Volume 15_Issue 5

VOLUME 15 ISSUE 5 MAY 2010

Special Focus

Retinal Detachment

Bill Aylward FRCS, FRCOphth, MD José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins

australia

Bekir Aslan

TURKEY

Bill Aylward Peter Barry

UK

IRELAND

Roberto Bellucci

ITALY

Hiroko Bissen-Miyajima John Chang

CHINA

Joseph Colin

FRANCE

Alaa El Danasoury Oliver Findl

SAUDI ARABIA

AUSTRIA

I Howard Fine Jack Holladay

USA

Thomas Kohnen

Boris Malyugin

GREECE

RUSSIA

Marguerite McDonald

Ulf Stenevi

USA

INDIA

Thomas Neuhann Robert Stegmann

GERMANY

GERMANY SOUTH AFRICA

SWEDEN

Emrullah Tasindi

TURKEY

Marie-Jose Tassignon Manfred Tetz

BELGIUM

GERMANY

Carlo Enrico Traverso Roberto Zaldivar

There are many other highlights in the programme, including nine major sessions with updates from international experts in their field covering the full range of retinal practice, and tackling issues at the very forefront of modern retinal treatment. For the first time we have a symposium organised by the German Retinal Society which will include new information from the SpR study, one of the best sources of evidence for the management of RD.

The next EURETINA congress in Paris at the beginning of September will offer a great deal to those interested in RD. The congress represents a landmark for EURETINA in two quite different ways. Firstly, it is our 10th congress since EURETINA was founded in 2001, and is likely to be the most successful, and well attended yet. Secondly, it is the first time we have joined forces with our sister organisation ESCRS, so that our two meetings are being held consecutively in one location. As well as being convenient for those delegates who plan to attend both meetings, this arrangement gives us a number of exciting opportunities, including the ability to organise two major joint symposia covering issues common to both the front and the back of the eye. The first will be on endophthalmitis, a devastating complication of constant concern to all ophthalmic surgeons, and the second will cover myopia, including its pathology, treatment and the thorny issue of prophylaxis prior to refractive or cataract surgery.

We are also fortunate to have our regular contribution from the FAN Club, to which delegates are encouraged to submit their own interesting cases. There will also be a Eurolam symposium, and of course the Amsterdam Retinal Debate, which is a popular format for entertaining and informative exchanges of views. This year the debates will be on timing of anti-VEGF injections, and screening in uveitis.

The number and range of our instructional courses continues to grow, and in Paris we will have no less than 22 courses offering practical and up-to-date advice on a range of subjects, from OCT interpretation to management of retinopathy of prematurity. Our popular extended courses on RD and uveitis will both be running as usual.

Finally, there will be a full programme of industry-sponsored satellite symposia and a comprehensive commercial exhibition.

Overall, we hope to make EURETINA a ‘one stop shop” covering all the requirements of the ophthalmologist interested in retina. * Bill Aylward FRCS, FRCOphth, MD is president of EURETINA, The European Society of Retina Specialists, and consultant vitreoretinal surgeon at Moorfields Eye Hospital.

GREECE

HONG KONG

Gisbert Richard

This issue of EuroTimes focuses on Retinal Detachment (RD), which remains one of the most important diseases in ophthalmology. Despite significant advances in treatment since the pioneering work of Jules Gonin in the 1920s, there are still many unresolved issues. Patients with identical detachments will receive different forms of treatment depending largely on their geographical location, and the controversy over the best modality of treatment is likely to continue for many years to come. Proliferative vitreoretinopathy remains the major cause of ultimate failure of surgical treatment for RD, and it is still an unsolved problem. Finally, although surgeons have become good at re-attaching the retina, the issue of restoring visua function following macular-off RDs has received very little attention. It is likely that the application of neuro-protection to this problem will be a new and productive field of research.

GERMANY

Anastasios Konstas

Cyres Mehta

EURETINA congress programme to tackle issues at the forefront of modern retinal treatment

USA

Vikentia Katsanevaki

Dennis Lam

JAPAN

Editorial

Editorial May

Medical Editors

ITALY

ARGENTINA

EuroTimes is the number one ophthalmological magazine in Europe The average net circulation of EuroTimes as certified by ABC for the period January to December 2009 is 29,537, the highest average net circulation recorded by the magazine and the highest audited figure for any ophthalmic magazine circulating in Europe. This represents an increase of 1,393 readers on 2008’s readership figure of 28,144, a 4.94 per cent increase.

Emanuel Rosen, chairman of the ESCRS Publications Committee said: “The ESCRS is very proud of the achievements of our magazine since its foundation in 1996. For the last 14 years, EuroTimes has been providing a global view on ophthalmology from a uniquely

European perspective. That, and the continuing influence of the ESCRS on the development of European ophthalmology, has been our biggest strength and I am glad that our readers continue to recognise the unique service provided by EuroTimes.

“Our circulation figures are independently audited by ABC [Audit Bureau of Circulations], internationally recognised audit certification systems. EuroTimes has been audited by ABC since 2001 and has reported year-on-year increases since we first took part in the audit.

“As European ophthalmology has evolved, so has the magazine and this

year we have introduced a number of additional features including new columns on research and young ophthalmologists.

“EuroTimes will also play an important role in the promotion of European Year of LASIK, one of the most important projects developed by the ESCRS since its foundation.

“I would like to thank all of our readers and advertisers for their continued support for EuroTimes and on behalf of the ESCRS assure them that we will continue to strive for the highest standards in editorial excellence in the months and years ahead, ” said Dr Rosen.

1

Contents

Special Focus – Retinal Detachment 6 Cover Story: Risk factors, prevention and treatment for RD discussed

>

17 Cataract

11 Call for more research studies to prevent RD

Cataract Update 15 Precautions can help prevent no-benefit surgery outcomes

>

18 Refractive Lens

17 Femtosecond lasers have potential to reduce complications of cataract surgery

Refractive Lens 18 Encouraging results with new IOLs

>

24 Retina

Refractive Laser 20 ESCRS Congress will showcase major symposium

to celebrate European Year of LASIK

Cornea Update

>

35 Feature

21 A preview of the first EuCornea Congress More Contents 2

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Contents

>

Features

38 Features

EUROTIMES

ESCRS

>

36

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Published by The European Society of Cataract and Refractive Surgeons

Editorial Staff

Glaucoma Update 22 Better screening techniques needed to deal

with increase in glaucoma

Retina Update

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick

24 New imaging instrument to aid retinal specialists

Production Editor Angela Sweetman Senior Designer Paddy Dunne

25 Combination treatments for AMD

Assistant Designer Janice Robb

Ocular Update

Circulation Manager Angela Morrissey

30 EBO Residency Exchange Programme gives

participants a chance to broaden their knowledge

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post Seamus Sweeney Gearóid Tuohy

ESCRS News 31 Young ophthalmologists need role models 32 Greek ophthalmologists embrace EUREQUO project

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40 Calendar

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

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EUROTIMES Supplement May 2010

2010 Laser Vision Correction: Using Biostatistics to Revolutionise Refractive Surgery Outcomes

With this issue...

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As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2009 and 31 December 2009 is 29,537.

Special Focus

Retinal Detachment

Researchers home in on risk factors for retinal detachment

Dermot McGrath in Paris

ALMOST a century has passed since Jules Gonin performed the first intervention for retinal detachment (RD), achieving successful outcomes in close to 50 per cent of his cases. Despite initial scepticism and occasional hostility from many of his contemporaries, Gonin’s trans-scleral cautery heralded the modern era of vitreoretinal surgery in which techniques such as scleral buckling and pars plana vitrectomy would bring the surgical success rates to over 90 per cent, saving the sight of numerous patients in the process.

Considerable progress has also been made in terms of understanding the epidemiology and pathophysiology of rhegmatogenous retinal detachment (RRD) and identifying populations at risk. The understanding that cataract surgery is a risk factor for RD has existed since at least 1929 when Bauermann reported a two per cent incidence after extracapsular surgery with a 10 per cent detachment rate if vitreous was lost.

Other studies in the scientific literature have since demonstrated that non-phakic eyes are indeed at increased risk for RD in their lifetime compared to phakic eyes, with approximately 40 per cent of RDs occurring in the non-phakic eye (Haimann et al, Arch Ophthalmology 1982; 100:289-292). On this basis, previous cataract surgery represents the most important risk factor for patients undergoing surgical repair of RD. Number crunching and risk assessment Putting the current data into context, Emanuel Rosen MD, FRCS told EuroTimes that while there are still significant gaps in the knowledge base, ophthalmologists today have a much better understanding of the various preoperative and intraoperative risk factors for RD and can counsel their patients accordingly.

“If we take a normal population, then one eye in about 8,500 will get an RD irrespective of surgery. For myopic eyes, it is nearly 10 times the rate, or one in 900 eyes. However, if you remove the crystalline lens and implant an IOL, it is also 10 times the rate for a normal population, or around one in 850 eyes. So we can say that removing the lens and implanting a lens increases the risk of RD by a factor of 10.

However, it is still a relatively small risk of one in 850 eyes,” said Dr Rosen, director of the Rosen Eye Clinic, Manchester, England.

Dr Rosen noted that a paper by Stephen Tuft et al at Moorfields Eye Hospital (Tuft et al, Ophthalmology 2006; 113: 650-656) found that patient characteristics as well as surgical complications constitute major risk factors for RD. 6

“The major risk factors for detachment included posterior capsule tear, zonular dehiscence, retinal detachment in fellow eye, axial length greater than 23mm and male gender,” he said.

A major complicating factor in assessing the risk of RD after cataract surgery is the fact that the detachment may occur many years after the crystalline lens has been removed, said Dr Rosen, referring to a study (Erie et al, JCRS 2007; 33: 1273-1277) which showed that the cumulative risk of RD after extracapsular cataract extraction and phacoemulsification is increased for up to 20 years after surgery.

The cumulative probability ratio of RD at 20 years after ECCE and phacoemulsification was four times higher than would be expected in a similar population group not undergoing cataract extraction. Increased axial length was also identified as a risk factor, said Dr Rosen, citing a further study (Alio et el, American Journal of Ophthalmology 2007; 144, 93-98) which reported an overall incidence of RD of 2.7 per cent, with eyes under 50 years of age deemed at greater risk.

Risk underestimated by cataract surgeons?

For some observers, the delayed onset of RD has perhaps contributed to an underestimation of the risk of detachment by cataract surgeons.

“The main problem is that retinal detachment is a late complication of cataract surgery which may occur a decade or more after the surgery and very few cataract surgeons see their patients after five years,” said Horst Helbig MD of the University of Regensburg, Germany. “So the subjective impression they may have is that their patients never have a retinal complication, which is certainly true for the first year or two, but not later on when it is the vitreoretinal surgeon who will be confronted with the problem.”

To illustrate the point, Dr Helbig cited a paper (Neuhann et al, JCRS 2008; 34: 16441657) that reported the absolute incidence of postoperative RD in 1,519 consecutive highly myopic patients as between 1.5 per cent and 2.2 per cent with a follow-up of between zero and 218 months.

“The interesting thing is that KaplanMeier survival analysis of this series of patients showed a cumulative maximum risk for RD of five per cent after more than 10 years, which adds up to 10 per cent for both eyes. Another recent publication (Sheu et al, American Journal of Ophthalmology 2010: 149: 113-119) looked at late-onset RD after cataract extraction and showed that patients with high myopia may be at increased risk for late pseudophakic detachment after four years, especially in male patients. The risk for detachment in

highly myopic young patients after about 10 years comes close to 20 per cent,” he said.

As Dr Helbig explained, the majority of late onset detachments in uncomplicated cataract surgeries are brought about due to fundamental changes in the physiology of the eye that occur over years.

“The scientific literature shows that if we don’t experience intraoperative complications, then the surgery itself doesn’t play a major role in the pathophysiology of retinal detachment.

However, there are quite a few chronic changes in the physiology of the eye after cataract surgery, including changes in the geometry of the vitreous cavity and changes in the diffusion barrier properties between the anterior and posterior segments that ultimately leads to accelerated vitreous liquefaction,” he said.

Dr Helbig also noted that the concentration of hyaluronic acid in the vitreous has been shown to be lower in aphakic than phakic eyes.

“A lower concentration of hyaluronic acid in the vitreous is associated with an increased risk of posterior vitreous detachment. A study (Hilford et al, Eye 2009; 23: 1388–1392) in young patients who had unilateral cataract surgery showed

that half of the patients (51 per cent) had a PVD [posterior vitreous detachment] after five years compared to 21 per cent in the unoperated fellow eye. So cataract surgery clearly induces PVD, a factor which is likely to be associated with the increased risk of retinal detachment observed in this age group,” he said.

Myopia on the increase One worrying aspect of the emerging epidemiological data on RD is the likelihood that there will be an increase in the incidence of detachments in the future due to an increase in myopia. The issue is also likely to become more pertinent in the future as the lines between cataract and refractive surgery continue to blur and patients have their crystalline lens removed at a younger age. Both myopia and young age are known risk factors for RD after cataract extraction. Furthermore, high myopia is also associated with cataract and a relationship between myopia and cataract has been suggested in the scientific literature (Nielsen et al, JCRS 1993; 19: 675680, Tielsch et al, Ophthalmology 1996;103: 1537-1545).

“Apart from careful preoperative screening and avoiding intraoperative

Richard Packard

complications, we really do not have any firm idea at the moment of how to reduce the risk for retinal detachment. Myopia is becoming extremely common and when we look at the numbers from Asia around 80 per cent of the young population are myopic, which is an enormous burden for the healthcare system because we are obviously going to see a lot more retinal detachments in the future,” noted Dr Helbig.

One possible way to reduce the risk is to favour phakic IOLs over refractive lens exchange (RLE) in younger patients at risk, advises Richard Packard MD, FRCS, consultant surgeon, King Edward Hospital, Windsor, England.

“High myopia and posterior vitreous detachment are the factors to watch for especially in younger patients. Performing RLE in hyperopes is a no-brainer as they don’t get detachments in the same way and certainly no more than the normal population would. If the patient is –12 D, male, under 50 and has not had a PVD then there is no way I would proceed with any lens surgery. A phakic IOL is a better option for these patients – the Alcon Cachet lens for instance has 10 years of clinical data and is a less invasive option than implanting an ICL,” he said.

Avoid decompression of myopic eyes during surgery Another point worth bearing in mind to reduce the risk of PVD in the short term and RD in the longer term is to avoid any possibility of decompressing the eye during the cataract surgery, said Dr Packard.

“If you are doing cataract surgery on a myope that has not had a PVD, it is important to take precautions to make sure that you do not decompress the eye. This means using lots of viscoelastic when you remove the phaco probe or the irrigation/ aspiration handpiece to ensure that the anterior chamber remains stable, so that there is as little chance as possible for the eye to decompress and induce a PVD,” he said.

Dr Packard said that a meta-analysis he carried out some years ago of 60 clinical reports published between 1996 and 2004 comprising 1,800 myopic eyes with a mean follow-up of 43 months found a RD rate of less than two per cent.

While Joseph Colin’s landmark 1999 study on RLE in high myopes recorded a 10 per cent rate of RD over a 10-year follow-up period, Dr Packard said he believed that these results had been skewed somewhat by the fact that a relatively low percentage of Dr Colin’s patients had PVD probably due to the low average age, and a high proportion (60 per cent) required treatment of pre-existing or acquired retinal lesions during the course of the follow-up.

The vexed question of retinal prophylaxis Controversy also surrounds the question of routine prophylactic treatment of retinal lesions, retinal holes and lattice degeneration in eyes deemed at risk of RD. Some surgeons advocate universal treatment of peripheral retinal lesions while others argue for a more restricted use of laser photocoagulation in eyes with asymptomatic peripheral lesions.

