Volume 15_Issue 9 by EUROTIMES

VOLUME 15 ISSUE 9 SEPTEMBER 2010

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Laser assisted in-situ keratomileusis (LASIK) can only be performed by a trained ophthalmologist and for specified reduction or elimination of myopia, hyperopia, and astigmatism as indicated within the product labeling. Laser refractive surgery is contraindicated for patients: a) with collagen vascular, autoimmune, or immunodeficiency diseases; b) who are pregnant or nursing women; c) with signs of keratoconus or abnormal corneal topography; d) who are taking one or both of the following medications: Isotretinoin (Accutane®) and Amiodarone hydrochloride (Cordarone®). Potential side effects to laser refractive surgery may include glare, dry eye, as well as other visual anomalies. LASIK requires the use of a microkeratome that cuts a flap on the surface of the cornea, potential side effects may include flap related complications. Patients are requested to consult with their eye care professional and Patient Information Booklet regarding the potential risks and benefits for laser refractive surgery, results may vary for each individual patient. Restricted Device: U.S. Federal Law restricts this device to sale, distribution, and use by or on the order of a physician or other licensed eye care practitioner. U.S. Federal Law restricts the use of this device to practitioners who have been trained in its calibration and operation and who have experience in the surgical treatment and management of refractive errors. Please see brief statement on adjacent page. ©2010 Abbott Medical Optics Inc. Abbott trademarks and products in-licensed by Abbott are shown in bold and italics. Accutane is a registered trademark of Hoffmann-LaRoche Inc. Cordarone is a registered trademark of Sanofi-Synthelabo, Inc. 2009.09.09-IL1311 Rev. B

ESCRS

EUROTIMES

september 2010 Volume 15 | Issue 9 This month... 20 Years of LASIK 6

Aegean Cornea X meeting report from Crete

Cataract Update 8 11

Reducing the incidence of PCO The use of femtosecond lasers in cataract surgery

Refractive Lens

13 14

Broadening range of accommodating IOLs Promising results with FluidVision IOL

Refractive Laser 16 19 20

Good early results with INTRACOR Effective new treatment for presbyopic emmetropes FS laser presbyopia treatment

Cornea Update 22 23

Leaders confident of bright future ahead for EuCornea Restoring long-term vision with Boston KPro

Glaucoma Update 25

Temporal LRI avoids unpredictability of superior locations

Retina Update 27 29

Tackling diabetes-related ocular complications Combination treatments in AMD

Ocular Update 32 33 35

Working collectively for your patients Online OCT could improve safety of ophthalmic surgery procedures Eyeland Design showcases its work at WOC Opening Ceremony

Global Ophthalmology 36 37

Experts strive for onchocerciasis elimination in Africa Challenges for VISION 2020

News 38 40

Candidates talk about importance of EBO Diploma EUREQUO at advanced stage in Slovakia

Features

44 editorial staff

ESCRS

EUROTIMES

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

4 Newsmaker Interview 42 Practice Development 42, 50 Journal Watch 44 Outlook on Industry 46 Product Update 48 Bio-Ophthalmology 49 Fyodorov Lecture 50 EU Matters 51 Letter from Crete

52 54 55 56 57 60

Eye On Travel Book Review JCRS Highlights Industry News Eye on History Calendar

With this month’s issue... Driving the Future of Refractive Surgery and Presbyopia Correction supplement, 15th ESCRS Winter meeting preliminary programme & XXIX Congress of the escrs first announcement Assistant Designer Janice Robb

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

Colour and Print Times Printers

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

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

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

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

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

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

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EUROTIMES

Editorial

ESCRS

GUEST EDITORIAL

Medical Editors

Volume 15 | Issue 9

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

Two outstanding meetings

Paris welcomes delegates to 10th EURETINA and XXVIII ESCRS Congresses by Béatrice Cochener MD

International Editorial Board

t the beginning of September 2010, two major meetings will be held in partnership, the XXVIII Congress of the European Society of Cataract and Refractive Surgeons (ESCRS), 4-8 September, and the 10th EURETINA Congress, 2-5 September, in Le Palais des Congrès de Paris. As president of the French Society of Ophthalmology (Société Française d’Ophtalmologie – SFO) and on behalf of French ophthalmologists, it is my pleasure and honour to welcome the attendees of both of these different and exciting meetings to Paris, France.

Emanuel Rosen Chairman ESCRS Publications Committee

Outstanding scientific programmes are planned, with numerous lectures, presentations, courses, posters and videos. Leading experts of these two sub-specialities (or “hyper”-specialities), will present the latest scientific knowledge in research and state-of-the-art of ophthalmology. There will be two joint symposia and a combined industry exhibition which will open on Friday September 3 and close on Tuesday September 7. Special thanks go to the sponsors and exhibitors for their support. Without their contributions this meeting, merging two very different topics, usually separated by a gap in many aspects: pathology, surgical methods, links to basic research, evidence-based medicine and, not to be forgotten… different levels of income, would not have been possible. This “ecumenical” pursuit towards reliable standard of treatment in medical science, the importation of knowledge and skills through modern methods and the rational policy in affording care services, is an important point that ophthalmologists of different expertise are striving for.

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY part of artistic and cultural treasures at your disposal: over 180 museums and monuments may be visited for your enjoyment with renowned collections of paintings, sculptures and decorative arts. Let me again welcome you to Paris. Let us look forward to these two outstanding congresses, to enjoy collegial exchange, meeting old friends and making new ones, bridging knowledge for ophthalmologists from antipodes of the eyeball: anterior segment and ocular fundus!

John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY

Many hot topics will be discussed: Femtosecond lasers as a tool of a new era of surgical treatments, for instance new design of corneal grafts, or as a high-tech means in exploration of anterior segment, but also the new developments for treatment of presbyopia, multifocal and accommodative IOLs, management of difficult vitreoretinal diseases, immunology in uveal melanomas, screening in uveitis, when to inject anti-VEGF, the lens and the retina of myopic eyes, angiographic cases (FAN club) and last but not least, the ESCRS-EURETINA joint symposium on Endophthalmitis, with the standing debate about antibiotic prophylaxis. In addition to the scientific discourse in Paris, the social programme offers a fabulous amount of possibilities for personal and cultural exchanges. The symbol of the city, the Eiffel Tower, built for the universal exhibition in 1889 is celebrating its 120th anniversary. The Louvre, one of the largest museums in the world, Versailles estate, Orsay museum are quite famous, but represent only a small

Hiroko Bissen-Miyajima JAPAN

Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN BÉATRICE COCHENER Béatrice Cochener is the president of the French Society of Ophthalmology (Société Française d’Ophtalmologie – SFO).

Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA

EUROTIMES | Volume 15 | Issue 9

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Newsmaker Interview

PCO Prevention

ridley medal lecture

More progress needed to reduce incidence of PCO

David Spalton FRCS, FRCP, FRCOphth, trained as a resident in ophthalmology at Moorfields Eye Hospital and St Thomas’ Hospital, London. In 1981 he was appointed consultant ophthalmologist to the Charing Cross Hospital and then in 1983 moved back to St Thomas’ Hospital where he has been a consultant ophthalmic surgeon ever since. He is particularly known for his work on the prevention of posterior capsule opacification (PCO).

How does it feel to be doing the Ridley Medal Lecture at this year’s ESCRS Congress?

It is the pinnacle of my professional career. It’s the most prestigious honour for a cataract surgeon in Europe.

The award commemorates the work of Harold Ridley, who was based where you work at St Thomas’ Hospital. Did you work with him? I once assisted him in putting in an anterior chamber lens. It must have been about 1975-76. He had retired by then but was still in private practice at the time.

Were IOLs still controversial in those days?

Oh yes, very controversial. Ridley implanted the first lens in 1950 but it wasn’t until the 1980s that they came to be accepted in the UK. So there was a 30-year gap. As a resident I did my training at Moorfields and there was no discussion about IOLs there at all. There was a cabal of five or six senior surgeons who were opposed to the idea. They had some justification because many of Ridley’s patients had complications such as decompensated corneas, chronic iritis and angle closure glaucoma which in those days were largely untreatable and sadly lead to eventual blindness.

Were the minimum standards of safety lower back then?

Yes, it’s a totally different thing now. We now have a much more scientific approach. In Ridley’s day there was much more of a try-it-and-see approach. But we have to view these things by the standards of the time.

Was the opposition he faced a little extreme given that in the end he had the right idea?

It was an idea that was before its time in that people didn’t have surgical microscopes or microsurgical instruments with which to operate, they didn’t understand the physiology of the cornea, and they didn’t understand the problems in sterilising intraocular lenses. To make implant surgery into the successful operation it is today required the improvement of microsurgical technique and a better understanding of the physiology of the eye. The advances have been amazing and without the stimulus of Ridley’s pioneering work, IOLs would have happened less quickly. EUROTIMES | Volume 15 | Issue 9

The title of your Ridley Medal lecture is “Life and Death on the Posterior Capsule”. What kind of matters will you be discussing? I will be discussing where we are in the prevention of PCO. PCO is less of a problem, but it has not been conquered.

What kind of progress has there been in the elimination of PCO following cataract surgery since IOLs came into common use? When IOLs were first introduced, PCO was thought to be an inescapable part of the operation. However, when Alcon brought out the AcrySof lens in 1993 a German ophthalmologist, Ekkehard Medhorn MD, saw that in German trials the patients had very little PCO with this lens. At that time I had developed a method of objectively quantifying PCO and Alcon approached me to compare the AcrySof lens with two other lenses, one made of silicone and the other of PMMA. My research showed that eyes with the AcrySof lens had considerably less PCO. This was quite a surprise and no one knew what the reason was. There were all sorts of theories going around and then Dr Nishi showed through elegant animal studies that it was the edge profile of the lens that prevented PCO.

Presbyopic lens exchange and refractive lens exchange tend to involve younger patients who are likely to be more prone to PCO. Do you think the incidence of PCO may actually increase? This is a problem. People are undergoing refractive lens exchange with premium lenses and they will have very high expectations, but multifocal IOLs can be sensitive to PCO and PCO can also be a problem with accommodative lenses.

What are some of the newer approaches that are under investigation?

There have been studies with modifications in surgical technique such as Tassignon’s bag-in-the-lens concept, irrigating the capsular bag with drugs using the Perfect Capsule device and there is also recent work using the ARC/ Dodick laser to blast off the lens epithelial cells.

Some say that eliminating all of the lens epithelial cells from the posterior capsule could cause instability of the IOL in the bag making it wobble or rotate... what is your view? This is a question that remains to be answered. We have developed a new model to grow lens epithelial cells in the human capsular bag which is much more physiological than previous models. In my presentation I will end with a description of our experiments. Dr Spalton was interviewed by EuroTimes contributing editor Roibeard O’hEineachain

contact

David Spalton - dspalton@hotmail.com

20 years of lasik

A landmark event

Crete conference showcases ophthalmology’s rich heritage and future direction

by Dermot McGrath in Crete

n the picture-postcard setting of Hersonissos, Crete, ophthalmologists from all over the world gathered on Greece’s largest island this summer to help celebrate a landmark event in ophthalmological history. For it was here 20 years ago that Ioannis Pallikaris became the first surgeon to use the LASIK hinged flap technique, a key development that helped to usher in a new era of laser refractive surgery that would benefit millions of patients worldwide. Over three days of stimulating symposia and scientific sessions at Aegean Cornea X, some of the leading opinion-leaders in ophthalmology shared their thinking on topics such as corneal crosslinking, corneal pathologies, femtosecond lasers, keratoplasty techniques, presbyopia and corneal biomechanics. Welcoming delegates to Greece and speaking on behalf of his fellow members of the Organising Committee, Prof Pallikaris said it was a great honour to be hosting such an event. “This is a triple celebration and I am delighted that so many of my colleagues and friends from all over the world came to Crete to help make this meeting such a success. This year we are celebrating the 10th anniversary of the Aegean Cornea Meeting and the 20th anniversary of Vardinoyiannion Eye Institute of Crete (VEIC), so it is fitting that these events coincide with the 20th anniversary of the first LASIK procedure here in Crete,” he said. Since its inception, the biennial Aegean Cornea Meeting has become established as a prestigious, low-key but highly respected fixture in the ophthalmic calendar. The members of its Organising Committee, Perry Binder MD, Marguerite McDonald MD and Prof Pallikaris, have worked hard over the years to put together a compelling Scientific and Social programme for delegates. “In the last five years we increased the profile and the quality of the meeting,” said Prof Pallikaris. “Part of that evolution came from organising the popular Summer School in Visual Optics just before the main meeting. The basic idea was to have scientists, PhD students and ophthalmology residents attend classes and then stay on for either the cornea or DG SUHPLXP VROXWLRQ [ (1* Y MPR (8527,0(6 LQGG EUROTIMES | Volume 15 | Issue 9

“

This is a triple celebration and I am delighted that so many of my colleagues and friends from all over the world came to Crete to help make this meeting such a success Ioannis Pallikaris

retina meeting depending on which was taking place on that particular year,” he said. Under the guidance of the Organising Committee the presentations and discussions at this year’s meeting focused on recent clinical and technical developments in the fields of medical cornea and refractive surgery. Many of the major ophthalmological societies held symposia during the meeting. These well-attended sessions gave rise to some lively debate, typified by the opening day’s exchanges at the “Femto Olympics” organised by MEACO and devoted to establishing the pros and cons of the main femtosecond laser devices currently on the market. In a discussion after the formal presentations, co-moderator Perry Binder MD, urged surgeons interested in investing in femtosecond technology to make their choice based on hard science rather than the subjective impressions of a few surgeons. After hearing the various arguments for each laser, the audience voted by a fairly convincing majority for the IntraLase laser, followed by the VisuMax. Indepth reports of individual presentations at the Aegean Cornea X meeting will appear in forthcoming editions of EuroTimes.

contact Ioannis Pallikaris – pallikar@med.uoc.gr

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Update

Setting the standard.

cataract

Preventing PCO

Insuring against the complication, short and long term by Roibeard O’hEineachain in Budapest

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EUROTIMES | Volume 15 | Issue 9

HE development of IOLs with square-edged optics has greatly reduced the incidence of PCO following cataract surgery, but there are other factors within a surgeon’s control that can reduce the risk of the complication still further, said David Spalton FRCP, FRCOphth, St Thomas’ Hospital, London, UK. “Over the years we have learned that PCO is a multifactorial problem. There are some things which we have to accept. We know, for example, that PCO is going to be higher in younger patients and in those with coexisting diseases such as diabetes, but there are also surgical factors, in particular the type of IOL implanted, which also plays a role,” Dr Spalton told the 14th ESCRS Winter Meeting. Researchers originally misattributed the PCOpreventing property of IOLs with square-edged optics to the hydrophobic acrylic material of the AcrySof® IOLs (Alcon) in which they first observed the phenomena, he said. However, it was Okihiro Nishi MD who was able to show in a number of studies published from 1999 onwards that it was the square edge rather than the hydrophobic acrylic material of the AcrySof IOL that was key to the prevention of PCO, Dr Spalton explained. Those studies and other research indicated that the square-edged optic prevents PCO by inducing a barrier effect against the migration of lens epithelial cells across the posterior capsule. “Following cataract surgery the collapse of the capsular bag and the fibrosis of the anterior capsule pushes the IOL edge against the posterior capsule and creates a mechanical pressure barrier to lens epithelial cell migration,” he added.

Not all square edges the same Many manufacturers have in the intervening years incorporated various types of square-edged optics into their IOL design. However, the different lenses vary in their efficacy regarding PCO prevention, Dr Spalton noted. The differences in PCO rates appear to result from differences in the sharpness of the optic edge and the discontinuities of the sharp edge at the optic/haptic junction. For example, in a study in which Dr Spalton and his associates compared the AcrySof SN60 IOL with the Hoya YA-60BB, which is another hydrophobic acrylic IOL with a square-edged optic, the median percentage of PCO at two years’ follow-up was 30 per cent in eyes with the Hoya lens, compared to less than five per cent in eyes with the AcrySof lenses. A subsequent study in which Dr Spalton and his associates used scanning electron microscopy showed that AcrySof IOLs had sharp posterior optic edges with radii less than 10 microns. In comparison, the Hoya lens had a rounder posterior optic edge with radii 19 microns. Their research also showed that several other IOLs have optic edges with similar sharpness to those of the

AcrySof IOLs. They include the hydrophobic acrylic Sensar® (AMO), and some of the silicone IOLs such as the Clariflex®, the Tecnis® and the Tecnis multifocal (AMO), and the Soflex SE and SofPort AO® IOLs (Bausch + Lomb), he noted. The hydrophilic acrylics, meanwhile, generally have rounder optic edges, he pointed out. The optics of the Bausch + Lomb Akreos™ and Akreos AO IOLs and the Rayner Superflex™ IOL have edge radii greater than 10 microns. The Lenstec Tetraflex has the roundest posterior optic edge, with radii of more than 20 microns. “Hydrophilic acrylic lenses are manufactured in a dehydrated state and some of the edge profile’s sharpness is lost on rehydration of the lens material. The one exception is the HumanOptics line of IOL, which uses its own unique lathe-cutting technique,” Dr Spalton said. But even IOLs with 360-degree sharp-edged optics can be vulnerable to PCO if the square edge does not extend completely around the optic’s perimeter, he noted. There remain on the market some IOLs prone to an Achilles’ heel effect, wherein lens epithelial cells migrate onto the posterior capsule through a gap in the optic’s square edge at the optic/haptic junction, he said. The surgeon’s precision in performing a cataract procedure can also influence the rate of PCO even with IOLs with all of the optimal features to prevent the complication, Dr Spalton noted. In a study involving eyes implanted with the MA30 AcrySof IOL, which has 360-degree square optic edge, he and his associates found that there was a loss of contact between the anterior capsule rhexis and the lens in 80 per cent of cases with more than 10 per cent of the capsule covered with PCO, he said. The loss of contact appeared to result from asymmetric rhexes. When the rhexis does not lie evenly upon the surface of the IOL, capsular bag shrinkage exerts an uneven force bearing down on the lens, causing the lens to tilt away from the posterior capsule, thereby undermining the barrier function and allowing the migration of lens epithelial cells. Dr Spalton noted that compared to the 50 per cent incidence of PCO reported 20 years ago, many researchers are now reporting YAG rates of five per cent or lower. However, those studies have tended to involve highly skilled surgeons and ideal cataract patients without serious ocular or systemic co-morbidities. An audit of cataract patients performed by Georgia Cleary FRCS, a former research fellow of Dr Spalton, indicated that YAG rates of 10 per cent or less at two years might be a more realistic goal. “If your YAG rates exceed 10 per cent then you may need to reconsider the types of IOL you are implanting and whether your surgery is adequate,” he added.

contact

David Spalton - dspalton@hotmail.com

Accommodating. Aberration Free. Aspheric.

Crystalens® Accommodating Posterior Chamber Intraocular Lens BRIEF STATEMENT Rx only. Indications for Use: The Crystalens® is intended for primary implantation in the capsular bag of the eye for the visual correction of aphakia secondary to the removal of a cataractous lens in adult patients with and without presbyopia. The Crystalens® provides approximately one diopter of monocular accommodation which allows for near, intermediate, and distance vision without spectacles Warnings: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient. Some adverse events which have been associated with the implantation of intraocular lenses are: hypopyon, intraocular infection, acute corneal decompensation, and secondary surgical intervention. Precautions: Do not resterilize; do not store over 45°C. ATTENTION: Refer to the Physician Labeling for complete prescribing information.

