Volume 16_Issue 3 by EUROTIMES

VOLUME 16 ISSUE 3 MARCH 2011

REFRACTIVE LASER

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ESCRS

EUROTIMES

MARCH 2011 Volume 16 | Issue 3 This month... Special Focus Refractive Laser 4

Cover Story: A look at what the future holds for laser refractive surgery

The advantages of presbyLASIK over refractive lens exchange

Removing epithelium with laser reduces postoperative pain

Laser audits helps to monitor the performance of lasers

Cataract

Novel speculum may reduce endophthalmitis risk

Refractive Lens 15

Expanding toric IOL options to meet increasing patient needs

Cataract surgery looks towards LASIK-like outcomes

Corneal implant looks promising for presbyopia

Cornea 19

Biomechanics measurements aid with diagnosing corneal disease

Glaucoma

24-hour IOL monitoring aids glaucoma detection

Studies help to uncover glaucoma’s hereditary factors

Retina 23

Early trial of retinal implant shows promising results

Gene therapy for choroideremia a logical future choice, expert says

News 26

EBO Residency Exchange encourages ophthalmologists to share knowledge

ESASO is a vision of collaboration

A look at the new applications of ultrasound in anterior segment surgery

Features 33 Outlook on Industry

Book Review

Industry News

JCRS Highlights

EU Matters

Practice Development

Eye on Travel

Journal Watch

Calendar

With this month’s issue... XXIX Congress of the escrs preliminary programme & Trends in surgical and medical retina PROGRAMME

editorial staff

ESCRS

EUROTIMES

™

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

Assistant Designer Janice Robb

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

Colour and Print Times Printers

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

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

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

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

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

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

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EUROTIMES

Editorial

ESCRS

EDITORIAL

Medical Editors

Volume 16 | Issue 3

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

EXCITING BREAKTHROUGHS

Hardware and software advances will make laser vision correction surgeries safer and more effective

by Marguerite McDonald

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK

he new developments in laser vision correction can be divided into two groups: excimer laser-related and femtosecond laser-related. Starting with the excimer laserrelated, there are three areas where progress is being made:

Topography-guided LASIK Nidek and Alcon Wavelight both have topography-guided LASIK studies under way, with very promising results.

Hyperprolate ablations for presbyopia and SupraCor (both are new approaches to presby-LASIK) n Hyperprolate ablations are performed only on the non-dominant eye; the custom ablation reduces the optical zone/ablation zone from 6.0/8.0mm to 5.5/7.5mm, and the programmed keratometry is increased by 15 dioptres. New software to do this automatically is in preparation at Abbott Medical Optics Inc (AMO). n SupraCor is being developed by the Technolas team. Using lessons learned from the IntraCor studies (see below), a central 8 micron “bump” is incorporated into the ablation profile within the pupillary region, such that goals for simultaneous uncorrected distance and near acuities are met without inducing undesired aberrations. Better diagnostic instrumentation There is an effort throughout the industry to do what AMO is doing, which is to combine several instruments into one. The aberrometer, pachymeter, autorefractor, keratometer, and pupillometer are part of the iDesign unit that they are developing. Combining the instruments improves the performance for all functions and takes advantage of synergistic information while offering an integrated footprint.

Peter Barry IRELAND Femtosecond-related breakthroughs include Improved design features from all six femtosecond platforms (Zeimer Crystal; Technolas 2010; AMO/IntraLase iFS 150; Zeiss VisuMax; Alcon Wavelight FS 200; and the Schwind Smartech 150, which incorporates nanosecond technology). As a whole, the industry is moving toward higher resolution video microscopes with touch screen user interfaces and digital video output. All platforms are also rapidly developing or have developed the software to perform tasks other than the creation of LASIK flaps. The femtosecond laser companies are also improving the view for the surgeon of both the ablated area and the entire surgical field; providing better fixation lights; and providing the software for Dr Luis Ruiz’ IntraCor procedure (five concentric intrastromal femtosecond ablations centred on the pupil for the correction of presbyopia). Lastly, they are working on the software for surgeons to perform Dr Zaldivar’s CIRI procedure (conic intrastromal relaxing incisions). In summary, exciting hardware and software advances are continually being made in both excimer and femtosecond technologies, making our laser vision correction surgeries safer and more effective. MARGUERITE McDONALD MD, FACS Marguerite McDonald MD, FACS is clinical professor of ophthalmology, NYU Langone Medical Center, New York, and adjunct clinical professor of ophthalmology Tulane University Health Sciences Center, New Orleans, Louisiana, Ophthalmic Consultants of Long Island, Lynbrook, New York

Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz germany

EUROTIMES | Volume 16 | Issue 3

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Cover Story

REFRACTIVE LASER

beyond 20/20 in 2020

What’s next for laser refractive surgery? by Sean Henahan

“

We have to get away from the ‘eagle vs. the frog vision’ concept and speak more in terms of ‘natural’ instead of ‘super’ vision

Ioannis Pallikaris MD, PhD

“

In the future we hope to identify and rule out those candidates that might develop ectasia by using topographic and biomechanical analysis Perry S Binder MD

EUROTIMES | Volume 16 | Issue 3

aser refractive surgery has come a long way in a short time. Visual outcomes continue to improve while the incidence of adverse effects continues to decrease. Many of the challenges of 10 and 20 years ago have been addressed, leaving the question, what’s next? What does the future hold for the laser and refractive surgery? “I believe that it is time to speak of ‘super vision’ again, but based on a different concept than 10 years ago. We have to get away from the ‘eagle vs. the frog vision’ concept and speak more in terms of ‘natural’ instead of ‘super’ vision,” Ioannis Pallikaris MD, PhD, Institute of Vision and Optics, University of Crete School of Medicine, Heraklion, Crete, Greece observed. Starting in the present moment, LASIK is the dominant refractive surgical procedure, with many surgeons performing a majority of surgeries with an all-laser approach, ie, a femtosecond laser to cut the flap, and an excimer laser to perform the ablation. Preop assessment typically includes refractive, topographic and wavefront analysis. Results of recent large-scale reviews demonstrate why this approach has become so popular. Large-scale studies now report a majority of patients achieving 20/20 or better, with an increasing percentage achieving uncorrected acuity of 20/16 or better. Some of the best results with LASIK ever seen were reported at the XXVIII Congress of the ESCRS in Paris by David J Tanzer MD, a staff surgeon (and former fighter pilot) at the Naval Medical Centre in San Diego, CA, US. He presented a series of patients, all pilots, who underwent wavefront-guided LASIK with femtosecond flap creation. By two weeks after surgery, all of the patients had 20/20, and 94 per cent had 20/16 or better uncorrected visual acuity. After four weeks, 97 per cent were 20/16, and 87 per cent were 20/12, and all were qualified to fly. The patients also had