“Closely surveying the family history is a good starting point for these patients,” suggests Dr Rosen, “and it is important to do a full retinal survey to identify the pathology in the first place. If there are tractional breaks, then I don’t think many surgeons will hesitate to do welding with Argon laser. However, if there is no posterior vitreous detachment and there are atrophic breaks or even lattice degeneration without holes in phakic eyes, there is no firm evidence that prophylactic treatment makes any difference. A lot of it comes down to individual judgement on a case-by-case basis,” he said.

Steven Harsum PhD, MRCOphth, a vitreoretinal fellow at Moorfields Eye Hospital, London, UK, agrees. “Personally I do not believe in argon prophylaxis of lattice degeneration or round holes.

Norman Byer showed most peripheral lesions to be much safer than previously believed and recommended no treatment.

Nobody has produced evidence to the contrary,” he said.

In terms of other risk factors, there is as yet no evidence to implicate laser refractive surgery as increasing the risk of RD. While there have been some isolated case reports of RD after LASIK, there is no evidence of a cause-and-effect link between them, and surgeons do not anticipate any major increase in the RD rate as the first wave of LASIK patients reaches cataract age, said Dr Harsum.

“We all understand that u-tear detachments in the elderly are related to abnormal vitreoretinal adhesions in the context of a posterior vitreous detachment.

I can’t envisage LASIK increasing these adhesions or increasing the rate of retinal detachment when a PVD eventually develops,” he said.

He noted that myopic round hole detachments are still poorly understood, but said that he remains sceptical that modern LASIK, particularly with the introduction of femtosecond flap creation, could influence the RD rate.

“The major risk factors for detachment included posterior capsule tear, zonular dehiscence, retinal detachment in fellow eye, axial length greater than 23mm and male gender” Emanuel Rosen MD, FRCS is approximately 90 per cent, and with multiple procedures it is as high as 99 per cent says Dr Harsum.

He points out that vitreoretinal surgeons now have a range of treatment options open to them to deal with primary detachments.

“If the patient is phakic and there is no PVD, then a cryo/buckle is the preferred choice. Conversely, if there is a PVD or the patient is pseudophakic then the preferred option is a pars plana vitrectomy. It is the intermediate group that requires more careful thought: the young phakic nonpresbyopic patient that has a PVD-related u-tear. I tend to err on the side of a cryo/ buckle in this scenario, although some of my colleagues would always perform a vitrectomy if there was a PVD,” he said.

As vitreoretinal surgical techniques continue to evolve and more data becomes available on the risk of RD after cataract surgery, there are ample grounds to believe that progress will continue to be made in the prevention and treatment of RD. New research into potential genetic components of RD and experimental pharmacological therapies, as well as ongoing improvements in imaging techniques and vitreoretinal surgical devices should further reduce the burden of blindness associated with RD in the future. harsum@doctors.org.uk helbig@eye-regensburg.de eyequack@vossnet.co.uk erosen9850@aol.com

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EUROTIMES

ESCRS

Emanuel Rosen

Special Focus

Retinal Detachment

PODCAST

Reattachment surgery successful in over 90 per cent of cases In the worst-case scenario, if RD does occur, the positive news for patients is that the chance of successful reattachment surgery with one procedure 7

Newsmaker Interview

Retinal Detachment

Current best practice in treatment of retinal detachment Sebastian Wolf

THE continuing evolution of vitreoretinal surgery technology provides a host of new conundrums for the retinal specialist when dealing with retinal detachment (RD).

EURETINA Board member Sebastian Wolf MD, PhD, Department of Ophthalmology, University of Bern, Bern, Switzerland, spoke to EuroTimes contributing editor, Roibeard O’hEineachain, about his views on best practice in the treatment of RD.

ET: What are currently the major controversies regarding the treatment of RD? Wolf: There are several. One is the debate over whether we should do surgery from inside the eye or externally. Is the first choice of surgery buckling surgery or vitrectomy?

There is no controversy with the easier RD cases with a single break, where buckling is the surgery of choice, at least in phakic eyes. Similarly, vitrectomy is the obvious choice with complicated RDs. In cases that are intermediate there is a big controversy. The ‘Scleral buckling versus Primary vitrectomy in Rhegmatogenous retinal detachment (SPR)’ study investigated that issue. It showed that for phakic eyes it is better to do it from outside the eye with buckling, but with pseudophakic eyes it would be better to perform vitrectomy. But it is still not always really clear which is the best to do.

ET: Is this a question of needing to individualise treatments?

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Wolf: Yes, the individual patient has to be considered and the ability of the surgeon is also important.

Nowadays, training is geared more towards vitrectomy.

Vitrectomy has become easier or less complicated during the last decade and many people learn vitrectomy early in their career and they are more comfortable with vitrectomy. For

“Nowadays, training is geared more towards vitrectomy.

Vitrectomy has become easier or less complicated during the last decade and many people learn vitrectomy early in their career and they are more comfortable with vitrectomy” buckling surgery you need a lot of experience and it’s probably more difficult to learn and therefore people tend to do vitrectomy in less complicated cases.

ET: A proposed advantage of scleral buckling is that it is a minimal and less invasive surgery than vitrectomy. Do you think that is still true?

Wolf: Probably, although it’s difficult to say, nowadays, many surgeons perform 23-gauge and 25-gauge vitrectomy in eyes with RD and that is very non-invasive as well. On the other hand when you do vitrectomy in phakic eyes, you will induce early cataract formation.

Up to 100 per cent of patients who undergo vitrectomy with gas develop cataract. In younger people, you may want to preserve the crystalline lens in order to preserve accommodation. Therefore, there is a good argument in favour of treating RD in younger patients with scleral buckling.

ET: Is there a difference between the two approaches in terms of the recurrence of RD? Wolf: Not really. Overall, the results will be very similar if you do the right surgery for the patient. Of course, if you have a complicated RD there is almost no way to repair it with buckling, but, as a general rule, the visual outcomes and recurrence rates are very similar with the two types of technique.

ET: What difference has the introduction in recent years of new smaller gauge instrumentation made for RD surgery?

Wolf: It is getting easier and it is less invasive, but an additional controversy is whether or not we should use an encircling band in addition to vitrectomy in complicated RDs. There are hints from the SPR study, especially in pseudophakic eyes, that the combination of an encircling band and vitrectomy has a higher success rate compared to vitrectomy alone. So where you combine vitrectomy with encircling band it makes no difference if you use smaller gauge instruments because it is no problem to use 20-gauge instruments if you already have opened the conjunctiva.

ET: In those cases is using 20-gauge instrumentation easier?

Wolf: With 20-gauge surgery we have a wider range of instruments, it is also less

expensive than 23-gauge surgery. If you used 23-gauge you would still have to suture the sclerotomy and the new 20-gauge cutters are even more effective than the 23-gauge cutters.

ET: One of the reported disadvantages with smaller gauge instrumentation is a higher rate of endophthalmitis.

Wolf: Yes, this is probably true. The risk of endophthalmitis is probably related to hypotony after small-gauge surgery. Since the sclerotomies may leak in 23-gauge surgery there are quite a lot of eyes that develop hypotony after the surgery. But there are strategies to avoid this. If you fill the eye with air or with gas the risk of hypotony is very small, so I’m not sure that in 23-gauge RD surgery, where you are putting gas into the eye anyway, it has a higher risk of endophthalmitis. The risk might be increased in the case of macular pucker, where you are less likely to use a gas bubble.

ET: Does the type of incision made make a difference with regard to endophthalmitis risk?

Wolf: Yes with 23-gauge surgery a bevelled incision is probably better than a straight incision and if the incision is performed correctly the risk of hypotony is lower. But there will remain a certain risk of hypotony.

However, this is not an issue with RD surgery. I think with RD surgery, the issues with small-gauge are more to do with the instrumentation. However, if you have to do more complex cases or you have to use silicone oil, you may be better off with 20-gauge vitrectomy.

ET: Finally, in your capacity as a Board member of EURETINA, what can you tell us about the upcoming EURETINA Congress?

Wolf: I think it will be a very good meeting.

For the first time, we will have a back-toback meeting with the ESCRS, and we are expecting more people at this meeting than any previous meeting. With around 2,000 participants, this will be the largest retinal meeting in Europe and there will be sessions regarding all aspects of retina, including imaging innovations and new developments in the treatment of DME and AMD. So it will be a very inspiring meeting. sebastian.wolf@insel.ch

Retinal detachment: more research is still needed Thomas Olsen

Without complications the efficacy of a modern, well-performed lenticular surgical procedure is undisputed. We can cure the cataract and give patients their vision back and in many cases also improve their spectacle dependence correcting ametropia, astigmatism, as well as higher orders of aberration and presbyopia to a certain extent. It is no wonder that the value of these refractive improvements in terms of quality of life has changed the ‘indications’ for surgery as we used to say in the old days, but at the same time, patient expectations have risen as the news is often heard that, “I had this eye surgery and now I can see without glasses!”

Success does not always follow perfect surgery, however. Just like endophthalmitis, retinal detachment (RD) is a serious complication which may ruin an otherwise first-class surgery and even blind the patient. Since RD is a disease with a spontaneous incidence in the population the surgeon is not always the only one to blame. Even without surgery myopic patients have a higher risk than normal, and lattice degeneration, vitreous abnormalities, gender, age (middle age) and a history of trauma add to the list of known risk factors.

Pseudophakic RD There is little doubt, however, that lens surgery itself bears a risk over the natural occurrence and that due to current lens surgery trends, the proportion of pseudophakic RD appears to be increasing1.

Recent studies seem to indicate the risk to be about 1.3–2.2 per cent2;3 for extremely long eyes some years after surgery. The problem is that these eyes seem to be at increased risk after many years, especially in males4. Therefore, when a clear lens extraction (CLE) or a refractive lens exchange (RLE) is considered in a myopic patient we must always ask ourselves the questions: Would RD be likely to develop in this patient? Should I opt for another solution, ie LASIK or a phakic IOL?” (Phakic IOLs have been concluded to provide a better visual outcome than keratorefractive surgeries and better safety than refractive lens exchange for high myopia of -8 dioptres or more5.) And finally, how do I inform the patient about the risk? Can I do something to prevent it?

Crystalline lens Let us for a moment consider why the exchange of the crystalline lens with an artificial one predisposes to this complication? Consider the fact that the volume of the biological lens is about 200–250mm3, depending on the age of the patient (this number can be calculated from

the average dimensions of the natural lens assuming an overall diameter of 11mm, thickness 4.5mm and radii of curvature of 10 and 6mm of the front and back surface, respectively). The volume of a typical foldable, high refractive index IOL designed to be inserted through a small incision is only about 20mm3 (assuming an overall diameter of 6mm, thickness 1mm and radii of curvature 20mm of front and back surface, respectively). Hence, as the capsule shrinks and eventually anchors the IOL after surgery, the volume taken up by the new lens apparatus is 10 per cent of what it used to be! As a consequence, to fill the gap in the posterior segment, the vitreous will have to move forward and there is more room for rotational forces putting stress on the vitreous-retinal strands.

Ideal IOL From the retinal point of view, you might question whether the smallest IOL is always the best IOL. Maybe the ideal IOL would be an IOL that mimics the natural lens both in function and anatomy. In line with this thinking is the concept of lens refilling where researchers try to find methods to inject elastic, refractive material into the empty capsule to restore not only accommodation but also the anatomy of the natural lens. We are still waiting to see what the solution might be regarding material, prevention of secondary cataract, stability, optical predictability etc. Another option, which has been put forward by Fechner6 in the past, is the concept of an excessively posteriorly vaulted IOL which pushes backward into the vitreous by specially designed IOL haptics. The idea is to keep the position of the posterior capsule as intact as possible. In the modern endeavour to produce foldable, ever smaller IOL designs this concept seems to have been forgotten and awaits further study.

What about the retinal status, then? It is a clinical fact that myopic patients are not equal in their retinal appearance. Some have healthy, good looking retinae with no peripheral degenerations and no signs to indicate the possible development of RD while others (sometimes only moderately myopic) have terrible, peripheral degenerations and maybe subclinical tears, not forgetting those who already had an RD on their fellow eye. Very few would doubt that the latter group is at higher risk than the first group. The state of the vitreous also needs to be considered. In a recent study the incidence of posterior vitreous detachment (PVD) after normal cataract surgery has been found to be about 60 per cent in those 40 per cent of eyes that do not present with a PVD prior to surgery7.

Few studies seem to have been done to investigate the possible beneficial effect of surgical/laser intervention at the retinal level prior to lens surgery. This may seem odd considering the fact that other retinal diseases have the reputation of being controlled by prophylactic photocoagulation, as demonstrated in large series with a statistical significance around the five per cent level. It could well be that this situation has not been relevant in the past because lens surgery (read: cataract extraction) was only done when the vision was seriously hampered by the cataract leaving no other option, but nowadays RLE and CLE candidates often have perfectly clear lenses to allow for a thorough retinal examination and/or laser treatment if that option is considered. Therefore the clinical situation of today calls for more research studies aiming at the possible prevention of RD through prophylactic treatment of preRD degenerative lesions.

Maybe this is a good task for another multicentre, cross-European study – who wants to join? tkolsen@dadlnet.dk

Thomas Olsen MD, is professor, dr. med, University Eye Clinic, Aarhus Hospital, Denmark

Reference List 1. Mitry D, Charteris DG, Fleck BW, Campbell H, Singh J. ‘The Epidemiology of Rhegmatogenous Retinal Detachment - Geographic Variation and Clinical Associations’. Br.J Ophthalmol. 2009.

2. Neuhann IM, Neuhann TF, Heimann H, Schmickler S, Gerl RH, Foerster MH. Retinal detachment after phacoemulsification in high myopia: analysis of 2356 cases. J Cataract Refract Surg 2008;34:1644-57.

3. Zuberbuhler B, Seyedian M, Tuft S. Phacoemulsification in eyes with extreme axial myopia. J Cataract Refract Surg 2009;35:335-40.

4. Sheu SJ, Ger LP, Ho WL. Late increased risk of retinal detachment after cataract extraction. Am.J Ophthalmol. 2010;149:1139.

5. Huang D, Schallhorn SC, Sugar A, Farjo AA, Majmudar PA, Trattler WB et al.

Phakic intraocular lens implantation for the correction of myopia: a report by the American Academy of Ophthalmology.

Ophthalmology 2009;116:2244-58.

6. Fechner PU, Trier HG. Super-reversed intraocular lens. J Cataract Refract Surg 1990;16:471-6.

7. Mirshahi A, Hoehn F, Lorenz K, Hattenbach LO. Incidence of posterior vitreous detachment after cataract surgery. J Cataract Refract Surg 2009;35:987-91.

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paris 2010 10TH EURETINA Congress

MAIN SESSIONS MAIN SESSION 1: Research I: Retinal Imaging Chairperson: E. Stefansson Thursday 2 September 10.00 – 11.30 ~ MAIN SESSION 2: Research II: Stem cells / Gene therapy / Prosthesis Chairperson: D. Wong Thursday 2 September 11.30 – 13.00 ~ MAIN SESSION 3: Imaging to Monitor Progression Chairperson: J. Cunha-Vaz Thursday 2 September 14.00 – 16.00 ~ MAIN SESSION 4.

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paris 2010

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Thursday 2 September 16.20 – 16.35

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ESASO EURETINA: New & Future diagnostic tools for retinal diseases

Organiser: G. Guarnaccia Italy & B. Corcóstegui Spain

6.