Update

Cataract

A New era

28 Examinations in 56 Seconds *

Surgeons can reshape the cornea with precision using femtosecond lasers by Dermot McGrath in Paris

fter keratoplasty and refractive surgery, femtosecond laser manufacturers are now firmly setting their sights on the massive cataract surgery market and surgeons would be well advised to prepare for the coming revolution, according to Joseph Colin MD. “We have started to see the first cataract procedures using femtosecond lasers to create corneal incisions, perform an automated capsulorhexis and to break up the nucleus and liquefy the crystalline lens and the initial results seem very promising. Although it is still very early days, it is a method that appears to be reproducible, easy and safe,” Dr Colin told delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting. While the initial costs of the technology will act as a brake on its introduction to the mass market, Dr Colin said that previous experience with groundbreaking technologies suggests that femtosecond lasers will come to supplant current techniques. “The technology is certainly more complex than the phacoemulsification that we are used to today and it is significantly more expensive. However, despite the costs, we can anticipate strong pressure to adopt this technology from both industry and from patients who will hear about this new technology as the most advanced means of operating on cataracts. So there is an evolution which I think is going to take place quite quickly in which we will be routinely using the femtosecond laser for cataract surgery,” he said. After paying tribute to the pioneering work of Charles Kelman, the “father” of phacoemulsification, whose invention has benefited over 100 million people worldwide, Dr Colin said the time was right to ask what direction crystalline surgery would take in the era of the femtosecond laser. Dr Colin noted that the energy delivered by the femtosecond laser enables surgeons to reshape the cornea with “exceptional accuracy, precision and reproducibility and practically no side effects”. Focusing on applications for femtosecond technology in cataract and presbyopia surgery, Dr Colin said that the laser is currently able to create clear corneal incisions, limbal relaxing incisions, anterior capsulorhexis, as well as fragmentation and liquefaction of the nucleus for most grades of cataract. “We can create the form of incision we

EUROTIMES | Volume 15 | Issue 9

require using pre-programmed profiles in the femtosecond laser and the same goes for limbal relaxing incisions to correct corneal astigmatism. The capsulorhexis, which can sometimes pose problems for inexperienced surgeons, can now be performed in seven seconds. Using the femtosecond laser, the capsulorhexis will always be centred and the exact size required – the process is automatic and reproducible,” he said. Another advantage of this type of surgery is that it enables excellent visualisation throughout the procedure. Dr Colin said that the current range of femtosecond devices would probably add some time to the overall cataract procedure, since the machines are currently kept in a separate room from the phaco device and the patient needs to be moved to the operating room for lens removal and IOL insertion under sterile conditions to complete the surgery. It is anticipated that future versions of the machines will be located in the operating room next to the conventional equipment. Dr Colin said that there are currently three companies jostling for space in the emerging femto-phaco market: LensAR Inc., LenSx Lasers Inc. and OptiMedica Corporation. The LensAR system, which was originally conceived for presbyopia correction, has recently received FDA approval for anterior capsulotomies. It is also capable of lens fragmentation, limbal relaxing incisions and clear corneal incisions. The LenSx laser system uses integrated proprietary optical coherence tomography (OCT) technology to allow the surgeon to view the eye’s three-dimensional anatomy in real time. Anterior capsulotomy, corneal incisions, and lens fragmentation can all be accomplished in a single step outside the operating theatre. In an early clinical study of the device, Zoltan Nagy MD of Semmelweis University in Budapest demonstrated that lens fragmentation with the LenSx laser reduced average phaco power when compared to traditional, manual technique. The OptiMedica platform combines integrated OCT imaging and femtosecond laser technology to deliver customised capsulotomies, pre-fragmentation of the crystalline lens, and clear corneal and limbal relaxing incisions. Clinical trials of the system are currently ongoing.

contact

Joseph Colin - joseph.colin@chu-bordeaux.fr

* OCULUS

Pentacam – complete anterior segment analysis in only 2 seconds

ESCRS, Level 1 OCULUS booth #126

www.oculus.de www.pentacam.de

In just 2 seconds the Pentacam provides accurate diagnostic data for both, the anterior and posterior surface of the cornea. This supports you in the detection of early Keratoconus, to obtain more accurate K readings and to be more confident while interpreting the Pentacam results. Through the rotating scan, more measurement points are provided in the center of the cornea. The second pupil camera detects eye movements during the exam. Plus, it provides the EKR (equivalent keratometer readings) which supports in the IOL power calculation for patients who have underwent refractive surgery in the past. Pentacam – the gold standard in anterior segment tomography.

EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES * EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES ™ EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES * Average net circulation for audit period January to December 2009. See www.abc.org.uk EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES EUROTIMES

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Refractive Lens

orbtex

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ceramic orbital implant

Accommodating IOLs

21st century material

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Spectacle independence in cataract patients

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by Roibeard O’hEineachain in Budapest

orbtex cermamic orbital implant

ntraocular lenses employing a range of different approaches to mimicking physiological accommodation are continuing to show promise in the restoration of multifocality in cataract patients, according to presentations at the 14th ESCRS Winter Meeting. To achieve their accommodating effect, the IOLs all rely on the same actions of the ciliary muscle, zonule and capsular bag as control accommodation and alter the focus of the natural crystalline lens. They differ from each other in their interactions with the capsule, and in their optical designs. The Crystalens HD™ (Bausch + Lomb), the newest version of the original accommodating IOL, can provide a vision across a broad range of distances, with high patient satisfaction, according to sixmonth results of a study presented by Mark Tomalla MD, Duisburg, Germany. “After implantation of the Crystalens HD, we achieved convincing postoperative clinical results for both distance and near vision. The values in the intermediate range were particularly convincing,” he said. The study involved 17 patients implanted with the Crystalens HD. At six months’ follow-up, uncorrected distance vision was 1.0 or better in 11 per cent and 0.67 or better in 78 per cent. In addition, intermediate vision was 1.0 in 86 per cent, and near visual acuity was 0.5 or better in all eyes and was 1.0 in 27 per cent. In addition, none of the patients needed correction for distance vision, and 71 per cent no longer required reading glasses. Dr Tomalla noted that the Crystalens HD has the same mechanism of action as earlier versions of the lens, and uses hinged optics to allow forward movement of its optic in response to ciliary muscle contraction. However, the new model’s optic has a central 1.0mm zone with increased elevation of 3.0um to provide an additional pseudoaccommodative effect, he said. For optimal results, the capsule must be allowed to fibrose onto the IOL’s Biosil haptics over a period of two weeks following implantation, with accommodation suppressed with pilocarpine, he added.

Sustained accommodation with the Synchrony The long-term results of the dual-

optic Synchrony® (Visiogen) IOL indicate that the lens is highly biocompatible and continues to provide a functional range of vision exceeding that of multifocal IOLs for several years after implantation, said Ivan Ossma MD, MPH, MSc, Universidad Industrial de Santander, Bucaramanga-Colombia. “Over the past five years, several authors EUROTIMES | Volume 15 | Issue 9

including our group have shown that the Synchrony accommodating IOL provides good unaided visual function at all ranges, with objective evidence of accommodation and stability throughout time. Additionally, the lens has very low rates of capsule opacification,” he said. Dr Ossma presented results of a prospective study involving 17 eyes of 12 of the first cataract patients he implanted with a dual optic accommodating intraocular lens in 2003 and 2004. At five years’ follow-up, uncorrected distance and intermediate visual acuity was 20/40 or better in all patients and uncorrected near visual acuity was 20/40 or better in 87 per cent, he said. Furthermore, at all time points over the first five years of the study, best corrected distance visual acuity was better than 20/25 for all patients. In addition, with distance correction, intermediate acuities were better than 20/32 and near visual acuities were better than 20/40 in all patients. Moreover, only one eye required YAG laser capsulotomy, he added. “This is, to our knowledge, the longest follow-up of a cohort implanted with Synchrony and it covers patients implanted in a pilot study with forceps. Currently, we are using the injector system that allows for better astigmatism control. The evolution of the power calculation formula also allows us to have better refractive outcomes,” Dr Ossma said.

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Meanwhile, the preliminary results achieved with the WIOL – CF, a new accommodating IOL that mimics the geometry and plasticity of the crystalline lens, indicate that the implant can provide stable refraction and some measure of accommodation, said Ioannis Pallikaris MD, PhD, Institute of Vision and Optics, University of Crete School of Medicine, Heraklion, Crete, Greece. The IOL has no haptics and its shape, size and material are such that the posterior surface comes into contact with posterior capsule in much the same manner as does the natural crystalline lens, Prof Pallikaris noted. The lens design is intended to provide up to 2.5 D of accommodation through the IOL’s forward movement and the deformation of its optic edges in response to constriction of the ciliary muscle, he said. The IOL is implantable through a 2.8mm incision in its dehydrated state, and expands to its fully rehydrated state within the first 48 hours, he added. In a study involving 30 eyes of 15 cataract patients aged 56 to 81 years who underwent routine phacoemulsification surgery and implantation of the WIOL-CF lens, the mean uncorrected distance visual acuity improved from 0.45 preoperatively to

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0.66 after a mean follow-up of three months, and 64 per cent of patients had a near visual acuity of J1 or J2, Prof Pallikaris said. In addition, corrected distance visual acuity improved to 0.75 from 0.57 preoperatively and 71 per cent of eyes gained lines of corrected distance visual acuity, and no eyes lost any lines, he added. “The WIOL – CF can be considered a very promising alternative solution for patients who lead an active life and require good vision at near, intermediate and far. In our patient series all patients obtained some real level of accommodation objectively measured by Tracey Technologies which remained stable throughout the follow-up period,” Prof Pallikaris concluded.

contacts Mark Tomalla – mark.tomalla@ejk.de Ivan Ossma – ossma@mac.com Ioannis Pallikaris – pallikar@med.uoc.gr

Update

Refractive Lens %LRPHWU\ FRQQHFWHG ÂŤ Čą ČąĹ&#x;Ĺ&#x2013;Ĺ&#x2013;Č&#x203A;

FluidVision lens can be inserted using standard cataract surgery technique

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by Howard LarkinÂ in Boston

n its first test in three sighted eyes, the FluidVision accommodating IOL (PowerVision) produced accommodation averaging more than 5.0 D and distance visual acuity of 20/40 or better one month after implantation. In the wake of these promising results, researchers plan to implant up to 10 of the current design in this ongoing clinical trial, and hope to begin testing soon a version that may provide even more accommodation. â&#x20AC;&#x153;The FluidVision implant mimics the accommodative process of the natural crystalline lens with shape change and forward movement,â&#x20AC;? Louis D 'Skip' Nichamin MD, medical director of the Laurel Eye Clinic, Brookville, Pennsylvania, US, told a symposium at the annual meeting of the ASCRS. Implanted in an intact capsular bag, the lens works by squeezing fluid stored in annular haptics into a central chamber in response to contraction of the ciliary muscles. This incoming fluid moves the anterior optic forward by up to 100 microns, but more importantly changes its shape to increase refractive power. When the muscles relax, the silicone fluid, which has the same refractive index as the hydrophobic acrylic lens body, flows back into the haptics, reversing the effect. This mechanism of accommodation has been verified by Visante OCT imaging. As with earlier tests in animal models and non-sighted eyes, imaging of these sighted patients showed optic movement and remodelling in response to pilocarpine stimulation that closely corresponded to the subjectively measured amplitude of accommodation, said Dr Nichamin, who is a scientific advisor for PowerVision. The surgery on these sighted subjects was performed by Paul Roux MD, Pretoria, South Africa.

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Stable refraction The accommodation test Dr Nichamin reported is part of the second human trial of the FluidVision lens. The first trial was conducted in nonsighted end-stage glaucomatous eyes to determine whether the lens would remodel in the capsular bag under pharmacologic stimulation, and to assess its safety and stability. The success of that trial led to the first phase of the current sighted-eye trial. In it a

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5 D in first patients

version of the lens capable of internal shape change but without a deformable anterior optic was implanted in three sighted eyes with intact capsules. One purpose was to test the stability of the base refraction. All three achieved stable 20/40 or better distance vision. A second purpose was to assess the function of the lensâ&#x20AC;&#x2122; internal fluid transfer mechanism. Movement of the mechanism was shown to be sufficient to produce 4.0 to 6.0 D of accommodation in a lens with the entire accommodating mechanism. These favourable results were repeated in the second phase of the current trial, in which the first three of a planned 10 eyes were implanted with the accommodating version of the FluidVision lens. At 30 days all showed a stable base refraction within 1.0 D of emmetropia with a distance visual acuity of better than 20/40. Given that some of the initial six eyes had macular disease as well as astigmatism induced by sutures required for the manually inserted prototype lenses, Dr Nichamin considers this an excellent refractive result. More significantly, the three eyes implanted with the fully functional lens all achieved amplitude of accommodation within the range predicted by animal and preliminary human tests. Using a mini ETDRS chart in a standard push-down test the eyes accommodated 4.1 D, 5.4 D and 6.5 D, or about as much as a typical 35- to 40-year-old. OCT imaging also confirmed movement of the lens mechanism, including remodelling of the anterior optic, which is responsible for the bulk of lens power change, consistent with the subjective results, Dr Nichamin reported. â&#x20AC;&#x153;Our early results in the first sighted eyes are showing excellent visual acuity in general and on average more than 5 D accommodative power. All of this was achieved using standard cataract operative technique,â&#x20AC;? he added. Dr Nichamin noted that an injectable model with the potential for 20-50 per cent greater accommodation than the current lens is in development. This will allow insertion through a sub 4.0mm incision, eliminating the need for sutures. He hopes to begin testing it by yearâ&#x20AC;&#x2122;s end.

contact Louis D Nichamin - nichamin@laureleye.com

Update

Refractive Laser

TREATING presbyopiA

Femtosecond laser technique can restore good reading vision in presbyopes with low hyperopia by Roibeard O’hEineachain in Budapest 4-0371

4-03721

4-03751

11-03741

EUROTIMES | Volume 15 | Issue 9

4-03731

4-03761

11-03751

4-03741

he three-month to one-year results with the INTRACOR™ procedure indicate that the technique can restore good reading vision in presbyopes with low hyperopia with only a small sacrifice of distance vision in some patients, according to a series of studies presented at the 14th ESCRS Winter Meeting. Invented by Colombian refractive surgeon Luis Ruiz MD, the INTRACOR technique reshapes the central cornea through the creation of circular concentric intrastromal incisions with a femtosecond laser, said Mark Tomalla MD, Duisburg, Germany. “The femtosecond laser cuts are generated only in the stromal tissue, without damaging epithelium or endothelium. As a result, biomechanical properties are locally changed and central steepening of cornea is achieved,” he added. In a study involving 21 low hyperopic presbyopes who underwent the procedure, at one year’s follow-up, patients achieved a median gain of six lines of uncorrected near vision, and median gain of two lines of uncorrected distance vision, Dr Tomalla said. The patients were highly satisfied and did not appear to lose any contrast sensitivity, he noted. The patients in the study included 11 women and 10 men with a mean age of 53.8 years. All were presbyopic and their spherical error ranged from 0.5 D to 1.0 D. None had more than 0.5 D of cylinder. All underwent the INTRACOR procedure in their nondominant eye with the FEMTEC®, femtosecond laser (Technolas Perfect Vision), and all but one patient had completed 12 months of follow-up.

Best in low hyperopes Dr Tomalla noted that by one year all patients had gained lines of uncorrected near visual acuity, with an average gain of 4.8 logMAR lines. He said that 20 per cent gained one to three lines, 57 per cent gained four to six lines and 24 per cent gained seven to eight lines. “Low hyperopic patients are the winners with the INTRACOR procedure. The patients have stable refraction after four weeks and they lost the haloes after nearly four to 10 weeks. Sometimes there is a reduction of distance vision for six to nine months,” he told EuroTimes. He noted that uncorrected distance visual acuity remained unchanged or improved in over 75 per cent of the patients after 12 months. Furthermore, 40 per cent achieved 20/20, compared to 20 per cent preoperatively. On the other hand, due to the slight myopic shift the surgery induces, five per cent of the patients lost two lines of uncorrected distance vision and 10.5 per cent lost one line, “Patients with up to +1.0 D of hyperopia are the best candidates because we have a reduction up to 1.0 D of sphere in addition to the myopic shift up to 2.0 D in the central area. In emmetropic hyperopes additional intrastromal radial cuts will help preserve distance vision,” he said. When performing the INTRACOR procedure, Dr Tomalla created five intrastromal circular incisions with diameters of 2.0mm to 10.0mm, which he centred on the corneal apex as determined through Purkinje reflexes. To insure that there was 10 per cent to 15 per cent of stroma above and below the

incisions, he measured corneal thickness with the Pentacam® (Oculus) and Orbscan (Bausch + Lomb), Dr Tomalla said. He noted that the only complication so far has been scarring of the cornea in a couple of eyes, due to accidental damage to the Bowman’s membrane from the femtosecond laser. He added that he and his associates have started a new trial in which they will seek to determine whether INTRACOR performed with six, rather than five, concentric incisions will achieve better results in terms of near visual acuity.

Good early results with bilateral treatment In another study presented at the Budapest meeting, bilateral INTRACOR treatment achieved good results in presbyopic patients who were nearly emmetropic preoperatively, with a good preservation of distance vision and significant improvements in uncorrected near visual acuity, said Tarek Abdel Wahab MD, Cairo Egypt. The study involved 10 presbyopic patients with a mean age of 49.2 years. All of the patients were nearly emmetropic, with a mean sphere of +0.5 D, and they all required a near add of at least +1.75 D. All underwent INTRACOR in both eyes in the same surgical session, with femtosecond incisions based on Pentacam measurements of corneal thickness, Dr Wahab said. The mean uncorrected and distance-corrected near visual acuities appeared to stabilise three months at 0.8 and 0.9, respectively, Dr Wahab noted. However, mean distance visual acuity was slightly lower at 0.8, compared to 0.9 preoperatively, he added. In addition, Dr Wahab commented. the contrast sensitivity was not affected following the procedure. Under photopic conditions, no change was observed in contrast sensitivity, although postoperative can sometimes be better than preoperative contrast sensitivity. The keratometry values changed substantially from preoperatively to postoperatively, he said. Erik L Mertens MD, FEBO, director and ophthalmic surgeon at Medipolis Eye Center, Antwerp, Belgium told the meeting’s attendees that INTRACOR is a very patient-friendly technique, not only because of the satisfactory visual results it achieves, but also because the surgery is very quick and completely painless. “It’s a 20-second procedure and the patient does not feel it. Pain and discomfort has been an issue with a number of procedures. In my experience with CK people had a lot of pain afterwards and were photophobic for two days, but this procedure eliminates all those risks,” Dr Mertens said. He noted that in his preliminary results with the technique in 13 eyes of 13 patients, all gained four lines in near visual acuity and all were J3 or better. There was, however, a mean loss of one line of uncorrected distance visual acuity, he added.

contacts Mark Tomalla – mark.tomalla@ejk.de Tarek Abdel Wahab – tarekwah@gmail.com Erik L Mertens – e.mertens@medipolis.be

17-21 SEPTEMBER REED MESSE VIENNA AUSTRIA www.escrs.org

European Society of Cataract & Refractive Surgeons

contacts

Cati Albou-Ganem – cati.ganem@wanadoo.fr

Update

SECTION HEAD Refractive Laser Section sub head

Presbyopia correction

INTRACOR for presbyopic emmetropes by Dermot McGrath in Paris

EUROTIMES | Volume 15 | Issue 9

incoming light devoted to distance vision and 35 per cent to near vision. The 6.0mm optic has smooth steps for diffractive multifocality on its anterior surface and incorporates negative spherical aberration to compensate for the human cornea’s positive spherical aberration. The lens is injected into the capsular bag through a 1.6mm incision. The presbyLASIK approach involved correction with the Z100 excimer laser, customised spherical photo-ablation using Zyoptix and reduction of the optical zone size on one eye. The technique works by correcting the dominant eye for distance vision with an optical zone of 6.0mm, and a deliberate over-correction of the nondominant eye for near vision with an optical zone of 5.6mm. The INTRACOR patients were treated using the femtosecond laser to create five intrastromal, concentric ring cuts around an optical zone of 1.7mm in the 3.0mm central area of the cornea. Unlike presbyLASIK, the INTRACOR procedure is performed in the stromal tissue of the cornea and the epithelium and Bowman’s membrane are not touched or affected. In terms of indications for each procedure, Dr Albou-Ganem said that the choice of technique depends on the level of ametropia, patient age and degree of presbyopia, the patient’s visual needs and occupation, and the information derived from aberrometry and optical quality analysis (OQAS) exams. Main outcome measures in the study included distance and near visual acuity, accommodative ability, defocus curve and patient satisfaction questionnaires. Putting the results into context, the AT LISA multifocal implant was the most effective at near and distance vision, with a visual acuity of 10/10 in almost all 48 eyes of 25 patients implanted with the IOL, reported Dr Albou-Ganem. She noted that the presbyLASIK approach performed well at near, intermediate and distance vision in 74 eyes of 41 patients and outperformed the other modalities in terms of field of vision. (Figure 1.) The INTRACOR outcomes in 54 eyes of 54 patients were also very good at all distances, although certain patients performed less well for near vision, said Dr Albou-Ganem. “It was however the most effective of the three modalities at intermediate distance. (Figure 2.)

