out how to do something better. Overall this congress is great. There is something for everyone.â&#x20AC;? In addition to the annual congress programme, ESCRS is launching several initiatives to expand learning and training opportunities for young ophthalmologists, says Oliver Findl MD, who directed this yearâ&#x20AC;&#x2122;s programme and conducted the basic phaco course. â&#x20AC;&#x153;We want to involve more young ophthalmologists in ESCRS,â&#x20AC;? he says. One way to do it is to provide financial support for young colleagues, particularly from eastern countries, to attend the ESCRS annual congress and winter meeting. ESCRS provided grants to several attendees at this yearâ&#x20AC;&#x2122;s meeting and will continue to do so, Dr Findl says. He would like to see expanded wet labs for cataract and refractive surgery, as well as education programmes geared toward preparing trainees for national board exams. â&#x20AC;&#x153;It is essential to put more focus on trainees and their needs.â&#x20AC;? EUROTIMES | Volume 15 | Issue 10

To promote knowledge exchange on advanced surgical techniques, ESCRS is putting together an Observership Programme. â&#x20AC;&#x153;This would allow young ophthalmologists to spend five days in cataract or refractive surgery centres throughout Europe learning about the latest technology and procedures,â&#x20AC;? Dr Findl says. He and other ESCRS leaders are currently recruiting centres to participate. ESCRS also plans to financially support the programme. To encourage young ophthalmologists to build on the relationships they establish at meetings, ESCRS is adding a forum to its website, Dr Findl says. â&#x20AC;&#x153;The forum will provide new information and a place for asking questions and commenting. We hope it will be used more and more and grow over time.â&#x20AC;? ESCRS is also building an e-learning site that will include complete didactic courses on cataract and refractive surgery online. â&#x20AC;&#x153;The idea is to deliver information content to young ophthalmologists at home where they can retrieve it on their own time,â&#x20AC;? Dr Findl says. Dr Findl believes the expanded programmes will not only better disseminate learning, they will also promote research across Europe and bring more colleagues in eastern countries to the forefront of advancing surgery. Ivan Drosdov MD, who is studying DSAEK techniques for a PhD with Boris Malyugin MD in Russia, believes young ophthalmologists have a lot to contribute. â&#x20AC;&#x153;Young people have some extraordinary ideas which may be useful to all surgeons,â&#x20AC;? he says. â&#x20AC;&#x153;I am here not just to learn but to teach.â&#x20AC;?

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An Exceptional Mid-Winter Meeting A Spectacular and Convenient Location Next winter, join us for the 4th Annual ASCRS Winter Update. Hosted at the Forbes Travel Guide Five Star Ritz-Carlton Palm Beach, the 2011 program will continue the tradition of excellent education in a spectacular location.

New for 2011 â&#x20AC;&#x201C; ASOA Practice Management Track for Administrators ASOA is pleased to announce a new program track designed and developed specifically for administrators. Sessions are scheduled to minimize time away from the office. Donâ&#x20AC;&#x2122;t miss this opportunity to delve into critical issues and take home pearls to improve your practice!

Program Chair Steve Robinson, COE, OCS Faculty Debi Dilling Nancey K. McCann E. Ann Rose James L. Spires, MBA, COE Vonda L. Syler, COE Gil Weber, MBA

Interactive sessions. Accessible faculty. Pertinent topics. Practical tips. The Physicians Program is designed to provide the busy ophthalmologist with cutting-edge information and pearls that can be immediately implemented.

Program Chairs Edward J. Holland, MD Stephen S. Lane, MD Program Planning Committee David F. Chang, MD Eric D. Donnenfeld, MD Herbert P. Fechter, MD Roger F. Steinert, MD Keith A. Warren, MD Faculty Kevin J. Belville, MD Rosa Braga-Mele, MD Vincent P. de Luise, MD Gary J. Foster, MD

David A. Goldman, MD Norman S. Jaffe, MD Terry Kim, MD W. Barry Lee, MD Nick Mamalis, MD Nancey K. McCann William F. Mieler, MD Stephen A. Obstbaum, MD F. Rick Palmon, MD Steve Robinson, COE, OCS E. Ann Rose Jonathan B. Rubenstein, MD Steven R. Sarkisian Jr., MD Kerry D. Solomon, MD R. Doyle Stulting Jr., MD, PhD

Preliminary Program

Preliminary Program (subject to change)

(subject to change)

Thursday, January 27

12:45 PM â&#x20AC;&#x201C; 2:15 PM

Networking/Welcome Reception

Optional Luncheon Workshops

2011 Legislative Update

Friday, January 28

5:30 PM â&#x20AC;&#x201C; 7:00 PM

Nancey K. McCann

8:00 AM â&#x20AC;&#x201C; 10:00 AM

4:15 PM â&#x20AC;&#x201C; 5:45 PM

Managing Cataract Complications / Complicated Cases: "You Make the Call"

Friday, January 28 2:30 PM â&#x20AC;&#x201C; 4:00 PM

Medicare Reimbursement Challenges

E. Ann Rose

Saturday, January 29 8:30 AM â&#x20AC;&#x201C; 10:00 AM

Moderator: David F. Chang, MD 10:30 AM â&#x20AC;&#x201C; 12:30 PM

Cornea and External Disease: Practical Topics and Interactive Panel Discussion

Interpreting & Using Financial Statements

Moderator: Edward J. Holland, MD

James L. Spires, MBA, COE

12:45 PM â&#x20AC;&#x201C; 2:15 PM

10:30 AM â&#x20AC;&#x201C; 12:00 PM

Iâ&#x20AC;&#x2122;m a Leader â&#x20AC;&#x201C; Now What?