What, When and How: Surgical Discussions Organiser: C. Mateo Spain

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Cataract Update

Patient satisfaction not all down to surgical factors Mats LundstrĂśm

Roibeard O’hEineachain in Budapest

THE failure of cataract surgery to provide some patients with a net benefit can result from both surgical and non-surgical factors, but there are strategies to avoid a no-benefit outcome, according to Mats LundstrĂśm MD, EyeNet Sweden, Blekinge Hospital, Karlskrona, Sweden, in a presentation at the 14th ESCRS Winter Meeting.

Dr LundstrĂśm noted that although ocular co-morbidities and surgical complications may represent the greatest risk to a cataract patient’s visual outcome, even when surgery achieves all of the goals of optimal visual acuity and refraction without surgical complications, there will still be patients who will be worse off than they were before the surgery, with more difficulty performing everyday tasks than they had previously. “Patients with few problems with their vision before surgery may experience small difficulties after surgery and suddenly they are turned into this group of unhappy patients,â€? he added.

He presented results of a study that examined the responses of 2,114 cataract patients from 24 surgical units in Sweden to the Catquest-9SF questionnaire, administered in 2009. Dr LundstrĂśm and his associates developed the nine-scaled Rasch-analysed questionnaire over the course of several studies carried out over the years 1995-2005.

The EyeNet team therefore had at their disposal a database of responses to previous questionnaires from more than 20,000 patients who underwent cataract surgery.

They validated the current version of the Catquest questionnaire in a study carried out in 2008 involving 800 patients.

Dr LundstrĂśm noted that the results of the current study were consistent with those of the previous study in showing that ocular co-morbidities and serious surgical complications carried the greatest risk of a no-benefit outcome.

However, like the other studies the results also indicated that factors not directly related to the success of surgery or the health of the treated eye can have an impact. Those factors include an absence of disability with the treated eye before surgery on treated eye, discomfort with anisometropia when only one eye is treated and visual disturbance from cataract in the fellow eye.

A logistic regression analysis of the study’s findings showed that capsule complications increased the odds of no benefit outcome by over seven-fold and ocular co-morbidity increased the odds by 2.27-fold and having few preoperative difficulties increased the odds by 2.77-fold.

Among those who benefited from their cataract surgery, the rate of capsule complications was only 0.8 per cent and the rate of unexpected aphakia was 0.1 per cent.

That compared to a 4.5 per cent rate of

capsule complication and a 2.7 per cent rate surgery and ensure that patients thoroughly expectations if they have very few problems of unexpected aphakia among those with a understand the possible outcomes of the because the risk is there for more problems no-benefit outcome. None of the patients procedure. after surgery,â€? Dr LundstrĂśm added. who had postoperative endophthalmitis “It is important to give patients the right Mats.Lundstrom@ltblekinge.se benefited from their surgery, and the complication was present in 0.9 per cent of those with no benefit.

Among the ocular morbidities, diabetic retinopathy carried the greatest risk of a no-benefit outcome. Among those who benefited from surgery only 27.3 per cent had ocular co-morbidities, compared to 45 per cent of those who did not benefit from surgery.

Dr LundstrÜm noted that surgeons often deliberately make their patients anisometropic in their first-eye cataract surgery in order to make them emmetropic in that eye. In their current study, the Swedish investigators found that the average difference in refraction between the patients’ two eyes was 1.4 D after first-eye surgery and 0.7 D after secondeye surgery. However it was only among patients with more than 4.0 D of anisometropia that there was a significantly higher incidence of no-benefit outcomes.

Putting the data in another way, Dr LundstrĂśm said that the study indicated that, in general, around 3$7(17 one in 15 patients undergoing 3527(&7(' cataract surgery had a no-benefit outcome. That compares to one in 10 of patients with untreated symptomatic cataracts in their other eye, one in eight with no disability and one in seven with diabetic retinopathy.

Dr LundstrÜm said there are several means for avoiding a no-benefit outcome, depending on the reason. For example, surgeons can avoid problems with anisometropia or disturbing cataract in fellow eye by operating on both eyes within a short interval. Moreover, the referral &RQWDFW XV WR OHDUQ PRUH :LWK D \HDU WUDFN UHFRUG DQG PRUH WKDQ of more difficult cases to more RU WR DUUDQJH IRU D VXUJLFDO PLOOLRQ VXUJHULHV ZRUOGZLGH 9LVLRQ%OXHŠ experienced surgeons could GHPRQVWUDWLRQ KDV EHFRPH WKH VWDQGDUG RI FDUH IRU VDIHO\ reduce the occurrence of capsule VWDLQLQJ FDWDUDFWV IRU HQKDQFHG YLVXDOL]DWLRQ complications. ' 2 5 & ,QWHUQDWLRQDO % 9 He emphasised that RI WKH FDSVXORUKH[LV 7KLV LV WKH UHVXOW RI WLPH 6FKHLMGHOYHZHJ intracameral cefuroxime at the DQG FRVW LQWHQVLYH UHVHDUFK ZRUN SURWHFWHG E\ 91 =XLGODQG end of surgery and well-sealed (XURSHDQ DQG 86 SDWHQWV 7KLV SDWHQW SURWHFWLRQ 7KH 1HWKHUODQGV or sutured incision is adequate PHDQV WKDW ' 2 5 & ZLWK 9LVLRQ%OXHŠ LV WKH RQO\ 3KRQH to prevent the great majority of )D[

FRPSDQ\ LQ (XURSH DQG 86 WKDW OHJDOO\ FDQ cases of endophthalmitis. Among SURPRWH DQG VHOO FDWDUDFW VWDLQLQJ VROXWLRQ eyes with few preoperative WR YLVXDOL]H WKH FDSVXORUKH[LV problems, surgeons should carefully assess whether it is the right time to perform the

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15

ISTANBUL 15 th ESCRS Winter Meeting in conjunction with TOS Cataract & Refractive Surgery Society

18 â&#x20AC;&#x201C; 20 February 2011

Hilton Hotel, Istanbul, Turkey

www.escrs.org

European Society of Cataract and Refractive Surgeons

the Centro Laser, in Santo Domingo, Dominican Republic. It involved 20 sighted eyes with no anterior segment TWO new studies suggest that femtosecond pathology and grade two to four lasers could increase the precision and cataracts. A prototype femtosecond reproducibility of cataract, cataract refractive laser guided by proprietary treatment and refractive lens exchange procedures. planning software and real-time OCT Using imaging-guided lasers to create (OptiMedica) was used to create corneal incisions, capsulotomies and soften capsulorhexes of 5.0mm, 5.5mm and lens nuclei would likely add significant cost, 6.0mm. The laser also was used to create but the potential to reduce complications four-quadrant nuclear segmentation from and improve vision outcomes may be worth the bottom up, and to soften harder it, presenters told a symposium at the XXVII nuclei.

Congress of the ESCRS. All capsulotomy sections removed “The exciting part of this project is that from the eyes measured within 0.1mm just as the femtosecond laser improved of the intended diameter, and all edges the safety and predictability of LASIK flap were smooth with no defects, but the creation, so will it improve the safety, capsulotomy openings measured 0.4mm predictability and control of cataract larger than the resected tissue. surgery,” said William W Culbertson MD, “We think it may be stretching, professor of ophthalmology at the Bascom possibly from zonular tension or elasticity Palmer Eye Institute, University of Miami, of the capsule, that made the opening a Florida, US. little larger than the resected capsule.

The laser creates capsulorhexes that We made a nomogam adjustment for are much more uniform in size and this,” Dr Culbertson said. better centred than can be achieved by Lens nuclei were initially cut to 80 hand, which he believes will improve the per cent of thickness, leaving a 1,000 predictability and reproducibility of visual micron cushion to prevent damage to the outcomes, particularly with multifocal and posterior capsule. As the team gained accommodating lenses. Also, softening confidence, cuts were made to 90 per and pre-segmenting the lens nucleus with cent of thickness, leaving 500 microns, the laser simplifies phacoemulsification, Dr Culbertson said. Softening the harder potentially reducing the risk of capsular nuclei significantly reduced the amount of rupture and complications associated with phaco power needed to emulsify. exposure to higher levels of ultrasonic “Often we were able to turn off energy, he added. longitudinal phaco and use just torsional phaco. It turned what was a grade four OCT-guided systems tested cataract into the phacoemulsability of a Dr Culbertson and colleagues tested grade two nuclear cataract.” the safety and feasibility of the concept There were no complications in any in an IRB-approved trial conducted at eye resulting from the femtosecond laser, Dr Culbertson said. He plans to test the laser creating limbal relaxing and other incision to treat astigmatism, and to create cataract incisions precisely shaped to provide better wound sealing.

Zoltan Nagy MD, of Semmelweis University, Budapest, Hungary, reported similar results in a prospective trial comparing 60 capsulorhexes produced by hand OptiMedica laser OCT measuring dimensions of anterior chamber and position of anterior and posterior capsule with physician-directed placement of capsulotomy and lens-softening-segmentation cuts. Real time with 60 generated OCT detection of anterior and posterior surfaces of cornea (blue arrows), anterior surface of the lens (red by an OCT-guided arrows), posterior surface of lens (yellow arrows), planned position and diameter of anterior capsulotomy femtosecond laser (white arrows), and the position and depth of the lens segmentation and softening (green arrows)

Courtesy of William W Culbertson MD

Howard Larkin in Barcelona

(LenSx). All laser procedures were perfectly centred and within 0.25mm of the target size, while only 10 per cent of the manual procedures were within 0.25mm accuracy, he reported.

“The laser creates a uniform capsulotomy with edge features at least as smooth as manual anterior capsulotomy, which could be important in preserving the strength of the capsule and preventing radial tears,” Dr Nagy said.

In more than 250 cases on sighted patients to date, the laser has consistently produced more-precise capsulorhexis without any radial tears or adverse events, he added.

Dr Nagy also used the laser to liquefy the lens, cutting a series of concentric circles focused on the nucleus to soften it after hydrodissection. The laser also can be used to soften or chop the lens. Power can be adjusted to ensure complete liquefaction of a dense nucleus, which can then be easily aspirated, Dr Nagy said.

Getting to market Last August, LenSx cleared a big hurdle for getting its laser on the market.

The US Food and Drug Administration granted the LenSx 550 laser system clearance for capsulotomies for cataract surgery. The FDA decision was based on LenSx’s successful clinical trials, and the device’s similarity to other ophthalmic devices in use, including femtosecond lasers for corneal applications and the Fugo blade. While this means LenSx will not have to file a pre-market approval application, other regulatory requirements must be met before the device can be sold. The firm recently attracted more than €15m in venture capital to continue development.

OptiMedica CEO Mark Forchette told EuroTimes that the firm has not yet cleared its product for marketing, and would not comment on how soon he thought the system might be available.

The firm continues to conduct crucial research on how the technology can be used to soften and segment lenses, and to determine what, if any, risks may be

Cataract Update Courtesy of LenSx

Successful tests suggest femtosecond lasers could bring greater precision to cataract surgery

Capsulotomy created with LenSx laser

associated with using femtosecond lasers in this way. Technical details, like how the device will register on the eye, are still proprietary.

“The answers to those questions will be borne out in clinical research, but we want to take the technology as far as it can go,” he said.

A third firm, LensAR, also has begun human trials with a similar system. Established femtosecond laser manufacturers, including Ziemer and Abbott Medical Optics, would not comment on whether they plan to develop cataract applications. However, an AMO spokesman noted that the firm “pioneered femtosecond laser technology and we are working on many applications for various areas of ophthalmology.”

While it isn’t clear when femtosecond cataract systems will hit the market, it’s a sure bet that they will be expensive.

Current femtosecond lasers cost €250,000 or so, which has been a significant factor slowing their adoption for LASIK. Mr Forchette expects that the technology will be used first in the cataract refractive market. Precisely placing multifocal and accommodating lenses may improve outcomes, and these patients can afford it. But he believes it may be more widely adopted if it can be shown to cut complications and improve outcomes in general cataract practice. wculbertson@med.miami.edu nz@szem1.sote.hu laura@noblescommunications.com

17

Refractive Lens

New multifocal IOLs increase patients’ options Matteo Piovella

Jorge Alio

Roibeard O’hEineachain in Budapest

% Light Distribution

Near Intermediate Far Outside range

of vision 2mm 3mm 4mm 5mm

Pupil Pupil Pupil Pupil

34 47 31 20

38 16 9 6

28 33 57 72

0 4 3 2

“OptiVis represents a new concept in multifocal IOLs with optics combining benefits of both diffractive bifocal and progressive refractive designs and providing near, far and intermediate vision in one IOL,” he said.

Encouraging early results Dr Piovella reported the one- and threemonth results achieved with the lens in a series of 67 eyes of 39 patients after a follow-up of one-to-three months. The patients had a mean age of 69.5 years and the mean preoperative spherical equivalent was -0.03 D. At one month’s follow-up, the mean monocular uncorrected distance visual acuity improved from a preoperative value of 0.24 to 0.91, and the mean bestcorrected distance visual acuity improved from 0.43 preoperatively to 0.99. The refractive results were also very predictable with a mean postoperative spherical equivalent of -0.27 D, Dr Piovella said.

In addition, the mean monocular uncorrected near visual acuity at one month was J5 under both photopic and 18

Courtesy of Matteo Piovella MD

NEW multifocal IOLs are becoming available which employ innovative optical strategies with the aim of achieving a broader range of vision with sharper contrast and fewer visual disturbances, according to reports at the 14th ESCRS Winter Meeting.

One of the new IOLs is the OptiVis (Aaren Scientific). It has refractive-diffractive posterior surface design with 2.8 D effective add power. The lens has a progressive central portion 1.5mm in diameter to allow for depth of focus at far and intermediate foci, an apodised diffractive bifocal portion 3.8mm in diameter and a bi-sign aspheric base surface and periphery to improve image contrast at distance even with lens misalignment, said Matteo Piovella MD, Monza, Italy.

The result of the IOL’s optical configuration is that with a small 2.0mm pupil the lens distributes light about equally in the near, intermediate and distant foci, close to zero per cent of light outside its range of vision, Dr Piovella said. With a large 5.0mm pupil, the lens favours the distance focus, which receives 72 per cent of light, compared to only 20 per cent for the near focus, six per cent for the intermediate focus and only two per cent of light outside its range of vision, he noted.

OptiVis IOL

mesopic conditions, he noted. The mean distance corrected near visual acuity was J3 under photopic conditions and J5 under mesopic conditions, he added. The average best distance for near vision was 38.0cm to 40.0cm under photopic and mesopic conditions with and without correction, he pointed out. The mean intermediate visual acuity was J5 with and without correction for distance, he added.

Moreover, in 22 eyes that had completed three months of follow-up the mean monocular uncorrected distance visual acuity was 0.94 and the mean monocular BCVA was 1.0, Dr Piovella said. In addition, their photopic near visual acuity was J4 monocularly and J3 binocularly, with and without distance correction, he noted. Their monocular and binocular intermediate visual acuity at three months was J5 at 70.0cm with and without distance correction, he added.

None of the patients spontaneously reported severe visual symptoms at one month, Dr Piovella noted. However in reply to a questionnaire, a third of patients reported night-time glare, which was mild in 15.15 per cent and moderate in 18.18 per cent, he said. In addition, 13.63 per cent of patients also reported haloes and 7.57 per cent reported daytime glare. One eye had macular oedema, he added.

“The clinical results demonstrate good patient satisfaction with bilateral implantation of OptiVis, with good distance

and near vision, and functional intermediate vision,” Dr Piovella said.

Sector lens brings whole new approach Another of the new IOLs, the Lentis MPlus (Oculentis), takes a radically different approach to multifocality. Instead of the concentric sections providing different foci, the lens is divided into two different radial sectors. In addition, the two sectors, for distance and near vision, are both on the optical axis of the lens, therefore there is no “image jump” between the near and distance images, said Jorge Alio MD, Vissum Ophthalmology Institute, Miguel Hernandez University, Alicante, Spain.