Figure 1: Binocular vision: distant, medium, near vision decimal values for AT LISA, LASIK, INTRACOR

Courtesy of Cati Albou-Ganem MD

he INTRACOR intrastromal femtosecond laser correction procedure represents a potentially valuable addition to current treatment modalities for presbyopia and appears to be particularly effective as a means of treating presbyopic emmetropes, according to Cati Albou-Ganem MD. “INTRACOR is a very promising treatment option for presbyopic patients with lower amounts of hyperopia. In contrast to many other surgical procedures, the complete intrastromal ablation pattern is created without the need to cut the corneal surface, which eliminates the risks associated with the presence of a corneal flap and problems of dry eye,” Dr Albou-Ganem MD told delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting. Dr Albou-Ganem noted that while considerable progress has been made in recent years in the treatment of presbyopia, the issue of accommodation has not been satisfactorily addressed by existing techniques. The excimer laser treatment (PresbyLASIK) or multifocal IOLs provide satisfactory pseudo-accommodation even if the correction of emmetropes remains difficult. “Presbyopia surgery induces pseudoaccommodation, the effect of which is variable depending on the technique used. Multifocal implants differ in terms of light diffraction, optical zone, the add-power built into the lens and the patient’s pupil size. Corneal surgery also varies according to the degree of multifocality induced anteriorally, the degree of spherical aberration, and the relation between pupil diameter and the different refractive zones generated by the treatment,” she said. To try to establish the relative pros and cons of each approach, Dr Albou-Ganem and co-workers compared three different treatment modalities for presbyopia: the AT LISA M multifocal IOL (Carl Zeiss Meditec), presbyopic LASIK using the Z100 excimer laser (Bausch + Lomb) and INTRACOR correction using the femtosecond laser (Perfect Vision). Looking at each technique in turn, Dr Albou-Ganem noted that the AT LISA lens is a one-piece hydrophilic acrylic lens with a hydrophobic surface, an aspheric diffractive/ refractive optic with 65 per cent of the

Figure 2: Accommodative distance for AT LISA, LASIK, INTRACOR

It also carries the advantages of unilateral surgery for distance vision in demanding patients who are very particular about their quality of vision,” she said. Dr Albou-Ganem concluded that the study showed the importance of rigorous patient selection in order to select the most appropriate modality on a case-by-case basis. “All of the techniques we currently use for presbyopia correction are efficacious, even those which only induce pseudoaccommodation and not a genuine restoration of accommodative effect. The important point is that we need to select the method carefully based on patient age, ametropia, and visual requirements. We also need to inform the patients of the pros and cons of each approach and in particular those where distance vision might be somewhat compromised,” she said. Dr Albou-Ganem said that the real benefit of such a comparative study was to highlight the various compromises involved in current presbyopic treatments and pinpoint how they might be improved upon in the future. “The take-home message is that we need to

“

...we need to refine our indications for presbyopia surgery and learn to better evaluate our patients using simplified protocols in order to optimise our results Cati Albou-Ganem MD

refine our indications for presbyopia surgery and learn to better evaluate our patients using simplified protocols in order to optimise our results. The challenge of current multifocal implants is to ensure good visual acuity at all distances while maintaining good quality of vision. The challenge facing corneal surgical procedures is to deliver a useful and durable degree of pseudo-accommodation while ensuring the biomechanical integrity of the cornea.”

Update

Refractive Laser

FS laser surgery

Minimally invasive treatment is a really attractive option for the future by Howard Larkin in Boston

he first human trials of a femtosecond laser treatment of the crystalline lens for presbyopia achieved measurable objective accommodation in three of the five initial patients, and subjective near vision gains of up to four lines. If further development is successful, the technique could offer presbyopia correction without compromising vision quality, said Ronald R Krueger MD, Cleveland Clinic, US. “This minimally invasive treatment is a really attractive option for the future and we will continue investigating it in our future trials,” Dr Krueger told a standing roomonly seminar on advances in femtosecond laser surgery for cataracts and related conditions, for which he won the “Best Paper of the Session” award at the ASCRS annual meeting. Conducted in the Philippines under the direction of Harvey Uy MD, the feasibility trial involved five patients who were electing to have cataract surgery for refractive reasons. The patients, whose ages ranged from 50 to 59, had cataracts of grade 1 to 2, and preoperative best corrected visual acuities of 20/40 or better. Subjects with relatively good preoperative vision were chosen to avoid the potentially confounding effects of debilitating cataracts on postoperative vision in a test to assess presbyopia correction, Dr Krueger noted. All subjects underwent unilateral laser procedures in which a photoablation pattern designed to restore accommodation was cut within the crystalline lens with a femtosecond laser developed by LensAR, Winter Park, Florida, US. The laser was fixed to the eyes using a suction ring and guided by 3-D

Confocal Structured Illumination (CSI) to accurately place laser spots within the lens. Tissue was ablated in a multi-layered concentric shell pattern moving from posterior to anterior layers with pulses aligned in a grid pattern to minimise fracture of harder lenses and the centre spared to minimise the possibility of photic symptoms. The cuts allow layers of the natural lens to slide more freely over one another in response to contractions of the ciliary muscles, restoring lens flexibility and accommodation. One month after surgery the subjects’ objective accommodation was measured using a Grand Seiko auto refractometer. Two showed no accommodation, two showed between 0.25 D and 0.75 D objective accommodation, and one showed 1.62 D accommodation. Mean improvement in logMAR uncorrected visual acuity from baseline was 0.08 +/- 0.12, or nearly two lines, with the range from two lines worse to four lines better. Under slit lamp exam the treated eyes showed clear central refractive zones with a few discrete opacities, but no frank coalescing cataract. Dr Krueger pointed out that these are the earliest results in human subjects, and that refinement of the treatment pattern and the ablation algorithm continues despite the variability and lack of initial predictabiliy of the trial’s outcome. “Accommodation restoration is theoretically possible and experimentally feasible with an ultra-short pulse laser. In the absence of cataract and with sufficient efficacy, laser lens modulation could become a new strategy in the struggle for

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contacts

Ronald R Krueger – krueger@ccf.org Mark Schafer – marks@sonictech.com

presbyopic correction without compromise,” said Dr Krueger, who reported a financial interest in the LensAR system. The concept of using short-pulse lasers to produce cavitations and microperforations in the crystalline lens to restore flexibility dates back to 1998, when Dr Krueger and Raymond Myers OD published the idea in the Journal of Refractive Surgery. The two followed up with a 2001 study, published in Ophthalmology, in which an Nd-YAG laser was used to photodisrupt layers in paired cadaver lenses. The flexibility of cut and uncut lenses was compared by measuring their deformation when spun. This study found that after treatment, the flexibility of 54-year-old lenses increased to about the level of untreated 35-year-old lenses. To assess the risk of cataract formation, Dr Krueger conducted tests of photodisruption with a femtosecond laser on primates in collaboration with Jer Kuszak PhD of Rush University, Chicago, US. Microscopic visualisation and light-scatter results published in the Journal of Cataract and Refractive Surgery in 2005 suggested the treatment did not promote cataracts. An expert in lens structure and embryology, Dr Kuszak developed a finite element analysis of the crystalline lens showing overlapping sliding fibres at lens sutures, presented at ARVO in 2007. Based on this model several ablation patterns that might enhance lens flexibility were developed, including the concentric shell algorithm that in cadaver eyes found a mean change in refraction of 5.8 D +/- 2.8 D with mechanical spin tests. Primate studies by LensAR at the University of Wisconsin showed the procedure produced pinpoint opacities but no cataract three months after surgery. These successful animal tests laid the groundwork for the feasibility clinical trial that Dr Krueger reported. As with any new technology, long-term studies are needed to determine the impact of introducing laser energy within the crystalline lens, noted Mark Schafer PhD, president of Sonic Tech Inc, a consulting firm specialising in ultrasonic applications, Pennsylvania, US. He notes that while femtosecond lasers look promising not only for treating presbyopia but for reducing phaco energy needed to liquefy cataracts, it could introduce complications as yet unknown.

contacts

Update

cornea

José Güell – guell@imo.es Vincenzo Sarnicola – v.sarnicola@hotmail.it Harminder S Dua – harminder.dua@nottingham.ac.uk

1st EuCornea Congress

First meeting is major success

EuCornea faces challenges, but founders optimistic for the future by Cheryl Guttman Krader in Vienna

ttendees to the 1st Congress of the European Society of Cornea and Ocular Surface Disease Specialists (EuCornea) were officially welcomed to the meeting at a ceremony featuring addresses by the organisation’s officers and greetings from representatives of the many national and international organisations that helped EuCornea get its start. The enthusiasm and dedication displayed by the EuCornea leaders combined with the generous spirit of collaboration and support expressed by the other speakers suggest that the success of the first congress marks the beginning of a very bright future for the young society. José Güell MD, current president of the European Society of Cataract & Refractive Surgeons (ESCRS), gave a brief history of the origin of EuCornea. He explained that the idea for a European organisation dedicated to cornea and ocular surface disease germinated from discussions between himself, Vincenzo Sarnicola MD, EuCornea president, Harminder S Dua MD, PhD, EuCornea vice-president/presidentelect, and Francois Malecaze MD. “ESCRS has members working with a focus on cornea and ocular surface, but the creation of EuCornea offers a greater space for their special interests to grow,” said Dr Guell.

Forum for specialists Welcoming attendees to the first EuCornea meeting, Prof Sarnicola acknowledged what a great honour it was to be the first president of the new European society and to chair its first congress. He spoke of the goals of EuCornea, which are to disseminate knowledge in the field of cornea and ocular surface disease, to provide a forum for specialists in these areas to meet and share ideas, to improve know-how in disease management, and to facilitate a more generous standard of care for patients across the entire continent. “Concepts of democracy and mutuality can be easily expressed but may not be put into practice. We are science people, and we have a duty to spread knowledge,” said Prof Sarnicola. Speaking about the challenge of founding a new organisation and organising its first congress, Prof Sarnicola recalled the words of a close American friend who told him he would feel “birthing pain”. “He was EUROTIMES | Volume 15 | Issue 9

Opening Ceremony of the 1st EuCornea Congress

Michael Belin, Paolo Vinciguerra, Vincenzo Sarnicola and Donald Tan

Paolo Vinciguerra, Vincenzo Sarnicola, Giancarlo Caprioglio and Leonardo Mastropasqua

Industry Exhibition at the congress

right. However, EuCornea is real and has important aims that will surely be achieved as all of us give our best effort to make this possible,” he said. Prof Sarnicola also recognised the meeting’s corporate sponsors, recognising that EuCornea did not exist in the budget plan of any companies as it began to seek financial support for its first meeting. “The job of finding sponsors was hard, and so we give special thanks to all industry sponsors that believed in us from the beginning,” he said.

Moving forward In his address, Prof Dua congratulated Prof Sarnicola on the

“successful birth of EuCornea”. “Despite the pain you were told you would experience, you have delivered quite a healthy baby. Your efforts are recognised, acknowledged, and appreciated,” he said. Looking ahead to the 2nd EuCornea Congress, to be held in Vienna, September 16-17, 2011, just prior to the XXIX Congress of the ESCRS, Prof Dua noted the meeting’s success will depend on its participants. “That means all of you, and we look forward to your support with your presence and presentations at the meeting, but also with your suggestions and ideas for taking EuCornea forward,” he concluded.

Asia agreement The Signing of Agreement between the Asia Cornea Society and EuCornea was another highlight of the welcome ceremony. Donald Tan MD, president of the Asia Cornea Society, noted that the organisation’s aim is to help alleviate the burden of corneal blindness in Asia. “However, the world is shrinking and it is time for cornea societies to work together. Therefore, it is with great pleasure and honor that we can announce today the formal affiliation between EuCornea and the Asia Cornea Society,” said Dr Tan, inviting attendees to the second biennial meeting of the Asia Cornea Society in Kyoto, Japan, in December.

contacts

Claes Dohlman - claes_dohlman@meei.harvard.edu

Update

cornea 1st EuCornea Congress

Artificial cornea

Boston KPro inventor discusses challenges, solutions, and outcomes by Cheryl Guttman Krader in Venice

“

...I expect we will see better designs that will place us in an entirely different, greatly superior situation a few decades from now

Claes Henrik Dohlman DSc, MD EUROTIMES | Volume 15 | Issue 9

implantation between these different categories of eyes. Available data show the functional outcomes and device retention rate are quite good when the type I Boston KPro is used in appropriately selected eyes that are followed carefully,” said Dr Dohlman. He reported that in a series of 173 eyes implanted with the type I device and having diagnoses other than autoimmune disease or chemical burns, only two keratoprostheses had to be replaced during follow-up ranging to three years. In contrast, in a small cohort of eyes with Stevens-Johnson syndrome followed to five years, only about half retained BCVA of 20/200 or better despite intensive management.

72-year-old patient with a history of congenital cataract extraction, two failed corneal transplants, retinal detachment repair and tube shunt. Vision is hand movements

Innovations for better outcomes

The type I Boston KPro has a collar button design with front and back parts that are assembled together at the time of surgery and form a sandwich enclosing an 8.5mm corneal graft. The front part contains a PMMA plate, the central surface of which is the optical element, and a stem used to connect the front and back plates. A locking c-ring behind the back plate holds the device together. Design modifications that have been introduced include placement of fenestrations in the back plate, which allow aqueous inflow to the graft and minimise the risk of keratoprosthesis failure due to tissue melts. A threadless stem replaced the previous screw-type design and makes manufacturing and surgical assembly easier. Soon, the back plate will be manufactured with titanium instead of PMMA; titanium is more tissue friendly, thinner, and minimises the risk of retroprosthetic membrane development. Refinements have also been made in postoperative patient management. A soft, hydrophilic contact lens is now worn routinely on top of the keratoprosthesis to prevent ocular surface dehydration and ulceration. Simple and effective antimicrobial prophylaxis regimens have also been identified that make bacterial infections a rare complication. Patients without an autoimmune diagnosis or chemical burns need only instil a single drop daily of polymyxin B-trimethoprim, chloramphenicol, or a fluoroquinolone. “Fungal infection is rare, but must be watched for, especially in hot, humid climates. Short burst antifungal prophylaxis seems effective, and fungal infection can usually be

Courtesy of Claes Henrik Dohlman DSc, MD

tatistics on the global burden of corneal blindness and the modest impact that penetrating keratoplasty has on lessening its toll makes the need for an artificial cornea indisputable fact, not fancy, said Claes Henrik Dohlman DSc, MD, delivering his EuCornea Medal Lecture at the 1st EuCornea Congress. “According to data from the World Health Organization, about eight million people worldwide are blind from corneal disease, while fewer than 100,000 corneal transplants are performed annually. Moreover, data on failure rates document that the long-term fate of corneal grafts is not that good, and not all cases of corneal blindness are eligible for a graft procedure,” said Dr Dohlman, professor of ophthalmology, Harvard Medical School, Boston. It is against this background that Dr Dohlman and co-workers first began working on the Boston Keratoprosthesis (Boston KPro) in the mid-1960s and have continued to strive to refine the device and postsurgical patient management in order to achieve the goal of producing a keratoprosthesis that is simple to use and can safely and effectively restore vision long-term. The Boston KPro received FDA approval for marketing in the US in 1992, and it is expected that the CE mark will be obtained late in 2010. To date, about 4000 Boston KPro devices have been implanted worldwide with about 1200 of those procedures performed in 2009 alone. The Boston KPro is available in two models, although Dr Dohlman focused his remarks on the Type I device that would be suitable for the majority of eyes affected by corneal blindness, eg, those with a failed graft for corneal oedema, infections, or nonchemical trauma. “In our initial experience, it did not take us long to realise that there are enormous differences in prognosis after keratoprosthesis

28 months post Boston Keratoprosthesis Type I. Vision 20/30 (~ 0.7)

treated effectively with early recognition,” said Dr Dohlman. Glaucoma is common among Boston KPro patients, and research has also focused on the unique challenges relating to its evaluation and management. IOP is currently assessed by finger palpation, which is an inexact technique, but an intraocular IOP transducer has been developed and appears promising in terms of its performance and biocompatibility. While shunts are often needed for glaucoma control in Boston KPro eyes, utility of available shunts may become limited by formation of a flow-obstructing capsule. In collaboration with engineers at the Massachusetts Institute of Technology, research has been ongoing to find a solution to this problem, and a new shunt has been developed that delivers aqueous to distant epithelialised cavities (lower lid fornix, maxillary sinus) where an obstructing capsule is less likely to form.

“Directing aqueous to the lower lid fornix is helpful in dry eyes as tear replacement, and while infection was anticipated as a potential problem, in 34 eyes with cumulative followup of 250 years in which we have performed this procedure, there was only a single case of endophthalmitis, indicating that aqueous flow through the device is truly unidirectional,” Dr Dohlman said. Dr Dohlman acknowledged that the work he has done is just the beginning, and future advances in the field of artificial corneas will likely be forthcoming and significant. “Many groups around the world are working on the development of new keratoprostheses, and I expect we will see better designs that will place us in an entirely different, greatly superior situation a few decades from now. However, as this development continues, the researchers must keep in mind that while cost/affordability is an important issue, long-term safety is the primary concern.”