Steve Robinson, COE, OCS 12:00 PM â&#x20AC;&#x201C; 1:00 PM

Networking Luncheon

1:00 PM â&#x20AC;&#x201C; 2:30 PM

Effective Marketing Tracking Methods

Debi L. Dilling 3:00 PM â&#x20AC;&#x201C; 4:30 PM

Managed Care Contracting Nightmares

Optional Luncheon Workshops 5:30 PM â&#x20AC;&#x201C; 6:30 PM

ASOA for MDs: Legislative Update Nancey K. McCann

8:00 AM â&#x20AC;&#x201C; 10:00 AM

Challenging Cases in Ophthalmology Moderators: Eric D. Donnenfeld, MD, and Edward J. Holland, MD 10:30 AM â&#x20AC;&#x201C; 12:30 PM

Best of the Worst: Common Complications of the Usual Glaucoma Procedures Moderator: Herbert P. Fechter, MD 12:45 PM â&#x20AC;&#x201C; 2:15 PM

Optional Luncheon Workshops

7:40 AM â&#x20AC;&#x201C; 8:00 AM

E. Ann Rose

Guest of Honor: Norman S. Jaffe, MD 8:00 AM â&#x20AC;&#x201C; 10:00 AM

New Technology in Anterior Segment Surgery

Sunday, January 30

10:30 AM â&#x20AC;&#x201C; 12:30 PM

Nancey K. McCann Vonda L. Syler, COE

Sunday, January 30

5:30 PM â&#x20AC;&#x201C; 6:30 PM

Moderator: Stephen S. Lane, MD

Keeping an Eye on the Future: Medical Office Technology in 2015

Moderator: Stephen S. Lane, MD

Saturday, January 29

Gil Weber, MBA

8:30 AM â&#x20AC;&#x201C; 10:00 AM

Video Complications Seminar

Posterior Segment Challenges for the Anterior Segment Surgeon Moderator: Keith A. Warren, MD

ASOA for MDs: Medicare Update

Monday, January 31 7:00 AM â&#x20AC;&#x201C; 9:00 AM

Refractive Cornea and IOL Surgery: Improving Outcomes/Happier Patients Moderator: Eric D. Donnenfeld, MD 9:30 AM â&#x20AC;&#x201C; 11:30 AM

Faculty Roundtables/Wrap-Up Moderators: Edward J. Holland, MD, and Stephen S. Lane, MD

10:30 AM â&#x20AC;&#x201C; 12:00 PM

Internet Marketing: Website or Web Fright?

Debi L. Dilling

) )*!%$ %& * & )* )) *&!!%$ ) * $%*

Review

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JCRS Highlights Journal of Cataract and Refractive Surgery Intraocular lens calculations: what works?

Appropriate IOL selection continues to be a major challenge to cataract surgeons. The bewildering array of formulae made available for the task can intimidate the most experienced clinicians. The challenge is compounded by the consideration of individual patient requirements (monovision, presbyopic correction) and the growing population of patients who have undergone previous refractive surgery. JCRS associate editor WJ Dupps MD, PhD reviews the current state of affairs in an editorial, and puts out a plea for a deterministic approach to the problem. n WJ Dupps, JCRS, “Intraocular lens calculations: Call for more deterministic models”, Volume 36, Issue 9, 1447-48. Several articles in the journal address the question from different perspectives. For example, Savini and colleagues compare several approaches to IOL selection after myopic laser in situ keratomileusis. In a study of 32 eyes of 28 patients, the researchers compared various methods of IOL calculation including methods that adjust for overestimation of corneal power and methods developed to directly correct the calculated IOL power. The study considered information on pre- and postoperative corneal power and refraction that may or may not have been available in each case. The researchers concluded that when corneal power is known, the Seitz/Speicher method (with or without Savini adjustment) seemed to be the best solution to obtain an accurate IOL power prediction. Otherwise, the Masket method may be the most reliable option, they note. n Savini et al., JCRS, “Intraocular lens power calculation after myopic excimer laser surgery: Clinical comparison of published methods”, Volume 36, Issue 9, 1455–1465.

significant differences between methods using surgically induced change in refraction and methods using no previous data. They emphasise that further studies are needed, especially those that evaluate IOL calculators in eyes with previous hyperopic LASIK/PRK or RK. n Wang et al., JCRS, “Evaluation of intraocular lens power prediction methods using the American Society of Cataract and Refractive Surgeons Post-keratorefractive Intraocular Lens Power Calculator”, Volume 36, Issue 9, 1466–1473. In a third study, Hoffman and Hütz present a large biometric series of cataractous eyes based on partial coherence interferometry (PCI) technology. This study evaluated 23,239 data sets of 15,448 patients with a median age of 74 years. They used the IOL Master to measure axial length, corneal radii, anterior chamber depth, and horizontal corneal diameter (white-to-white distance). The mean axial length was 23.43mm; mean corneal radius, 7.69; mean WTW distance 11.82 ± 0.40mm; and mean anterior chamber depth was 3.11. The ACD and axis of astigmatism were correlated with age. The AL, corneal radius, ACD, and WTW were correlated with one other. Eight per cent of eyes had corneal astigmatism greater than 2.00 D, and 2.6 per cent had more than 3.00 D. Astigmatism was with the rule in 46.8 per cent of eyes, against the rule in 34.4 per cent, and oblique in 18.9 per cent. The researchers believe results in this analysis might provide normative data for cataract patients and a useful reference for multiple purposes. n P Hoffman et al., JCRS, “Analysis of biometry and prevalence data for corneal astigmatism in 23,239 eyes”, Volume 36, Issue 9, 1479–1485.