“When it comes to the future, there are three kinds of people: those who let it happen, those who make it happen, and those who wonder what happened” John M Richardson Jr

a greater than 50 per cent increase in low contrast acuity. Wavefront-guided LASIK with femtosecond laser flap cutting has rapidly become the most common form of laser vision correction. Most of the major manufacturers now offer a combination platform to facilitate these procedures. Debates of the near future are likely to focus on the best method of eye tracking and registration, wavefront vs. Fourier-based evaluations, and the virtues of the various different femtosecond and excimer lasers. Lasers are faster and more accurate, trackers are better at dealing with cyclotorsion, and complications are fewer. So where to go from here? “The next frontier is improving predictability of outcomes. We’ve pushed pretty hard in terms of wavefront algorithms, and they do exceedingly well, but I think there are cases, both virgin eyes and previously operated eyes, that will probably benefit better from topographic guidance. We can expect to see better laser algorithms and better lasers. I think we are going to see solid-state lasers, smaller beams, and better interaction between the laser and data acquired from other instruments such as topographers and wavefront sensors. These improvements will combine to produce even better visual results than we see today,” Perry S Binder MD, clinical professor of ophthalmology, non-salaried, Gavin Herbert Department of Ophthalmolgy, UC Irvine, CA, US, told EuroTimes. Dr Binder is also medical director for AcuFocus, and a medical monitor for Abbott Medical Optics. As good as LASIK has become, it still

has some issues. These include dry eye, and post-op ectasia, which appears to have declined significantly, but can still be a problem. The key to reducing problems associated with both dry eye and ectasia is in better identifying who is and who is not a good candidate for LASIK. Newer diagnostic approaches such as combining Placido and Scheimpflug imaging modalities (Galilei, Ziemer) to evaluate corneal thickness and curvature are helping in this regard. However, the next horizon appears to be developing technology for assessing corneal biomechanics. “We’re just scratching the surface in this area. We don’t have a good instrument yet. The Ocular Response Analyzer (Reichert) is a start, but it is just not sensitive enough. Although Bill Dupps MD from Cleveland Clinic is doing a fabulous job analysing corneal changes with the ORA, we don’t yet have good metrics we can apply to a given cornea. For example, we know that sometimes thinner corneas are not weaker, and thicker corneas can be weaker biomechanically, and we don't understand all of the reasons why. In the future we hope to identify and rule out those candidates that might develop ectasia by using topographic and biomechanical analysis,” says Dr Binder. It is also important to determine which patients might do better with surface ablation or some form of lens correction. It is now clear that there are limits to hyperopic PRK and LASIK. Many patients might be better served by clear lens extraction or phakic IOL surgery, he added.

Courtesy of Ron Krueger MD

b. Femtosecond laser treatment of the crystalline lens for accommodation restoration (a) immediately after laser delivery, and (b) one week following treatment. There is no sign of progressive cataract formation, and no symptomatic dysphotopsia experienced by the patient when a central clear zone is maintained

Post-op dry eye continues to be the number one complaint following LASIK. In the immediate term, clinical researchers are evaluating alterations to the size and location of the flap in an effort to improve wound healing and reduce post-LASIK dry-eye symptoms. Eric Donnenfeld MD and colleagues conducted a prospective comparison in which 40 eyes of 20 consecutive patients received bilateral simultaneous myopic LASIK with 150-kHz femtosecond laser flaps and wavefrontguided ablations. The eyes that had an elliptical flap with 150-degree reverse side cut angles and a 4.00mm hinge had better corneal sensation than those that received traditional round flaps with 70-degree side cut angles and 3.00mm hinges. The researchers believe this approach prevents resection of the vital peripheral corneal fibres, improving patients’ post-op comfort. A related study found a similar benefit for a 140-degree reverse side cut compared with a 30-degree side cut in femtosecond flap creation. A John Kanellopoulos MD, medical director of the Laservision Institute, Athens, Greece, and professor of ophthalmology at the New York University, Medical School in New York City, US, presented in 2010, at the ESCRS meeting in Paris and the AAO meeting in Chicago, a novel refractive procedure that utilises a continuous wave laser to “shrink” the half anterior stroma in concentric ring fashion without affecting the corneal epithelium that is cooled with a saphire applanating cone. The tissue shrinkage flattens predictably the cornea, and the procedure is completed with transepithelial (epithelium-on) CXL with 12mW/cm2 fluence and 0.1 per cent riboflavin enhanced with high concentration BAK preservative in order to facilitate transepithelial absorption. The novel technique is painless and in the first case follow-up up to 16 months appears to be very stable. EUROTIMES | Volume 16 | Issue 3

Cross-linking for post-LASIK ectasia Following promising studies with

the use of corneal collagen cross-linking (CXL) for the treatment of progressive keratoconus, many wondered if this might also be effective in the treatment of postLASIK ectasia. Clinical trial results suggest that the answer might be yes. Dan Epstein MD, University Hospital, Zurich, and colleagues conducted an 18-month follow-up study of 23 patients with documented post-LASIK ectasia who had been treated with CXL. Patients showed a statistically significant mean improvement in best-corrected acuity. Mean uncorrected and mean spherical equivalent refraction did not show significant differences. Topography maps showed marked reductions, and keratometry readings were stable. Mean central corneal thickness decreased significantly. This does suggest that the treatment did stop the progression of the ectasia. Dr Kanellopoulos has proposed a novel technique for managing post-LASIK ectasia. He evaluated a method of underthe-flap, partial, topography-guided therapeutic ablation (tLASIK) combined with simultaneous collagen cross-linking. Seven eyes had a partial topography guided ablation within the original flap, followed by instillation of 0.1 per cent riboflavin solution within the flap and then crosslinking with UVA irradiation for 10 minutes. Visual function improved during a 15-month mean follow-up and the mean keratometry reading decreased by 2.4 D. Two eyes did regress within one year. This novel approach has the advantage of minimal discomfort and recovery time, it appears though not to be as efficient as the Athens Protocol (combined topo-guided partial PRK and CXL) in the management of post-LASIK ectasia. A number of surgeons, including Dr Kanellopoulos, are now conducting clinical studies of cross-linking and refractive laser surgery. One question being actively

investigated is whether it is better to use a combined or sequential approach when using the two techniques. Additionally, Dr Kanellopoulos has reported using CXL as a prophylactic adjunct in higher risk femto-LASIK surgery (thinner corneas, high myopia-ESCRS 2009, 2010) as well as higher fluence CXL utilising 5, 6, 10 and 12mW/cm2 in order to shorten the CXL procedure time from 30 minutes to under 10 minutes. “Cross-linking at time of surgery, makes sense in many ways, as long as you are not damaging the endothelium. You are killing keratocytes, and you are putting UV light a lot closer to the endothelium, so we need to study that. But if we can predictably strengthen some of these thinner corneas, it could help. The problems with cross-linking are the predictability of outcome, and the degree of refractive change one can get. We are just now learning, through the work of Dr John Marshall and others, what this procedure does morphologically as well as optically to the cornea,” noted Dr Binder.