Vienna

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

Immediately preceding the XXIX Congress of the ESCRS

www.eucornea.org

contacts

Ike Ahmed – ike.ahmed@utoronto.ca

Update

Glaucoma

Temporal iridotomy

Set realistic expectations by Howard Larkin in Boston

atients are less likely to experience lid. The problem is the lid is dynamic; it is a bright line in the lower field of not always in the same position. Variations vision following laser peripheral in tear film contribute another element iridotomy if the LPI is placed of unpredictability in how a superior LPI temporally, well clear of the upper lid tear will respond,” Dr Ahmed told a glaucoma meniscus, rather than in the more common symposium at the ASCRS annual meeting. superior position, a prospective, randomised Previous research suggests that when fellow-eye study has found. The temporal the edge of the upper lid is close to the LRI avoids the unpredictability of superior LPI, the tear meniscus may act as a prism, locations, which may cause troublesome bending light up through the iridotomy, linear dysphotopsias even when they appear which diffracts it onto the retina, causing to be fully covered by the eyelid, said Iqbal the bright-line dysphotopsia characteristic of 'Ike' K Ahmed MD. iridotomy. faros_245x150_EuroT_e 6.5.2010 11:17 Uhr Seite 1 “You can try to put the LPI under the “For the temporal LPI there is no

meniscus present and no prism effect, so we do not find the bending of light,” said Dr Ahmed, who teaches at the University of Toronto, Canada, and the University of Utah, US. In addition to switching to a temporal or nasal position, Dr Ahmed recommends counselling LRI patients on the risk of postoperative linear dysphotopsias. Conducted with fellow Vanessa Vera MD and colleagues at the University of Toronto, the study Dr Ahmed reported compared the presence of dysphotopsias of several types before and one month after surgery in 153 patients, or 306 eyes. Each patient was randomised to a superior LPI in one eye and a temporal LPI in the fellow eye. Preoperative rates of dysphotopsia were comparable, even identical in most categories, for the temporal and superior eyes. Glare was most common at 22 per cent; followed by haloes at 14 per cent, ghost images at nine per cent and shadows at five per cent for both groups. Three per cent of the superior group and one per cent of the temporal group reported crescents

before surgery and one per cent of temporal reported lines. While previous studies, notably a case series of 172 eyes by George Spaeth MD and colleagues published in the Journal of Glaucoma in 2005, have found higher rates of shadows, ghost images and crescents associated with LPI compared with controls, this prospective study found only lines to be significant. “The streak of light is quite specific to iridotomy,” Dr Ahmed said. With the exception of lines, postoperative dysphotopsia rates actually declined in all categories, with glare down to about 15 per cent, and occurred at comparable rates for both groups. In the temporal group, three per cent reported lines after surgery, up from one per cent before surgery, compared with 11 per cent after surgery in the superior group, up from zero before surgery, a finding that was statistically significant. “A fully uncovered LPI, clear of the tear meniscus, is less likely to cause potentially troublesome linear dysphotopsia postoperatively,” Dr Ahmed concluded.

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contacts

Pascale Massin - p.massin@lrb.aphp.fr

Update

retina

Diabetes telemedicine

New strategy to tackle rise in diabetes by Dermot McGrath in Paris

successful diabetic retinopathy screening and telemedicine project in the Paris region may serve as a useful model for adopting a more widespread strategy to combat the coming epidemic in diabetesrelated ocular complications in France and perhaps further afield, according to Pascale Massin MD, PhD. “Diabetic retinopathy remains a major cause of vision loss despite the fact that very effective treatment has been available since 1980. Retinopathy is among the three major causes of blindness in the general population and the main cause of vision loss in patients younger than 65 years of age,” Dr Massin told delegates attending the French Society of Ophthalmology meeting. Dr Massin, Lariboisiere Hospital in Paris, warned that the coming diabetes epidemic would place a serious strain on France’s already over-stretched national health service, particularly for populations living outside the major metropolitan centres. “The current prevalence of diabetic retinopathy is around 30 per cent and the number of cases is expected to increase due to the increased number of diabetics and the earlier onset of the disease. Approximately 2.5 million individuals are affected by diabetes in France, 90 per cent of which are of the Type 2 variety. The prevalence of the disease is now close to four per cent, with a yearly average increase of 5.7 per cent,” she said. The situation is further exacerbated by the demographic problems facing the ophthalmic profession in the years ahead, warns Dr Massin. “The worrying aspect is when we compare the estimated rise in diabetes to the expected decrease in the number of ophthalmologists in France in the future. There are approximately 4500 ophthalmologists in France, but a 50 per cent decrease in their number is expected by 2015. A survey conducted by CNAM, the French National Health Insurance Fund, showed that in 1999 less than 40 per cent of Type 2 diabetic patients had seen an ophthalmologist during the preceding year. That statistic will only get worse unless a more efficient solution is found to diagnose and treat these patients,” she said. Dr Massin noted that various international and national guidelines over the years have recommended an annual funduscopic EUROTIMES | Volume 15 | Issue 9

examination for all diabetic patients. “Unfortunately, such examinations are not sufficiently carried out in France. The Liverpool Declaration of 2005 stated that European countries should reduce the risk of visual impairment due to diabetic retinopathy by 2010 by taking a series of measures, including setting up screening programmes that reach at least 80 per cent of the population, use trained medical professionals and personnel and provide universal access to laser therapy for patients,” she said. To compensate for the shortfall in annual fundoscopic examinations, non-mydriatic fundus photography hold potential as a valid method of evaluation for diabetic retinopathy and a viable alternative to ophthalmoscopy, said Dr Massin. Two pilot studies carried out in the Ile de France region initially demonstrated the feasibility of telemedical screening for diabetic retinopathy in both hospital and primary-care settings, said Dr Massin, and on that basis it was decided to develop a regional telemedical network, known as OPHDIAT, to facilitate access to regular annual evaluations of patients with diabetes while saving medical time. The system works thanks to a network of peripheral screening centres equipped with non-mydriatic cameras. Fundus photographs taken by technicians are sent to a reference centre where ophthalmologists grade the images. There are currently over 30 screening centres in the Ile-de-France region, all linked through a central server to one of a number of reading centres The images and the relevant patient information are securely transferred across the network using dedicated software (Ophcare). The entire process is subject to continuous statistical and quality control analysis to ensure optimal results are obtained within acceptable time frames and to minimise the risk of missed diagnoses. “It is important to develop rigorous quality assurance procedures for both image acquisition and grading to ensure the viability of the system,” said Dr Massin. “This helps to ensure that photographs are of adequate quality, that the grading is consistent and accurate, that abnormal screening results are reported in a timely fashion and that the expertise level of the graders is maintained at a consistently high level,” she said.

cent, with 5.6 per cent undiagnosed cases of severe retinopathy, and 8.5 per cent of photographs that could not be graded. The It is important to develop rigorous inter-grading agreement was found to be greater than 90 per cent and over 90 per cent quality assurance procedures for both of reports were produced within 48 hours. image acquisition and grading to Such positive results suggest that the ensure the viability of the system telemedicine network is essentially a winwin situation for both the ophthalmologist Pascale Massin MD, PhD and the public health authorities, believes Dr Massin. “Our firm conclusion is that task transfer Using such an approach, the reading associated with new technology improves centre is capable of processing the files of diabetic retinopathy screening efficacy. It around 40 patients in half a day, which must, however, be combined with a rigorous equates to a time saving of about 60 per cent quality assurance programme for training for the ophthalmologist, said Dr Massin. technicians and ensuring high levels of Looking at the overall results using consistency. The system saves considerable OPHDIAT from September 2004 to time for the ophthalmologist, but crucially December 2009, over 50,000 screening there is no compromise in terms of patient examinations were performed using six care because the ophthalmologist is still the certified graders/ophthalmologists. The person who oversees entire management Ins_easyPhaco_120x120_EuroTimes 6.5.2010 11:21 Uhr theSeite 1 diabetic retinopathy prevalence was 23.4 per of the patient,” she said.

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

18 â&#x20AC;&#x201C; 20 February 2011

Hilton Hotel, Istanbul, Turkey

www.escrs.org

European Society of Cataract and Refractive Surgeons

contacts

Anat Loewenstein – anatlow@tasmc.health.gov.il

Update

retina

AMD treatments

Different mechanisms may also be synergistic by Dermot McGrath in Berlin

here is growing evidence to suggest that combination therapy may offer definite advantages in certain patients over monotherapy in the treatment of exudative age-related macular degeneration (AMD), according to Anat Loewenstein MD. “We have all had some experience of patients that do not respond to the excellent anti-VEGF pharmacological treatments that are available today, and we need to be able to offer them an alternative strategy,” Dr Loewenstein told delegates attending the World Ophthalmology Congress. “There is definitely a rationale for combination therapy in AMD due to the

EUROTIMES | Volume 15 | Issue 9

multifactorial nature of the pathogenesis of the disease. And while there is an absence of large prospective, randomised controlled studies on combination therapies, I think the theoretical rationale probably translates into clinical practice,” she added. Dr Loewenstein, director of the Department of Ophthalmology at the Tel Aviv Medical Centre, and vice-dean of the Faculty of Medicine in the Tel Aviv University, Israel, noted that there are several good reasons to adopt combination therapy in the treatment of AMD. “With a complex pathophysiological process such as AMD it is no surprise that monotherapy does not always completely

address the pathogenesis of the disease. And since the mechanism of action is different for many drugs that we have in our treatment arsenal, the different mechanisms of a combination approach may also be synergistic,” she said. For example, laser treatment and photodynamic therapy can target the destruction of neovascular complexes and pathologic vessels, said Dr Loewenstein, while anti-VEGF drugs can inhibit neovascularisation, leakage and oedema. Finally, steroids can play an important role in the management of AMD thanks to their anti-inflammatory and anti-fibrotic effect. Combination therapy may also improve flexibility in meeting individual patient needs by reducing the burden of treatment and improving efficacy and safety, said Dr Loewenstein. Combination treatment options included dual therapy in the form of anti-VEGF drugs and photodynamic therapy, or antiVEGF compounds combined with steroids or irradiation treatments. Triple therapy may combine anti-VEGF drugs with PDT

and steroids, anti-VEGF and ICG-directed PDT and steroids or anti-VEGF with diode laser and steroids. Dual treatment with anti-VEGF drugs and PDT is perhaps the most commonly tried approach. The results of the recent Mont Blanc trial showed that combination therapy was not inferior to monotherapy in terms of visual outcome, although the overall number of ranibizumab injections required over the course of 12 months was not significantly reduced. Possible reasons that the Mont Blanc study did not demonstrate a greater benefit in outcomes could include the use of full-fluence rather than reduced-fluence PDT and the omission of corticosteroids from the treatment. Dr Loewenstein noted that the awaited results from the DENALI trial, which has a similar design to Mont Blanc but with a reduced fluence PDT, would help to shed light on the possible benefits of combination therapy. The second part of this article will appear in the October issue of EuroTimes.

Alcon in Paris EURETINA/ESCRS Congresses 3-6 September 2010

SURGICAL FACULTY Dr. Lucio Buratto Host Surgeon

PANEL FACULTY Dr. Donald N. Serafano Moderator

Medical Director Center Ambrosiano de Microchirurgia Oculare (C.A.M.O.) Milan, Italy

Complete Eye Care Associates Clinical Associate Professor University of Southern California Los Alamitos, California

Dr. Takayuki Akahoshi

Prof. Béatrice Cochener

Director of Ophthalmology Mitsui Memorial Hospital Tokyo, Japan

Professor of Ophthalmology University of Brest Brest, France

Dr. Luis Cadarso

Dr. Ozana Moraru

Head of Ophthalmology Hospital Meixoeiro Medical Director Clinica Cadarso Vigo, Spain

Medical Director Oculus Eye Clinic Bucharest, Romania

Dr. Philippe Crozafon

Dr. Yuri Takhtaev

Cataract and Glaucoma Surgery Clinic Saint George Nice, France

Ophthalmic Surgeon MNTK Eye Microsurgery Senior Lecturing Faculty Member St. Petersburg Medical Academy St. Petersburg, Russia

Dr. Marc Weiser

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Past President French Society of Cataract and Refractive Surgery Paris, France

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Ocular

Facing major challenges

Ophthalmologists need to work collectively to defend their interests, and those of their patients by Dermot McGrath in Paris

Women throughout the ophthalmic industry say:

OWL is a great place to network, find a mentor, and benefit from a variety of educational programs. OWL members enjoy free access to career boosting special events, the chance to plug into social networks, participate in webinars, and access OWL online networking. Join OWL in Paris! Enjoy cocktails and casual conversation on 6 September near Le Palais des Congrès. For more information, visit: www.owlsite.org email: info@owlsite.org EUROTIMES | Volume 15 | Issue 9

he vexed question of the role of optometrists, differing standards of care from one European country to another, and the challenge of delivering quality eye care to ageing populations with diminished resources are just some of the key issues facing European ophthalmologists in the near future, according to Michèle Beaconsfield MD. Addressing delegates attending the French Society of Ophthalmology (SFO) annual meeting, Dr Beaconsfield, president of the ophthalmology section of the European Union of Medical Specialists (UEMS), said that ophthalmologists need to work collectively to defend their interests, and those of their patients, in a rapidly evolving European landscape. She noted that medical qualifications, as well as standards of ophthalmic training and care, tend to vary considerably from one European country to another, as may the actual delivery of eye care in those countries. “The European Union is based on the concept of free movement, both of doctors and patients. However, we know in reality that the medical and specialist qualifications are not necessarily the same from one country to the next, and the same applies to the way that that healthcare is delivered,” she said. In the Baltic countries, for example, Dr Beaconsfield said that specialist postgraduate training as an ophthalmologist typically takes only three years, compared to a minimum of four or more years in the rest of Europe. “This is obviously not a desirable situation, although some progress has been made recently. Through the work of UEMS, Lithuania has now moved to a minimum four-year training like the majority of the rest of Europe and we hope other countries in the region will follow suit,” she said. At the other end of the scale, Dr Beaconsfield noted that specialist training as an ophthalmologist in the UK takes about six years. “This is because ophthalmology in the UK is almost exclusively a surgical specialty and therefore carries more years,” she said. The delivery of eye care is also very different from one European region to another, Dr Beaconsfield added. “In the UK and some northern European countries the majority of practitioners are based in hospitals, and it is the general practitioner and optometrist who will refer the patient onto that service, whether it be a publicly-funded hospital or a private practice. In some other European countries, the first person that a patient will see will be an ophthalmologist who works in the community. Depending on the patient’s condition, the ophthalmologist may then refer the patient to a colleague who is either in a hospital or in a private clinic for further treatment,” she said. On the controversial question of optometrists, Dr Beaconsfield said that a lot of the confusion comes from differing definitions of an optometrist from one country to the next. “We now have a lot of opticians calling themselves optometrists across Europe, which understandably raises the hackles of a lot of ophthalmologists. That is because this group of individuals are not what the Dutch, the Swedes and the British understand as optometrists. In the UK we have 5,500 opticians who only dispense glasses, and about 12,000 optometrists,” she said. The high number of optometrists is useful in the UK as it has only some 2,000 ophthalmologists, said Dr Beaconsfield.

“For many decades, in the UK we have enjoyed good relations with the optometrists. That is because it is a three-year university course with a year’s apprenticeship before they are fully registered and can work independently. And that is why they are able to exercise an expanded role compared to those calling themselves optometrists in some other parts of the EU. For instance, in the UK they are trained to detect ocular abnormalities and are then obliged to refer those patients on to their general practitioner (who may then refer them to the hospital eye service), or directly to the hospital ophthalmologist in some cases,” she said. The situation in the UK contrasts with that in France, said Dr Beaconsfield, where a very well developed orthoptic service with some 2,000 orthoptists has evolved over the years. An important controlling factor in France, however, is the official ‘decret’, a five-page document describing what orthoptists are entitled to do, and always under the jurisdiction of an ophthalmologist. As demands on ophthalmologists grow, hard choices will have to be made about the delegation of tasks, said Dr Beaconsfield. Nurses, technicians, optometrists, orthoptists and medical secretaries all have a role to play in delivering quality care to the patient, but the supervising medical role can only be the responsibility of the ophthalmologist, she said. “How you do it and whom you do it with is not really the issue – the issue is are you going to be able to deliver a service that is of similar good quality to the patient across the EU,” she said. Cataract, age-related macular degeneration, diabetic retinopathy and glaucoma are the pathologies that will particularly preoccupy Europe’s ophthalmologists in the coming years, said Dr Beaconsfield, who warned that strategies will have to be elaborated to deal with issues relating to cross-border mobility and health tourism in Europe. “The problem is that patients travel and what is considered normal practice in Romania is not the same as in Spain. The most important issue today is deciding who is actually responsible for the quality and safety of ophthalmic care of the patient. That has to be the ophthalmologist and not the paramedic,” she said. Harmonisation of standards and training across the entire European region also has a role to play, said Dr Beaconsfield. “It is more than just continuing profession development (CPD) and continuing medical education (CME). We all have to sing from the same hymn sheet and have comparable training from the beginning. It does not have to be identical, but it has to reach the same standard and how that is attained is up to the individual country,” she said. Dr Beaconsfield said that the concept of the “Medical Act” would help to protect ophthalmologists and patients in the delivery of healthcare in the years ahead. “After many years of battling and rewriting we persuaded all the UEMS specialty sections to agree on the definition of a medical act and it was formally adopted by the UEMS Council over three years ago. The key point is that the medical act is the responsibility of, and must always be performed by a registered medical doctor or under his or her direction, supervision or prescription. That is what ophthalmologists are for,” she concluded.

contact

Michèle Beaconsfield – mb@consultansee.co.uk

Update

Ocular

as seen from inside

Online OCT provides surgeons with interior view of intraocular structures during anterior segment surgery by Roibeard O’hEineachain in Budapest

n innovative set-up that allows surgeons to view OCT images of the anterior segment virtually in real time could improve the safety and efficacy of a number of ophthalmic surgery procedures, according to Gabor Scharioth MD, (Augenzentrum Recklinghausen, Germany and University of Szeged, Hungary) one of the system’s developers. He called this technique OCTAASS – optical coherence tomography assisted anterior segment surgery. “The use of intraoperative online optical coherence tomography in anterior segment surgery gives a new view at intraocular structures and the dynamics of surgery. It could be useful in routine and complicated cases in different indications as well as for scientific purposes,” he told the 14th ESCRS Winter Meeting. In his presentation, Dr Scharioth provided video demonstrations of the use of the imaging system in a range of anterior segment procedures. The system consists of a specially designed and modified OCT (Visante™, Zeiss) connected to an operating microscope and a video recording device. Dr Scharioth noted that during routine cataract surgery the online OCT setup enabled the surgeon to easily observe the IOL’s entry into the capsular bag. “We think cataract surgery could be one of the indications for this technology because it enables you to see the intraoperative fluidics, the lens density, the IOL position, and the incision architecture. For femtosecond laser assisted cataract surgery OCTAASS is mandatory and will improve results,” he said. In addition, during canaloplasty procedures even the 10-0 prolene suture was visible in cross-section, as it was drawn tighter within Schlemm’s canal. The enlargement of Schlemm’s canal as the catheter injected the OVD was also visible. Moreover, during implantation of an implantable Collamer lens (Visian™ ICL, Staar Surgical), the online OCT device was able to confirm the patency of the iridotomy and provide a measure of the IOL’s vaulting and distance from the crystalline lens, Dr Scharioth said. Other procedures utilising the device include keratoplasty, corneal refractive procedures, and secondary IOL implantation with his technique of intrascleral haptic fixation. In every case intraoperative

EUROTIMES | Volume 15 | Issue 9

visualisation of intraocular structures was possible, and no complication related to the device occurred. Other major advantages over other imaging systems are the non-contact characteristic of the system, no sterile assistance is required and that the surgeon is enabled to continue bimanual surgery. In a related presentation, Prof Beatrice Cochener MD, University of Brest, France, said that the Visante OCT is one of the best devices for imaging anterior segment currently available (easy to use with no contact) although it retains some important limitations. The other available imaging systems for assessing anterior segment are Sheimpflug camera (competitive to OCT) and high frequency UBM (operator dependant). She added it fulfils the required criteria for such a device through its high precision, resolution, and reproducibility. Its 1310 nm wavelength makes it optimal for imaging the anterior segment. It enables greater penetration of opaque tissues such as the sclera and cornea, than is possible with the 820 nm wavelength of the Stratus™ OCT (Zeiss). The Visante OCT also scans 20 times faster and with less distortion, and therefore reduces artefacts due to eye movement, she continued. Moreover, the device’s 1310 nm wavelength is more completely absorbed by water, which reduces retinal exposure, providing a possible safety benefit. There are some enhancements that will come to the market soon with version 2.0 of the Visante OCT software, Prof Cochener noted. Moreover, the new Visante Omni system enables linkage with an Atlas Placido disk topographer (Zeiss). Through correlation of the two instruments’ measurements it will be possible to obtain a topographic map of the posterior corneal surface, she noted. However, there are a few inherent limitations to OCT systems that will remain. But most importantly, OCT cannot penetrate the pigment of the posterior iris, which means it cannot provide imaging of the sulcus, or provide the sulcus-to-sulcus diameter for placement of ICLs. At present sulcus-to-sulcus measurements are only possible with high frequency ultrasound, Prof Cochener said.

contacts

G Scharioth – gabor.scharioth@augenzentrum.org B Cochener – beatrice.cochener@ophtalmologie-chu29.fr DGBFRUQHDBSURWHFW [ Y MPR (XURWLPHV LQGG

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Building a business from the extraordinary beauty of ophthalmology by Dermot McGrath in Paris

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Eyeland Design Network provided the animations, pictures and video material for the Opening Ceremony of the WOC in Berlin

n describing his chosen profession Karl Brasse MD uses a word that most ophthalmologists avoid lest it diminish their image as serious professionals â&#x20AC;&#x201C; fun! Yet Dr Brasse, an anterior segment surgeon in the German border town of Vreden, is more than happy to use the word "fun" to describe his encounters with that most wonderful of human organs, the eye. As partner of Eyeland Design Network, an ophthalmology-focused photography, design, and marketing firm, in addition to his full-time activity as an anterior segment surgeon, Dr Brasse gives the lie to the expression that familiarity breeds contempt. Eyes are his work, his passion and inspiration. â&#x20AC;&#x153;This is why I chose to become an ophthalmologist. Ophthalmology has beauty, fascination and emotion. We have wonderful therapies and there is a lot of new and exciting diagnostic equipment available. So itâ&#x20AC;&#x2122;s a lot of fun to be an ophthalmologist and I am happy to celebrate that fact with images.â&#x20AC;? This philosophy has enabled Eyeland to carve out a lucrative niche in providing stunning high-resolution images and animations for customers who use them for posters, calendars, advertising, billboards, educational materials and websites. The firm was founded in 1997 when Dr Brasse, then a newly qualified ophthalmologist, got back in touch with an old school friend, Guido Schulte, a graphic illustrator and musician.