In another article in the same issue, Wang et al. present a comparison of IOL prediction error after myopic refractive surgery for the many measurement/ formula combinations available through the American Society of Cataract and Refractive Surgery online calculator tool developed by Hill, Wang, and Koch. The survey found that methods using surgically induced change in refraction or no previous data had significantly smaller mean absolute IOL prediction errors, smaller variances, and a greater percentage of eyes within ±0.50 D and ±1.00 D of refractive prediction errors than methods using pre-LASIK/PRK keratometry (K) values and surgically induced change in refraction. There were no statistically

Don’t miss Book Review, See page 37 EUROTIMES | Volume 15 | Issue 10

Thomas Kohnen Associate Editor of JCRS

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

Feature

henahan prize winner 2010

My residency

We frequently have the opportunity to profoundly improve lives by Leigh Spielberg MD

he recurring corneal ulcer wasn’t a particularly difficult case, at least not in terms of ocular pathology. It was slow to heal, but the senior staff members were confident that it would recede sooner or later. Jonas was a shy, introverted 25-year-old patient who was uncomfortable around other people. His unusual personality and difficulty with social interaction were clearly aggravated by the ulcer’s pain and photophobia. His health insurance wouldn’t pay for a private room, but we provided him with one, free of charge, since this put Jonas and the other patients at ease. Jonas had been admitted to the ophthalmology inpatient department several times before. Each time, when his ulcer would heal, he would be discharged from the hospital and he would go off into the world, his own world, where various factors led to a new hole in his cornea. He didn’t seem to understand why they kept occurring. Neither, initially, did we. “This hole in my eye just seems to creep up on me and then there I am, half-blind and in terrible pain. Then I come to the hospital to see you guys.” We suspected that narcotics abuse leading to exposure keratitis, along with erratic and unhygienic contact lens use, contributed to the recurrent ulcers. Combined with his poor treatment adherence and long-standing refusal of psychological help, this was a difficult situation. When I met Jonas for the first time, I was the most junior resident on the ward. I had just learned how to perform a basic ophthalmic examination and then draw what I saw. These drawings were used for patient follow-up. In our department, we followed the standard color-coding conventions. Red indicates conjunctival injection. Green represents fluorescein-positive epithelial injury. Needless to say, this case required the use of a lot of red and green. Jonas noticed this. I was the resident responsible for coordinating the care of inpatients with chronic pathology. It wasn’t a particularly busy week, so I had time to spare. This was fortunate, because I was inexperienced and my examinations proceeded very slowly. But Jonas was a patient patient. He tolerated the endless cycle of slit lamp observation and drawing, twice a day, day after day. It must have been an unusual experience for him,

EUROTIMES | Volume 15 | Issue 10

considering his usual state of social isolation. Twice-daily exams performed by a young resident add up to a significant amount of time. These seemed to be rare moments of genuine human contact in his life. He had long been the centre of his own attention, but he was now at the centre of mine as well. I was his audience. We spoke a lot. Besides discussing his eye, we talked about his life and his plans, his hopes and his dreams. This was somewhat unusual. The practice of ophthalmology does not always require a close doctor-patient relationship. Indeed, I have heard an internist lightheartedly compare ophthalmology to veterinary medicine because in many cases we require very little patient input to help make the correct diagnosis. A quick look into our patients’ eyes can tell us a great deal about their overall health. But only by talking to them can we learn a great deal about their state of mind. It isn’t enough to see that the diabetes is out of control. “Why,” we must ask them, “is this happening? What happened to your blood pressure medications?” Or, as in Jonas’ case, in which psychological factors were at play, the questions might be much more open-ended: “What’s going on?” My experience with Jonas taught me that conversation, discussion and interaction sometimes add up to the most powerful treatment available. Speaking also offers us a way to connect. Because ophthalmology is so strongly based on visual diagnosis, there is a very wide gap between our experiences and those of our patients. Good vision is essential for an ophthalmologist, and our ability to see well is one of our greatest assets. If we lose our vision, we can no longer perform our job. A cardiologist can suffer from angina and an obstetrician can give birth. A paediatrician’s daughter can have the flu and a dermatologist can develop psoriasis. But an ophthalmologist cannot be blind. Indeed, many residency programmes require prospective residents to undergo visual acuity and optometric testing before they sign a contract. We can never really know blindness because we have never experienced it, and this inherent difference sets us apart from many of our patients. Darkness remains a mystery to us, and we can only try to imagine why blindness is the most feared affliction after death and cancer.1 But we can narrow this gap of experience by speaking with our

Dr Leigh Spielberg (left) receives the John Henahan prize from Dr Emanuel Rosen, chairman of the judging panel

patients. Only then can we get an idea of what it is like to be without sight. And yet, many of us were initially attracted to ophthalmology by the microsurgical procedures. I was fascinated by the finesse of phacoemulsification, with its clean incisions and beautiful results, and the other-worldly experience of a vitrectomy. But the initial excitement of surgery was gradually replaced by the long-term satisfaction of close patient contact. This satisfaction, and the realisation that we frequently have the opportunity to profoundly improve lives – these are the things that have kept me interested and motivated. The ulcer in Jonas’ cornea eventually healed. As I handed him his hospital discharge papers, a simple exchange turned into a career-defining moment and the

Journal Watch

Red wine therapy

outstanding memory of my residency. He said, “I hope I don’t need to see you again. But I also hope you’re around if I do.” As he said this, he gave me an old-time, wooden cigar box full of new pens in all shades of red and green. Inside the lid, he had carved, in cursive, “Freed from the Darkness”. “Thank you doctor,” he said, “and good luck.” Dr Leigh Spielberg is the winner of the 2010 John Henahan prize. 1

Faal, H. and Gilbert, C. “Convincing Governments to act: VISION 2020 and the Millennium Development Goals.” Community Eye Health Journal. 20.64 (2007): 62-64. http://www.cehjournal. org/0953-6833/20/jceh_20_64_062.html

by Sean Henahan

The polyphenolic compound resveratrol – found in red wine, grapes, blueberries, peanuts and other plants, and often touted for its anti-ageing powers – appears to have potent anti-angiogenic properties – a finding that could lead to a new class of drugs to treat AMD and related diseases. Investigators found that when mice that developed abnormal blood vessels in the retina after laser treatment were given resveratrol, the abnormal blood vessels began to disappear. Examining the blood-vessel cells in the laboratory, they identified a pathway – known as a eukaryotic elongation factor-2 kinase (eEF2) regulated pathway – that was responsible for the compound’s protective effects. The researchers note that the novel pathway could become a new target for therapies, not only for eye disease but also in other diseases where angiogenesis plays a role. The amount used in the mouse studies was equivalent to human consumption of several bottles of wine. The researchers comment that a pill form would be preferable. n AA Khan et al., American Journal of Pathology, “Resveratrol Regulates Pathologic Angiogenesis by a Eukaryotic Elongation Factor-2 Kinase-Regulated Pathway”, 2010 177: 481-492.