Variety of presbyopic treatments

The other primary issue that LASIK really has yet to deal effectively with may well be the major consumer demand of the future, presbyopia treatment. The field of refractive surgery is characterised by innovation and experimentation. This is certainly true when it comes to presbyopia. One approach, multifocal ablation, either on the surface of the cornea, or under a flap, has been investigated for many years. Although there are some reports of success, it has generally proved difficult to replicate them. It is still possible that this approach may prove itself with better algorithms and newer technologies, but that remains to be seen. Intrastromal ablation is getting a lot of attention as a potential treatment for presbyopia. This approach uses a femtosecond laser to steepen the cornea from the inside out. Invented by Colombian

refractive surgeon Luis Ruiz MD, the IntraCor® (Technolas Perfect Vision) technique reshapes the central cornea through the creation of circular concentric intrastromal incisions created with a femtosecond laser, without disturbing the epithelium or the endothelium. To date, most studies with IntraCor have involved presbyopic hyperopes and presbyopic emmetropes. Two-year data now available for a study conducted by Mike D Holzer MD, University of Heidelberg, Germany, showed stable refractive outcomes for 25 patients with preoperative hyperopia of as much as 6.0 D. The mean uncorrected near visual acuity improved from 20/100 to 20/30. Postoperative recovery was fast and painless, and to date there has been no regression or weakening of the cornea. Questions remain about the effect of this procedure on distance vision. Haloes and glare were reported by some patients in the immediate post-op period, but tended to resolve over time. Dr Holzer conducted another study in which he used a modified IntraCor femtosecond laser pattern for the correction of emmetropic presbyopes. At 12 months, patients showed mean improvements in near uncorrected visual acuity from 0.60 logMAR (range 0.30 – 0.80) to 0.10 logMAR (range 0.00 – 0.20). Mean uncorrected distance visual acuity was 0.00 logMAR (range 0.10 – -0.20) preoperatively and 0.10 logMAR (range 0.20 – -0.10) at 12 months. The procedure is quick and safe, and patient satisfaction is high, according to Dr Holzer. Predictability and side effects are two issues associated with the intrastromal femtosecond laser approach to presbyopia treatment. In some cases, patients do not respond to the treatment at all. This raises the question, what would be the next step for such a patient? Problems with glare and haloes also need to be addressed. New variations on the intrastromal femtosecond laser front are being evaluated. Gustavo Tamayo MD director, Bogotá Laser

contacts

Cover Story

Courtesy of A John Kanellopoulos MD

REFRACTIVE LASER

A cornea pictured 14 months after the novel CW-CXL procedure - the fine white circles in the anterior stroma are still visible

Refractive Institute, Colombia is currently conducting a study of the efficacy and safety of a new intrastromal femtosecond ablation, with a specially designed T shape that leaves the centre for distance vision and the periphery for near vision. He plans to treat the non-dominant eyes of 50 emmetropic presbyopes. He believes this approach should improve near vision with the advantage of protecting the central area providing better overall quality of vision. The Intralase femtosecond laser (AMO) is also being evaluated for intrastromal laser correction of presbyopia. Francisco Sánchez León MD and colleagues at Instituto Novavision, Naucalpan, Mexico, conducted a prospective clinical study treating presbyopes and mild hyperopes, targeting for good uncorrected near vision. At three months, patients demonstrated stable uncorrected near visual acuity with a mean gain of four lines of near visual acuity and no change in best-corrected distance vision, he has reported. An entirely different approach to presbyopia treatment involves using the femtosecond laser to increase the flexibility of the crystalline lens with the hope of restoring accommodative vision. Marcus Blum MD and colleagues at Augenheilkunde, Helios Klinikum Erfurt, Erfurt, Germany, reported some early promising results at the last ARVO conference. Earlier in vitro studies showed that the femtosecond laser (VisuMax FS, CZM) could successfully make well-centred microincision on the lens. Subsequent animal studies showed that this could be done in living eyes with no ill effects on the retina, and no cataract formation. Dr Blum called the tests ‘promising’, suggesting that clinical trials in humans should be considered eventually. Ron Krueger MD, medical director, Department of Refractive Surgery at the Cleveland Clinic’s Cole Eye Institute studied the same idea in a different way. His team used computer modelling to evaluate the EUROTIMES | Volume 16 | Issue 3

potential of femtosecond laser treatment (LensAR) of the crystalline lens for presbyopia. They then progressed to human cadaver eyes and ultimately to living rabbits and monkeys. These studies supported the notion that the laser did indeed reduce lens stiffness in cadaver eyes. The animal studies showed no cataract formation for as long as two years. The group has begun clinical trials in the Philippines under the direction of Dr Harvey Uy, and so far the investigated laser patterns with an optical clear central zone are showing no signs of progressive cataract formation, but with yet unpredictable changes in accommodation using both objective and subjective testing

The return of thermal collagen shrinkage? Many versions of thermal

collagen shrinkage have been tried as treatments for presbyopia and hyperopia over the past 20 years, such as laser thermal keratoplasty, and all have failed. Problems have included serious side effects including damage to Bowman’s membrane, and instability of the refractive outcome. Nonetheless, there is some optimism surrounding a new thermal approach known as the Keraflex procedure (Avedro). This approach delivers a single low energy microwave pulse to the cornea using a dielectrically shielded microwave emitter that contacts the epithelial surface. This raises the temperature of the selected region of corneal stroma to approximately 65°C, shrinking the collagen and forming a toroidal lesion in the upper 150 microns of the stroma. Next the system cools the surface of the cornea during the treatment to isolate and protect Bowman’s membrane from the thermal effects of the microwave energy. The lesion created during the Keraflex procedure is intended to flatten the central cornea to achieve myopic correction without compromising the biomechanical integrity of the cornea. Keraflex is currently under clinical investigation in Europe for treating myopia and keratoconus. Another popular aspect of the