EUROTIMES | Volume 15 | Issue 9

â&#x20AC;&#x153;When the idea came to me I immediately thought of Guido,â&#x20AC;? said Dr Brasse. â&#x20AC;&#x153;We were friends for years and worked on some creative film projects in school. We started the company and now we have a core team of four, with Guido, myself, Curt-Wilhelm Flakowski and Rene Paradies, both of whom are experts in 3-D design,â&#x20AC;? he said. This expertise was to prove key to one of Eyelandâ&#x20AC;&#x2122;s first major projects, building a three-dimension eye. In a major boost for the firmâ&#x20AC;&#x2122;s profile, Eyeland Design Network was recently asked to provide the stunning sequence of animations, pictures and video material for the Opening Ceremony of the World Ophthalmology Congress (WOC) 2010 in Berlin. The challenge was to take the audience on a exploratory journey into the rich complexity and wonder of the human eye using 3-D images. â&#x20AC;&#x153;We wanted to do something different and really grab peopleâ&#x20AC;&#x2122;s attention. There has been a spectacular development in imaging technology in the last few years so the timing was right for a company like ours. We tried to showcase a lot of the latest techniques in the sequences we put together for the WOC. In one animation, we fly through the pupil, the cornea, the macula and then into the retina for a spectacular race between rods and cones,â&#x20AC;? he said.

contacts

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Update

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ith onchocerciasis on track for elimination in the Americas in the next couple of years, there are cautious grounds for optimism that the same results can eventually be obtained in Africa where the disease is most prevalent and the need is greatest, according to Adenike Abiose FRCOphth. “Approximately 17.7 million people worldwide are infected with river blindness and more than 99 per cent of those infected live in Africa. Yet while the challenges are immense, we have seen in recent years a definite paradigm shift from controlling the disease to a situation where we can hope to eliminate it completely in certain countries,” she told delegates attending the World Ophthalmology Congress (WOC). Dr Abiose, medical director of Sightcare International in Ibadan, Nigeria, noted that large-scale control of onchocerciasis commenced over three decades ago, initially through the Onchocerciasis Control Programme (OCP) in West Africa and more recently the African Programme for Onchocerciasis Control (APOC). The goals of OCP were to eliminate onchocerciasis as a public health problem and to mitigate its negative impact on the social and economic development of affected regions, said Dr Abiose. Using vector control and ivermectin (Mectizan) administration, the programme succeeded in preventing infection and eye lesions in an estimated 40 million people and averted an estimated 600,000 cases of blindness. With APOC, the strategic objective has been to protect the remaining 120 million people at risk of the disease in Africa through the establishment of community-directed treatment with ivermectin. “One of the key lessons is that to eliminate onchocerciasis we need to continue treatment for a sufficiently long period of time. There is a need for intervention with adequate geographic and therapeutic ivermectin treatment coverage over a sufficient time period. We also know the importance of monitoring epidemiological and entomological data in sentinel areas to give us better predictive models for the disease. And we also need a sufficiently long posttreatment surveillance period – at least three years according to WHO guidelines – in order to declare elimination of the disease,” she said.

To review progress in Africa and to discuss future strategies, two meetings were held in Burkina Faso in 2009 and 2010. “The conclusions of those meetings were that onchocerciasis can be eliminated at least from parts of Africa and the ‘infection map’ successfully shrunk, particularly in West and East Africa,” she said. Nevertheless, there are several issues to be addressed in moving from control to elimination in Africa, cautioned Dr Abiose.“We need to obtain more empirical evidence of the feasibility of elimination and required interventions. We also need to develop clear guidelines for countries on what has to be done to achieve elimination and prove the absence of transmission.” In a separate presentation, Frank Richards MD, director of the River Blindness Programme of the Carter Centre said that patience and perseverance were needed to eliminate onchocerciasis. To successfully eliminate onchocerciasis, Dr Richards highlighted three challenges: first, finding drugs that kill the adult worms, second, designing better mathematical models to predict the course of infection, and finally, developing better diagnostics. While ivermectin has been successful at killing the microfilariae and disrupting transmission of the disease, it does not actually kill the adult worms. Efforts to develop a macrofilaricide drug (one which kills the adult worms) through the WHO Macrofil project have resulted in some success, said Dr Richards. The antibiotic doxycycline, for instance, is a potent agent against Wolbachia bacteria, which play a vital role in the fertility of the onchocerciasis parasite. Another promising treatment is moxidectin, said Dr Richards. Since moxidectin may kill not only the microfilaria but could also sterilise or kill the adult worms, it has the potential to interrupt the disease transmission cycle within around six annual rounds of treatment. If human trials prove successful, the drug could be distributed through the community-directed mechanisms set up in collaboration among APOC, African control programmes, and NGOs for the distribution of ivermectin.

contacts Adenike Abiose – adenikeabioseo@yahoo.com Frank Richards – frich01@emory.edu

Update

Vision 2020

Eye care in Africa characterised by limited resources by Stefanie Petrou Binder MD in Berlin

n a stimulating discussion on blindness prevention, held at the World Ophthalmology Congress (WOC), 2010 in Berlin, African doctors and healthcare organisers looked at the shortcomings of the VISION 2020 programme to date. They agreed that until the African people own the problems of eye care, blindness will persist. According to Ngoy Kilangalanga MD, a paediatric ophthalmologist and head of the eye department at St Joseph’s Hospital in Kinshasa, Republic of Congo, programmes without community participation will fail to have an impact on the local population. “People visiting eye centres in Africa either can afford to pay for eye care or were referred by family members. The masses of needy people simply do not seek help,” he said. Dr Kilangalanga noted his experience over the past 10 years in Kinshasa as a model of community involvement that could work for other African countries. He was part of an initiative that trained community field workers in eye disease identification, in association with the local church. By taking personal responsibility for a certain number of villagers, the field workers were able to identify 150 cases of cataract in 58 Congo communities. Although only 24 individuals received surgery, this showed a large measure of success and commitment on the community level, he observed. “Community volunteers are trained to identify eye diseases such as cataract, glaucoma and lid diseases. Training helpers on the community level is what it takes to implement a change in mentality, actually get through to people, and get help to where it is needed,” he said. Wanjiku Mathenge MD, an ophthalmologist from Kenya who serves also as an eye care consultant for the Fred Hollows Foundation, believes that in addition to providing eye care, eye care workers at all levels need to collect evidence in order to determine their level of success at reducing blindness. Indicators need to be established, such as those, for instance, already implemented in malaria programmes. This information is both useful to physicians and important as feedback to the people. “Eye care is a personal and parental responsibility, and educators need to penetrate into the communities to communicate the role each person plays and teach self-responsibility,” she said. EUROTIMES | Volume 15 | Issue 9

Blindness has to compete for attention with a host of other health issues in Africa. As blindness does not kill, like malaria, tuberculosis, or HIV AIDS, it is harder for this cause to be heard and gain the requisite support. Malian ophthalmologist and coordinator of VISION 2020 in West Africa, in the West African Health Organisation, Doulaye Sacko MD, urges for eye care to be included in other healthcare programmes so that it is not ignored or put on hold. "How can the prevention of blindness become a priority for decision makers? I think we should move from a blindness control concept to an eye health development concept," Dr Sacko said. "The reason is that there are more people with eye health problems than who are blind. Whilst about 0.5 per cent to one per cent of the population are blind, more than 20 per cent need eye care. This approach could be interesting for advocacy. “We need to continue to demonstrate the link between blindness and poverty,” Dr Sacko said. Governments and funding programmes need to understand the negative financial repercussions of blindness, in order to show how much money could be saved by its prevention, he said. Kovin Naidoo, International Agency for the Prevention of Blindness (IAPB) Africa Chairperson and International Centre for Eyecare Education (ICEE) Global Programs Director had a realistic take on the results of the VISION 2020 programme. “On a global level coordinated planning has been successful mainly due to VISION 2020 but we have been confined to the eye care sector and that’s a major weakness,” Prof Naidoo said. Coordinated planning on the global, regional and national levels are needed to promote the wise use of limited resources, aid advocacy through joint efforts, and maximise the impact of islands of success through their duplication. He pulled for greater financial input from NGOs, the integration of eye care into healthcare plans among the broader health and development sectors, WHO collaboration beyond eye care, and called for an end to lip service and the implementation of practical changes.

contacts

Doulaye Sacko – bayesacko2000@yahoo.frk. Kovin Naidoo –naidoo@icee.org.au Wanjiku Mathenge –Wanjiku.Mathenge@lshtm.ac.uk

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News

EBO European Board of Ophthalmology

European excellence in action Candidates converge on Paris to try to earn the coveted EBO Diploma

by Dermot McGrath in Paris

hey came from different backgrounds and spoke different languages, but there was no mistaking the intensity of purpose that united the 300-plus ophthalmology residents and specialists who came to Paris this year in search of the coveted European Board of Ophthalmology Diploma (EBOD) qualification. As in previous years, the EBOD examination comprises a multiple choice written exam (MCQ) as well as a fourpart viva-voce exam, the latter seeing each candidate examined on the four key topics of ophthalmology by a team of eight examiners. For the first time in its history, this year’s EBOD saw the introduction of negative marking to the MCQ. The reason for adopting this system was to increase the discriminating power of the MCQ examination by eliminating uneducated guessing and rewarding knowledge. However, the good news for the highest number so far of 310 candidates from 27 different European countries who sat the exam was that this year’s pass rate of 92 per cent was even slightly higher than previous years. “This confirmed the fact that this new system need not have a negative or harsh impact on the pass rate of students but simply elevates superior students from those relying more on guesswork,” said Marko Hawlina MD, PhD, FEBO, president of EBO. Prof Hawlina added that the success of the examination was greatly due to more than 180 examiners from all over Europe to whom he expressed gratitude for their voluntary participation. Once the examination had concluded, sponsors Laboratoires Théa organised a fun and informal dinner event where all candidates, together with their examiners, could unwind in a relaxed atmosphere and celebrate the truly European spirit of the EBO exam. All the successful candidates, as well as the award winners for the best exam results, were commended for their achievements at the traditional awards ceremony. Panagiotis Georgoudis of Greece was awarded the prize for Best Overall EBOD 2010, while the other main prize winner EUROTIMES | Volume 15 | Issue 9

was Iris Steinbrugger from Austria who received the Alan Ridgway Award for best MCQs result. Dr Ridgway himself was on hand to present the award, bringing another successful EBOD examination to a close for 2010.

Right picture: Successful EBOD candidates Efstratio Mendrinos (left) and Mattheos Antoniadis from Greece Below (from left to right): Rashed Al Sowaidy, Hüsnü Berk and Markus Schulze Schwering from Germany, who also received the EBOD qualification

EBOD 2010 success stories

A great honour to represent Croatia

A qualification respected throughout Europe Panagiotis Georgoudis, Greece, was awarded the Best Overall EBOD in the 2010 examinations: “I thought I did well in the exam but with so many candidates and such a high standard, I never really expected to come first, so I was pleasantly surprised. It is nice to have recognition after years of hard work which have gone into reaching this point. “I wanted to take this examination because I thought it would be useful to have a qualification that is respected throughout Europe. I have already done similar exams in the United Kingdom at the Royal College of Ophthalmology, so I thought it would be interesting to try the EBO exam and support in some way the European ideal. Panagiotis Georgoudis “After I finish my fellowship at the Bristol Eye Hospital, I would perhaps like to work in France or Germany or maybe even stay and work in the United Kingdom. I really want to focus on my subspecialty in medical retina and become very good at that. It’s an ongoing process and it is important to keep trying to progress, to learn more and become a better surgeon for the benefit of your patients.”

A difficult but fair exam Nicolas Mesplie and Aurore Muselier were two of the local French candidates who shared the third place award for Best Overall EBOD. Nicolas Mesplie: “The EBO examination is obligatory for all ophthalmology interns in their final year in France. I was relatively confident before the exam, although naturally I was a bit stressed because I did not want the final exam of my university studies to end in failure. “The real merit of the EBO exam is that it compels us to revise some of the finer details that were perhaps not sufficiently focused on during our studies. It also enables us to evaluate our knowledge at the end of our university programme and to spot areas of weakness that can be then improved upon. The qualification also enables us to validate our knowledge and work in another European country.”

Nicolas Mesplie

Aurore Muselier: “I think that the EBO examination allows us to have a fresh look at a specialty we have been studying for five years. It is very important to reinforce our practical knowledge with all the theoretical basis of our specialty. “Overall, the EBO examination was a positive experience which allowed me to review the rudiments of ophthalmology and to learn more about subspecialties which I had not fully studied such as paediatrics, and so on. This experience allowed me to step back somewhat from my knowledge and to see my profession from another point of view.”

Ivana Bednar Babić was one of two Croatian candidates who participated at EBOD 2010: "I am very proud to be one of the two Croatian candidates who participated at the EBOD exam. This was the first time for our country to participate, so it was a great honour to represent Croatia. My main motivation for taking the exam was to test myself and my knowledge. I took the specialist diploma Ivana Bednar Babic examination in Croatia in 2007, so I was curious to see if I had lost some of the knowledge in the meantime and I also wanted to compare our education with European standards. "All in all, it was a great experience. I met many new colleagues with whom I can now share my professional experiences and I have renewed and enhanced my ophthalmic knowledge."

It was a perfect time and a wonderful experience Iris Steinbrugger from Austria shared the overall third place at EBOD 2010 and received the Alan Ridgway Award for best MCQs result: "I thought that the EBOD would be of benefit because the examination is oral as well as written, with more emphasis on active learning rather than just memory work. The exam also takes place at a perfect time – after the winter and you get to have a few days in Paris, which is always nice! "I came away with the best memories of the entire experience. It was a perfect time, even the day of the examination which I enjoyed too, strangely enough. I would definitely recommend other residents to take this examination. It is an excellent examination with the chance to meet other great people and to expand one’s knowledge in ophthalmology."

Flawless organisation

Aurore Muselier

A chance for personal growth and achievement John Grech Hardie was the sole candidate from Malta who took this year’s EBOD examination: “I have followed the progression of the European Board of Ophthalmology Diploma and have wanted to attain this increasingly universal and prestigious award for quite some time now but because of a busy work schedule as a practising ophthalmologist I never found the time. This year I made it a personal challenge to sit for the examination. “The last couple of weeks leading up to the exam were obviously quite stressful not knowing quite what to expect but the examination turned out to be very fair. The MCQ paper was balanced with both John Grech Hardie straightforward as well as some difficult questions while the viva voces were fair and involved mostly routine ophthalmological cases. “I must say my experience of the EBOD examination was very positive. My fondest memory is of the Award Ceremony where I felt I had joined a multinational family of ophthalmologists from all over Europe. I do encourage residents to take the examination. In fact having no exit examination of its own, the Maltese training programme recommends the EBOD examination at the end of training. I think that apart from awarding an official European recognition of status, the EBOD examination offers a chance for personal growth and achievement: a ‘rite of passage’ so to speak.

Lorenzo Franscini shared the third place award for Best Overall EBOD 2010. "Switzerland, in line with some other European countries, has recently substituted traditional Board exams with the unified EBO exam. I think it is essential that a single exam guaranteeing the highest of standards be applied as widely as possible. I was very pleased at the flawless organisation in Paris, notwithstanding the large number of candidates and examiners. "The MCQ and oral exams were well balanced and reflected a wide range of difficulty levels. I highly recommend the exam to residents at the end of their studies as it allows one to verify one’s knowledge on a European scale."

Success brings self confidence Svetlana Belova from Estonia: "My main motivation for taking the EBOD examination was to find out if my knowledge in ophthalmology satisfied the requirements of the European Board of Ophthalmology in spite of shorter duration of residency in Estonia (three years). Waiting for the examination was stressful, but clear guidelines on the EBO homepage, personal instructions and friendly staff relieved anxiety on the day. Colleagues who had already passed the EBO exam also encouraged me to take the exam this year. "It was a very interesting, positive experience overall, especially discussing case reports in the oral part with examiners from different countries and realising that we have very similar approaches to the management of ophthalmic diseases. I would recommend other residents to take the examination because success will enhance their self-confidence and help to raise the standards of ophthalmology."