EuroTimes

Feature

product update

9/10

Technolas unveils laser procedure innovations

Anticipating every move. Now thatâ&#x20AC;&#x2122;s smart.

Technolas Perfect Vision (TPV) GmbH has unveiled two new laser procedures in the fields of cataract surgery and the treatment of presbyopia. TPV has now developed a new femtosecond laser procedure, known as CUSTOMLENSâ&#x201E;˘, for performing the key steps in the cataract surgery procedure. CUSTOMLENS will be the latest procedure module to become available on the Technolas Femtosecond Workstation. In addition to the cataract procedures, the device can perform the INTRACOR presbyopia treatment, CUSTOMFLAP LASIK flaps, and the therapeutic indications, CUSTOMSHAPE. Dr Kristian Hohla, CEO of TPV, said: "In the two years since the formation of Technolas Perfect Vision, we have remained focused on bringing value to our users. With the addition of the CUSTOMLENS module to our femtosecond laser, surgeons will be able to perform cataract, intrastromal, refractive and therapeutic procedures using the same femtosecond laser." TPV has also developed a corneal approach to treating presbyopia with an excimer laser, known as SUPRACORâ&#x201E;˘. SUPRACOR is a new aberration-optimised presbyopic algorithm which is designed to be applied to myopic, hyperopic and emmetropic eyes, as well as postLASIK cases. Rupert Veith, chief commercial officer of TPV, said, â&#x20AC;&#x153;With the advent of SUPRACOR, we are truly positioning ourselves as the presbyopia company. The complementary offering of SUPRACOR and INTRACOR provides surgeons and patients with true solutions for presbyopia.â&#x20AC;? SUPRACOR is expected to receive the CE Mark in the first half of 2011. n www.technolaspv.com

Ziemer Group introduces the GALILEIâ&#x201E;˘ G2

Experience the intuitively adaptive control of NEW OZilÂŽ IP. Featuring innovative OZilÂŽ Intelligent Phaco, the InfinitiÂŽ Vision System puts optimized OZilÂŽ torsional emulsification and dynamic fluidic management at your fingertips. With significantly enhanced capabilities, OZilÂŽ IP is always thinking one step ahead. For more information, contact your Alcon representative.

is a registered trademark of Alcon, Inc. ÂŠ2010 Alcon, Inc. INF546EU

EUROTIMES | Volume 15 | Issue 10 ,1) (8 (7 LQGG

Ziemer Group has produced a new generation of its GALILEI Dual Scheimpflug Camera System. The company says that with a new, powerful computer system, system response, performance and computing power have been improved by 30 to 40 per cent. "The GALILEI continues to be the leading high-performance optical topography and anterior chamber tomography system with its unique combination of dual revolving Scheimpflug camera and Placido topographer. The high resolution data gathered simultaneously by these two system modalities are matched and merged into a single set of 3D precision data of the anterior chamber," said a Ziemer spokesman. The Ziemer GALILEI G2 Dual Scheimpflug Camera System is available for immediate delivery. n For more information, visit www.ziemergroup.com.

Haag-Streit completes range of LED powered slit lamps

Haag-Streit says that with the introduction of the BM 900 and BP 900 models, the company now has a complete range of LED-powered slit lamps. "The BQ 900 LED was introduced in 2009 and this innovative new technology has been quickly adopted worldwide and is recognised as a major step forward in slit lamp biomicroscopy," said a company spokeswoman. "A bright, more homogenous light patch shows more detail, provides a sharper slit and offers improved fluorescein observation. The colour output is specifically developed at Haag-Streit to match the well established tungsten light of traditional devices but the LED need never be replaced during the life of the instrument. Furthermore, the LED facilitates an economic integration of a background illumination system from the same light source and thus improving the options and quality for those who wish to perform imaging. In-table controls complete the package and offer precise and positive illumination adjustment directly at your fingertips," she said. n For more information visit www.haag-streit.com.

LONDON 2011 11 EURETINA CONGRESS TH

26–29 May 2011 QUEEN ELIZABETH II CONFERENCE CENTRE LONDON, UK

www.euretina.org

Feature

eye on travel

On the lighter side

Four suggestions to make your trip to Istanbul more memorable by Maryalicia Post

TO REMEMBER ISTANBUL For a souvenir worthy of this historic city, visit the Galeri Alfa Antikacilik. Specialising in antique prints and maps, the gallery is run by art historian Dr Ayse Yetiskin Kubilay. In her shop in an apartment building in Beyoglu (north of the Golden Horn in the Pera district - take a taxi and ring the buzzer at the entrance). Dr Kubilay offers authenticated Ottoman prints and maps dating from the 15th to the 19th century at prices ranging from $10 to $4,000. For a very different souvenir, have a look at the Turkish tin soldiers sold exclusively at the Galeri. These handmade collectors’ pieces include accurately costumed Gallipoli figures at $75 and colourful Sultans at $100. Some of the Ottoman figures have been designed as chessmen. The Galeri is at Faikpasa Yokusu, Fzilet Apt 43/2, Cukurcuma, Beyoglu. Telephone: 0212 251 16 72. Closed Sunday but open 11.00 – 19.00 and until 20.00 on Saturday. Credit cards accepted.

n between visits to Istanbul’s aweinspiring sights, it sometimes feels good to come up for air. Here are four suggestions for Istanbul experiences on the lighter side and one tip for souvenirs worth taking home.