The OCT of the same cornea at 14 months documenting the anterior stromal shrinkage

femtosecond laser is its ability to create very precise channels or pockets in the cornea, suitable for the placement of refractive inlays. There are three types of corneal inlays, each expressing a different aspect of visual optics of the human eye, used to restore near and intermediate vision in presbyopic patients. Flexivue-Microlens (Presbia) inlay is a 3mm diameter inlay inserted in 300 microns of the anterior stroma of the cornea. Having a peripheral zone of refractive power and a central zone without refractive power, it offers a bifocal element in the optical system of the human eye. The AcuFocus Corneal inlay 7000 (ACI 7000, AcuFocus Inc.), utilises the pinhole effect to increase depth of focus. Presbylens (Revision) is a disc-like inlay that changes curvature and refraction of the anterior cornea when placed under a superior hinged lamellar LASIK flap. Prof Pallikaris reports one-year very promising results of Flexivue inlay implantation in the corneal stroma of the non-dominant eye of 41 patients. Six months after treatment 85 per cent of patients have achieved uncorrected near visual acuity of 20/20. Mean uncorrected distance visual acuity in the operated eye has reduced, while mean uncorrected binocular distance visual acuity remained 20/20. 100 per cent of patients stated that they have got rid of their glasses for near, 80 per cent perceive their uncorrected near visual acuity as excellent and 80 per cent of the patients perceive their uncorrected binocular distance visual acuity as unchanged. Gunther Grabner MD, University Eye Clinic, Paracelsus University, Salzburg, Austria, reported his results with one such inlay, the Kamra (AcuFocus), at the Paris ESCRS Congress. The Kamra uses the aperture concept to improve near and intermediate distance in presbyopes. It has an overall diameter of 3.8mm and has a 1.6mm central aperture which blocks unfocused light and allows focused light

Ioannis Pallikaris - pallikar@med.uoc.gr Perry S Binder - garrett23@aol.com Ron Krueger - Krueger@ccf.org A John Kanellopoulos - ajk@brilliantvision.com

into the eye. The result is an increased depth of field. A three-year follow-up study of presbyopic emmetropes showed a mean gain of 4.6 lines of uncorrected near visual acuity and the mean uncorrected distance visual acuity was 20/20 with a mean loss of 0.8 lines. Uncorrected intermediate visual acuity was 20/32 or better in 95 per cent of eyes and 20/ 20 or better in 50 per cent of eyes. The improved near and intermediate visual acuity came at the cost of some loss of visual acuity in the treated eye, Dr Grabner said. Another recent study suggested that combining the inlay with LASIK could also provide functional near vision for ametropic presbyopes. The PresbyLens (ReVision Optics) corneal inlay uses a different optical strategy. The 2.0mm diameter inlays are placed under a thin flap or within a pocket to steepen the cornea. In early clinical trials the PresbyLens appears to improve near and intermediate vision, with very little loss of distance vision. The femtosecond laser also plays a key role in a novel approach known as lenticule extraction. Called variously refractive lenticule extraction (Relex), femtosecond lenticule extraction (Flex), and smallincision lenticule extraction (SMILE), the femtosecond laser is used to carve a lenticule intrastromally. That lenticule is then removed via a flap or small incision. The hope is that this approach might be better for higher myopia, would induce fewer higher order aberrations, and might carry less risk of ectasia. Rupal S Shah MD, New Vision Laser Centres, Vadodara, India has considerable experience with femtosecond lenticule extraction. He conducted a prospective study in 21 patients (36 eyes) with myopia and myopic astigmatism. Most patients showed statistically significant improvements in visual acuity at three months’ follow-up. However, nine eyes had lenticule failure requiring follow-up LASIK. Other groups, including researchers at the Solomatin Eye Centre in Riga Latvia, have reported that FLEX procedures produce equivalent visual outcomes to LASIK, with early indications of reduced induction of higher order aberrations.

Nanosecond lasers on the horizon Theo Seiler MD, PhD,

chairman of the Department of Ophthalmology at the University of Zurich in Switzerland, is an early pioneer in laser vision correction. His pioneering spirit continues, as seen in a new study evaluating the use of a pulsed nano-second laser for flap creation. Working in pig eyes, his group used a nanosecond laser system to produce smooth and precise flaps. The nanosecond laser did not create any tissue bridges, or any effects of filamentation, known to occur with femtosecond lasers. The early research hints that a safer, faster way to cut flaps may be coming soon.

The BAK*-free Multidose PGA

Introducing TRAVATAN® BAK*-free formulation

TRAVATAN 40 micrograms/ml eye drops, solution (travoprost) (Refer to full Summary of Product Characteristics (SmPC) before prescribing) Presentation: Plastic bottle containing 2.5 ml eye drop solution; 1 ml of solution contains 40 micrograms travoprost. Indication(s): Decrease of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma. Posology and method of administration: Adults, including the elderly: One drop in the affected eye(s) once daily, optimally in the evening. Children and adolescents: Not recommended. Hepatic and renal impairment: No dosage adjustment necessary. Contra-indications: Hypersensitivity to travoprost or any of the excipients. Warnings and precautions: TRAVATAN® may gradually change eye colour. This occurs slowly and may not be noticeable for months to years. Before treatment is instituted, patients must be informed of the possibility of a permanent change in eye colour. Unilateral treatment can result in permanent heterochromia. Long term effects on melanocytes and any consequences are currently unknown. After discontinuation of therapy, no further increase in brown iris pigment has been observed. Periorbital and/or eyelid skin darkening has been reported. TRAVATAN® may gradually increase the length, thickness, pigmentation, and/or number of eyelashes in the treated eye(s). Exercise caution in aphakic patients, pseudophakic patients with a torn posterior lens capsule or anterior chamber lenses, and in patients with known risk factors for cystoid macular oedema or iritis/ uveitis. Skin contact with TRAVATAN® must be avoided. Patients must remove contact lenses prior to application of TRAVATAN® and wait 15 minutes after instillation before reinsertion. TRAVATAN® contains polyoxyethylene hydrogenated castor oil 40 and propylene glycol which may cause skin reactions or irritations. Interactions: none known. Pregnancy and lactation: Pregnancy: Do not use unless clearly necessary. Women of child-bearing potential: Do not use unless adequate contraceptive measures are

•

Demonstrates comparable IOP-lowering efficacy as original formulation TRAVATAN® 1

•

Contains Polyquad®, which has demonstrated a gentler effect on the ocular surface than BAK* in laboratory studies2,3