“The Lentis Mplus is based on the concept of rotational asymmetry. The light is refracted to other foci only in a specific sector; the rest of the lens has a monofocal lens behaviour. The potential advantages of this approach include more light on distance foci, leading to improved contrast sensitivity, less duplication of images, and therefore less haloes and glare, and finally – better image quality, without the effect of scattering of light by the diffraction,” Dr Alio added.

Dr Alio reported the preliminary results of a study in which 42 eyes of 22 patients aged 36 to 79 years underwent implantation of two versions of the Mplus lens. Thirtytwo eyes of 17 patients received the version with the +3.0 D near add, and 10 eyes of

five patients received the version with the +1.5 D near add, he said.

At one month’s follow-up, best-corrected distance visual acuity was 1.0 or better in over 80 per cent of eyes in both groups and all were 0.8 or better, he noted. In addition, near visual acuity with best correction for distance was J1 or better in 90 per cent of eyes in both groups. Moreover, the mean best-corrected distance visual acuity improved from 0.79 to 0.98 (p=0.002), he said. The mean uncorrected visual acuities for distance, intermediate, and near visual acuity were 0.82, 0.80, and 0.62, respectively, he added.

Furthermore, both myopic and hyperopic eyes had a significant reduction in their spherical error. Among myopes the mean sphere improved from -2.07 D to +0.14 D and among hyperopes, the sphere improved +1.50 D to +0.21 D (p=0.018 and 0.042 respectively). Photic phenomena were relatively uncommon, Dr Alio noted. Without prompting, only one patient reported haloes and only one reported glare, and one reported ghost images. On inquiry, five reported haloes and three reported glare, he said.

“The Lentis Mplus is a truly multifocal intraocular lens providing excellent visual outcomes as a consequence of its new optical concept,” Dr Alio added. piovella@piovella.com jlalio@vissum.com

Reduced Congress Fees

EuroTimes

Journal of Cataract & Refractive Surgery

Memberâ&#x20AC;&#x2122;s Area

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ESCRS on DEMAND - reduced rates

Membership Pack

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ESCRS Membership See the benefits

To find out more, visit www.escrs.org European Society of Cataract & Refractive Surgeons, Temple House, Temple Road, Blackrock, Co. Dublin, Ireland Tel: +353 1 209 1100 Fax: +353 1 209 1112 Email:escrs@escrs.org www.escrs.org

Refractive Laser

ESCRS to host major symposium in Paris to celebrate European Year of LASIK

The ESCRS is holding a major symposium at its XXVIII Congress in Paris, France to celebrate European Year of LASIK. The symposium, which will be chaired

20

by Beatrice Cochener, France and Vikentia Katsanevaki, Greece will discuss “20/10 in 2010, the 20th Anniversary of LASIK”.

Michael Knorz, Germany will introduce the speakers when the symposium starts at 11am on Monday 6 September. The first speaker is John Marshall, UK who will discuss, “Evolution of excimer delivery systems”. Lucio Buratto, Italy, will describe “The mechanical LASIK flap concept and its refinements” and this will be followed by presentations

by Theo Seiler, Switzerland on “Iatrogenic ectasia” and Julian Stevens, UK on “Customized Treatments”. Joseph Colin, France, will talk about “The advent of the femtosecond laser” and the final speaker is Ioannis Pallikaris, Greece who will discuss “The future of LASIK”.

LASIK originated in Europe and former ESCRS president and 2009 Binkhorst Medal lecturer Ioannis Pallikaris was the first surgeon to use the hinged flap technique in 1990.

Approximately 3.5 million LASIK surgeries are performed every year for the correction of myopia, hyperopia and astigmatism and the ESCRS, as the leading professional society for European refractive surgeons, has decided to designate 2010 as European Year of LASIK. Dr Pallikaris will also highlight European Year of LASIK with an Anniversary Congress in Crete, Greece in July 2010 which will be supported by the ESCRS. The 10th Aegean Cornea meeting is scheduled to take place from July 9-11, 2010.

ESCRS has also hired public relations consultants BursonMarsteller to coordinate the promotion of European Year of LASIK. As part of this campaign, a special video will be prepared featuring interviews with some of the LASIK pioneers. A number of other key events are planned which will be announced in future issues of EuroTimes.

Dr José Güell MD, president of the ESCRS, said European Year of LASIK will give ophthalmologists the chance to show the excellent work that had been done in developing the technique over the last 20 years and also to debate the challenges that lie ahead.

“European Year of LASIK will give us the opportunity to

José Güell, president of the ESCRS

celebrate the achievement of Dr Pallikaris and the LASIK pioneers, but it is very important that we look forward,” he said.

“As ophthalmologists, we are constantly trying to improve standards in all areas of our profession, including LASIK. It is also important during European Year of LASIK that we inform the international media of the progress we are making which will help us to give patients increased adequate awareness in the procedure,” he said. “I think it is also important,” he said, “that we stress the importance of patient selection for LASIK.”

“European Year of LASIK will give us the opportunity to celebrate the achievement of Dr Pallikaris and the LASIK pioneers...”

José Güell MD, president of ESCRS Dr Güell said that while no surgical procedure is 100 per cent safe, with improved diagnostic methods and the availability of excellent lasers, LASIK is a very effective procedure for those who have no contraindications for it.

“As president, I look forward to taking part and listening to the debates which we will host this year at Dr Pallikaris’s congress in Greece, the ESCRS Congress in Paris and other major meetings,” he said. “I would also encourage ESCRS members and readers of EuroTimes to let us know about their individual experiences with LASIK and also any suggestions they have as to how we can promote the procedure during European Year of LASIK.”

will discuss new and evolving techniques in their respective areas of expertise and share the latest results of clinical trials involving a wide range of ophthalmic technology.

On Thursday 17 June, the programme kicks off in vibrant fashion with a free paper session on vision and refraction, with the keynote paper on corneal wound healing being given by Francois Malecaze MD. This will be followed by sessions on a wide range of topics including a timely update on advances in corneal biomechanics and ocular surface reconstruction, femtosecond keratoplasty techniques, deep anterior lamellar keratoplasty, stem cell research, eye banks and high-risk corneal transplants.

Friday morning starts with an instruction course on transplants and implants in conjunction with the Italian Society of Ophthalmic Universities, followed by a scientific session on endothelial keratoplasty with the keynote address being given by Mark Terry MD on current and future trends in DSAEK surgery. Corneal cross-linking is also under the spotlight on Friday morning,

a

Eu

Corn

e

1 EuCornea Congress st

with a keynote address by Theo Seiler MD looking at the past, present and future of this exciting treatment modality.

At midday, delegates will have much to enlighten them at the joint Cornea Society of the United States and Asia Cornea Society Symposium. The afternoon sees the focus shift firmly to deep anterior lamellar surgery and ocular surface, with keynote lectures from Rudy Nuijts MD on steps to attaining successful DALK outcomes and Sunil Shah FRCS on intraoperative complications in lamellar keratoplasty.

The half-day session on Saturday is devoted to an instructional course in the morning on challenging cases in corneal and ocular surface surgery, followed by live evaluation of patients, case discussions, the presentation of two EuCornea Medals and a keynote lecture

by Sadeer B Hannush MD on in-office corneal procedures.

Further details on the first EuCornea Congress is available at the website: www.eucornea.org.

Eu

a

The countdown is well and truly under way to the very first EuCornea Congress, which is scheduled to take place in the beautiful Italian city of Venice from June 17 to 19.

Since its official launch at the XXVII Congress of the ESCRS in Barcelona, the EuCornea Board has been extremely active in promoting the new organisation which was set up to provide a vibrant forum of exchange and collaboration for specialists interested in corneal and ocular surface diseases.

The level of interest from European corneal specialists, as well as those further afield, augurs well for the success of the forthcoming congress in Venice, believes Prof Vincenzo Sarnicola, president and one of the founding members of EuCornea.

“We are very happy with the initial response, especially considering the current economic climate and the fact that there are so many meetings competing now in the ophthalmic calendar. We have put together a very

interesting scientific programme covering a broad range of topics relating to ocular surface and cornea. There is also a diverse selection of instructional courses available on topics such as paediatric cornea, corneal cross-linking, DSAEK surgery and much more,” he said.

Another bonus for participating delegates is the fact that the EuCornea Congress will be accredited by the European Accreditation Council for Continuing Medical Education (EACCME) and the Italian Ministry of Health to provide CME points for medical specialists.

Initial registration estimates indicate that an impressive number of delegates will make the trip to Venice, the celebrated Queen of the Adriatic, enticed by a packed three-day programme of scientific sessions, free papers, instructional courses and keynote lectures.

This first-ever EuCornea meeting will provide a valuable platform for delegates to take stock of recent developments in the field of ocular surface and corneal diseases. Leading specialists in the field

C o r n

e

Dermot McGrath in Paris

Cornea Update

Inaugural EuCornea Congress in Venice will provide a vibrant forum for debate and collaboration

European Society of Cornea and Ocular Surface Disease Specialists

Venice

2010

June 17-19

in Joint Meeting - Società Italiana Cellulle Staminali e Superficie Oculare (S.I.C.S.S.O.) - Società Oftalmologica Universitaria (S.O.U.) - Refr@ctive.on-line

AVAILABLE ONLINE:

Local Organiser: Giancarlo Caprioglio Scientific Co-ordinator: Paolo Vinciguerra

www.eucornea.org

n REGISTRATION n PRELIMINARY

PROGRAMME n HOTEL BOOKINGS

REGIONE DEL VENETO

21

Glaucoma Update

Improved screening is needed to cope with global surge in angle-closure glaucoma

Howard Larkin in Boston

IMPROVED screening techniques and evidence-based prophylaxis are needed to

cope with a coming surge in angle-closure glaucoma (ACG), David S Friedman MD, Wilmer Eye Institute, Baltimore, US, told the 2009 World Glaucoma Congress. The

EuroTimes

problem is pronounced in Asia, where angle-closure is present in over one in 100 people over 40 years of age, much higher than in Europe. In China alone there are already an estimated nine million people with angleclosure who have elevated intraocular pressure or peripheral anterior synechiae, of which 4.5 million have actual glaucoma and 1.7 million are bilaterally blind, Dr Friedman noted. And like open-angle glaucoma (OAG), ACG is an age-related phenomenon. With China’s population over age 50 set to more than double to about 600 million by 2050, those numbers will only go up.

“One of the most urgent issues in ophthalmology will be identifying and treating these people so they don’t develop blindness.”

Screening will be a key issue, Dr Friedman said. But there are several issues with current screening technology.

One is that angle-closure and glaucoma are separate phenomena. As with elevated eye pressure and the development of OAG, not everyone with a narrow or occluded angle will develop optic nerve damage. He estimated that patients with angle-closure outnumber those with ACG by about 10 to one.

In developed countries, patients with angle-closure typically receive prophylactic peripheral laser iridotomy.

While this clearly prevents acute angle-closure attacks, few studies have assessed whether or not iridotomy prevents chronic angle-closure from developing, Dr Friedman said.

Dr Friedman and others are conducting a trial in which 10,000 older persons were screened to enrol nearly 750 persons with angle-closure who will receive iridotomy in one eye only to determine how the procedure influences the natural history of the condition compared with the untreated fellow eyes. The study will also assess the harm peripheral iridotomy may cause. The study will also assess other risk factors for progression, such as elevated IOP at baseline and anterior segment OCT findings, with

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the goal of developing more-reliable methods for predicting progression.

A more fundamental problem with angle-closure screening is that it isn’t very precise.

“Gonioscopy is the gold standard, but it is subjective. If you and I examined a patient we would almost certainly grade them differently in some quadrants,” Dr Friedman said. There are other tests, but comparing them with a gold standard that is flawed complicates the issue, he added.

To come up with a better screening test, Dr Friedman and colleagues have examined several alternate methods to determine their sensitivity and specificity.

One was an updated oblique flashlight test using a slit lamp to allow the testing stimulus as well as the grading of shadows to be conducted in a more systematic fashion. The thought was that if it were successful, a simpler instrument could be developed for field screening.

The sensitivity and specificity were good, but not good enough, generating a false positive rate of about 20 per cent. Considering that 100-200 million screening tests might be done annually, that translates into a lot of unneeded referrals for exams, he noted.

Dr Friedman’s current favourite is gauging limbal anterior chamber depth using the van Herick method of slit lamp grading of the angle width.

More-sophisticated diagnostic equipment has also been tested. A major study carried out at Singapore polyclinics compared data from the IOL Master, OCT and SPAC with gonioscopy. The study in this clinic-based population confirmed some of the classic risk factors for angle-closure, including higher mean spherical error, shorter axial length and shallow central anterior chamber depth, Dr Friedman said. OCT tended to identify more patients with angleclosure than gonioscopy; additional research is needed to see if these “false positives” are at increased risk of developing glaucoma.

The IOL Master achieved a sensitivity of 87 per cent but only 77 per cent specificity while SPAC registered nearly 100 per cent sensitivity but only 60 per cent specificity. Dr Friedman believes SPAC may be useful in the ophthalmologist’s office as a quick way to rule out angle-closure. Still, these methods identify persons with angleclosure, not those with ACG. With screening techniques not wholly reliable, the best option may be to target groups with known risk factors, Dr Friedman said. dfriedma@jhsph.edu

ESCRS

EUROTIMES

™

3–6 September 2010 During the XXVIII Congress of the ESCRS Le Palais des Congrès, Paris, France

Friday 3 September

09.00 – 17.00

Practice Development Masterclass Business Skills for Ophthalmologists Keith Willey, associate professor, London Business School Course fee €200. Only 50 places available.

Book through www.escrs.org

Sunday 5 September

14.00 – 16.00

Practice Development Workshops – Managing a Practice – A Practice Manager’s View – Organisational Leadership and the Benefit to Clinicians – Marketing your Ophthalmological Practice – The Golden Telephone: Turn More Enquiry Calls into Patients

14.30 – 16.00

Monday 6 September

How Can Business Planning Improve your Ophthalmological Practice?

– The Consent Process and Patient Satisfaction – Social Media – Why Ophthalmologists Should be Using the Internet, including Facebook and Twitter (NEW) Workshops are free of charge but must be booked online in advance at www.escrs.org

Retina Update

Two deformable mirrors better than one Zoran Popovic

A NEW adaptive optics imaging instrument can provide a clear view of a large section of the retina in a single picture, providing a useful adjunct to the diagnostic technologies of retinal specialists, according to the Swedish team that developed the instrument.

The new camera enables a wider view of the retina by using two deformable mirrors and five separate reference light sources to correct aberrations at both the pupil and close to the retinal plane.

The research team, founded in 2004 and today consisting of Drs Popovic, Thaung, Knutsson, and Owner-Petersen, adopted their approach because of the inherent limitations of conventional adaptive optics systems using a single deformable mirror and a single reference light source, or guide star, said Zoran Popovic MSc, PhD, Department of Ophthalmology, University of Gothenburg, Sweden.

“We realised that using the previous technique of adaptive optics with just one mirror we were very limited in the ability to correct the aberrations of a larger field of view of the retina. That’s when we decided to explore the possibility of doing what is called multi-conjugate adaptive optics, that is correcting the aberrations using more than one mirror in separate conjugate planes to widen the corrected field of view of the image, and that is basically what we have demonstrated so far,” he told EuroTimes in an interview.