Don’t miss Outlook on Industry, see page 44 EUROTIMES | Volume 15 | Issue 9

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eurequo

Slovakia on board

Despite a difficult beginning, Slovakian ophthalmologists see benefits of EUREQUO by Dermot McGrath

he roll-out of the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) is now at an advanced stage in Slovakia and efforts are being accelerated to bring the majority of ophthalmologists in the country into the network, according to Prof Andrej Cernak. “It was not so easy in the beginning, but we are pleased that more ophthalmologists in the Slovak Republic are actively participating in the EUREQUO project, with cooperation established with almost all the major university, national and private refractive surgery practices and hospital-clinics. We created a network and liaised with all of them, and supported each clinic individually according to its needs,” said Prof Cernak. The real breakthrough in implementing EUREQUO in Slovakia came only after the annual congress of the Slovakian Ophthalmological Society had taken place, said Prof Cernak. “Up until that meeting, the initial feedback from our ophthalmologists was not all that positive. However, the

congress gave us the opportunity to present the benefits of EUREQUO to our members and to convince them to participate,” he said. A key component of the Slovakian EUREQUO national plan was to target the largest clinics first rather than attempt to convince each ophthalmologist on an individual basis. “Our strategy was to focus on clinics with the biggest amounts of surgeries. That meant that we solicited the agreement with professors and heads of ophthalmology departments of each hospital and we think that was the key to successful participation. They understood that for all of us this was a great opportunity to have an online database,” he said. To build on the progress made to date, Prof Cernak said that the coming months will see the EUREQUO team continue to collecting data, to focus on qualitative results and target the remaining university clinics that have still not signed up to the registry. While surgeons are understandably wary of adding further layers of administration to

EUREQUO European Registry of Quality Outcomes for Cataract & Refractive Surgery

EUREQUO EUREQUO for improving my outcomes European Registry of Quality Outcomes for Cataract & Refractive Surgery

paris 2010 XXVIII Congress of the ESCRS

Le Palais des Congrès

Project co-financed from the EU Public Health Programme

their already hectic schedules, Prof Cernak believes that the time invested in EUREQUO will ultimately reap dividends for all participants. “From my perspective there are only positive outcomes from the registry. It will help us to improve our surgical skills, and having better results means our patients will also be more satisfied. Furthermore, it is important to be able to compare our results with the rest of Europe, to learn from our mistakes and from those of our colleagues elsewhere and to be able to draw on a database that we can use any time,” he said. Unlike the Netherlands and some Scandinavian countries, Slovakia did not have an existing registry in place. While the lack of a national registry gives Slovakia the opportunity to build EUREQUO from scratch, the implementation brings its own technical challenges, explained Prof Cernak. “We had some technical problems because of the absence of an online registry, which meant that each clinic had its own system in place. In the beginning, we tried to find compatibility between EUREQUO and our systems but it simply wasn’t possible. So we decide to do it the old-fashioned way, printing protocols and sending them to the clinics, which would then fill them in and send them back to us to be put into the system. Other clinics were able to do it online themselves which obviously makes life easier for everybody,” he said. As Slovakia continues to ramp up its registry efforts, Prof Cernak paid tribute to

Sunday 5th September

Constantin Kakoulidis – kakoulidisk@gmail.com

Constantin Kakoulidis (left) and Andrej Cernak

the ophthalmologists and background team who have worked so hard to get EUREQUO off the ground. “I would sincerely like to thank all the participating clinics and every single surgeon that is participating in the project. We are also grateful to the EUREQUO management team for their continuous support and, of course, our registry managers here in Slovakia, Constantin Kakoulidis and Adela Kosova for all their efforts,” he said.

FREE TO ALL DELEGATES

08.00 – 10.00

Instructional Course Introduction EUREQUO, purpose, background & design Mats Lundström SWEDEN What do we need to know about cataract surgery? Ype Henry THE NETHERLANDS What do we need to know about refractive surgery? Paul Rosen UK Presentation of the EUREQUO system Eva Wendel SWEDEN Pause

Tools for clinical improvement Susanne Albrecht SWEDEN How can we do better cataract surgery using EUREQUO? Ype Henry THE NETHERLANDS How can we do better refractive surgery using EUREQUO? Paul Rosen UK Output from the EUREQUO system for benchmarking Mats Lundström SWEDEN Concluding remarks Mats Lundström SWEDEN

Monday 6th September Free Paper Sessions 14.00 -16.00

14.30 -17.00

Do not miss this opportunity to become part of the future. Come and see the benefits to be gained by you!

Salle Ternes

Amphitheatre Bleu

Practice Styles

Presbyopia

See www.eurequo.org for more information

1. Outcomes of Cataract & Refractive Surgery as Reflected by EUREQUO Mats Lundström SWEDEN

President’s Address: Refractive Outcomes: EUREQUO and International Audit

2. The Dutch Cataract Outcome Data and EUREQUO Ype Henry THE NETHERLANDS

EUROTIMES | Volume 15 | Issue 9

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PRACTICE DEVELOPMENT

contact

Feature

John Banja - jbanja@emory.edu

Breaking news on medical errors

Preparing and controlling your defensiveness helps patients understand by Howard Larkin

reaking bad news to a patient is never easy, particularly when the bad news involves your having made a mistake. As a result, admitting errors is often done poorly and can compound problems for both the patient and ophthalmologist, according to John Banja PhD, a medical ethicist at Emory University, Atlanta, US, and author of Medical Errors and Medical Narcissism. Failing to disclose bad news in a way that the patient can understand and emotionally process leads to confusion and resentment, Dr Banja told an audience at the annual meeting of the American Society of Cataract and Refractive Surgery. It’s not good for the patient’s morale or recovery. It may even lead an otherwise reasonable patient to retaliate with a lawsuit or complaint. So if frankly and compassionately disclosing medical errors is the ethical and practical thing for you to do, why is it so hard? “A medical error challenges your professional self-image and esteem,” Dr Banja says. Acknowledging it challenges what he calls “the narcissist in us all”. By narcissism, Dr Banja means the hardwired tendency to feel good about ourselves,

Journal Watch

which is a part of the psychology of selfpreservation. Health professionals tend to feel whole and valuable when they perceive themselves as competent, useful and in control. Narcissism is psychologically healthy when it drives us to be better prepared and informed. It can make us more confident and responsive. But it becomes destructive when the need to feel in control and powerful is so strong that we deny evidence that we are not perfect, Dr Banja explains. “It is good to feel you are competent and in control. It is pathological when you have to feel this way all the time.” Of course, there’s nothing like committing a serious error to make you feel imperfect. It’s common to feel disappointed and angry with yourself. Disclosing the error to a patient can often heighten already charged emotions within you.

Overcoming defensiveness

It’s little wonder, then, that ophthalmologists and other physicians often resort to a variety of psychological strategies to limit the pain of discussing errors. Denying blame,

by Sean Henahan

More to vision than rods and cones

A new study calls into question the dogma that rods and cones are the only cells involved in visual perception. Using a mouse model, a team of US researchers found that some vision could still occur in the absence of rods and cones when intrinsically photosensitive retinal ganglion cells (ipRGCs) were present. The ‘blind’ mice were able to form lowacuity yet measurable images, using ipRGCs. The study also found that, far from being homogenous, ipRGCs come in five different subtypes, with the possibility that each may have different lightdetecting physiological functions. These observations hint that, in the past, mammals may have used their ipRGCs for sight/image formation at an early stage of evolution. The findings also offer hope that a blind person could be trained to use his or her ipRGCs to perform simple tasks that require low visual acuity, the researchers note. n J Ecker et al., Neuron, “Melanopsin-Expressing Retinal Ganglion-Cell Photoreceptors: Cellular Diversity and Role in Pattern Vision”, Volume 67, Issue 1, 49 – 60.

EUROTIMES | Volume 15 | Issue 9

rationalising, numbing yourself emotionally, omitting information, and telling half-truths are common, Dr Banja says. But if you are trying to disclose an error in a patientcentred way and the patient has no idea that an error occurred after the conversation, you have not ethically succeeded, he notes. He emphasises that breaking bad news is more about feelings than about information. Often, communication fails because the physician is occupied managing her or his own emotions and fails to consider the patient’s feelings and response. To manage their own discomfort, physicians often stand during the entire conversation rather than sit down with the patient, they lapse into “medicalese,” and they dominate the conversation. Such defensive actions, however, make it harder to connect with the patient. “If you are bracing for the patient’s response and are busy defending yourself, you are likely to do a poor job of communicating,” Dr Banja says. Such an approach means you are likely to ignore or dismiss the patient’s emotional reactions. This is a cardinal mistake, Dr Banja says. Instead, you should empathise with the patient. And sometimes showing empathy means tolerating silence. After all, it may take time for the patient to respond, and the patient certainly won’t be able to respond if you don’t shut up. The key to successful communication is to prepare for the bad news conversation, Dr Banja says. Try hard to stay calm and humble, which can create a situation in which a patient can express himself or herself in a manner to which you can respond. He recommends the following: Prepare a private environment – no phones, beepers faxes or other devices. Allow space for patients or others to get up and walk around. Make sure tissues are available. Introduce yourself and others present. It may be appropriate to include a chaplain or professional facilitator to keep the conversation on track. Sit down and stay seated. Standing over a patient expresses dominance and impatience. Don’t slouch back with your legs crossed, rather lean toward the patient. Do not sit behind a desk. Try to make eye contact. If you can’t, keep your eyes on the patient’s nose or forehead. Try to get your eyes lower than the person you are talking to; it helps them feel

respected because it feels like you’re looking up to them. Speak slowly. It keeps the tone of your voice lower, making you appear calmer. It helps the patient hear better and encode what you are saying. If the patient looks away, stop talking and wait, though this may be hard to do.

“

It is good to feel you are competent and in control. It is pathological when you have to feel this way all the time

“

Briefly disclose the bad news or error – AND STOP TALKING. Give the patient time to absorb what you said and respond. If the patient asks questions, validate them with phrases like “that is an excellent question.” Then answer in a few sentences and stop again. This gives patients a signal that it is OK to respond. You may ask, “Is this making sense?” Identify and acknowledge the patient’s responses with empathic phrases like, “This must be awful or confusing for you to hear.” But don’t say, “I know how you feel” – it’s presumptuous and probably not true, and the patient knows it. Repeat back what patients tell you: “Let me make sure I understand ….” If you are certain an error has occurred, get to the point. You might say: “We asked you here to tell you that while you were here there was an error in your care.” Then pause and ask, “Would you like to know what happened or is there someone else you would like us to inform?” If the patient wants to talk, disclose the nature of the error or harm, when and where it occurred. Apologise and emphasise your commitment to taking care of the patient’s needs, and explain your efforts to make sure it won’t happen again. Even if the patient reacts strongly, your efforts at empathy will help repair your relationship, Dr Banja says. Patients replay these sessions in their minds and may regret their initial reaction. “It is hard to stay mad at someone who is trying to help you.”

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Feature

outlook on industry

New laser solutions

‘SCHWIND is developing new lasers which are cost effective’

by Colin Kerr in Dublin

CHWIND eye-tech-solutions is marking the XXVIII Congress of the ESCRS in Paris, France with the introduction of the new SmartTech Laser. The new laser, according to SCHWIND chief executive officer Rolf Schwind, marks a paradigm change in laser-guided refractive and therapeutic corneal surgery. "Within the scope of the product portfolio, today it is important for a company, which is active in the refractive field like SCHWIND eye-tech-solutions, to offer a femtosecond laser," said Mr Schwind. "Our laser system is not based on femtosecond laser technology. It is based on nanosecond laser technology." This means, he said, that instead of a highly complex femtosecond laser, an innovative microchip laser with a shorter wavelength in the UV range (wavelength = 355 nm) will be used. "In close cooperation with the Scientific Medical Laser Center in Lübeck with Prof A Vogel we have found out in histological examinations and scanning electric microscopes, that the cutting procedure is more precise than with a femtosecond laser due to the focal spot size (only 1/3)," he said. One of SCHWIND's main goals was to develop a system which is cost effective throughout the entire life cycle of the laser. "At present many ophthalmologists and clinics cannot afford a femtosecond laser," said Mr Schwind. "In developing the SmartTech Laser we have been very conscious of the need to develop new technology that is cost effective for the user," he said.

Therapeutic applications As well as offering doctors a new platform for refractive surgery, SCHWIND says SmartTech also offers a platform for therapeutic applications. "Besides flap creation, which will be the first step," said Mr Schwind, "the SmartTech Laser will offer platforms for therapeutic applications, including lamellar keratoplasty as well as corneal inlays and corneal rings. In addition to these applications another big advantage is that the SmartTech Laser can be used easily and flexibly because of its mobility,” he said. “This mobility guarantees easy handling between non-sterile and sterile operating rooms.” Patient safety Patient safety is one of SCHWIND's major goals and Mr Schwind said they will achieve this goal with a state-of-the-art low energy spot and short treatment time with continuously controlled eye applanation pressure. "Furthermore, a pupil tracking and pupil offset entry will be integrated to prevent decentred cuts," he said. "The flap zone jumps automatically to the later planned excimer treatment zone which means that the flap and excimer treatment zones match perfectly. Reliability is also important," said Mr Schwind. "On the one hand, this laser system will be a low-maintenance product and on the other hand it will react less sensitively to influences of temperature and humidity, to minimise the risk of breakdowns." EUROTIMES | Volume 15 | Issue 9

SmartTech Laser

In developing the SmartTech Laser, it was important to ensure that it could be integrated into the SCHWIND eyetech-solutions product family. "As already mentioned," said Mr Schwind, "nowadays it is indispensable for a refractive company to offer a flap cutting laser but as a company SCHWIND is always conscious of the need to introduce new and groundbreaking technologies.”

SCHWIND AMARIS 750S and 500E lasers

The company is launching a new SCHWIND AMARIS 750S laser at the ESCRS conference. "The goal with the SCHWIND AMARIS 750 S is to increase our technological capability," said Mr Schwind. "Besides a 1050 hz eyetracker on the basis of a six-dimensional tracking all possible eye movements, the 750 hz laser offers the opportunity to reduce the ablation time of 1 dioptre myopia to 1.5 seconds," he said. SCHWIND is also introducing a new SCHWIND AMARIS 500E laser system, which will be affordable to surgeons who do not have access to more expensive equipment. "State-of-the-art technology does have its price," said Mr Schwind, "and the price of this technology can be discouraging for some potential customers. This again is the reason why we decided with the AMARIS 500 E to offer a laser system equipped with the key advantages of the leader in technology and at the same time a less expensive solution." Finally, ESCRS has designated 2010 as European year of LASIK. As one of the leading laser manufacturers, SCHWIND will continue to invest in LASIK, said Mr Schwind. "In the past years, there has been something of a renaissance for PRK," he said, "but I believe LASIK will remain the preferred option for surgeons."

contact Antje Splittdorf – antje.splittdorf@eye-tech.net

LONDON 2011 11 EURETINA CONGRESS TH

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

www.euretina.org

Feature

product update

Rieck DSAEK insertion instrument

For a gentle insertion of the DSAEK donor tissue using the pull-through technique, Geuder has, in cooperation with Prof Peter Rieck of the CharitĂŠ Eye Clinic in Berlin, developed a new DSAEK insertion instrument. A Geuder spokeswoman said the instrument's hinge design guarantees a controlled folding of the donor tissue without overlapping or compression. During the surgical implantation procedure, the incision is kept open by the guiding plate which also protects the tissue from being crushed while it is being pulled into the anterior chamber. TheÂ implantation procedure is suture-free and self-sealing.

Rhein injector cartridge loading forceps This instrument, said a company spokesman, is designed to pick a lens out of its case, place the lens in an open cartridge, push the lens down as the cartridge wings are closed, and when the forceps are closed, the distal tips are used to push the lens down the barrel of the cartridge. The instrument is made of stainless steel, and is multi-functional.Â

IRIDEX IQ 532 laser systems

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EUROTIMES | Volume 15 | Issue 9

Â&#x2021; 2QH &DUWULGJH IRU $OO 3URFHGXUHV

IRIDEX has recently announced the commencement of commercial shipment of the IQ 532 laser systems. The IQ 532 is a high-power, 532 nm, dual port multi-purpose laser system for use by ophthalmologists to treat sight-threatening eye diseases such as diabetic retinopathy, age-related macular degeneration and glaucoma; and for use by otolaryngologists to correct certain types of conductive hearing loss. â&#x20AC;&#x153;The time and effort we invested to perfect our core system platform and obtain regulatory approval for a family of laser products has made it possible to introduce the IQ 532 green laser within one year of shipping the IQ 577 yellow laser,â&#x20AC;? said Â Theodore A Boutacoff, president and chief executive officer of IRIDEX. â&#x20AC;&#x153;Continuing with this platform approach, we look forward to the timely introduction of additional systems currently under development.â&#x20AC;?

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European CE mark for Complete RevitaLens

Abbott Medical Optics has received the European CE mark for Complete RevitaLens, a multipurpose solution for the disinfection of soft contact lenses. A company spokeswoman said the solution will deliver high quality disinfection and increased comfort for patients with the convenience of a one-bottle multipurpose solution. The solution was developed in partnership with the Brien Holden Vision Institute in Australia (formerly the Institute of Eye Research). Â

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Feature

bio-ophthalmology

New indication

Ranibizumab plus laser treatment for DME by Gearoid Tuohy

new trial has found that Lucentis (ranibizumab) with laser therapy is more effective than laser therapy alone for treating diabetic macular oedema (DME). The double-blind Phase III trial in 691 patients found that 0.5mg Lucentis plus prompt or deferred laser therapy provided a significant improvement in BCVA score compared to laser therapy alone (9 vs. 3 letters, p<0.001). Focal/grid photocoagulation has represented the standard of care for 25 years since benefit was demonstrated in the ETDRS (Early Treatment Diabetic Retinopathy Study). The relatively recent anti-VEGF approach is based on the observation of increased levels of VEGF in the retina and vitreous of diabetic retinopathy patients. Previous work by the Diabetic Retinopathy Clinical Research Network (DRCR.net) showed that while laser treatment increased visual acuity by ≥2 lines in approximately one-third of patients treated, an estimated 20 per cent worsened by ≥2 lines. Consequently, several studies have been initiated to explore the use of antiVEGF or triamcinoclone protocols either alone or in combination with laser.

Clinical trial The DRCR clinical trial was designed to evaluate three treatment modalities: (1) Lucentis combined with prompt laser (within one week); (2) Lucentis combined with deferred laser (deferred by at least 24 weeks); (3) triamcinolcone combined with prompt laser. The treatment modalities were compared against sham plus prompt laser across a total of 52 clinical sites in the US under an Investigational New Drug Application from the US Food and Drug Administration. Results of the DRCR trial, published in the journal Ophthalmology (2010, 117: 1064-77), showed that the oneyear mean change (± std. dev.) in visual acuity from baseline was greater in Lucentis plus prompt laser group (+9±11, p<0.001) and Lucentis plus deferred laser group (+9±12, p<0.001) compared to triamcinoclone plus prompt laser (+4±13, p<0.31) and sham plus prompt laser group (+3±13). In summary, the Lucentis plus laser treatment demonstrated superior visual acuity and OCT outcomes compared with laser alone. Approximately half of the patients on the Lucentis protocols recorded a substantial visual acuity improvement of a ≥10 letter gain from baseline while an estimated 30 per cent gained ≥15 letters. In comparison, triamcinoclone with laser did not show any superior visual acuity outcomes when compared with laser alone. The gains observed with Lucentis and laser are thought sufficient to allow some people read normal size print or to drive again.

Don’t miss Eye on Travel, see page 52 EUROTIMES | Volume 15 | Issue 9

From the study, the researchers concluded that Lucentis, as applied in the study, “should be considered for patients with DME and characteristics similar to those of the cohort in this clinical trial.”