•

Significantly less toxic to human conjunctival and corneal epithelial cells when compared to latanoprost solution (preserved with 0.02% BAK*) in vitro4

in place. Breast-feeding women: Not recommended. Effects on ability to drive and use machines: If blurred vision occurs, wait until vision clears before driving or using machinery. Undesirable effects: Very common: conjunctival hyperaemia, ocular hyperaemia, iris hyperpigmentation. Common: headache, punctate keratitis, anterior chamber cell, anterior chamber flare, eye pain, photophobia, eye discharge, ocular discomfort, eye irritation, abnormal sensation in eye, foreign body sensation in eyes, visual acuity reduced, vision blurred, dry eye, eye pruritus, lacrimation increased, erythema of eyelid, eyelid oedema, eyelids pruritus, growth of eyelashes, eyelash discolouration, skin hyperpigmentation (periocular), skin discolouration, conjunctival hyperaemia. Serious: Herpes simplex, keratitis herpetic, macular degeneration, iridocyclitis, uveitis, peptic ulcer reactivated, macular oedema. Prescribers should consult the SmPC in relation to other side effects. Overdose: A topical overdose may be flushed from the eye(s) with lukewarm water. Treatment of a suspected oral ingestion is symptomatic and supportive. Special Precautions for Storage: None. Legal Category: POM Package Quantities and Basic NHS Costs: 2.5ml £9.98 GMS Price: €17.91 MA Number(s): EU/1/01/199/001-002. Further information available from: Alcon Laboratories (UK) Limited, Pentagon Park, Boundary Way, Hemel Hempstead, Hertfordshire. HP2 7UD. Telephone: 01442 341234. Date of preparation: November 2010 (V4). Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Alcon Laboratories (UK) Ltd. Tel.: 01442 341234. Email gb.adr@alconlabs.com

*benzalkonium chloride References: 1. Denis P, Gandolfi S et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 12-17, 2010; Madrid, Spain. 2. Labbé A, Pauly A, Liang H. J Ocul Pharmacol Ther 2006; 22(4):267-278. 3. Liang H, Brignole-Baudouin F et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 2-17, 2010; Madrid, Spain. 4. Brignole-Baudouin F, Riancho L et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 2-17, 2010; Madrid, Spain.

Date of preparation: January 2011 TBF:EUR:01/11:HC

d n o c e s to FLAeSm IK Instruments Thorlakson Z-LASIK Flap Lifter

Special Focus

REFRACTIVE LASER

Presbyopic LASIK

Different approaches to presbyopic LASIK can provide increased spectacle independence

Top View

by Roibeard O’hEineachain in Paris

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Top View

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EUROTIMES | Volume 16 | Issue 3

ASIK procedures designed to provide presbyopic patients with multifocality or an increased depth of field continue to show promise at different centres around the world as the related technology evolves, according to Jorge Alio MD, VISSUM, Instituto Oftalmologico de Alicante, Alicante Spain.

Alicante, Spain “The advantages of presbyLASIK over refractive lens exchange are that it does not mutilate the natural lens of the eye or involve the risks of intraocular procedures, such as endothelial cell loss and endophthalmitis. Furthermore, presbyLASIK presents no barrier to future intraocular procedures, should they become necessary, Dr Alio said. There are two main approaches to presbyopic LASIK, Dr Alio said. They are central presbyLASIK, where the central portion of the cornea has the near focus, and peripheral presbyLASIK, where the peripheral cornea’s curvature is altered so as to provide greater depth of field for near vision. Dr Alio said that he has been performing central presbyLASIK in recent years using a patented technique called PresbyMAX®, which he and his associates developed jointly with Schwind at the VISSUM centre. He and his associates have completed a multicentre study with the technique. “Central presbyLASIK’s advantages are its synergy with convergence miosis, the minimal tissue ablation and neuroadaptation required. It produces immediate results with the focus dominance for far and near depending on pupil size. It also induces minimal higher order aberrations or degradation of the quality of the retinal image,” he said. The PresbyMAX procedure involves the use of the Amaris Schwind platform to create a bi-aspheric central presbyLASIK ablation profile. The aim of the ablation profile’s design is to produce a refractive surface with the minimum of aberrations at the near and distance foci, based on the predicted Strehl ratios. Multicentre study Dr Alio presented a multicentre study (which included contributions from Michiel H A Luger, The Netherlands, Detlef Uthoff, Germany, Tarek A Wahab, Egypt and Eduardo Martines, Brazil) involving 104 eyes of 52 patients who underwent the central presbyMAX procedure. Inclusion criteria for the study were -7.0 D to +3.5 D of sphere and up to 3.0 D of cylinder. In addition, all patients had a preoperative keratometry reading between 40.0 D and 48.0 D, a preoperative best-corrected visual acuity of 20/25, and near vision of J3 when using an add up to 2.5 D, Dr Alio explained. At six months’ follow-up, 78 per cent of patients had distance and near uncorrected visual acuities of 20/40 or better and J5 or better, respectively. In addition, 73 per cent had uncorrected distance visual acuities of 20/25 or better and 51 per cent of patients had an uncorrected near visual acuity of 20/25 or better, he continued. The patients achieving a distance visual acuity of 20/25 or better included 60 per cent of hyperopes, 89 per cent of

emmetropes and 80 per cent of myopes, Dr Alio said. All eyes except for five per cent of the myopes achieved an uncorrected distance visual acuity of 20/40 or better, he added. Those achieving a near visual acuity of 20/25 or better included 50 per cent of hyperopes, 22 per cent of emmetropes and 65 per cent of myopes, he noted. Three-fourths of hyperopes achieved an uncorrected logMAR near visual acuity of 0.13 or better, as did 67 per cent of emmetropes and 85 per cent of myopes, he said.

Peripheral presbyLASIK The principle involved in peripheral presbyLASIK is the induction of a precise amount of coma or spherical aberration to increase the cornea’s depth of field. The treated cornea has a steepened central zone for near vision and a peripheral zone that is optimised for distance vision. Unlike central presbyLASIK, the peripheral approach requires patients to undergo a period of neuroadaptation in order to become accustomed to their new aberration pattern, Dr Alio said. Peripheral presbyLASIK also requires a large amount of tissue ablation, especially in presbyopic myopes and the technique is more commonly practised in presbyopic hyperopes. He noted that the results reported by Bruce Jackson MD, University of Ottawa, Ottawa, Ontario, Canada, appear to demonstrate the efficacy of the peripheral approach. In a series of 76 hyperopes who underwent the procedure 64 per cent achieved a near visual acuity of J1 and 89 per cent achieved J3 or better at six months' follow-up. In addition among 25 patients who had reached 12 months' follow-up, all achieved binocular visual acuity of 20/25 or better for distance and J3 or better for near, and 88 per cent achieved binocular visual acuity of 20/25 or better for distance and J1 or better for near, Dr Alio said. Moreover, mean contrast sensitivity under mesopic conditions was within normal range for untreated eyes at 12 cycles per degree and at 18 cycles per degree. Furthermore, only two per cent of patients needed glasses for driving at day or night, and none required them during recreational activities. However, approximately half of the patients still required glasses for reading. Dr Alio noted that all of the major laser manufacturers are developing presbyopia-correcting ablations, and formal trials are under way in the US and Europe. However, some inherent problems remain, he said. For example, it is not possible to centre a multifocal ablation on the line of sight since the line of sight is different for near and distance vision. In addition, ophthalmic science has yet to determine precisely the amount of spherical aberration the human brain can comfortably tolerate, he said. “The results vary with both central and peripheral techniques and we need stronger scientific evidence in order to consolidate these techniques for the practising surgeon,” Dr Alio concluded.

contact

Jorge Alio - jlalio@vissum.com

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EURETINA INNOVATION AWARDS

INNOVATION AWARDS The European Society of Retina Specialists is delighted to announce the 2011 EURETINA Innovation Awards, a new initiative sponsored by EURETINA to support and encourage innovation in the field of retinal medicine.