Treat yourself to a view to remember In the 19th century, the

mystique of Constantinople was at its romantic height. Julian Viaud, a French naval officer who wrote under the pen name of Pierre Loti, was just one of those enchanted by the city. Loti used to climb the hill behind Eyup’s tomb to write in a humble coffee shop with a remarkable view of the Golden Horn. This 19th century coffee shop, now called the Loti Café, is still there. And the view, too, is still worth the journey. Take a taxi, or better still, use the funicular signposted from the Eyup Mosque. (Eyup was a friend of the Prophet Mohammed and his was the first mosque built after the Turks took Constantinople.) The funicular glides up and over the ancient Ottoman cemetery that extends uphill from Eyup’s tomb – like a landslide in reverse – to

bring you to the coffee shop terrace. From here, you can survey the Golden Horn in all its sinuous beauty. The view is best at twilight, when the sun’s rays gild the water of this natural harbour. Pierre Loti Café is open daily from 8.00 to 24:00. It serves non-alcoholic drinks and snacks. No credit cards. The funicular costs 1.30 Turkish lira. There’s a token dispenser at the station.

Commune with Agatha Christie at the Pera Palace The mystery

writer Agatha Christie began her love affair with Istanbul in 1923. She visited many times in the next few years and always stayed in room 411 at the Pera Palace Hotel, where she was inspired to write Murder on the Orient Express. Guests can still stay in room 411 where the key to her diary was found hidden under the floorboards three years after her death. Agatha Christie’s books form part of the décor. But you don’t have to book in to the hotel to enjoy the atmosphere. Take afternoon tea under the magnificent domes of the Kubbeli Salon, have a meal in the Agatha Restaurant, or muse over a drink in the Orient Bar, a

Don’t miss Practice Development, see page 39 EUROTIMES | Volume 15 | Issue 10

favourite of Ernest Hemingway’s. The father of the Turkish Republic, Ataturk, stayed at the Pera Palace too, and his preferred room – 101 – is now a museum open to visitors. Just ask a bellman to show it to you. Pera Palace Hotel, Meşrutiyet Caddesi No. 52 Tepebaşı Beyoğlu 34430 Telephone: +90 212 222 80 90. (Room 411 is a ‘Grand Pera Suite” and costs €300 per night.) For details, see www.perapalace.com.

Explore the Koc Industrial Museum This is the private world

of a world-class collector, Rahmi M Koc. Thousands upon thousands of items are housed in an elegantly restored 18th century anchor house and in 14 adjacent waterside buildings that were once a ruined dockyard on the Golden Horn. It’s impossible to describe the inventory adequately; it includes gleaming ranks of vintage cars, an olive oil factory, the Sultan’s railway car, a submarine (book in advance to visit) an airplane, a 1917 X-ray ambulance – just about everything that has wheels that go round or a motor. There’s also miniature doll’s house furniture, sailboats, a horse-

pulled tram, and a street of reconstructed shops; I can only recommend that you see it for yourself. The museum is located at Haskoy Avenue No. 5. Open 10:00 to 17:00 Monday-Friday and until 19:00 Saturday and Sunday. For details, visit www.rmk-museum.org.tr.

Cruise like a Sultan on a Sultanboat A cross between a royal

barge and a massive Venetian gondola these splendid open vessels hold 30 passengers and make regular excursions throughout the year. When the Sultan travelled on his gilded and bejewelled vessel loyal subjects bowed to him from the shore. As your boat passes under the Galata bridge, pedestrians and fishermen greet you almost as enthusiastically. Prepare to wave! Cruises on the Golden Horn depart from the dock outside the Halic Kultur Merkezi in Sutluce daily at 10.00 and 20:00. For a shorter outing take the Sultanboat shuttle from the Dolmabahce Palace on the European shore across the busy Bosphorus to the Beylerbeyi Palace and the Kucuksu Summer Palace on the Asian shore (daily except Monday and Thursday). Or book a Sultanboat for a private cruise any day between 10:00 and 20:00. Visit www.sultankayiklari.com for further information.

Vienna

2nd EuCornea Congress 16â&#x20AC;&#x201C;17 September 2011 Vienna, Austria

Immediately preceding the XXIX Congress of the ESCRS

www.eucornea.org

Feature

industry news

Recent developments in the vision care industry

Carl Zeiss Meditec on growth course

Bausch + Lomb to acquire Miochol®-E

Bausch + Lomb has announced that it has concluded its acquisition of a portion of the assets and intellectual property for Miochol®-E from affiliates of Novartis AG. A company spokesman said Bausch + Lomb intends to complete the acquisition of the remaining assets and intellectual property upon the necessary regulatory clearance. Bausch + Lomb has completed its purchase in the US, Canada, Australia and Korea, along with various other markets outside the European Economic Area (EEA). The company intends to complete full purchase of the Miochol®-E assets and intellectual property existing within the EEA upon approval from the European Commission. Miochol®-E is an injectable miotic pharmaceutical used during certain eye surgeries to constrict the pupil. Miotics are most commonly used in cataract surgery to stabilise the iris fluids inside the eye when small tears occur in the capsule of the lens. Under the agreement, Bausch + Lomb will be provided technical assistance by Novartis to assist in the transfer of Miochol®-E manufacturing. The companies have not disclosed more detailed purchase terms.

IRIDEX granted US patent for MicroPulse technology

IRIDEX Corporation has announced that it has received a US patent for the company’s MicroPulse™ technology. IRIDEX says MicroPulse provides the ophthalmologist with fine dose control of laser energy during eye surgery. “Ophthalmologists are using MicroPulse technology to treat patients suffering from diabetic retinopathy and other sight-threatening retinal and glaucoma disorders,” said a company spokesman. “Treatments using MicroPulse technology demonstrate favourable outcomes and significantly less damage to healthy retinal structures compared to traditional continuous wave laser treatment,” he said.