Benchmark Underscoring the DRCR’s recommendation, Prof George Williams of the Eye Research Institute at Oakland University, Rochester, Michigan, US, told the Bernstein Report on BioBusiness that “the Lucentis and laser combination becomes the benchmark by which we will have to judge products such as Illuvien, VEGF Trap-Eye, and Lucentis alone.” He further described the impressive results as a “gamechanger” in the treatment of DME. As a result of the DRCR study, Lucentis (or some other anti-VEGF drug) may shortly become the new comparator for subsequent trials and therefore new entrants will need to demonstrate clear improvement over established data in order to win over regulators. In the same issue of the Bernstein Report, Dr Steven Pakola, chief medical officer of Thrombogenics Corp., commented that “anybody developing an experimental drug that works on a similar pathway or via a similar mechanism may be dramatically affected in that they now have to go head-to-head with Lucentis.” The development is unlikely to come as too much of a surprise for companies developing anti-VEGF therapies. Current and future drug applications may well seek to emphasise additional benefits such as longer half-life, less frequent injections and improved patient compliance. Two experimental anti-VEGF approaches currently in the clinic for DME include VEGF-Trap-Eye (Bayer AG & Regeneron Pharmaceuticals Inc) and MP0112 from Molecular Partners AG. While both companies are progressing with their clinical trials it is clear the field will become increasingly competitive as the anti-VEGF approaches extend into other possible indications. In the Bernstein Report, Prof Joan Miller, chief of ophthalmology at the Massachusetts Eye & Ear Infirmary, has commented that “this [DRCR] study went a long way towards clarifying that Lucentis combined with laser therapy is going to be what doctors are going to use first.” If such sentiment is widespread, companies considering the investment of scarce resources will seek clear evidence that an experimental compound has a good chance to trump Lucentis in a reasonable period of time. If not, a shift in favour of targeting new pathways or developing entirely new approaches is likely to appear over the coming years.

contact

Boris Malyugin – boris.malyugin@gmail.com

Congress Preview

Fyodorov lecture

commemoration

Lecture at XXVIII ESCRS Congress to honour Russian ophthalmologist By Colin Kerr in Dublin

he 10th anniversary of the death of the distinguished Russian ophthalmologist Prof Svyatoslov Nikolayevich Fyodorov will be marked at the XXVIII ESCRS Congress in Paris, France with a commemorative lecture on Sunday 5 September at 16.30. The lecture will be delivered by Prof Khristo Takhchidi, director of the Fyodorov Institute and president of the Russian Society of Ophthalmologists and Prof Boris Malyugin, deputy director of the Fyodorov Institute and editor of Russian EuroTimes. After graduating in 1952, Fyodorov worked as a doctor in the village of Veshenskaya

EUROTIMES | Volume 15 | Issue 9

in the Rostov Region and then in the town of Lysva in the Sverdlovsk Region. He then completed a post-graduate course at the Rostov-on-Don Medical Institute in 1957. From 1958, he worked as the head of the Clinical Department at the Cheboksary Branch of the State Institute of Eye Diseases named after Helmholz. In 1960 he developed an artificial crystalline lens and carried out the first-ever operation to implant an artificial crystalline lens. From 1961 to 1967, he worked in the Medical Institute in Archangelsk as head of the eye disease clinic before coming to Moscow as chair and head of the Laboratory

for the Implantation of Artificial Lenses at the 3rd Moscow Medical Institute. In 1969, he started research into the implantation of artificial cornea. Four years later he developed the modern technique of radial keratotomy (RK) which drew international recognition to the clinic. Up to his premature death, Prof Fyodorov was honoured not only by his colleagues in Russia and the international ophthalmological community but also by the people of Russia who elected him to the Congress of People's Deputies in 19891991 and to the lower house of the Russian parliament, the State Duma, in 1993. In 1996, he unsuccessfully ran for election as president of the Russian Federation, an election which was won by Boris Yeltsin In 2000, still young enough to pursue a political and professional career, Fyodorov died when his clinic's four-seater helicopter crashed on the outskirts of Moscow after returning from a conference. From his initial Moscow clinic, Prof Fyodorov developed a network that spread to 11 Russian cities. Those clinics now employ

4,000 persons and perform more than 300,000 ophthalmic operations every year on patients from Russia and abroad. The clinic in Moscow, as well as being a major teaching and research centre, also publishes two Russian language ophthalmology journals and manufactures surgical equipment for Russian doctors. “Fyodorov was a genius,” said Prof Takhchidi. “He helped to develop not only Russian ophthalmology but also international ophthalmology. I worked with him for 15 years and as a young ophthalmologist, I learned so much from him. He taught me how to think big ideas and even when he was dealing with local problems, he thought about how the lessons he learned could be brought not only to Russia but to other parts of the world. “ The Fyodorov lecture, as well as being available to delegates in Paris, will have a live transmission to the Fyodorov Institute. As part of the live transmission, Russian doctors will also be able to enjoy the ESCRS Congress Opening Ceremony from Paris.

Feature

eu matters

Future of biotech drugs cloudy

EU court decision case limits protection of biotech patents by Paul McGinn

oybeans may have little to do with ophthalmology, but a decision by the European Union’s highest court about meal made from genetically modified beans may actually deter biotechnology companies from investing in new drugs for ophthalmic and other medical uses. That prospect, highlighted in this column in June, was confirmed by the EU Court of Justice in a judgment handed down in July. In its decision, the Court of Justice ruled that the Monsanto Corporation, the world’s biggest seed company, can’t use an EU patent on its Roundup Ready soybeans to block a Dutch company from importing soy meal made from those soybeans. At issue was whether a patent granted for a genetically modified substance for a particular use – known as a “biotechnological invention” – should apply to other possible uses of the same genetically modified substance. In the case of the Roundup Ready soybeans, that patent specifically protects a genetically manipulated DNA sequence the particular use of which is to make soya plants resistant to Monsanto’s own herbicide, “Roundup.” Farmers who plant the genetically modified Roundup Ready soya can then use the Monsanto herbicide to kill surrounding weeds without harming

Journal Watch

the genetically modified soya plants as they grow. The plants, known as “Roundupready” soya plants, are cultivated in various countries over the world, including Argentina.

EU patent In 2005 and 2006, Dutch companies imported soy meal from Argentina, where Roundup-ready soya is cultivated on a vast scale. Because Monsanto does not hold a patent for use of the DNA sequence in Argentina, it chose to enforce its patent rights for the genetically modified seeds by suing the Dutch-based importers of the harvested soybeans in the Netherlands on the basis of its EU patent. Faced with complicated arguments about whether Monsanto’s EU patent applied to the imported soy meal, the Dutch court referred the case to the Court of Justice, which sits in Luxembourg. In its decision, the EU court focused on the 1998 Directive on the Legal Protection of Biotechnological Inventions. The directive protects DNA-derived chemical substances through patents, including the patent issued to Monsanto for the Roundup-ready soya. The court ruled, however, that patent protection for any substances is only available when those substances perform the specific function for which they were patented.

by Sean Henahan

Vision-sparing cancer therapy

Vision loss is a devastating yet common side effect of radiation therapy for ocular melanoma. A new study suggests that a simple adjunct, silicon oil, can shield the eye and appears to protect vision in patients undergoing radiation therapy. Standard treatment consists of stitching a gold plaque containing radioactive seeds to sclera and removing it a few days later. Researchers at UCLA developed a method whereby they removed the vitreous gel prior to radiation and replace it with silicon oil. After removing the radiation plaque from the treated eye, the oil is replaced with saline. Initial results indicate that the silicon oil absorbs nearly 50 per cent of the radiation. Studies are ongoing. n T McCannel et al., Arch Ophthalmology, “Attenuation of Iodine 125 Radiation With Vitreous Substitutes in the Treatment of Uveal Melanoma”, July 2010; 128: 888 - 893.

EUROTIMES | Volume 15 | Issue 9

Dr Tara McCannel, one of the research authors

Soybean Field

In particular, the court examined Article 9 of the 1998 directive. “‘The protection conferred by a patent on a product containing or consisting of genetic information shall extend to all material… in which the product is incorporated and in which the genetic information is contained and performs its function,” the article reads. “Article 9 of the Directive makes the protection for which it provides subject to the condition that the genetic information contained in the patented product or constituting that product ‘performs’ its function in the ‘material… in which’ that information is contained,” the court wrote. “The usual meaning of the present tense used by the Community legislature and of the phrase ‘material… in which’ implies that the function is being performed at the present time and in the actual material in which the DNA sequence containing the genetic information is found.”

Patent protection The court added that in assessing the extent to which a patent could protect a product, it had to consider the function for which the patent was granted. “In the case of genetic information such as that at issue in the main proceedings, the function of the invention is performed when the genetic information protects the biological material in which it is incorporated against the effect, or the foreseeable possibility of the effect, of a product which can cause that material to die,” the court commented. “The use of a herbicide on soy meal is not, however, foreseeable, or even normally conceivable. Moreover, even if it was used in that way, a patented product intended to protect the life of biological material containing it could not perform its function, since the genetic information can be found only in a residual state in the soy meal,

which is a dead material obtained after the soy has undergone several treatment processes.” “It follows from the foregoing, that the protection provided for in Article 9 of the Directive is not available when the genetic information has ceased to perform the function it performed in the initial material from which the material in question is derived,” the court found. In coming to its findings, the court accepted much of the advice of its advocate general, who reviewed the case on behalf of the court earlier this year. The advocate general had advised that the 1998 directive enabled the Court of Justice to draw a distinction between a “discovery”, which is not patentable, and an “invention,” which is patentable. By legal definition, a “discovery” involves the isolation of a DNA sequence without any indication of a function; an ‘invention” involves that discovery together with an indication of the function that the discovered substance will perform. If the ruling against Monsanto is taken to its logical conclusion, biotech research companies may think twice about investing in ophthalmology and other areas of medicine because any research “discoveries” may not be able to be properly patented for all possible uses at the time of discovery; at the same time, companies that made no such investment in the discovery of the biotech substance could ultimately exploit such discoveries, leaving the discoverer of the biotech substance without any means by which to recoup its research investment. For more details about the case, Monsanto Technology LLC –v- Cefetra BV and others (Case C‑428/08), visit the European Court of Justice website at www.curia.eu.

EuroTimes

Feature

letter from crete

9/10

a better future

Crisis may be a turning point for economy if Greeks apply lessons from ophthalmology

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

by Dermot McGrathÂ

iven the turmoil currently gripping the worldâ&#x20AC;&#x2122;s economies and financial systems, it is perhaps appropriate that the word â&#x20AC;&#x153;crisisâ&#x20AC;? is of Greek origin. Type â&#x20AC;&#x153;Greek crisisâ&#x20AC;? into Google and the search engine will return over 19 million hits, which indicates the scale of the public relations disaster that has befallen the country over recent months. By any standards, 2010 has been â&#x20AC;&#x201C; to borrow a Latin term â&#x20AC;&#x201C; an â&#x20AC;&#x153;annus horribilisâ&#x20AC;? for Greece. Its debt crisis almost resulted in bankruptcy, an eventual bailout from the EU and the International Monetary Fund, mass public protests, strikes and even riots. All of these events have taken their toll on Greeceâ&#x20AC;&#x2122;s international reputation. Tourism, which accounts for around 15 per cent of Greeceâ&#x20AC;&#x2122;s gross domestic product, looks set to be seriously affected by the negative publicity of recent months. On Greece's largest island, Crete, about one-third to one-half of workers depends on tourism for their livelihoods. Arriving at the islandâ&#x20AC;&#x2122;s main airport in Heraklion at peak hour in the middle of the tourist season, this reporter anticipated a long wait for a taxi in the searing heat. Instead, I had my choice of car from a long queue of bored taxi drivers. â&#x20AC;&#x153;Things are bad this year,â&#x20AC;? confirmed my driver as we zipped along some spectacular coastline to Hersonissos, the location of the conference centre and hotel complex where I was staying. â&#x20AC;&#x153;People are afraid to come because of the strikes and the economic crisis.â&#x20AC;? That evening, walking around the old port of Hersonissos, one didnâ&#x20AC;&#x2122;t need to scratch too far beneath the surface to feel the imprint of the crisis everywhere. Along the townâ&#x20AC;&#x2122;s main drag, only a handful of the dozens of restaurants along the seafront had filled their quota of diners. Most of the others were half-full at best, with anxiouslooking waiters standing in the street trying to entice potential clients inside. And yet, despite the international gloom and doom surrounding Greece, the Cretans I spoke to remained resolutely cheerful and upbeat in the face of their difficulties. Economic crises may come and go, they seemed to say with one voice, but better times will return in the near future. EUROTIMES | Volume 15 | Issue 9

And perhaps they have reason to be optimistic. Perhaps the Greeks remember the earlier meaning of the word â&#x20AC;&#x153;crisisâ&#x20AC;? as a time of decision rather than just a time of trouble. In English, the use of the word in the mid16th century was used to describe a turning point in the course of a disease, either for better or worse. The Greeks know that they have reached a turning point in their own history, and their gut feeling is that recovery rather than decline is the only acceptable outcome of their own crisis. Back at the convention centre in Hersonissos, delegates were given ample evidence of what can be achieved when qualities such as vision, innovation, and risk-taking are allied to hard work.Â Over the past 30 years, Ioannis Pallikaris has almost single-handedly succeeded in putting Crete on the map as a centre of excellence in terms of ophthalmology. This yearâ&#x20AC;&#x2122;s Aegean Cornea meeting marked a triple celebration of Prof Pallikarisâ&#x20AC;&#x2122; achievements. Firstly, it was the 10th anniversary of the Aegean meeting, which has grown to become an established feature in an increasingly crowded ophthalmic calendar. Secondly, this year, designated by the ESCRS as the European Year of LASIK, marks 20 years since Prof Pallikaris performed the first hinged flap laser in situ keratomileusis (LASIK) procedure. Furthermore, 2010 is the 20th anniversary of Vardinoyiannion Eye Institute of Crete (VEIC), founded by Prof Pallikaris and internationally recognised as a centre of excellence in ophthalmic science and research. In his delivery of the Binkhorst Lecture at the ESCRS Congress in 2009, Prof Pallikaris reflected on the fact that false starts and wrong turns form an integral part of the scientific process. What counts, he said, was to continue to innovate, to dream, to step back from day-to-day concerns in order to see the bigger picture. What is true of ophthalmology is equally true of Greeceâ&#x20AC;&#x2122;s wider economic situation. Greece has had its fair share of false turns and wrong starts, but it has never lost the capacity to dream of a better future. The Greek crisis may not yet have run its course, but the evidence from Crete suggests that the Greek patient is determined to emerge stronger and fitter from the crisis that almost killed it.

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Feature

eye on travel

turkish delight

Istanbul offers more than enough to keep you busy by Maryalicia Post

The Rustem Pasha mosque’s interior is lavishly decorated with rare, 16th century tiles

ou could drown in history in Istanbul. Two thousand years of civilisation in the city that was Byzantium and then Constantinople have left behind a myriad of mosques and palaces, museums and markets. Choosing what to see and what to leave out becomes a personality assessment, a touristic Rorschach test. So I will disclose that I skipped two of the three most famous sites in Istanbul – the Blue Mosque and Topkapi Palace – and used the time to drop in at a Moda cafe for pistachio ice cream made with mountain orchid root, to linger in a bubble pipe cafe (I didn’t inhale), to elbow through the Grand Bazaar, and to get lost among the brooms and saucepans in the back streets around the Spice Market. But back on the old town tourist track, I did pay my respects to Istanbul’s most famous monument, the Hagia Sophia. Consecrated in 537AD as a Christian basilica, the Vatican City of its time, it became a mosque in 1453 and a museum in 1935. Its solemnly beautiful Christian era mosaics are being liberated from the plaster that hid them when the Hagia Sophia was a mosque. The great dome, seemingly suspended in space, was completed in five years almost a EUROTIMES | Volume 15 | Issue 9

millennium before St Pauls’ Cathedral was built. Urgent restoration and monitoring work began in 1995 and is ongoing, so expect scaffolding and dust. The Hagia Sophia is closed on Mondays. You can continue from the Hagia Sophia across the Hippodrome to the Topkapi Palace. The four gilded bronze horses, now a feature of St Mark’s Basilica in Venice, stood here in Roman times. Just before the entrance to Topkapi Palace, a picturesque pedestrian street wandered off to the left, and I wandered with it. Sogukcesme Sokak ran between a high wall of the Hagia Sofia and a lineup of colourful 19th century wooden houses backing up to Topkapi Palace. These nine dwellings had been restored by the Touring and Automobile Club of Turkey and transformed into a charming hotel. www. ayasofyapensions.com Further along the narrow road, stone steps to the right led down to the Caferaga Medresesi, a cafe-restaurant and craft shop set in a 16th century school. Under an arcade surrounding a leafy courtyard, 15 classrooms are still in use. Today, subjects include marbling, calligraphy, Sultan turban making, jewellery making, and glass and china painting. Book a workshop at least a day in advance and produce your own souvenir of

Istanbul. The inclusive fee per hour is 250 lira plus tax for for one person or as many as five. Telephone (0212) 513 36 01-02 or e-mail caferagamedrese@tkhv.org to reserve a place. Craft items are for sale and the cafe serves Turkish-style dishes. You could visit any of four dozen museums in Istanbul and a good number of palaces. The Turkish and Islamic Art Museum, which fronts on the Hippodrome, gives you two for one. The museum is installed in a 16th century palace that belonged to Ibrahim Pasha, Suleyman the Magnificent’s Grand Vizier. The contents are worthy of the building – more than 40,000 gorgeous artefacts date from the seventh to the 19th century. There’s also an impressive display of carpets and fragments of carpets dating back to the 13th century and, in the basement, an intriguing exhibition of the evolution of the Turkish house. The series of life-size reconstructions extends from carpeted nomadic tents to the Frenchinspired interiors of the 19th century. The museum is located at Meydani 46, Sulatnahamet, near Hagia Sophia and the Topkapi Palace. Open 9:00 to 16:30. Closed Mondays.