All eligible entries will be evaluated by a Judging Panel comprising of:

The purpose of the Awards is: n To support, encourage and reward individuals, who actively consider and develop novel and innovative ideas relevant to the field of retinal medicine; n To facilitate and support an entrepreneurial culture to deliver new market applications for the ultimate benefit of patients with retinal disorders; n To engage and encourage the networking potential of the retinal community across the EU to improve both patient care and outcomes.

Prof. Einar Stefansson PhD,

Landspitali University Hospital, Iceland, Chairperson of the EURETINA Research Committee (Judging Panel Chairperson)

Prof. Dr. Sebastian Wolf,

University of Bern, Switzerland, General Secretary of EURETINA

Mr Douglas Anderson OBE FRSE FRSA,

Founder and VP of Global Advocacy, Optos Plc, Founder and Chairman of Crombie Anderson Associates

Prof. Pete Coffey BSc, DPhil,

Head of Ocular Biology & Therapeutics, University College London

Mr Richard Condon,

Director of Marketing (Ophthalmology), Bayer UK/Ireland.

Dr Gearoid Tuohy PhD,

Ocular Genetics Unit, Smurfit Institute of Genetics, Trinity College Dublin and Founder of Genable Technologies Limited

LONDON 2011

A 1st Prize of €20,000, a 2nd Prize of €10,000 and a 3rd Prize of €5,000 will be awarded at the 11th EURETINA Congress, which takes place at the QEII Centre in London from 26-29 May 2011. The competition is open and entries will be accepted until 5pm on Monday, March 14th, 2011. You can enter by applying online at www.euretina.org/Innovation

11TH EURETINA CONGRESS

Further information is available on the website or you can contact:

26–29 May 2011

Dara Conlon, EURETINA Project Manager at 00-353-1-2100092; email dara.conlon@euretina.org

contact

Xiangjun Chen - chenxiangjun1982@hotmail.com

Special Focus

SECTION HEAD REFRACTIVE LASER Section sub head

No-touch PRK

Courtesy of Xiangjun Chen MD

Removing epithelium with laser speeds healing and reduces pain of corneal surface ablation by Roibeard O’hEineachain in Paris

CORNEAL surface ablation technique called cTEN™, which removes the epithelium with an excimer laser, appears to provide visual outcomes comparable to those of PRK, but with less postoperative pain and faster re-epithelialisation, according to the results of a study presented at the XXVIII Congress of the ESCRS by Xiangjun Chen MD, Oslo, Norway. The prospective study involved two groups of 40 myopic patients. One group

“

With the cTEN procedure we can limit the de-epithelialisation to the area of the refractive ablation, which theoretically will lead to faster re-epithelialisation Xiangjun Chen MD

underwent custom trans-epithelial ablation with iVIS-Suite 1000 Hz laser (iVIS technologies), with de-epithelialisation integrated within excimer laser ablation and the other group underwent PRK with WaveLight Allegretto 400 Hz laser (Alcon) using an Amoils brush for de-epithelialisation. The mean preoperative spherical equivalent was -2.90 D in the trans-epithelial ablation group and -3.06 D for the conventional PRK group. “For PRK we perform a mechanical removal of the epithelium first followed by a refractive ablation of the stroma. The Custom trans-epithelial no-touch ablation consists of two components: one transforms the corneal shape with an aspheric curvature and the other adds the stratified epithelial thickness to the ablation plan. This is done with one single procedure,” Dr Chen said. She noted that trans-epithelial ablation requires a fast 1000 Hz laser because the volume of epithelium to be ablated is typically four to six times larger than the refractive ablation volume. However, unlike standard epithelial removal techniques it does not require removal of a circular

True COMICS

Different area required between the cTEN and mechanical deepithelialisation. Left: deepithelialisation area with cTEN technique fits the exact outer edge of the custom ablation (blue line). Right: mechanical deepithelialisation scrapes a larger area of epithelium (orange area) than the custom ablation

area with a diameter equal to the widest meridian of the area to be ablated, she said (see figure above). “With the cTEN procedure we can limit the de-epithelialisation to the area of the refractive ablation, which theoretically will lead to faster re-epithelialisation,” she said. The cTEN™ module of the iVIS technologies laser suite incorporates the epithelial ablation profile with a topography-guided custom aspheric ablation profile provided by CIPTA software, she added. Dr Chen noted that the duration of surgery was more than a minute longer in the PRK group, lasting 4.90 minutes compared to 3.88 minutes in the trans-epithelial ablation group. The de-epithelialisation area was 8.0mm x 8.0mm in the PRK group, compared to 7.72mm x 7.76mm in the cTEN group. Moreover, the subjective pain score,

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EUROTIMES | Volume 16 | Issue 3

which was measured each day until re-epithelialisation was complete, was significantly lower in the laser de-epithelialisation group (p=0.01), she pointed out. The mean re-epithelialisation time was slightly faster in the laser de-epithelialisation group and took 2.63 days, compared to 2.9 days in the conventional PRK group (p= 0.07). Visual outcomes were similar in the two groups, Dr Chen noted. The mean postoperative UCVA was 0.95 at one week and 1.17 at one month in the laser de-epithelialisation group, and 0.83 at one week and 1.07 at one month in the mechanical debridement group. “The advantages of custom transepithelial custom ablation include shorter surgery time, smaller de-epithelialisation area with faster re-epithelialisation less pain and reduced risk of infection as a result,” Dr Chen concluded.