New languages to select from on the Megatron S4

Geuder's Megatron S4 now offers additional languages to select from. “In addition to the most common European languages, languages such as Arabic, Chinese and Russian will soon be available to ensure comfortable and, above all, safe usage of the system in one's own native language,” said a company spokeswoman. “These increased multi-language options are further examples of the flexibility which has come to exemplify the Megatron® S4. Other such features include the flexible hybrid pump system which combines different forms of vacuum creation to enable quick vacuum using just one cassette. The combined system for the anterior and posterior segments of the eye is easy and flexible to handle and requires minimal space,” she said

With a 20 per cent increase in revenue in the third quarter compared with the same quarter of the previous year, Carl Zeiss Meditec says it has generated very solid results and the company is now on a growth course. The company grew by a total of three per cent in the first nine months of financial year 2009/2010, to €490.8m (previous year €478.5m) and increased its gross margin by 1.7 percentage points year-on-year, to 52.1 per cent. Earnings before interest and tax rose by 11.8 per cent to €60m. “We did all our homework during the times of global economic crisis – for us, this also included continuing to strategically invest in our innovative strength. This policy is now paying off – which is clear not only from our figures,” says Dr Ludwin Monz, president and CEO of Carl Zeiss Meditec AG.

OptiMedica sells retina and glaucoma business to Topcon

OptiMedica Corp. has announced that it has signed a definitive agreement to sell its retina and glaucoma assets to Topcon Corp. OptiMedica says that this is a strategic move that positions OptiMedica to focus exclusively on the continued development and commercialisation of advanced technologies for the treatment of cataract. The largest acquisition by Topcon’s medical division to date, the sale provides OptiMedica with significant additional funding for the global market launch of its laser cataract surgery system as well as continued cataract-focused research and development. “This is a very exciting time for OptiMedica, as we transition our highly successful retina and glaucoma franchise to Topcon and devote all of our energy towards revolutionising cataract surgery,” said Mark J Forchette, OptiMedica president and chief executive officer.

OD-OS opens global headquarters in San Francisco

OD-OS has opened its US headquarters in San Francisco, California, where the company will base its commercial operations, including marketing, sales and customer support for the Navilas retina navigation therapy solution. Peter Falzon, who was appointed chief commercial officer of OD-OS and president of OD-OS, Inc in February will head the US Office. “As OD-OS transitions from a pure research and development organisation to a fully integrated commercial company, we recognised the need to open a US headquarters that will provide local infrastructure and customer support. As we move closer to our global market introduction of Navilas, we will need to build our sales, marketing and technical support functions,” said Mr Falzon.

Join the network EUREQUO

EUREQUO gives a unique opportunity to monitor and compare results

European Registry of Quality Outcomes for Cataract & Refractive Surgery

What is EUREQUO? EUREQUO is a European Quality Registry for visual outcomes of cataract and refractive surgery

with the kind contribution of

EUROTIMES | Volume 15 | Issue 10

The project aims to:

Quality registries create a sufficient basis for studying rare diseases, treatments and complications

Improve treatment and standards of care for cataract and refractive surgery

Collecting data will support you to make an audit report

Develop evidence-based guidelines for cataract and refractive surgery across Europe

The collection of your data will facilitate the analysis of surgical outcomes and the development of evidencebased European Quality Guidelines

Make significant impact on the exchange of best practice between practitioners in relation to patient safety

See www.eurequo.org for more information

Feature

Book review

A new dimension

These two chapters are relatively brief, and we move then onto what will be of most In the foreword to this slim volume, Dr interest to the majority of readers – the use Kristian Hohla writes about how the public of femtosecond lasers in ophthalmology. perceives lasers as the “sexy” symbol of Firstly, the overall issue of where ultrafast high technology. We see this in everything femtosecond lasers may be applied in the from James Bond movies to the promotion field is discussed. With femtosecond lasers, of LASIK surgery. “If we can accurately there is obviously a briefer time of exposure measure the distance to the moon down to the laser, and therefore the tissue-laser to the nearest centimetre, if time can be interaction is characterised by a cut with measured with the unbelievable accuracy of superior precision and minimal collateral 10-18 seconds, and if atomic nuclear fusion effects and damage. The next chapter deals can even be initiated with lasers, then just with the overall clinical applications of the think what might be possible in the human femtosecond laser. This chapter proceeds body,” Dr Hohla observes. by considering intrastromal femtosecond It is in ophthalmology that lasers have laser incisions. found their most crucial role. This is no Following this are sections on surprise in a way. Lasers are simply light, performing perforating keratoplasties, and light is the essence of optics – and of penetrating keratoplasties, anterior ophthalmology. lamellar keratoplasties, endothelial grafts, The first chapter of the book presents and astigmatic keratoplasties, all with the an historical overview of milestones in the femtosecond laser. Each section follows a development and application of the ultrashort pattern of describing the surgery, results, wave femtosecond laser. We then have an case studies and references. account of the physics behind the6.5.2010 generation 11:17 Uhr Seite 1 faros_245x150_EuroT_e The next major chapter is on refractive and amplification of ultrashort laser pulses. surgery with the femtosecond laser. There

are two subsections – flap dissection during LASIK, known also as Femto-LASIK, and intrastromal refractive correction. Finally we have a chapter on the future applications of the femtosecond laser. Here it is suggested that refinement of femtosecond laser technology will lead to a greater convergence between diagnostic processes and therapeutic femtosecond laser technology. It is also suggested that femtosecond lasers will be used in other parts of the eye. A range of other exciting potential applications are discussed. This is a relatively slim volume, focused narrowly on the issue in hand. The book is clearly designed and laid out, with copious illustrations. The text involves a high degree of knowledge of ophthalmic practice and the physics and optics underlying these techniques. Clearly this is a rapidly evolving area in ophthalmology. Modern ophthalmic surgery is now barely conceivable without lasers – indeed with the gradual eclipse of the CD player by the MP3, perhaps laser eye surgery is now the most well known application for lasers among the general public.

books editor: Seamus Sweeney publication: Femtosecond laser – Principles and Applications in Ophthalmology BY: Mark Tomalla, in collaboration with Gerd Auffarth, Josef Bille, G I W Duncker, Kristian Hohla, Mike Holzer, Laszlo Kiraly, Michael C Knorz, George Korn, Frieder Loesel, Udo Ludwig, Tobias H Neuhann, and Anna Sasse UNI-MED Verlag, Bremen, 2010

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

Brings Light to the World

Ecknauer+Schoch ASW

by Oertli®, another milestone in eye surgery. Designed for cutting-edge surgical techniques and optimal results in cataract and vitreoretinal interventions, it is light, elegant and compact – a simply smart device made for you!