“We are now looking at magnetic deformable mirrors which have a better performance in terms of stroke than the previous mirrors that we’ve been using and can correct larger aberrations” Zoran Popovic MSc, PhD After first modelling and evaluating the system using ZEMAX optical system design software, Dr Popovic and his associates developed a demonstration model with which they have been able to obtain very high resolution images – with up to seven degrees square field of view – of retinal features such as cone photoreceptors and retinal capillaries surrounding the foveal avascular zone.

24

Courtesy of Zoran Popovic MSc, PhD

Roibeard O’hEineachain in Dublin

Average of two registered images centred on the fovea of the photoreceptor layer in a normal subject

“Most adaptive optics systems available today have a field of view of only one to maybe two degrees. So, in order to obtain a wider field of view with a singleconjugate adaptive optics camera, you would have to stitch together a lot of images and that is a very time consuming process to use in a clinical setting,” Dr Popovic said.

Stars in their eyes Adaptive optics originated in astronomy as a means of improving the acquisition of images of stars through the turbulent atmospheric media. When applied to ophthalmology it has conventionally involved a laser beam as a point light source or guide star, a HartmannShack wavefront sensor to measure the wavefront, a control computer to analyse the wavefront data, and a deformable mirror to correct the aberrations for the reference beam.

However, as the field angle increases, the aberrations detected for a single reference beam correlate to a lesser and lesser degree with the axially distributed aberrations. The result is that only a small field of view can be corrected. It was in response to such difficulties that astronomers then went on to develop multi-conjugate adaptive optics, which uses multiple deformable mirrors to separate the aberrations of each of the turbulent layers of the atmosphere, and several guide stars to increase the corrected field of view.

In its current design, the Swedish team’s retinal imaging instrument has five guide stars, one in the centre and four in

Retinal capillaries surrounding the foveal avascular zone in a normal subject

a square formation equidistant from the central star. It also has two deformable mirrors, one conjugate to the pupil plane, and the other conjugate to a plane just in front of the retina, Dr Popovic said.

“If you imagine the tip of the cone of light as it reflects from the back of the retina as the guide star, and the pupil as the base of the cone, you can see that with only one guide star your information is basically confined to the aberrations that are within that cone of rays. But if you use several displaced points on the retina as guide stars you can obtain information about the optics in several different directions. By using two mirrors you can make an average correction in the pupil combined with corrections individual to the outer points,” he said.

Potential as diagnostic tool Dr Popovic noted that, together with glaucoma, retinal diseases such as AMD and diabetic retinopathy are the leading causes of legal blindness in the western world. Higher resolution images provided with adaptive optics technology could prove useful in the detection and monitoring of such conditions.

Thiemo Rudolph, MD, A specialist at Gothenburg University who volunteered himself as a test subject with the new adaptive optics camera, told EuroTimes that the new imaging device might prove to be a useful adjunct to, and in some cases even a replacement for, fluorescein angiography.

“It will not replace fluorescein angiography completely, but it may replace it for a few indications and during follow-up.

He added that it is too early to say with certainty how useful the multiconjugate adaptive optics system will be in diagnosing retinal pathologies, since, to date, it has only been tested in healthy eyes. However, he noted that the very high-resolution pictures it provides of both vessels and the photoreceptor mosaic would not be possible with conventional retinal imaging or angiography.

“On the other hand angiography provides information about leakage from vessels and that is something the adaptive optics system cannot provide. Therefore, it is not a replacement for angiography but it’s a very nice complement,” Dr Rudolph said.

Dr Popovic said that he and his associates will be making a few more modifications to their retinal imaging system. One of the changes will be in the type of deformable mirror they use, he noted.

“There are various kinds of deformable mirrors, previously we’ve used micromachined and piezo-based deformable mirrors produced by Flexible Optical BV (a.k.a. OKO Tech). We are now looking at magnetic deformable mirrors which have a better performance in terms of stroke than the previous mirrors that we’ve been using and can correct larger aberrations,” he added. zoran@oft.gu.se thiemo.rudolph@web.de

Retina Update

Two studies find a strong rationale for combination treatments in AMD Hakan Kaymak

Dermot McGrath in Nice

WITH so much attention in recent years focussed on the performance of anti-VEGF compounds in the treatment of age-related macular degeneration (AMD), is there still a role for photodynamic therapy (PDT) in the treatment regimen of today’s AMD patients?

The answer is emphatically yes, according to the authors of two studies presented at the 9th EURETINA Congress.

“Combination therapies which target all the various components of AMD – intravitreal triamcinolone for the antiinflammatory effect, PDT for the vasoocclusive effect and anti-VEGF therapy to inhibit VEGF – is significantly more effective and safer than PDT monotherapy in the treatment of CNV secondary to AMD,” said Süleyman Kaynak MD, Dokuz Eylul Faculty, Izmir, Turkey.

All patients underwent ophthalmic examination, fluorescein angiography and OCT before and after treatment, with a mean follow-up of 12 months in group one and 11 months in group two.

Dr Kaynak said that combination therapy offers two main advantages in the treatment of exudative AMD: greater medical effectiveness compared to monotherapy as well as greater overall cost effectiveness.

Dr Kaynak noted that AMD is a multifactorial disease and physicians should therefore aim to treat as many of the relevant factors as possible.

Dr Kaynak’s study included 80 eyes of 80 patients diagnosed with CNV secondary to AMD between January 2005 and July 2008.

The patients were divided into two groups: group one, in which 40 patients received photodynamic therapy only, and group two of 40 patients who received combination treatments comprising 4mg intravitreal triamcinolone (IVTA) injections, followed by PDT and then anti-VEGF injections of 1.25mm bevacizumab in 20 eyes and 0.3mg pegabtanib sodium in 20 eyes four days after the IVTA injection. All patients underwent ophthalmic examination, fluorescein angiography and OCT before and after treatment, with a mean follow-up of 12 months in group one and 11 months in group two.

The decrease in vision of less than three lines in group one patients was 67 per cent

and group two 87 per cent at the six-month mark, and 56 per cent and 80 per cent after one year respectively, reported Dr Kaynak.

At 12 months, central foveal thickness decreased an average of 50µm in group one and 125µm in group two based on pretreatment measurements. The mean number of PDT sessions was 2.00 in group one and the mean number of combined treatment sessions was 1.15 in group two.

Summing up, Dr Kaynak said that tri-therapy for the treatment of AMD with CNV decreases the frequency and number of treatment sessions for an improved visual prognosis for patients.

The beneficial role of PDT in combination with anti-VEGF therapy was also highlighted by Hakan Kaymak MD, who presented the results of a retrospective nonrandomised study carried out at Bundesknappschafts Hospital Eye Clinic in Sulzbach, Germany.

Dr Kaymak’s study included 115 eyes of 110 patients with exudative AMD, 56 of whom received an intravitreal injection of bevacizumab only and the other 59 a combination of PDT followed by bevacizumab injection two days later.

Patients underwent visual acuity, OCT, and fluorescein angiography checks at baseline and at four, 12 and 25 weeks postoperatively. The need for re-injection was also controlled every month.

The results after six months showed that macular thickness decreased by about 150µm in both groups with no statistically significant difference between patients in the monotherapy or combination therapy groups.

Both groups of patients showed a similar mean decrease in lesion size over the follow-up period and a similar improvement in mean visual acuity.

The key difference between the two groups, however, was the indication for retreatment at the end of the six-month followup point, said Dr Kaymak.

“There was no indication for retreatment in 78 per cent of the patients treated by a combination of PDT with Avastin injection compared to 41 per cent of the patients

treated by Avastin injection alone. This is the main take-home message – the combination of PDT with Avastin injection seems to be advantageous because of fewer

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retreatments, which means less risk of complications and less costs,” he said. skaynak@retina-gm.com Chauck98@aol.com

25

paris 2010 XXVIII Congress of the ESCRS

4–8 September Le Palais des Congrès

Available at www.escrs.org: • Congress Registration • Courses and Wetlabs • Scientific Programme • Hotel Bookings

Ridley Medal Lecture

other highlights

Life and Death on the Posterior Capsule David Spalton St Thomas’ Hospital, London

Journal of Cataract & Refractive Surgery Symposium Controversies in Cataract and Refractive Surgery 2010

Sunday 5 September, 14.00 – 16.00

Sunday 5 September During the Opening Ceremony, 10.00 – 10.45

Chairpersons:

T. Kohnen GERMANY E. Rosen UK

Refractive Surgery Didactic Course Saturday 4 September, 08.30 – 17.00

CLINICAL RESEARCH SYMPOSIA

Surgical Video Symposia

Saturday 4 September

‘New Technology Applications in Ophthalmic Surgery’

Monday 6 & Tuesday 7 September, 14.00 – 16.00

New IOL Materials and Micro Design

Myth and Reality of Clinical Research?

Video Symposium on Challenging Cases

Chairpersons:

(Joint Symposium with EVER)

Saturday 4 September, 16.30 – 18.00

Chairpersons:

Chairperson:

J. Alio spain P. Sourdille france

M. Tetz germany Representative from EVER

Biomechanics of the Cornea Chairpersons:

F. Malecaze spain C. Roberts usa

The Role of the Vitreo-Lenticular Interface

High Definition Diagnostics and Imaging Chairpersons:

T. Olsen denmark D. Reinstein uk

R. Osher USA

Workshop on Visual Optics Sunday 5 September, 09.00 – 16.00 Chairpersons: I. Pallikaris GREECE M.J. Tassignon BELGIUM

Young Ophthalmologists Programme

(Joint Symposium with EURETINA)

Saturday 4 September, 09.00 – 16.00

Chairpersons:

Chairpersons: O. Findl AUSTRIA C. Zetterstrom NORWAY

paris 2010

M.J. Tassignon belgium S. Wolf switzerland (EURETINA)

XXVIII Congress of the ESCRS

4–8 September

main symposia Sunday 5 September

Tuesday 7 September

The 10 EURETINA Congress will take place from 2–5 September at the Palais des Congrès in conjunction with the ESCRS Congress.

11.00 – 13.00

11.00 – 13.00

Endophthalmitis

Astigmatism

Joint Symposia will take place on Saturday and Sunday.

Chairpersons:

Chairpersons:

For full details of the EURETINA programme please go to www.euretina.org

11.00 M. Cormican IRELAND

Bacterial isolates around the world and multiresistant organisms

TH

Saturday 4 September 14.00 – 16.00

Myopia: The Lens and the Retina Chairpersons:

P. Rosen UK B. Aylward UK (EURETINA)

14.00 A. Antón SPAIN

Definition and epidemiology of myopia

P. Barry IRELAND G. Richard GERMANY (EURETINA)

11.15 P. Montan SWEDEN

The intracameral cefuroxime/moxifloxacin debate: a critical look at the literature 11.30 J. van Meurs THE NETHERLANDS

Endophthalmitis after anti-VEGF injections 11.45 L. Cordoves SPAIN

A comparison of the Endophthalmitis Vitrectomy Study and the ESCRS endophthalmitis studies 12.00 A. Naseri USA

Prophylaxis and cost effectiveness

14.15 C. Hammond UK

Aetiology and genetics: a route for therapy?

12.15 E. Feretis GREECE

Vitreous biopsy/intravitreal antibiotics vs vitrectomy: European vs American approach

14.30 J. Vryghem BELGIUM

Surgical options for correcting myopia

12.30 Questions and Answers

14.45 B. Corcostegui SPAIN

Myopic macular pathology: risks and treatment 15.00 J. Holladay USA

The optics of (high) myopia and lens power calculations 15.15 P. Polkinghorne NEW ZEALAND

Risks and prophylaxis of retinal detachment prior to laser or lens surgery

11.15 B. Malyugin RUSSIA

Corneal surgical techniques: incisional 11.30 D. Reinstein UK

Corneal surgical techniques: excimer ablation 11.45 T. Kohnen GERMANY

Corneal surgical techniques: ring segments, coagulative procedures 12.00 R. Nuijts THE NETHERLANDS

Intraocular surgical techniques: phakic IOLs 12.15 G. Auffarth GERMANY

Intraocular surgical techniques: pseudophakic IOLs 12.30 Questions and Answers 13.00 End of Session

Monday 6 September

Wednesday 8 September

11.00 – 13.00

11.00 – 13.00

20/10 in 2010: The 20th Anniversary of LASIK

New Solutions for Presbyopia

Chairpersons:

B. Cochener FRANCE V. Katsanevaki GREECE

11.00 M. Knorz GERMANY

Introduction 11.05 J. Marshall UK

Evolution of excimer delivery systems 11.20 L. Buratto ITALY

The mechanical LASIK flap concept and its refinements 11.35 T. Seiler SWITZERLAND

Iatrogenic ectasia

instructional courses and wetlabs

11.50 J. Stevens UK

Customized treatments

There will be an extensive programme of Instructional Courses and Wetlabs during the Congress.

12.20 I. Pallikaris GREECE

The future of LASIK

Full details are available online at www.escrs.org

11.00 N. Alpins AUSTRALIA

Astigmatism: definition and measurement

13.00 End of Session

15.30 Questions and Answers 16.00 End of Session

J. Güell SPAIN K. Vannas FINLAND

12.05 J. Colin FRANCE

The advent of the femtosecond laser

Chairpersons:

D. Epstein SWITZERLAND D. Spalton UK

11.00 A. Glasser USA

Correction of presbyopia: dreams and reality 11.15 O. Findl AUSTRIA

Objective testing of near vision 11.30 J. Alio SPAIN

The corneal way - presbylasik and other excimer strategies 11.45 G. Grabner AUSTRIA

Corneal inlays - will they work this time?

12.00 M. Holzer GERMANY

Flapless and painless: can the femtosecond laser really correct presbyopia?

12.15 R. Bellucci ITALY

The lens approach - CLE and multifocal lenses 12.30 Questions and Answers 13.00 End of Session

12.35 Questions and Answers 13.00 End of Session

paris 2010

XXVIII Congress of the ESCRS

EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

4-8 September 2010

PARIS 2010

Lunchtime Symposia (lunchbox included)

Lunchtime Symposia (lunchbox included)

Saturday 4 September

Sunday 5 September

13:00 – 14:00

13:00 – 14:00

Ziemer Satellite Symposium

Maximizing Surgical Outcomes: Therapeutic Considerations and Clinical Experiences

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Beyond 20/20: The Future of Laser Vision Correction

13:00 – 14:00

Impact of New Torsional Technology on Interesting Cases Sponsored by Sponsored by 13:00 – 14:00

Carl Zeiss Satellite Symposium

13:00 – 14:00

Croma Satellite Symposium Sponsored by Sponsored by 13:00 – 14:00

Bausch + Lomb Satellite Symposium

13:00 – 14:00

Rayner Satellite Symposium Sponsored by Sponsored by 13:00 – 14:00

Innovations in Spectral OCT and Retina Function Testing

13:00 – 14:00

Leading Technology in Refractive Surgery Sponsored by A Division of OPKO Health, Inc.

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13:00 – 14:00

Advanced Optical Biometry for Premium IOL Surgery

13:00 – 14:00

Carl Zeiss Satellite Symposium Sponsored by Sponsored by 13:00 – 14:00

Comprehensive Diagnosis of Retina & Glaucoma…

What you have been missing…

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PARIS EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

Satellite Education Programme

XXVIII Congress of the ESCRS

4-8 September 2010

Lunchtime Symposia (lunchbox included)

Evening Symposia

Monday 6 September

Saturday 4 September

13:00 – 14:00

Surgical Techniques: Injecting the Latest Technologies

13:00 – 14:00

Ellex Satellite Symposium

18:15 – 20:00

Cataract and Refractive Live Surgery

Sponsored by

Sponsored by

13:00 – 14:00

Sunday 5 September

Sponsored by

13:00 – 14:00

Satellite Symposium

Innovating Premium Cataract Surgery – Optimizing Vision

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13:00 – 14:00

Technolas Satellite Symposium Sponsored by

18:15 – 20:00

in conjunction with

Innovations in Refractive IOL and Laser Technology Sponsored by

13:00 – 14:00

Carl Zeiss Satellite Symposium Sponsored by

Monday 6 September 18:15 – 20:00

STAAR Satellite Symposium Sponsored by

18:15 – 20:00

Bausch + Lomb Satellite Symposium Please note that this is a preliminary programme and is subject to change

Sponsored by

Ocular Update

EBO Residency Exchange Programme gathers momentum Vytautas Jasinskas

As part of its ongoing mission to safeguard and harmonise the highest standards of ophthalmic care and training in Europe, the European Board of Ophthalmology (EBO) is expanding its Residency Exchange Programme in 2010.