contact

Special Focus

REFRACTIVE LASER

David Gartry - David@gartry.com

Laser audit

Careful audit of refractive outcomes is key to knowing whether lasers are functioning effectively by Gary Finnegan in Brighton

onducting regular audits is essential to ensure that lasers used for refractive surgery are delivering the energy output, and therefore the refractive outcomes, promised by manufacturers, according to David Gartry MD. Speaking at the United Kingdom & Ireland Society of Cataract and Refractive Surgeons (UKISCRS) annual meeting, he urged colleagues to embrace web-based programs which help surgeons compare their results as well as monitor the performance of lasers. Prof Gartry, who is a consultant surgeon and director of the Refractive Service at Moorfields Eye Hospital, London, and a professor at City University, London, said that a detailed knowledge of your refractive outcomes is essential for

algorithm and nomogram adjustments. “Audit has become even more important because we now have the Royal College of Ophthalmologists’ Assessment/Certificate in Laser Refractive Surgery [in the UK] and an important part of that examination is presenting a portfolio or an audit of your results,” he said. Prof Gartry reminded the audience of his presentation at the UKISCRS annual meeting in 2008 where he discussed the Waring graphs – a standard set of six graphs for displaying results for refractive surgery. This method for displaying results is invaluable for surgeons keen on comparing their outcomes with colleagues or with those reported in journals. The graphs, originally described by George Waring MD in a 2000 edition of the Journal of Refractive Surgery, can be

Eye Chat with Oliver Findl

“

Prof Findl talks to Dr Bill Aylward (president of EuRetina, consultant at Moorfields) about ‘Myopia: the Lens and the Retina’

Listen to our podcasts at

www.eurotimes.org

podcast EUROTIMES

ESCRS

Podcasts are also available on iTunes

™

viewed on a single page. They comprise a scattergram of expected versus achieved refraction; a spherical equivalent refractive outcome bar graph; a defocus equivalent bar graph; a visual acuity bar graph; a change in spectacle-corrected visual acuity bar graph; and a stability of refraction graph. Prof Gartry has been using an Internetbased refractive analysis software program, designed by Bruno Zuberbühler MD, who worked with him at Moorfields, which he says has been tremendously helpful in allowing him to study his results in great detail. “We’ve used this system for almost four years. It’s web-based which makes it very flexible and you can produce all of the Waring graphs from this type of software with just a few keystrokes – no laptops required, no USBs, no floppy disks, no CD-ROMs or anything that can get lost – very important these days in terms of information governance,” he said. In Moorfields, six of the nine laser refractive surgeons are using this system, which means they can look at the hospital’s results as a whole, and then compare their own data with this main database. The hospital opened a new unit in January 2009 and installed two very commonly used lasers: the Star S4 from Abbott Medical Optics Inc (AMO) and the Z100 with dynamic rotational tracking from Technolas Perfect Vision (formerly the laser refractive arm of Bausch + Lomb). This allowed surgeons a unique opportunity to directly compare these two brand new machines over the same time course. Looking at his own results in 412 eyes divided into two groups, Prof Gartry said that the Z100 gave around a one per cent over-correction for patients up to -6.00 D as compared with a nine per cent undercorrection with an equivalent refractive group with the AMO Star S4 laser. “When we looked at the outcomes for the Abbott-AMO Star S4, in my particular

“

The most important point is that if we don’t collect the data and analyse it, we’ll never know whether new lasers are over- or undercorrecting, or whether they are, in fact, perfectly calibrated David Gartry MD

patient database we found a significant under-correction in the group with relatively moderate amounts of myopia (up to -6.00 D). For every parameter we analysed using my own data, we had either a slight or significant improvement with the Technolas Z100 laser. We’re going on to look at why we should be getting better results with this laser but it may be related to key technical differences such as the high frequency at 100Hz, 1 and 2mm spot sizes and dynamic (real-time) rotational eye tracking,” Prof Gartry reported. He said, however, that both laser systems were excellent and gave exceptionally good results but surgeons must analyse their data carefully in order to detect any consistent tendency to overor under-correction. “The most important point is that if we don’t collect the data and analyse it, we’ll never know whether new lasers are over- or under-correcting, or whether they are, in fact, perfectly calibrated. It’s very important to review your cases regularly and not make any assumptions when bringing in a new laser – even if it is the same make and model as used previously,” concluded Prof Gartry.

Don’t miss Research Update, see page 29 EUROTIMES | Volume 16 | Issue 3

THE SMART COMBINATION REFRACTIVE AND CATARACT SURGEONS WANT

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Some of the products and/or speciﬁc features as well as the procedures featured in this document may not be approved in your country and thus may not be available there. Design and speciﬁcations are subject to change without prior notice as a result of ongoing technical development. INTRACOR, SUPRACOR, CUSTOMLENS and CUSTOMSHAPE are NOT approved for use in the US. INTRACOR, CUSTOMLENS, SUPRACOR and CUSTOMSHAPE are not approved in all countries. CUSTOMLENS will be available soon in selected markets. Please contact our regional representative regarding individual availability in your respective market. The trademarks (™ and ®) and logos used in this document are the property of Technolas Perfect Vision GmbH or the respective owner. Design by kbcomunicacion. Ref. TPV-005/01-2011 ©2011 Technolas Perfect Vision GmbH. All rights reserved.

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Update

cataract

Novel speculum

Donut-shaped device with attached drape reduces bacteria on ocular surface in cataract surgery by Howard Larkin in Paris

EUROTIMES | Volume 16 | Issue 3

Courtesy of Masataka Kasaoka MD

any cases of post-cataract surgery endophthalmitis are caused by the normal flora of the conjunctiva, eyelids and meibomian glands infiltrating the surgical wound. Appropriate draping is one of the ways of preventing surgical field contamination that can lead to infection during procedures. But it is difficult to completely drape eyelashes and eyelids with conventional procedures, Masataka Kasaoka MD told a symposium of the XXVIII Congress of the ESCRS. So he and colleagues at Kurume University, Kurume City, Kyushu, Japan, are experimenting with a novel speculum with an attached drape that does away with the need for metal clamps and separate eyelid drapes. This lid speculum has been developed by collaboration between Kurume University and HAKKO CO, LTD, medical device supplier in Japan. In early tests, the novel speculum has significantly reduced both the proportion of eyes with detectable bacteria present during surgery, as well as the number of bacterial species isolated. This novel lid speculum consists of two rings of polyacetal resin and a transparent silicone sheet attached to the rings. It completely drapes the eyelashes and eyelids. When placed on the eye, the device covers the entire area, including eyelids and eye lashes. A hole in the center of the device allows access to the cornea and surrounding sclera. The speculum holds the eye open without the need for clamps beneath the eyelids. In a prospective study of 43 eyes in 39 patients undergoing cataract surgery, Dr Kasaoka and colleagues compared the effectiveness of the novel speculum with conventional drapes and clamps for preventing surgical field contamination. There were no significant differences between the 21 eyes in the novel group and the 22 in the conventional group, and no intraoperative complications were encountered. Before installation of the speculum, and before disinfection, the conjunctival sac was scraped and cultured. After the speculum was attached, irrigation solution samples aspirated before the incision and during surgery were cultured. The results strong favoured the novel