OS3

EUROTIMES | Volume 15 | Issue 10

Feature

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eu matters

Research fraud Code of conduct seeks to reduce false, fabricated, and plagiarised clinical studies by Paul McGinn

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Solutions by Ziemer

EUROTIMES | Volume 15 | Issue 10

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he European Science Foundation has drafted a code of conduct to curtail research fraud in ophthalmology and every other field of medical and scientific study. According to the foundationâ&#x20AC;&#x2122;s European Code of Conduct for Research Integrity, research fraud â&#x20AC;&#x201C; in any guise â&#x20AC;&#x201C; represents a disease that must be destroyed. â&#x20AC;&#x153;Research misconduct is harmful for knowledge,â&#x20AC;? the code states. â&#x20AC;&#x153;It could mislead other researchers, it may threaten individuals or society â&#x20AC;&#x201C; for instance if it becomes the basis for unsafe drugs or unwise legislation â&#x20AC;&#x201C; and, by subverting the publicâ&#x20AC;&#x2122;s trust, it could lead to a disregard for or undesirable restrictions being imposed on research.â&#x20AC;? According to the foundation, misconduct takes many forms: n Fabrication: â&#x20AC;&#x153;making up results and recording them as if they were real.â&#x20AC;? n Falsification: â&#x20AC;&#x153;manipulating research processes or changing or omitting data.â&#x20AC;? n Plagiarism: â&#x20AC;&#x153;appropriation of other peopleâ&#x20AC;&#x2122;s material without giving proper credit.â&#x20AC;? The code provides that research misconduct also includes â&#x20AC;&#x153;failure to meet clear ethical and legal requirements such as misrepresentation of interests, breach of confidentiality, lack of informedÂ consent and abuse of research subjects or materials. Misconduct also includes improper dealing with infringements, such as attempts to cover up misconduct and reprisals on whistleblowers.â&#x20AC;? The code seeks to complement existing laws and codes of ethics, according to the foundation. â&#x20AC;&#x153;It is not intended to replace existing national or academic guidelines, but represents agreement across 30 countries on a set of principles and priorities for self-regulation of the research community.â&#x20AC;? The foundation hopes that the code might serve as a model for global code of conduct for all research. The European Science Foundation is an independent, non-governmental organisation. Explaining the need for the code, the foundation quotedÂ leading ethicist, Nicholas H Steneck PhD, director of the Research Ethics and Integrity Program of the Michigan Institute for Clinical and Health Research and a consultant to the US Office of Research Integrity. In an address to the First World Conference on Research Integrity in Lisbon

three years ago, Dr Steneck, estimated that the numbers of cases of research misconduct could number in the tens of thousands worldwide. â&#x20AC;&#x153;Studies suggest that as many as one in every 100 researchers engages in serious misconduct over the course of a three- to five-year period,â&#x20AC;? said Dr Steneck. Under the terms of the code, all stakeholders in research â&#x20AC;&#x201C; including the researchers themselves, the institutions that employ them, companies who fund research, societies at which researchers present their results, and journals that publish research results â&#x20AC;&#x201C; must take all necessary steps to ensure that: n the research is conducted objectively, impartially, and independently; n the methods by which the research are conducted are open, accessible, and reliable; n the results of the research are communicated honestly; n that references and credit for those who perform the research are provided fairly.

Tell the truth The code states that those who pay researchersâ&#x20AC;&#x2122; salaries or who fund research must take particular care. At the heart of the code is the duty to tell the truth. â&#x20AC;&#x153;Fabrication, falsification and the deliberate omission of unwelcome data are all serious violations of the ethos of research,â&#x20AC;? the code states. The code also requires researchers, institutions, and journals to adhere to practices that reduce the risk of misconduct and fraud. â&#x20AC;&#x153;Deviations from research procedures include insufficient care for human subjects, animals, or cultural objects; violation of protocols; failure to obtain informed consent; breach of confidentiality, etc,â&#x20AC;? the code provides. â&#x20AC;&#x153;It is unacceptable to claim or grant undeserved authorship or deny deserved authorship. Other publicationrelated lapses could include repeated publication, salami-slicing or insufficient acknowledgement of contributors or sponsors. Reviewers and editors too should maintain their independence, declare any conflicts of interest, and be wary of personal bias and rivalry.â&#x20AC;? For more details visit the European Science Foundation website at: www.esf.org

contact

Rod Solar – info@liveseysolar.com

Feature

PRACTICE DEVELOPMENT

boosting sales

With proper training, phone staff can turn far more enquiries into consults by Howard Larkin

hen your practice converts a prospect from thinking about LASIK to making an exam appointment, how are they most likely to have contacted you? “It doesn’t happen by email. It doesn’t happen by Twitter. It doesn’t happen on blogs or on Facebook. These technologies are very interesting and they have a great future, but right now people still use the telephone,” says Rod Solar, practice consultant and trainer with LiveseySolar Practice Builders in London. That makes your telephone one of your most powerful marketing tools, says Mr Solar, who has worked with dozens of refractive surgery practices in the UK and Canada. “If you put up a website, people will call your telephone. If someone hears about you by word of mouth, they will call your telephone. If you have referral relationships with optometrists or other ophthalmologists, they will call your telephone.” Just how much impact effectively answering your phones can be is illustrated by a UK refractive practice chain that Mr Solar recently worked with. In the first month after training receptionists how to guide callers to make an appointment and gather assessment and follow up information, conversion rates of enquires to appointments rose from 16 per cent to 19.5 per cent. That translated into a 26 per cent sales increase, from £11m to nearly £14m annualised. Over five months conversion rates rose to nearly 25 per cent and sales jumped to £17.5m as phone staff became more skilled and received follow-up training. That’s an increase in sales of £6m, or 59 per cent, from baseline. “If you’re looking for one or two steps to begin the marketing and development of your practice the telephone is one of the major steps you should take,” Mr Solar says. Increasing conversion rates also reduced the chain’s cost per patient for other marketing efforts, such as its website and advertising, from about seven per cent of sales to four per cent of sales. “If you are spending any money on marketing at all, you need to answer the phone. It multiplies your investment,” Mr Solar adds.