Already a central part of the EBO’s activities, the Residency Exchange Programme gives residents, teachers and programme directors the opportunity to

broaden their knowledge and deepen their experience within the countries of the EU in order to achieve the highest standards of training and education.

“This Residency Exchange Programme has become even more important since 12 new countries joined the European Union since 2004. Our goal now is to take the scheme to the next stage, expand the network of participating centres and encourage more participants to avail of this wonderful opportunity to learn and share new ideas, approaches, techniques and knowledge in a European setting.

This goes to the very heart of the EBO mission,” said Marko Hawlina MD, PhD, current president of EBO and former chairperson of the EBO’s Residency Exchange Committee.

For 2010, the programme will cater for up to 40 residents, 10 teachers and 10 chair/programme director visits to one of the EBO certified centres in Europe, explained Vytautas Jasinskas MD, PhD, current chairperson of the EBO’s Residency Exchange Committee. The programme has been very popular as more than 75 applications were received OCULUS SDI 4c/BIOM 4c – before this year’s Wide Angle Observation deadline.

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that showcases the core values of this organisation in terms of improving European standards of training and care across the participating countries,” he said.

The period of exchange is one month for residents, two weeks for teachers and three-to-four days for chairmen/programme directors. The chosen resident receives an honorarium of €1,000 and the teachers, chairmen or programme directors €500 to compensate for travel expenses. The resident is expected to cover any additional expenses or to negotiate them with their home chairperson.

In return, the EBO requests a short written report of the exchange.

Prof Jasinskas explained that the mission of the Residency Exchange Programme has been given added impetus by the expansion of the EU in recent years to include many eastern European countries.

“The exchange of residents among EBOcertified institutions has been taking place since 2001. From that point on, both training and teaching ophthalmologists have been offered the possibility of exchange in order to unify teaching practices. It was felt that the welcoming of new countries in the EU presents a new challenge to the EBO since ophthalmic care in these countries may have had distinctly different historical and professional backgrounds,” he said.

Prof Jasinskas added that while the hosting centres need to be EBO certified to be part of the programme, the same criteria does not apply for the sending centres, which can participate so long as they have an established academic component to their ophthalmic training.

While the current core network gives EBO a solid platform from which to expand the Residency Exchange Programme, there is nevertheless a real need to recalibrate the current geographical distribution of participating institutions in the network.

“We felt that our core network should be training hospitals. At the moment, we have 35 centres that have been accredited

by EBO but they are located in only 10 out of 27 states of the European Union,” explains Prof Hawlina. “We have no EBO accredited training centres in many countries of ‘old’ Europe, such as Switzerland, Italy, Spain, Portugal and Austria, and also the Scandinavian countries with the exception of Finland and Denmark. And we have just one centre in some large countries such as UK,” he said. In Eastern Europe, accredited centres are in Ljubljana, Slovenia and Budapest, as well as Pecs in Hungary.

This restricted choice causes an imbalance as residents tend to narrow their selection to the most popular centres.

“In an ideal scenario, EBO would like to have more centres in more ‘desired’ countries, and have at least one per country of the European Union countries. We would

also like to see more training centres in eastern Europe, for example in the Czech Republic, Poland or the Baltic states. To help us to achieve this goal, EBO’s chairman of Residency Review Committee, Mr Wagih Aclimandos, is issuing formal requests to the directors of the most prestigious teaching centres to become EBO accredited,” he said.

Prof Jasinskas, who is professor and chair of ophthalmology at Kaunas University of Medicine, Lithuania, believes that the efforts to harmonise standards of training and education across Europe needs to be accelerated. In this respect, Prof Jasinskas is happy to lead by example, as his own centre has this year begun the process of obtaining EBO accreditation.

“Some developments can happen quickly in eastern Europe, especially in terms of acquiring the latest technologies in the more prosperous fields of private cataract and refractive surgery, for instance. However, teaching and residency education may not be to the same standard in some of these countries. We are aware of some countries where residents are not paid any salaries or may even be asked to pay for training themselves,” he said.

Prof Hawlina is optimistic, however, about the future prospects of these newer members of the EU. “We have seen some very good training centres which have emerged in eastern Europe thanks to the efforts of progressive leaders and these developments need to be supported. Many such leaders do send their young residents and staff members to EBO or SOE supported observerships and we would like this trend to continue in the future,” he said.

One way of accelerating the east-west harmonisation would be to establish an innovative programme of chairperson visits, believes Prof Hawlina.

“The EBO might benefit if it were to establish a programme in which the chairperson or programme director of nonaccredited institutions would visit a desired EBO-accredited training centre for three or four days. This could in many ways make the key changes in European institutions where leadership is traditionally centralised.

Closer contacts of chairpersons can create networks and accelerate harmonisation.

This programme could be synergistic to the traditional “junior level” of the residency exchange, especially in Eastern Europe,” he said.

With so much forward momentum, the Residency Exchange Programme seems set to take the EBO into new territory and encourage more ophthalmologists to participate in a vibrant network of exchange and collaboration.

Further information about the EBO’s Residency Exchange Programme can be found online at www.ebo-online.org.

ESCRS News

Young Ophthalmologists

Research shows that young ophthalmologists need guidance from older colleagues

by Colin Kerr

Colin Kerr in Dublin

Research carried out by the ESCRS at the 14th ESCRS Winter Meeting in Budapest shows that younger doctors recognise the important role played by the ESCRS in education and training, but more needs to be done to support these doctors in training and in the early years of their practice.

The research, carried out by ASE Research, was commissioned by ESCRS in cooperation with the Young Ophthalmologists’ Forum.

“The purpose of the research,” said Dr Oliver Findl, chairman of the ESCRS Young Ophthalmologists’ Forum, “is to reach out to younger ophthalmologists and understand their needs better.

“This will help the ESCRS to develop initiatives that will encourage young ophthalmologists to participate in the society’s activities from the moment they begin training.”

The research was developed through a number of focus groups in Budapest where ophthalmologists were asked a number of

questions about their view of the ESCRS and also their needs as young ophthalmologists in training.

Some 20 ophthalmologists attended the focus groups representing 19 countries across Europe. These ophthalmologists were a mixture of residents and recently qualified ophthalmic surgeons with between one and six years of experience since qualification.

The key findings were: · ESCRS has an important role to play in setting standards and furthering education. · While ESCRS is very good at meeting the needs of those well established in the profession, it needs to address the needs of those members who are “finding their feet”. · Younger doctors, who have the theory but not the experience, need support as they transition into practice. · E-learning has a critical role to play where cost and available time inhibits attendance at meetings and forums but EuroTimes and the Journal of Cataract and Refractive Surgery continue to be essential resources for young doctors.

Dr Findl, commenting on the research, said: “It is important to note that there were stark differences in the residency experience across different countries. We also learned that the transition from residency to practice can be very difficult for young doctors, particularly where they have had limited or no surgical experience during residency, “ he said.

Handling complications The research showed that handling complications is a key concern and an area that may be overlooked in CME training.

Young doctors can also find it difficult dealing with patients who may be more suspicious of younger doctors than their older colleagues. This is particularly difficult, the research found, in the internet age where patients may feel they have the information to challenge a particular diagnosis.

“The findings from the research suggests,” said Dr Findl, “that as more established ophthalmologists, we have a duty to mentor and advise our younger colleagues. This is something that the ESCRS has been doing in the past but we need to step up our efforts.”

Access to fellowships Another key finding from the research was that young doctors can face major difficulties getting fellowships, particularly where there is keen competition.

“If you had a list of all the hospitals or universities that offer fellowships and that are looking for residents from other countries, that would help,” said one of the young doctors who attended the focus groups.

Dr Findl said that there was a lot of information from the research that needs to be assessed by the ESCRS but he added that the results were very encouraging.

“We have learned a lot from this exercise and the challenge for us as a society now is to act on the recommendations of our younger members, to the best of our ability. This will be done at our meetings but also through our website, www.escrs.org and also through this Young Ophthalmologists’ column, to which I hope younger doctors will contribute in the future.”

Win

a €1,000 travel bursary to the XXVIII Congress of the ESCRS in Paris and a special trophy at the Young Ophthalmologists’ Award Ceremony Entrants must write a 1,000-word article on the topic of

The Outstanding Memory of My Residency Ophthalmologists who are members of the ESCRS and who are 40 years of age or under are invited to enter The John Henahan Prize for 2010.

The closing date for entries is Friday June 26, 2010.

Entries received after this date will not be considered.

Entries, which must be accompanied by the author’s date of birth and an ESCRS membership number, should be sent to Colin Kerr, executive editor, EuroTimes at colin.kerr@escrs.org.

The prize is named in honour of John Henahan the founding editor of EuroTimes, who edited the magazine from 1996 to 2001.

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ESCRS News

EUREQUO

Greek ophthalmologists look forward to the challenge of establishing EUREQUO Register

Colin Kerr in Dublin

Greece has a proud history in ophthalmology and this year, European Year of LASIK celebrates the first LASIK procedure which was performed in Greece in1990 by Ioannis Pallikaris MD. The ESCRS has declared 2010 European Year of LASIK and Greece will have an important part to play in marking this major landmark in medical history.

This year also marks another important landmark in Greek ophthalmology as doctors take part for the first time in the EUREQUO project which aims to support improved treatment and standards of care for cataract and refractive surgery.

This is being done through the development of a Europe-wide network of National Registries reporting clinical outcomes of cataract and refractive surgery. EUREQUO also aims to make a significant impact on the exchange of best practice between practitioners in relation to patient safety in this field.

Dr Pandelis A Papadopoulos, president of the Hellenic Society of Intraocular Implant and Refractive Surgery (HSIOIRS) is the man responsible for bringing the message of EUREQUO to his Greek colleagues.

It is a major challenge, as with any new project, he says, but Dr Papadopoulos believes that in years to come

EUREQUO will be recognised as one of the most important projects in European ophthalmology.

“There are challenges ahead,” he said, “but we are prepared to face those challenges. This is the first registry in Greece and it is our first chance to collect data on refractive and cataract surgery. We will be able to compare our results, not only with our Greek colleagues, but also with our colleagues in the other countries taking part in the EUREQUO project.”

Information campaign Dr Papadopoulos and his colleagues in the Hellenic Society have launched a major campaign to encourage Greek ophthalmologists to take part in the project. Three of the key messages in this campaign are: 1) By taking part in a quality registry, doctors can not only compare their results but also show their commitment to providing the highest standards of patient care; 2) The system is simple to operate. Paper forms can be used to collect data with data input to computer at a later stage and by third-party if required; 3) The system is completely anonymous.

Individual doctors cannot be identified and the data is owned by the national society, in this case the Hellenic Society and ESCRS.

“We have already made presentations on the EUREQUO project at two of our previous meetings,” said Dr Papadopoulos. “We also had a presentation in Athens by Dr Mats Lundstrom and we have sent emails to all of the Hellenic Society members, signed by me, urging them to participate in the EUREQUO project.”

It is a major challenge, as with any new project, he says, but Dr Papadopoulos believes that in years to come EUREQUO will be recognised as one of the most important projects in European ophthalmology Information on Eurequo is also available on the Hellenic Society’s website at www.hsioirs.org and in the society’s quarterly journal Ophthalmic Surgery Notes.

“We are also planning to send targeted newsletters, once a month, to encourage doctors to participate in EUREQUO,” said Dr Papadopoulos. “We also have

Pandelis A Papadopoulos

a DVD which we will be sending next month which will contain Dr Lundstrom’s EUREQUO course showing doctors how to enter the data.”

The registry manager in Greece is also planning to personally contact people with directors of all ophthalmological clinics in the country.

Time pressures The biggest obstacle facing the Hellenic Society, as with other national societies taking part in the EUREQUO project, is that ophthalmologists are very busy in their surgeries and may find it difficult to find the time to input their data.

“Of course this is a problem,” said Dr Papadopoulos, “but all we can say to our members and to Greek ophthalmologists is that this is a very important project and it will benefit them and their patients in future years. There are so many things to accomplish in a short time but if my colleagues try to establish a balanced schedule that helps them to devote the amount of time needed for EUREQUO they will get a lot of satisfaction in the years to come. These are exciting times for our EUREQUO pioneers and I urge all of my colleagues to support this very exciting project.” eyedoc@hol.gr

EUREQUO 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

The project aims to:

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1

Improve treatment and standards of care for cataract and refractive surgery

2

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

3

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

Join the network EUREQUO gives a unique opportunity to monitor and compare results

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

Collecting data will support you to make an audit report

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

See www.eurequo.org for more information Funded by

Missed the XXVII ESCRS Congress in Barcelona or the 14th ESCRS Winter Meeting in Budapest?

Symposia

Free Papers

Other Key Sessions

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Available to view now at www.escrsondemand.org

Practice Development Feature

No more running to the filing cabinet Integrated electronic ophthalmic images and records can make operations more efficient and improve patient care – but make sure the system does what you need

A

few months back, Michael Jacobs MD, a comprehensive ophthalmologist in Athens, Georgia, US, implemented the FORUM image and report management system from Carl Zeiss Meditec AG, Jena, Germany. The system’s ability to instantly combine information from a range of ophthalmic diagnostic devices at the click of a button has had a huge impact on the efficiency of his practice – and even his clinical effectiveness.

“As a physician my time is much better spent because I have the studies I want to see when I need to see them and I don’t have to go down the hall trying to find a printout,” Dr Jacobs says. The system is highly customisable, allowing him to choose among images from field analysers, OCT, fundus cameras, IOL Master and corneal topographers depending on the patient’s condition. “You will be able to create templates for different types of glaucoma, diabetic retinopathy, AMD. It enhances my ability to assess patients. Not only do I have all the tests over time, but I can review them simultaneously.”

The system also helps with patient counselling, Dr Jacobs adds. “They can see the black spot in their visual field is getting smaller or the swelling on the OCT is getting better. I believe it leads to increased compliance. It’s a great extra benefit I wasn’t anticipating.”

And there’s the cost savings. “My techs are singing the praises of FORUM. When a patient goes from one machine to the next they just click on the patient’s name

and it is added to their record. They spend less time inputting patient information and more time testing patients.” The cost of printing and handling paper records is also reduced, Dr Jacobs notes.

While Dr Jacobs has not yet moved to an electronic medical record, he can scan records into the FORUM image system, making notes available along with diagnostic images. He plans to buy an EMR soon to meet new government requirements, but bought the image management software because it better met his clinical needs. He looked at several EMRs that can import PDF images of tests, but they were not as flexible as FORUM. When he does choose a record system sometime in the next two to three years, the image management software will be able to communicate directly with it in both directions in part because it incorporates DICOM data interchange standards, he notes.

A number of software vendors offer electronic ophthalmology records with advanced features including the ability to input images and data from all kinds of diagnostic devices. For example, ifa systems AG, Frechen, Germany, which currently serves more than 7,000 ophthalmologists and related professionals in 15 countries, and stores data on more than 70 million patients, can pull images from slit lamp cameras, fundus cameras, A/B scanners.