Meatballs near the mosque On Divanyolu Street, a few minutes’ walk from the Hagia Sophia, a row of restaurants offer Turkish meatballs. The one to try – the original – is Tarihi Sultanahmet Koftecisi at number 12. There may be a queue outside its door, but the line moves quickly and it’s worth the wait. Entering, you pass the oven on the right where the meatballs are grilled and see the cooks turning out white bean salad as if on an assembly line. Since 1921, this restaurant has been serving its famous meatballs bean salad and a yoghurt drink called Aryan to celebrities, politicians, tourists and locals. There are other dishes but they come for the meatballs, which sell for 7 lira. The bean salad costs 4 lira and the Aryan 2 lira. A waiter in a white jacket will be setting your meal down on the marble table top, along with a basket of crusty bread, almost before you finish ordering. For 4 lira, try the traditional dessert – irmik helvasi – a semolina pudding with attitude. Credit cards not accepted. Open daily 10:30 to 23:00. An unmissable mosque that’s hard to find Built over vaulted shops

whose rents were also intended to give financial support, the Rustem Pasha mosque is a perfect little jewel. The mosque was built by Mimar Sinan, the great Ottoman architect, for the Grand Vizier Rustem in 1563. This date coincided with the greatest period in Iznik tile making. Glorious tiles in floral and geometric patterns cover the interior. The mosque is small and not

Spice Market, cheaper than the Grand Bazaar, is good for dried fruits, caviar, sweets and souvenirs

Courtesy of Maryalicia Post

A panel of rare Iznik tiles on the facade of the Rustem Pasha mosque

overwhelmed by tourists. You can approach the walls and admire the tiles at your leisure. As this is a mosque, not a museum, it closes five times a day for prayer and you will be required to remove your shoes to enter. The mosque is in the “Hasircilar Carsisi,” the Strawmat Weaver’s Market. To reach the mosque, leave the Spice Market by the waterfront entrance, then turn left towards Eminonu Square. The main entrance to the mosque is through a decorated archway set in the wall. Istanbul is the venue for the 15th ESCRS Winter Meeting from 18-20 February 2011. For further details visit www.escrs.org

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Feature

Book review

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EUROTIMES | Volume 15 | Issue 9

Imaging has revolutionised medicine more than any other single technology. A sweeping statement perhaps, but from Rontgenâ&#x20AC;&#x2122;s X Ray to the present day wonders revealed by functional MRI scanning, imaging has transformed not only clinical practice but how humanity views itself. It is a little bracing, for someone whose medical education began in 1996, to read that optical coherence tomography (OCT) â&#x20AC;&#x153;has come a long way since its initial introduction in the ophthalmic market in 1996â&#x20AC;?. Like many technological innovations, OCT was initially slow and limited in functionality, not unlike the early computers. Producing images of low definition and resolution â&#x20AC;&#x201C; and so expensive that only major centres could afford them â&#x20AC;&#x201C; OCT was of limited clinical utility. The RTVue was the first of a new generation of OCT systems that transcended these limitations. It used Fourier-domain technology, which increased the speed of OCT almost a hundred fold. Unsure what â&#x20AC;&#x153;Fourierdomain technologyâ&#x20AC;? actually refers to? Well, this is the book for you. This leap in speed allowed the rapid production of high-definition images. Thus a clinical revolution could begin. OCT began to be applied to more and more situations, and the technology became cheaper and quicker. Thus, the same pattern we see in computing prevails â&#x20AC;&#x201C; early, pioneering technology is often unwieldy and seems to be no great improvement on what has preceded it, but suddenly a critical mass of miniaturisation and cost reductions leads to a breakthrough in usability. And then we canâ&#x20AC;&#x2122;t imagine our lives without the blessed â&#x20AC;&#x201C; or cursed â&#x20AC;&#x201C; technology. As the title of the book indicates, this technology now transcends any division into anterior and posterior ophthalmology. From the cornea to the head of the optic nerve, OCT allows high-resolution imaging at a speed that the early pioneers could only have dreamed of. This is one of the most elegantly presented books I have had to review for this column. The clinical images are beautifully presented, and allow for a good deal of differentiation. One of the issues with illustrations of ophthalmic imaging in particular is the importance of the highest quality, so that what is presented is not just a series of red dots. Some of the images

Donâ&#x20AC;&#x2122;t miss Calendar, see page 60

have a truly impressive aesthetic quality, in particular the illustration by Ms D Piccioli on page 89 of an RTVue en face scan. The editors themselves are based predominantly in the US, with Bruno Lumbroso of the Rome Eye Hospital representing Europe (and the rest of the world). The contributors they have assembled are from Japan, Egypt, and Brazil as well as the US and Italy. The book is clearly focused on the practicality of using OCT, especially the clinical practicalities. There are a total of 28 chapters, moving from an initial introductory chapter to a series of chapters focused on the clinical use of the technology in each anatomical area of ophthalmic practice. The publishers indicate on the back cover that the book is aimed at biomedical engineers as well as practitioners of ophthalmology. Certainly, the level of detail on the technology is extremely comprehensive and enough to satisfy the mechanically as well as clinically inclined. It is hard to image a more definitive book on this topic.

books editor: Seamus Sweeney publication: Imaging the Eye from Front to Back with RTVue Fourier-Domain Optical Coherence Tomography BY: David S Huang, Jay S Duker, James G Fujimoto, Bruno Lumbroso, Joel S Schuman, Robert N Weinreb

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

Feature

JCRS Highlights Journal of Cataract and Refractive Surgery

IOL, LASIK and peripheral aberrations

Spherical intraocular lenses as well as myopic LASIK are known to affect positive spherical aberration in the eye. However, less is known about the effect of refractive surgery on peripheral aberrations. A group of Australian researchers measured the effect of spherical IOL implantation and conventional myopic LASIK on peripheral ocular aberrations in 12 patients who had undergone one of the procedures. Hartmann-Shack aberrometry across 42 degrees × 32 degrees of the central visual field, they observed higher rates of quadratic change in spherical equivalent (SE) refraction, higher-order root-meansquare (RMS) aberrations, and total RMS aberrations across the visual field in IOL recipients compared with emmetropic controls. They saw similar results in the myopic LASIK patients versus myopic controls. While both procedures increased spherical aberration across the field, the increase was higher after IOL implantation. LASIK reversed the direction of change in coma across the field. n A Mathur et al. JCRS, “Influence of spherical intraocular lens implantation and conventional laser in situ keratomileusis on peripheral ocular aberrations”,Volume 36, Issue 7, 1127-1134.

Best way to measure pre- and post-op visual function?

Accurate visual function surveys play a key role in cataract surgery outcomes management. But which scale does the best job? Researchers compared eight short and long versions of the Visual Function Index14 (VF-14) in a cohort study of 210 patients. All versions were able to detect large gains in visual functioning following cataract surgery. The largest gain in precision, 125 per cent (relative precision, 2.25), occurred for VF-8R. Short forms that were not Rasch scaled showed gains in precision, from 23 per cent to 80 per cent. The VF-8R also showed the largest gains in precision in two subgroups: with ocular co-morbidity (relative precision, 2.14) and without ocular co morbidity (relative precision, 2.48). The investigators concluded that the eight-item, Rasch-scaled VF-8R appears ideally suited for measuring cataract surgery outcomes given its high precision and short test time.

Primary pars plana vitrectomy combined with lensectomy

Although pars plana vitrectomy (PPV) with lensectomy is a well-established method, studies of its relative risks and benefits as a primary procedure for the visual correction of complicated cataract not associated with other posterior segment diseases are few. Researchers at Bascom Palmer Eye Institute evaluated the results of 40 cases of PPV combined with lensectomy as a primary procedure for the visual correction of dislocated, intact cataracts. Patients presented with traumatic lens dislocation, Marfan syndrome, idiopathic lens dislocation, and pseudoexfoliation syndrome. The median corrected distance visual acuity improved from 20/185 preoperatively to 20/30 three months postoperatively. Complications included retinal detachment (6.5 per cent), transient vitreous haemorrhage (13.0 per cent), choroidal detachment (4.3 per cent) and CME (13.0 per cent), which occurred more frequently in eyes with a history of trauma. The researchers conclude that pars plana vitrectomy with lensectomy yields favourable visual outcomes in eyes with complicated cataract in which standard anterior segment techniques were prohibitive or risky. n J Oh, JCRS, “Pars plana lensectomy combined with pars plana vitrectomy for dislocated cataract”, Volume 36, Issue 7, pages 1189-1194.

JCRS Symposium Controversies in Cataract and Refractive Surgery 2010 Sunday, September 5, 2010

14:00-16:00 Chairs: Emanuel S. Rosen, MD, FRCSEd Thomas Kohnen, MD, FEBO Presbyopia Treatment: Cornea or Lens n

Accommodating and/or Multifocal IOL Gerd U. Auffarth, MD

PresbyLASIK or Implant Richard L. Lindstrom, MD

Astigmatism Management in Cataract and RLE Surgery: Toric IOL or Corneal Incisions n Incisions

Louis D. Nichamin, MD n Toric IOL

Rudy M. Nuijts, MD, PhD

Pediatric Refractive Surgery n Pro’s

Michael O’Keefe, FRCS n Con’s

Elie Dahan, MD, MMedOphth

Phakic IOL n Anterior Chamber R. Doyle Stulting, MD, PhD

Thomas Kohnen Associate Editor of JCRS

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

Don’t miss Industry News, see page 56 EUROTIMES | Volume 15 | Issue 9

VK Gothwal et al., JCRS, “Measuring outcomes of cataract surgery using the Visual Function Index-14”, Volume 36, Issue 7, pages 1181-1188.

n Posterior Chamber Roberto Zaldivar, MD

During the XXVIII Congress of the ESCRS, Paris, France

Feature

K N I V E S

industry news

Recent developments in the vision care industry

Regulatory

Lucentis approval for macular oedema

S U T U R E S

The US FDA has approved LucentisÂŽ (ranibizumab injection) for the treatment of macular oedema following retinal vein occlusion. The FDA approved this new indication after a six-month Priority Review. The approval followed completion of clinical trials in which significantly more people treated with monthly Lucentis showed sustained vision improvement over a six-month period, with effects seen as early as seven days. Lucentis is a vascular endothelial growth factor (VEGF) inhibitor that was first approved in the US for the treatment of neovascular age-related macular degeneration in 2006. n www.gene.com

Sustained steroid delivery system

C A N N U L A S

Alimera Sciences has submitted a New Drug Application (NDA) to the FDA for Iluvien, which was developed by pSivida and licensed to Alimera in 2005 for the treatment of diabetic macular oedema (DME). Iluvien is a sustained release drug delivery system releasing the steroid fluocinolone acetonide. Alimera requested priority review, which if granted, could result in an action letter from the FDA in the fourth quarter of 2010. The NDA submission includes the 24-month low-dose data from two pivotal phase three clinical trials (collectively known as the FAME Study), which involve 956 patients in sites across the US, Canada, Europe and India. Alimera has indicated that it plans to follow this NDA submission with registration filings in certain European countries and Canada in the near future. In fact, the company submitted a Marketing Authorization Application (MAA) to the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK for IluvienÂŽ. Applications have also been submitted to the following other Concerned Member States (CMS) in the EU: Austria, France, Germany, Italy, Portugal and Spain. n www.alimerasciences.com

Clinical Trials

P U N C T A L

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Slowing diabetic eye disease

Intensive blood sugar control can reduce the progression of diabetic retinopathy compared with standard blood sugar control. In addition, combination lipid therapy with a fibrate and statin also reduces disease progression compared with statin therapy alone. These findings come from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study. Intensive blood pressure control provided no additional benefit to patients compared with standard blood pressure control. The landmark ACCORD study included 10,251 adults with Type 2 diabetes who were at especially high risk for heart attack, stroke or cardiovascular death. n www.accordtrial.org

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EUROTIMES | Volume 15 | Issue 9

EyeGate Pharma reports it has begun enrolling patients in the ALLUVION (EvALuation of Dexamethasone Phosphate DeLivered by OcUlar Iontophoresis for the Treatment of Dry Eye in the Controlled Adverse EnVIrONment [CAE] Model) pivotal phase III study of EGP-437 for the treatment of dry eye syndrome. EGP-437 is a dexamethasone-derived corticosteroid custom formulated for delivery using a proprietary system (EyeGate II). An exploratory phase II study demonstrated significant improvements in the signs and symptoms of dry eye during and after CAE exposure. The CAE exacerbates the signs and symptoms of dry eye in a controlled setting. n www.eyegatepharma.com

Novel glaucoma drug

SYL040012, a novel glaucoma drug candidate that is based on RNAi technology completed a Phase 1a clinical trial. Thirty healthy volunteers received the drug in eye drop form during the trial. The volunteers showed excellent local and systemic tolerance, leading to positive trial results. The drugâ&#x20AC;&#x2122;s developer Sylentis plans to start a Phase I/II clinical trial in patients with elevated intraocular pressure as soon as possible. Sylentis is based in Madrid. n www.sylentis.com

Feature

Eye on History

A German master in Paris by Colin Kerr

rĂŠdĂŠric Jules Sichel (14 May 1802 â&#x20AC;&#x201C; 11 November 1868) is credited with bringing modern ophthalmology to France from Austria and Germany. Volume 7 of Julius Hirschberg's The History of Ophthalmology deals with the first half of the 19th century in France and Sichel's name figures prominently in the 336-page volume. Sichel stated in 1834: "France was the birthplace of ophthalmology and the creators were St Yves, Janin and Maitre-Jan; our specialty has recently been neglected because its true importance has been ignored as it has been confused with

a medical specialty... in reality, it encompasses the large domain of medical surgical symptomatology and therapy." Hirschberg credits Sichel with initiating the "renaissance of French ophthalmology" and details how his early upbringing was to influence his subsequent work.

A free spirit Sichel was the son of a Jewish merchant and in his later years paid tribute to the excellent schools and free and independent spirit of his birthplace Frankfurt/Main. After his initial training in WĂźrzburg, Berlin and Vienna, he

moved to Paris towards the end of 1928 at the suggestion of his teacher and friend Friedrich JĂ¤ger. According to Hirschberg, JĂ¤ger suggested the move because he knew that ophthalmology was neglected in France and JĂ¤ger hoped that Sichel would introduce the ideas and culture of German ophthalmology to Paris. Sichel was diplomatic enough to ensure that he was not seen as an outsider imposing his ideas on the French ophthalmic community. When Sichel Â passed his French licencing examination in 1833, the president of the examining committee Guill Dupuytren told Sichel that the faculty would be proud to receive such a scholar in Paris. In 1832, Sichel founded the first private eye clinic in Paris which he directed until his death in 1867. In 1833-1834 Sichel lectured at the HĂ´pitaux St Antoine and during this time he was at the forefront in the fight against cholera which was ravaging Paris. He became a French citizen in 1834 and in 1840 he received the cross of a Knight of the Legion of Honour from King Louis Philippe. Hirschberg described Sichel as the greatest

ophthalmologist in France for 20 years and noted that he also had the largest ophthalmic private practice in world until he was surpassed by Albrecht von Graefe.

Philosophical stoicism

Unsurprisingly, Sichel was not held in such high esteem by all of his colleagues and in 1845 he was forced to rebut the accusation that he was, asÂ JĂ¤ger had intended, using his influence in Paris to champion the concepts of French ophthalmology. "As a Frenchman," said Sichel, "by naturalisation and conviction, I thought it my duty to acquaint my new fatherland with the valuable advances which were made in our times in neighbouring countries." Hirschberg argued that Sichel, despite his early recognition, never received the honours or awards which his work justified but says that he tolerated all mishaps with "philosophical stoicism". After his death von Graefe wrote: "Ophthalmology has lost one of its most faithful workers who was motivated all his life by an enthusiastic love to science."

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5HIOH[B(XURWLPHVB [ PPB E LQGG EUROTIMES | Volume 15 | Issue 9

FrĂŠdĂŠric Jules Sichel

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

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

Interactive sessions. Accessible faculty. Pertinent topics. Practical tips. The Physicians Program is designed to provide the busy ophthalmologist with cutting-edge information and pearls that can be immediately implemented. Program Chairs Edward J. Holland, MD Stephen S. Lane, MD Program Planning Committee David F. Chang, MD Eric D. Donnenfeld, MD Herbert P. Fechter, MD Roger F. Steinert, MD Keith A. Warren, MD

Faculty Debi Dilling Nancey K. McCann Frank McDonough E. Ann Rose James L. Spires, MBA, COE Gil Weber, MBA

Preliminary Program (subject to change)

Friday, January 28 2:30 PM â&#x20AC;&#x201C; 4:00 PM 2011 Legislative Update Nancey K. McCann 4:15 PM â&#x20AC;&#x201C; 5:45 PM Medicare Reimbursement Challenges E. Ann Rose

Saturday, January 29 8:30 AM â&#x20AC;&#x201C; 10:00 AM Interpreting & Using Financial Statements James L. Spires, MBA, COE 10:30 AM â&#x20AC;&#x201C; 12:00 PM Iâ&#x20AC;&#x2122;m a Leader â&#x20AC;&#x201C; Now What? Steve Robinson, COE, OCS 12:00 PM â&#x20AC;&#x201C; 1:00 PM Networking Luncheon 1:00 PM â&#x20AC;&#x201C; 2:30 PM Effective Marketing Tracking Methods Debi L. Dilling 3:00 PM â&#x20AC;&#x201C; 4:30 PM Managed Care Contracting Nightmares Gil Weber, MBA

Sunday, January 30 8:30 AM â&#x20AC;&#x201C; 10:00 AM Keeping an Eye on the Future: Medical Office Technology in 2015 Frank McDonough

Faculty Rosa Braga-Mele, MD Vincent P. de Luise, MD Gary J. Foster, MD Terry Kim, MD W. Barry Lee, MD Nick Mamalis, MD Nancey K. McCann Stephen A. Obstbaum, MD F. Rick Palmon, MD Steve Robinson, COE, OCS Jonathan B. Rubenstein, MD E. Ann Rose Steven R. Sarkisian Jr., MD R. Doyle Stulting Jr., MD, PhD â&#x20AC;Śmore to come!

Preliminary Program (subject to change) Thursday, January 27 Networking/Welcome Reception

Friday, January 28

Moderator: Stephen S. Lane, MD

Sunday, January 30

8:00 AM â&#x20AC;&#x201C; 10:00 AM Cataract/Anterior Segment Moderator: David F. Chang, MD

8:00 AM â&#x20AC;&#x201C; 10:00 AM Challenging Cases in Ophthalmology Moderators: Eric D. Donnenfeld, MD, and Edward J. Holland, MD

10:30 AM â&#x20AC;&#x201C; 12:30 PM Cornea Moderator: Edward J. Holland, MD

10:30 AM â&#x20AC;&#x201C; 12:30 PM Glaucoma Moderator: Herbert P. Fechter, MD

12:45 PM â&#x20AC;&#x201C; 2:15 PM Optional Luncheon Workshops

5:30 PM â&#x20AC;&#x201C; 6:30 PM ASOA for MDs: Legislative Update Nancey K. McCann

5:30 PM â&#x20AC;&#x201C; 6:30 PM ASOA for MDs: Medicare Update E. Ann Rose

Saturday, January 29

Monday, January 31

7:30 AM â&#x20AC;&#x201C; 8:00 AM Special Session 8:00 AM â&#x20AC;&#x201C; 10:00 AM New Technology in Anterior Segment Surgery Moderator: Stephen S. Lane, MD

7:00 AM â&#x20AC;&#x201C; 9:00 AM Refractive/Refractive IOLs Moderator: Eric D. Donnenfeld, MD 9:30 AM â&#x20AC;&#x201C; 11:30 AM Roundtable/Wrap-Up Moderators: Edward J. Holland, MD, and Stephen S. Lane, MD

10:30 AM â&#x20AC;&#x201C; 12:30 PM Retina Moderator: Keith A. Warren, MD 12:45 PM â&#x20AC;&#x201C; 2:15 PM Optional Luncheon Workshops 5:30 PM â&#x20AC;&#x201C; 7:00 PM Video Complications Seminar

10:30 AM â&#x20AC;&#x201C; 12:00 PM Internet Marketing: Website or Web Fright? Debi L. Dilling +#+,&(%!() #, ) +, ++ ,)&&(% + , %(,

Reference

Calendar of events Dates for your Diary

September 2010

Madrid, Spain

16-20

beijing, china

12-16 EDINBURGH, SCOTLAND

24-26

Alexandroupolis, Greece

October

November

10th EURETINA Congress www.euretina.org

9th European Glaucoma Society Congress www.oic.it/~egsmadrid2010/

XXVIII Congress of the ESCRS www.escrs.org

9-11 MUNICH, GERMANY

2011

18-20 TURKEY

ISTANBUL,

15th ESCRS Winter Meeting www.escrs.org

28th Annual ESOPRS Meeting www.esoprs2010.org

SIDUO XXIII Congress www.siduo2010.org

2010

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

16-19 chicago IL, usa American Academy of Ophthalmology www.aao.org/annual_meeting

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

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

December

9-12

2010

MACAU, CHINA

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

March

January 2011

12-14

Vienna, Austria

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

BELGRADE, SERBIA

2011

26-29 11th EURETINA Congress www.euretina.org

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

11-12 Alicante, Spain ARI Monographic 2011 -“The best and most updated information about Lens, Cataract and Refractive Surgery” www.alicanterefractiva.com

June London, UK

2011

4-6

2010

Delhi, India

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

27-28 India

new Delhi,

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

2011

6-10 Argentina

Mar del Plata,

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

25-30 San Diego CA, USA

September

November

4-7 16-17 PARIS, 29-2 FRANCE 17-21

2011

GENEVA, vienna, austria SWITZERLAND

Joint Congress of SOE/AAO www.soe2011.org

3rd Greek University Congress of Ophthalmology www.unieyecongress.gr/2010/

15-17 India

www.apaosydney2011.com/

ASCRS/ASOA Symposium and Congress www.ascrs.org

May

25th Congress of the APAO in combination with the 15th National Congress of the COS www.apao2010beijing.org

April

2011

20-24 Sydney, Australia 2011 Congress of the APAO

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

2010

12-17

2-5 PARIS, FRANCE 4-8 PARIS, FRANCE

February

September

2nd EuCornea Congress www.eucornea.org

new Delhi,

62nd Annual Conference of Delhi Ophthalmological Society www.dosonline.org

13-16

2011

Seoul, Korea

2011 APACRS-KSCRS Annual Meeting www.apacrs.org

World Glaucoma Congress 2011 www.worldglaucoma.org

XXIX Congress of the ESCRS www.escrs.org

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