Training, scripts and experience

Trouble is most European ophthalmology clinics don’t do a very good job of answering the phone. In a mystery caller survey EUROTIMES | Volume 15 | Issue 10

consisting of 30 calls to randomly selected refractive practices in each of seven European countries, Mr Solar found that less than 40 per cent asked the caller to book an appointment. “What makes for success on the phone is a call to action. The most important thing is to ask the patient to make an appointment.” Asking a patient for an appointment may seem pushy in some countries, Mr Solar notes. But people are calling because they are interested. “You are looking to influence the people in the middle, who haven’t quite made up their minds,” Mr Solar says. “You are giving the patient an opportunity to do what they wanted to do, but didn’t know how to ask.” Mr Solar emphasises that the goal of the phone conversation should be limited to getting the patient in for an exam. Doing so requires that your phone staff know about your procedures and be able to provide information, but prospects should be told they will need to be seen to assess their options. “At the phone call you are selling the appointment. You cannot sell the treatment over the phone.” Performance was even worse on other questions that might help gauge a prospective patient’s needs and interest in refractive options. Only 20 per cent asked when the caller might purchase the service. Fewer than 10 per cent asked the caller to describe the problem, if they had had similar services in the past, or about work or hobbies. Only 14 per cent asked if the caller was an existing patient or a new enquiry. Nearly 80 per cent failed to ask the caller for details, like a phone number, address or email. “If you don’t get their name and contact information, how can you follow up?” Mr Solar asks. Effectively answering the phone also means working in messages that differentiate your practice from others. Whether it is price, no-cost assessment, open after regular business hours or special services, this information will reinforce your marketing message and help patients make the decision to see you. Attitude and connecting with patients is also important, Mr Solar says. More is communicated by the tone of voice than the words. Telling the caller your name encourages them to reciprocate. In many cases, clinic phone staff members have talent and enthusiasm. What they need is training, a

script and the right questions to ask, Mr Solar says. Then, after the excitement wears off, said. “You need to give them a script and say people slip back and performance drops. ‘here is how you lead the patient through the After a couple of months a refresher course phone call'.” Staff also need to understand will bring performance back. With experience that they are a critical part of your practice’s and monitoring to reinforce disciplined success, and the better they do their job the phone process, performance typically more successful you all will be. continues to climb, he adds. Measured by conversion rates and a series And what happens if your staff doesn’t of key metrics that include what questions properly handle a call from a prospective are asked and how they are asked, phone patient? “They call somebody else,” Mr Ins_easyPhaco_120x120_EuroTimes 11:21 Uhr Seite 1 performance typically improves dramatically 6.5.2010 Solar says. with just a day or two of training, Mr Solar

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Reference

Calendar of events Dates for your Diary

November

October 2010

CRETE, GREECE 6-9 European Assocation for Vision and Eye Research 2010 www.ever.be

16-19 chicago IL, usa American Academy of Ophthalmology

February 2011

18-20 TURKEY

ISTANBUL,

15th ESCRS Winter Meeting www.escrs.org

www.aao.org/annual_meeting

21-24 HAMBURG, germany 23rd International Congress of German Ophthalmic Surgeons www.doc2010.de

28-31 CHANDIGARH, INDIA 10th Annual Conference of Uveitis Society of India & Moorfields Uveitis Course www.usi2010.in

December

9-12

2010

MACAU, CHINA

The International Symposium on Ocular Pharmacology and Therapeutics – ISOPT ASIA www.isopt.net

4-6

2010

Delhi, India

5th International Congress on Glaucoma Surgery ICGS www.oic.it/icgs2010/

27-28 India

new Delhi,

Mid Term Conference of Delhi Ophthalmological Society www.dosonline.org

January 2011

12-14

Vienna, Austria

2nd International course on ophthalmic and oculoplastic reconstruction and trauma surgery www.ophthalmictrainings.com

BELGRADE, SERBIA

3rd International Symposium on Macular Disease www.milosklinika.com

February

3-5

2011

Verona, Italy

Present & Future Challenges in severe Retinal Diseases www.retinaldiseases2011.com

24-27

Athens, Greece

25th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery www.hsioirs.org

2011

Barcelona, Spain 3-6 2nd World Congress on Controversies in Ophthalmology (COPHy) www.comtecmed.com/cophy

11-12 Alicante, Spain ARI Monographic 2011 -“The best and most

Joint Congress of SOE/AAO www.soe2011.org

World Glaucoma Congress 2011 www.worldglaucoma.org

2011

6-10 Argentina 26-29 Mar del Plata,

19th Argentinian Ophthalmology Congress www.oftalmologia2011.com.ar

London, UK

11th EURETINA Congress www.euretina.org

20-24 Sydney, Australia 2011 Congress of the APAO www.apaosydney2011.com/

25-30 San Diego CA, USA

ASCRS/ASOA Symposium and Congress www.ascrs.org

2011

1-3 4-7 PARIS, 29-2 FRANCE GENEVA, SWITZERLAND

May

April

updated information about Lens, Cataract and Refractive Surgery” www.alicanterefractiva.com

July

June 2011

March

September Leuven, Belgium

Leuven Retina Meeting www.leuvenretinameeting.eu

2011

vienna, austria

16-17 17-21 2nd EuCornea Congress www.eucornea.org

November

13-16

2011

Seoul, Korea

2011 APACRS-KSCRS Annual Meeting www.apacrs.org

XXIX Congress of the ESCRS www.escrs.org

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