It can even integrate specialised software routines that interpret data from visual field analyzers, OCT and HRT scanners.

Journal Watch

by Sean Henahan

Shining a light on eye cancer A new technology, bioluminescence imaging (BLI), should allow doctors to detect tumours earlier, and to quickly choose a method of treatment that doesn’t necessarily involve surgery. Researchers in Shanghai developed an animal model in which they could induce human ocular tumours, and then use the new imaging technique to diagnose and monitor the tumours. Bioluminescence imaging takes advantage of light emission from one of several organisms. The three main sources are the North American firefly, the sea pansy (and related marine organisms), and bacteria-like Photorhabdus luminescens and Vibrio fischeri.

The DNA encoding the luminescent protein is incorporated into the laboratory animal either via a viral vector or by creating a transgenic animal.

Q Huang et al, Ophthalmology & Visual Science, “Non-invasive visualization of retinoblastoma growth and metastasis via bioluminescence imaging”, 2009 50: 5544-5551.

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by Howard Larkin

“As a physician my time is much better spent because I have the studies I want to see when I need to see them and I don’t have to go down the hall trying to find a printout” Michael Jacobs MD The ifa system can even do things like set up automated phoropters based on the patient’s last prescription. It also supports all types of administrative and billing activities, and enables co-management arrangements through data networks among separate clinics and medical offices. The firm’s software complies with international data exchange standards including HL7 and DICOM, and its engineers promise interface support for all types of electronic ophthalmology devices. It also supports administrative and billing systems, and customised clinical, quality improvement and management reports.

But taking advantage of the quality and efficiency gains possible with sophisticated record and image management systems requires effort from physicians, says Marlene Jones, a consultant with PivotHealth, Brentwood, Tennessee, US, who has overseen implementation of medical record systems at dozens of medical practices – often after an attempted implementation has failed. She offers the tips below for a successful transition to EMR. * Select a physician champion.

This person often has an affinity for computer technology and may naturally take over, especially in smaller practices. In a large practice you might consider hiring a temporary medical director with specialised computer training to manage the transition.

* Involve physicians early.

Physicians who will be working with the system need to get on board to make sure their needs and expectations are met. A set of objectives for the system should be established along with a preliminary budget. This will help create a sense of ownership and expectation for the project and guide the selection process. * Review multiple systems.

EMR and image management systems have a variety of interfaces and capabilities and costs can vary widely.

The best way to figure out what might be best for you is to look at several systems, as Dr Jacobs did.

* See how systems work in live practices.

Ask current users about their experiences and visit them if you can.

This will help you understand how well the system might meet your practice needs. Be sure to ask about training, technical support and upgrades because these are critical.

* Make sure you have adequate hardware. Modern systems often require computing power well beyond what was available even a few years ago, particularly if you host the system onsite. Technical issues such as backup and system recovery are also essential.

Some vendors now offer records on a remotely hosted model, which can reduce the cost of equipment and on-site technical staff.

* Train, train, train.

This means everyone, most especially physicians. And be prepared to foot the bill for some lost productivity during the transition period.

* Be prepared to re-engineer workflows.

This can be difficult for physicians, but it is essential. A consultant who knows how to get the most out of a system can be helpful. Feedback to physicians on how well they are adhering to revised practice standards can be very helpful.

Vendors such as ifa may be a good source for implementation assistance.

They also offer extensive online training and technical support. Some vendors are even moving toward a model of selling EMR systems not as software and hardware, but as an integrated solution installed and maintained by the vendor as a service for a monthly fee. But whatever system or approach you choose, make sure it fits your practice needs before you invest. mjacobsmd@athenseye.com

Industry News

Industry News Recent developments in the vision care industry Regulatory Update Carl Zeiss gets approval for Field Analyzer Carl Zeiss Meditec has gained US FDA approval for its Humphrey Field Analyzer (HFA) II-i with Guided Progression Analysis (GPA) software. The 510(k) Class II approval allows the device to be marketed for use as a diagnostic device to aid in the detection and management of ocular diseases including glaucoma. The company notes that the new instrument is the only automated perimeter with GPA software that has received clearance from the FDA to assess the rate of visual field loss over time. www.meditec.zeiss.com Fast track for dry AMD treatment The US FDA has given Fast Track designation to ACU-4429, an investigational oral treatment for dry age-related macular degeneration (AMD) being developed by Acucela Inc. and Otsuka Pharmaceutical Co Ltd. The drug is now in Phase 2 clinical trials under the rubric ‘Evaluating a Novel VISION (ENVISION) treatment for AMD Clarity Trial’. According to the company, the product takes advantage of visual cycle modulation (VCM) technology to prevent or inhibit the generation of toxic by-products of the visual cycle that can lead to degenerative eye conditions such as dry AMD. www.acucela.com/

Ingeniously gentle

Company news New chairman at Bausch + Lomb Bausch + Lomb (B + L) has named Fred Hassan as chairman of the Board of Directors and has named Brent Saunders as CEO and member of the Board of Directors. Current chairman and CEO Gerald M Ostrov is retiring, and will serve as a consultant to the new leaders. Mr Hassan served most recently as chairman and CEO of Schering-Plough Corporation until its merger with Merck & Co in November 2009. Previously Mr Hassan was chairman and CEO of Pharmacia Corporation. New CEO Brent Saunders was previously senior vice-president and president of ScheringPlough’s Consumer Healthcare unit.

B + L also announced that ReNu MultiPlus multi-purpose solution was named “Best Eye Care Product of the Year – Asia” for its revolutionary bottle design at this year’s A S Watson Global Suppliers Awards, Held in Hong Kong at the beginning of March. The awards recognise international brands for outstanding performance in bringing innovation, differentiation and excitement to the consumer experience.

The combination of precise refractive femtosecond laser technology and lenticule extraction marks the start of a new era in refractive surgery: ReLEx. Discover the advantages of this innovative procedure: Precise refractive correction even in cases of high refractive errors Comfortable and fast, due to complete vision correction with only one laser Gentle, due to short treatment times, lowest intraoperative IOP increase and smallest possible flaps Robust, as it is independent of intraoperative environmental conditions

Product Update US FDA approval for TECNIS IOL Abbott has received US Food and Drug Administration (FDA) approval for the TECNIS® Multifocal 1-Piece intraocular lens (IOL) for cataract patients with and without presbyopia.

The TECNIS lens has also received presbyopiacorrecting IOL status by the Centers for Medicare and Medicaid Services (CMS), providing Medicare beneficiaries with the option to receive a TECNIS Multifocal 1-Piece lens for an additional fee as part of cataract surgery.

“With this approval, Medicare cataract patients have a new opportunity to enjoy near, intermediate and distance vision without needing glasses, with nearly nine out of 10 patients reporting that they never wear glasses following surgery,” said Jim Mazzo, senior vice-president, Abbott Medical Optics. www.abbottmedicaloptics.com.

For more information about ReLEx as well as our WOC programme you may visit and register at our website: www.meditec.zeiss.com/woc.

Envision new opportunities in the world to see: WOC, Hall 13

Carl Zeiss Meditec AG Jena /Germany Tel.: +49 (0) 36 41 22 03 33 info@meditec.zeiss.com www.meditec.zeiss.com

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Feature

EU Matters European help on way for ophthalmologists owed money from insurers and state authorities

A

proposed law now before the European Parliament could help ophthalmologists recover debts quicker from insurance companies and state bodies.

Under the proposed “Directive of the European Parliament and of the Council on combatting late payment in commercial transactions”, ophthalmologists and ophthalmic clinics that contract to provide their services will be legally entitled to collect interest and collection charges from all debtors after 30 days and to collect new penalty charges from any public authority that owed them money.

Although the proposal will improve the chance of ophthalmologists and clinics receiving payment for services that they offer on a contractual basis to insurers and state agencies, the proposal will not help them obtain quicker payment from private patients who fail to pay on time.

Patients are defined as “consumers” in the directive and are specifically excluded from the terms of the proposed law.

In addition, the proposed law will not affect individual ophthalmologists who work for a salary. Their employment rights – including the right to be paid on time – will still be governed by existing EU and national labour legislation.

In proposing the directive, the European Commission stated that the directive is necessary to protect the internal market of the European Union during the ongoing recession by promoting the growth and efficiency of business throughout all of the 27 EU countries.

“This proposal aims at improving the cash flow of European business which is particularly important in times of economic downturn. It also aims at facilitating the smooth functioning of the internal market via the elimination of related barriers to cross-border commercial transactions,” the commission stated in proposing the new law.

Late payments The proposal for this new directive follows by 10 years the adoption of a similar late payments law by the European Union. That law, passed in 2000, did allow creditors to charge interest on late payments after 30 days, based on the rate of the European Central Bank, plus a minimum of seven per cent.

According to the European Commission, the level of interest in the old law was not high enough to impel many debtors to pay on time. Also, the process of chasing companies for their bad debts under the directive often proved more costly than any interest or collection charges received for the 36

Bad debt is a significant problem for European ophthalmologists

late payment. Of particular note to the commission was that the worst offenders in many cases were public authorities – including public hospitals and health authorities – who often left their debts unpaid for many months. Often, the most affected creditors were small and mediumsized enterprises (SMEs).

“Late payment by public administrations undermines the credibility of policies and contradicts declared policy objectives to provide for stable and predictable operating conditions for enterprises and foster growth and employment,” the commission stated. “Given the importance of public procurement in the EU – more than €1,943bn per year – late payment by public authorities has a strong negative impact on enterprises, notably SMEs.” “Many public authorities do not face the same financing constraints as businesses and late payment in their case is avoidable.

It should therefore be more severely sanctioned when it occurs. Moreover, diverging payment attitudes across the EU might hamper business participation in public tenders, which not only distorts competition and undermines the functioning of the internal market, but also reduces the capacity of public authorities to get best value for taxpayers’ money.”

Penalty clause In light of the difficulties with the original directive, the European Commission proposed to repeal the current directive in its entirety and to replace it with one that would give ophthalmologists and other service providers the right to:

· collect interest – at the rate of that charged by the European Central Bank plus a minimum of seven per cent – from the day following the end of the period of payment fixed in the contract; · if a date is not so fixed in the contract, the right to collect such interest 30 days from the date of the receipt of the invoice by the debtor; · bill the debtor for reasonable recovery charges; · if the debtor is a public hospital or other state or public authority, the ophthalmologist or other creditor has a right to collect an additional five per cent of the debt as a penalty for the late payment.

According to the commission, the introduction of a special penalty clause is necessary to curb abuses by public authorities, who often hold a dominant position in the purchase of goods and services in sectors such as health.

“The budgetary impact for national authorities will be proportional to their capacity to ensure compliance with the provisions of the directive,” the commission stated. “In addition, the expected improvement in payment behaviour of public authorities will help reduce the number of business bankruptcies and thus reduce the social costs that they entail.”

Bad debts Like any other persons who contract with a business to supply a service, ophthalmologists, too, are affected by the

by Paul McGinn

speed at which their debtors pay – or fail to pay – their bills. Whether the debtor is a hospital or a health system, any delay has a knock-on effect on the ability of an ophthalmologist to pay his or her own debts and earn an income.

Although there are no published statistics about the effect of bad debt on European ophthalmologists who contract with state bodies, statistics from medical device companies indicated that bad debt is a significant problem for that industry.

According to a recent study from Eucomed, a trade group that represents EU medical device manufacturers and suppliers, public hospitals take an average of 121 days to pay their invoices. The worst offenders were public hospitals in Greece, which took an average of 579 days to pay their debts. Other poor performers were Italy, Portugal, and Spain, where public hospitals took an average of 223, 205 and 196 days, respectively, to pay their debts to medical device suppliers.

Public hospitals in only nine EU countries paid their debts within an average of 60 days of invoice – France, Denmark, Estonia, Britain, Sweden, Finland, the Netherlands, Austria, and Germany.

In only one of those nine countries – Germany – did public hospitals pay their debts within 30 days on a regular basis, according to the survey.

As expected, a number of EU countries are opposing the new directive because of its potential effect on strapped public finances.

One amendment to the proposal, now before the European Parliament, would extend the time for charging interest to 60 days after the date of invoice for state bodies that run hospitals or provide healthcare. Proponents of such an extension argue that the nature of public health authorities and the differences in the way they are governed throughout the EU would make a 30-day limit unworkable.

European Parliament members have also tabled a number of amendments to the proposal that would reduce the late penalty for public bodies to two per cent or provide that penalties for late payments be increased as the debt became older.

A vote by the parliament and further review by the EU Council of Ministers about the final terms of the proposed directive is expected within the coming months.

For more information about the proposed directive, visit www.europarl.europa.eu.

Consultation at the ‘curbside’

by Seamus Sweeney

Curbside Consultation in Retina – 49 Clinical Questions Edited by Sharon Fekrat SLACK Incorporated

Where collegiality and clinical practicality determine retinal care

Despite the promotion of evidencebased his is probably the most impressive medicine – book I have yet reviewed for this with its focus column. It is clear, concise, and on written achieves exactly what it sets out to do. resources It is accessible to clinicians at a wide range – there of stages of training and addresses those is much awkward aspects of practice that can evidence prove challenging. that doctors European readers may not be familiar often use with the term “curbside” consultation. informal A curbside consultation — perhaps more consultation with a colleague, peer, commonly referred to on this side of the acquaintance or friend within the profession Atlantic as an “informal” consultation — in preference to consulting these resources. refers to any incident in which a fellow With the rise of text messaging and email, medical professional seeks advice on informal consultations can occur using patient management without going through these technologies which unlike a spoken the usual formal referral or consultation conversation leave a physical trace. processes. The doctor initiating the referral There are two main academic surveys will provide information about the patient, of curbside consultations. One is Perley’s but the patient will not be directly examined “Physician use of the curbside consultation faros_250x140_EuroT_e 2.10.2009 14:49 Uhr Seite 1 needs: report on a by the doctor receiving the referral. to address information collective case study.” [J Med Libr Assoc 94(2)

T

April 2006 137-44]. The other survey is by Keating, Zaslavsky and Ayanian in “Physicians’ Experiences and Beliefs Regarding Informal Consultation” [JAMA. 1998;280(10):900-904].

The Perley survey comes more from the perspective of medical librarianship and focuses on the concern with the quality of information access, and why physicians do not use other information resource.

The Keating-led survey describes physician attitudes and experiences. Not surprisingly, most physicians had a largely positive view of curbside consultations, unless they had a negative experience, such as a complaint or medical negligence lawsuit.

There is, therefore, a certain irony in a book titled Curbside Consultation, or an entire series. What this quite cleverly allows the editors to do, however, is to focus on particular clinical dilemmas and situations without having the burden of including introductory material to the whole area. It also allows a certain collegiality and downto-earth clinical practicality to enter into the proceedings.

There is a nice blend of the informal and the formal to the text, with each individual

Feature

In Your Good Books

clinical question covering a few pages. The replies to each question, written by an expert in the field, are clear and practical.

In her foreword, Julia A Haller, ophthalmologist in chief at the Wills Eye Institute, writes of how as a resident “how great it was to be able to grab a faculty member by the sleeve in the hallway and run a difficult case management issue by him or her.”

This book gives some of the flavour of that experience, and indeed is part of a whole genre of medical book focused on “clinical pearls” and recapturing the heady sense of amazement at the expertise of one’s seniors.

We live in an age where expertise is a dirty word when it comes to medical practice, almost — hence the information scientists’ concerns at the curbside consultation phenomenon. And yet, thinking back to your own medical training, just how much did you learn from formal lectures and tutorials, and how much from your peers, colleagues, and senior physicians?

Haller advises using this book, like all medical resources, in an intelligent, alert, and above all open-minded fashion.

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37

Feature

Out & About

There’s plenty to do in Berlin in June before and after WOC 2010

Berlin Air Show Magnificent people in the latest flying machines are promised for everyone at the ILA Berlin Air Show. Held every two years for the past decade at Schönefeld Airport, the show is primarily for specialists in the air and aerospace trade who will do billions of euros of business. Come the weekend, there is a series of spectacular air displays for the general public featuring all kinds of aircraft. This year is being celebrated as the 100th anniversary of the show; the first was held in Frankfurt am Main in 1909 when airships were the order of the day. Visitors this year are promised about 300 aircraft to see on the ground and in the air.

11-13 June, 10am-6pm, one-day ticket €19. www.ila-berlin.de Berlin Biennale Year-in, year-out, the city teems with artists making work in all manner of squats and reclaimed buildings and making their mark on the international arts scene, too, but it is difficult for the short-term visitor to find the good ones. Every two years the sixth Berlin Biennale, curated by Kathrin Rhomberg, brings cutting-edge international contemporary art to the German capital and enables the best young artists of many countries put their work before the public at large. Last time, in 2008, more than 150 artists showed. Expect the unexpected and prepare to be immersed in the new, strange and experimental. The powerhouse and centre of the action is the Kunst-Werke Institute for Contemporary Art, a recycled margarine factory in the heart of the Mitte district, but exhibitions take place at many other places around the city.

11 June–8 Aug. www.bb6.berlinbiennial.de

Topography of Terror Bright and lively though modern Berlin is, there is no denying that it is uniquely and sadly rich in opportunities for “dark tourism” and offers many memorials to its war-torn and divided past. The Topography of Terror is an exhibition on the site of former Nazi headquarters next to the Martin-Gropius-Bau and not far from Potsdamer Platz. Between 1933 and 1945 this was the administrative nerve centre for the systematic elimination of Europe’s Jews and anyone else deemed to be an opponent of the state. Although the building was demolished in the 1950s, the original basement interrogation cells remain and there has been an open-air exhibition here since 1987. In May this year a new documentation centre with four new exhibition areas opened. Here, too, you’ll find one of the few remaining sections of the Berlin Wall.

Niederkirchnerstrasse 8, 10am-8pm, entry free. www.topographie.de 38

Peaceful revolution Last year saw the anniversary of 20 years since the Fall of the Berlin Wall.

To commemorate this, a free, open-air exhibition of photographs of the notable incidents of the period 1989-90 has been mounted in Alexanderplatz. The first section, called Awakening, charts the spread of dissidents in eastern Europe. Opposition took many forms – even fashion shows in the underground arts culture of East Berlin.

The second section, Revolution, shows how the people of the eastern states began to move in the first months of 1989, crossing borders in their thousands, and leading up to the momentous night of the fall of the Wall on 9 November 1989. Finally, Unity shows the period when Germans east and west came together to form a new state.

Alexanderplatz, open 24/7, exhibition free, guided tours Saturdays, 1pm, €5. www.revolution1989.de German-French people’s festival Fun for all ages and tastes is promised at Berlin’s French festival, an annual favourite for decades. This year the event, held on Berlin’s National Fairground in the Wedding district, will feature a French village for visitors to wander through while sampling French wine and food – Alsatian quiche, frogs’ legs and snails are on the menu – but so anxious are the organisers to include all that’s best about France, don’t be surprised that this village also includes a model of the Eiffel Tower. As well as boules tournaments and French bands, there are fairground rides for extra thrills and fireworks on Saturday nights. On Wednesdays all rides are halfprice, while on Fridays there is 20 per cent off everything, including, food and drink.

Kurt-Schumacher-Damm 207, from 11 June to 14 July, Mondays-Thursdays 3pm-11pm, Fridays 3pm-12 midnight, Saturdays 2pm-12 midnight, Sundays 2pm-11pm, entry €1.50. www.volksfest-berlin.de Kreuzberg open-air cinema Another great summer city tradition is showing films outdoors. The Kreuzberg open-air cinema is one of the longestrunning, though the organisers have recently added a bar and new seating, improved the projection equipment and are even promising to mow the lawn more often.

Titles had not been announced at the time of going to press but the programme will be a mix of new international releases with the classics of world cinema. There’s a different film every night and the movies are usually shown in their original language with German subtitles, though German films are shown with English subtitles.

Courtyard of the Künstlerhaus Bethanien at Mariannenplatz, tickets, €7.30 in advance

at all concert booking outlets or €6.50 or €5 with Berlin Card at the box office on the night – box office opens 30 minutes before the performance.

Check what’s screening at www.freiluftkinokreuzberg.de or by telephoning (00 49 30) 29 36 16 20.

Sandsation Few beach bars have sand, so for a real seaside experience make for the Hauptbahnhof, the main train station, and you’ll be confronted with great heaps of the stuff being fashioned into fantastic forms. This is Europe’s only urban sand sculpture festival and the experts who take part are all vying to create a winning entry and take home thousands of euros. It’s a popular public event since ordinary people can vote on which they like best as well as having fun in the Sandsation sandpit. Covering an area of about 4,000 square metres, this offers plenty of room for relaxing with a drink, sunbathing or partying to the live music.

Berlin Hauptbahnhof, Europaplatz/ Invalidenstrasse 6 June – 29 August 2010. www.sandsation.de Frida Kahlo With her fierce eyes staring out from under her strong eyebrows, the Mexican painter Frida Kahlo made herself one of the most recognisable artists of the 20th century.

Despite personal tragedy – she was run over by a trolleybus when young and spent the rest of her life crippled and in pain – and a turbulent marital relationship with fellow artist Diego Rivera, she continued to paint her vibrant, characterful canvases.

“I paint myself because I am often alone and I am the subject I know best,” she said.

The retrospective of her work at MartinGropius-Bau is the most comprehensive ever mounted, with more than 150 paintings and drawings, including two late works from 1954, the year of her death – a self-portrait in oils as a sunflower and a self-portrait drawing – which are being shown in Europe for the first time.

Martin-Gropius-Bau, Niederkirchnerstrasse 7 / Corner Stresemannstrasse 110, daily 10am-8pm, until August 9, €10. www.martin-gropius-bau.de

by Renata Rubnikowicz

Capital Beach Bar

Beach bars As soon as the fine weather comes, Berliners like to make for the beach – or rather the beach bars along the river and in other open spaces. Look out for the one that started it all: the Strandbar overlooking the Spree and Museum Island, or, also along the river, Capital Beach at Hauptbahnhof. From lazy morning coffees, to lunchtime snacks, to DJ nights on Fridays and Saturdays, the mood changes according to the time of day – this year you can check out the action beforehand on live webcam on the website.

Capital Beach, opposite Hauptbahnhof, near Kanzleramt, 10am-12 midnight daily depending on the weather. www.capital-beach.eu Double Sexus, Bellmer-Bourgeois Years after his death in 1975 the work of Hans Bellmer, the German-born French surrealist, remains controversial. His deformed and overtly sexualised dolls still have the power to shock. He fled from the Nazis to arrive in Paris in 1938, the year when Louise Bourgeois, now best known for her giant spiders, was leaving for New York.

The two artists never met but their work shown in dialogue here – does have parallels.

The title “Double Sex” alludes to the themes of female and male fantasies, the connections between the creative and the erotic, and the ambiguities of sex and the more than 70 works by the two artists include some recent 2009 pieces by Louise Bourgeois.

Sammlung Scharf-Gerstenberg, 70 Schlossstrasse, until 15 August, Tue-Sun 10am-6pm, closed Mondays. www.smb.museum/smb/ For further information on WOC 2010, which takes place from June 5-9, 2010, visit www.woc2010.org.

by Thomas Kohnen

Journal of Cataract and Refractive Surgery jointly published by the ESCRS and ASCRS

Do accommodating IOLs really accommodate?

Current published study results differ regarding the amount of useful accommodative vision that is provided by accommodative IOLs. Japanese researchers now report long-term results with the Human Optics 1CU biconvex accommodating IOL. Four-year followup data was available for 12 eyes of eight cataract patients with a mean age of 59 years. The mean postoperative spherical equivalent at one year and four years was significantly more hyperopic than at one month. The mean uncorrected distance acuity increased significantly at four years compared with one month. However, there were no significant changes in corrected distance acuity, uncorrected or corrected near acuity. The change in the minimum add power to attain CNVA and in the subjective and objective accommodation amplitudes also did not change significantly over time.

PCO occurred in more than half of the eyes. The researchers conclude that the accommodating IOL did not provide sufficient accommodation amplitude for near vision.

They note that the accommodation amplitude of the IOL was not very different from that of monofocal IOLs in the early postoperative stages and did not change significantly during the four-year follow-up. They suggest possible

factors affecting accommodating amplitude, such as size of the capsule opening and treatment for capsular bag contraction, as topics for future research.

M. Saiki e al., JCRS, “Biconvex posterior chamber accommodating intraocular lens implantation after cataract surgery: Long-term outcomes”, April 2010, Volume 36, Issue 4, 598-603.

New phaco record In what would appear to be a new milestone, Chinese researchers report successful phacoemulsification cataract surgery in two 105-year-old patients. The first case involved a man with two mature cataracts.

Under local anaesthesia he underwent an intracapsular procedure with IOL implantation through a 3.00mm incision. The second eye was operated the next day. The uncorrected distance visual acuity was 0.8 in both eyes. The patient lived for four years after surgery. The second case involved a woman who presented with white mature cataracts. Despite some problems with anaesthesia, IOL implantation was successful.

By six months her vision had improved to 0.6 and the corneas were clear. The patient is still alive. The surgeons note that while very elderly patients do require special care, they do benefit from cataract surgery in terms of functional outcome, and that they are satisfied

Journal Watch

JCRS Highlights

JCRS Highlights

because the surgical outcomes correspond to their expectations. They conclude that advanced patient age should not necessarily be considered a contraindication to phacoemulsification cataract surgery.

W. Li et al., JCRS, “Phacoemulsification surgery in 105-year-old patients”, April 2010, Volume 36, Issue 4, 691-692.

Post-LASIK tonometry Measuring IOP after LASIK can be problematic because of the reduced central corneal thickness. Hong Kong investigators compared post-LASIK IOP measurements obtained using an iCare rebound tonometer and a Goldmann applanation tonometer in a study of 96 eyes of 96 patients. The preoperative IOP measured by rebound tonometry was statistically significantly higher than by Goldmann applanation tonometry.

There was no statistically significant difference in postoperative measurements between the A. Lam et al., JCRS, “Effect of laser in situ two tonometers. The IOP reduction with keratomileusis on rebound tonometry and rebound tonometry was positively correlated Goldmann applanation tonometry”, April 2010, 5.10.2009 with preoperative IOP.easyPhaco_sw_95x140_EuroTimes Therefore it appears Volume 36, Issue 4, 631-636. 10:43 Uhr Seite 1 that this method is more affected by LASIK surgery.

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by Sean Henahan

Green tea versus glaucoma?

Green tea is now widely promoted for its healthful properties and high antioxidant content. A new study shows for the first time that green tea catechins can penetrate into tissues of the eye. This is the first report documenting how the lens, retina and other eye tissues absorb these substances. Analysis of animal eye tissues showed that eye structures absorbed significant amounts of individual catechins. The retina, for example, absorbed the highest levels of gallocatechin, while the aqueous humour tended to absorb Green tea contains healthful substances that can penetrate eye tissues, raising the epigallocatechin. The effects of green possibility that the tea may protect against glaucoma and other eye diseases tea catechins in reducing harmful oxidative stress in the eye lasted for up to 20 hours.

It raises the possibility that green tea may protect against glaucoma and other common eye diseases, the researchers note.

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C Pang et al., Journal of Agricultural and Food Chemistry, “Green Tea Catechins and Their Oxidative Protection in the Rat Eye”, 2010, 58 (3), pp 1523–1534.

39

Calendar May

May 2010

September 2010

19-22

NATAL, BRAZIL XI International Congress of Cataract and Refractive Surgery

Web: www.catarata-refrativa.com.br/2010

19-22

ROME, ITALY 8th SOI International Congress

Web: www.soiweb.com

5-9

BERLIN, GERMANY World Ophthalmology Congress

Web: www.woc2010.de

Web: www.eucornea.org

26-27

CAIRNS, AUSTRALIA 2010 APACRS-AUSCRS Combined Annual Meeting

Web: www.fusion2010.org.au

2

Brighton, East Sussex, UK Contact Lens Basics and Laser Refractive Surgery Complications Course

9-11

Web: www.esoprs2010.org

12-16

EDINBURGH, SCOTLAND SIDUO XXIII Congress (International Soc. of Ophthalmic Ultrasound)

18-23

MONTREAL, CANADA ISER 2010 XIX Biennial Meeting of the International Society for Eye Research

Web: www.kenes.com/iser

August 2010 7

Website: www.apao2010beijing.org

crete, greece European Assocation for Vision and Eye Research 2010

Web: www.ever.be

16-19

chicago, IL, usa American Academy of Ophthalmology

Web: www.aao.org/annual_meeting

21-24

Hamburg, germany 23rd International Congress of German Ophthalmic Surgeons

~AND~

TOM CASEY MEMORIAL LECTURE Presented by

Mr. William Power - Ireland

Grand Round TOPICS:

n n n

NEW TECHNIQUES IN PRESBYOPIA WOUND HEALING PAEDIATRIC REFRACTIVE SURGERY

Further Details from: Helen Murphy Secretary to: Prof. Michael O’Keeffe Suite 5, Mater Private Hospital, Eccles St., Dublin 7.

Tel: (00 353 1) 885 8626 Email: hmurphy@materprivate.ie

Registration Fee: €170

Web: www.doc-nuernberg.de

December 2010

MACAU, CHINA The International Symposium on Ocular Pharmacology and Therapeutics – ISOPT ASIA

GENEVA, SWITZERLAND PRESBYMANIA 2010

Web: www.presbymania.com

Web: www.isopt.net

13-15

MUMBAI, INDIA EyeAdvance 2010

11

BELGRADE, SERBIA 3rd International Symposium on Macular Disease

Web: www.eyeadvance.com

20-22

Advertising Directory

Beijing, China 25th Congress of the Asia-Pacific Academy of Ophthalmology (APAO) in combination with the 15th National Congress of the Chinese Ophthalmological Society (COS)

9-12

Presented by

Prof. Eugene De Juan - USA

Web: www.aegeancornea.gr

DERMOT PIERSE MEMORIAL LECTURE

Web: www.siduo2010.org

October 2010

Croke Park Conference Centre, Dublin, Ireland

MUNICH, GERMANY 28th Annual ESOPRS Meeting

CRETE, GREECE Aegean Cornea X

9-11

6-9

Email: richard.lee@bsuh.nhs.uk

XXVIII Congress of the ESCRS

THURSDAY 11th NOVEMBER 2010

STRESA, ITALY 16th Retina International World Congress

July 2010

Web: www.escrs.org

16-20

Web: www.retinaitalia.org

1-4

4-8

VENICE, ITALY 1st EuCornea Congress

17-19

Web: www.euretina.org

June 2010

7th INTERNATIONAL REFRACTIVE MEETING

Paris, France 10th EURETINA Congress

2-5

Vilnius, Lithuania XIII Baltic Ophthalmologicum Balticum Web: www.fob2010.com

Web: www.milosklinika.com

February 2011 18-20

ISTANBUL, TURKEY 15th ESCRS Winter Meeting

September 2010 PARIS, FRANCE 2-5 10th EURETINA Congress

4-8

Web: www.euretina.org

XXVIII Congress of the ESCRS

Web: www.escrs.org

Web: www.escrs.org

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