Lid speculum with a drape

speculum design. While pre-instillation bacterial detection rates and number of isolates were nearly identical – 81.8 per cent and 19 isolates for the conventional group, v. 81.0 per cent and 20 isolates for the novel speculum group – the rates dropped sharply after the devices were installed. However, after disinfection and before incision, the bacterial detection rate in the conventional group was 36.4 per cent, rising to 45.4 per cent during surgery, with the number of isolates also increasing from eight to 10. By contrast, in the novel speculum group the bacterial detection rate was less than half that at 15.0 per cent preincision, and actually fell to 9.5 per cent during surgery. The number of isolates also dropped, from three pre-incision to two during surgery. The number of P. acnes isolates during surgery was seven in the conventional group v. one in the novel group. All these results were statistically significant. “The use of this novel disposable lid speculum with a drape is effective in preventing intraoperative contamination of the surgical field at cataract surgery,” Dr Kasaoka concluded.

contact Masataka Kasaoka - kasaoka@med.kurume-u.ac.jp

Update

Refractive Lens

Astigmatism

Broad choice of toric pseudophakic implants good tools for addressing diverse patient needs

Keratograph Topographer Conquers the Elements

by Cheryl Guttman Krader In Paris

n expanding array of toric IOL options will help cataract surgeons to meet increasing patient demands for good uncorrected postoperative vision, including those wanting a presbyopia-correcting lens, according to reports at the XXVIII Congress of the ESCRS. “Considering the many standard toric IOLs available, surgeons can correct up to 6.0 D of pre-existing astigmatism, while much higher astigmatism, including in eyes post-penetrating keratoplasty, can be corrected with a custom-made lens,” said Gerd Auffarth MD, acting chairman, Department of Ophthalmology, University of Heidelberg, Germany. Currently, six manufacturers provide pseudophakic toric IOLs on the European market. Models with only fixed cylinder are available from both Staar Surgical (model AA-4203TF) and Alcon (models SN60T3-9). Rayner, Acri.Tec/Zeiss, Dr Schmidt/ HumanOptics, and OcuLentis have more diversity in their toric IOL lines. They market standard and custom-order IOLs with cylinder power steps and ranges varying depending on the manufacturer and the specific model. Rayner offers monofocal toric IOLs (T-flex 573 T and T-Flex 623 T), multifocal toric IOLs (M-flex T 588F and 638F), and a sulcus piggyback toric IOL (Sulcoflex 653T). Acri.tec/Zeiss markets a small incision plate toric lens (Acri.Comfort 646 TLC), a 3-piece toric IOL model (Acri. Comfort 643 TLC), and a bifocal toric implant (Acri.Lisa Toric 466TD). Dr Schmidt/HumanOptics markets two toric IOLs for capsular fixation (MicroSil MS6116 TU and MS 614 T lens) and one for sulcus piggybacking (MS714TPB). The toric IOL line from Oculentis includes two monofocal models (LU-312T and LU-313-T) and a multifocal toric lens (LU-313 MFT). Dr Auffarth said that careful diagnostics are essential in achieving good outcomes with toric IOLs. Keratometry measurements should be obtained at the beginning of the ophthalmic exam, prior to any manipulation of the eye, and at least two weeks after discontinuation of any contact lens wear. Dr Auffarth uses partial coherence interferometry (IOLMaster, Carl Zeiss Meditec) for all biometry data, including keratometry readings, and reported excellent results using different toric IOLs to correct a wide range of astigmatism. EUROTIMES | Volume 16 | Issue 3

In a series of 68 eyes implanted with an Alcon SN60T1-3 toric IOL for preoperative astigmatism between -1.5 and -4.0 D, 74 per cent of eyes had <0.5 D of residual astigmatism at three months after surgery and median logMAR UCDVA was 0.20. Among 11 eyes implanted with Alcon toric IOL models SN60T6-9, residual astigmatism was <0.5 D in 90 per cent of eyes and median logMAR UCDVA was 0.30. Using the Rayner T-Flex IOLs in 27 eyes, of which 41 per cent had more than 6 D of astigmatism, he achieved a mean postoperative SE of -0.16 D and the refraction was ±1.0 D of target in 85 per cent of eyes. Accurate and stable cylinder outcomes were achieved in 14 eyes with mean preoperative cylinder of -2.38 D implanted with the small incision Oculentis LU-303 T IOL. Compared with toric IOLs, the range of astigmatism that can be corrected via limbal relaxing incisions (LRIs) is much lower. However, the procedure can be effective and has a number of benefits, said Boris Malyugin MD, PhD, Fyodorov Eye Microsurgery Complex, Moscow, Russia. “LRI surgery is less expensive than toric IOLs, and for the surgeon, it represents a simple procedure with a flat learning curve and no requirement for expensive or complex equipment,” he said. Dr Malyugin suggested considering LRIs for patients with up to 2.0 D of corneal astigmatism if they have more than 1.0 D of with-the-rule astigmatism or more than 0.5 D of against-the-rule astigmatism. A variety of LRI nomograms have been published. Paired incisions are used for higher amounts of cylinder while a single incision is performed in eyes needing less correction. Corneal topography should also be considered in the surgical plan. “For eyes with symmetrical topography, the main cataract incision is usually placed in the weak meridian and paired arcuate incisions perpendicularly. However, if the corneal topography is asymmetrical, it may be logical to combine the cataract incision with just one arcuate incision in the same steep corneal meridian,” Dr Malyugin said.

contacts Gerd Auffarth - ga@uni-hd.de Boris Malyugin - boris.malyugin@gmail.com

Water and oxygen are important for the cornea Non-contact assessing of the tear film in less then 30 seconds – Modern Topographers can do more then only topography. Two new software applications are now available:  “TF-Scan” (Tear Film Scan), analyses the quality (NIBUT, BUT) and quantity (tear meniscus height) of the tear film and displays it as a coloured map  “OxiMap” (Oxygen Map), displays the oxygen transmissibility of soft contact lenses OCULUS – We focus on progress

www.oculus.de

contacts

Update

Refractive Lens

Roger F Steinert MD - steinert@uci.edu John Vukich MD - javukich@gmail.com

Femtosecond cataract technology

Challenge to find ways for cataract surgeons to move towards 'LASIK-like' outcomes by Dermot McGrath in Paris

Courtesy of Roger Steinert MD

EUROTIMES | Volume 16 | Issue 3

of 1.0 D from target refraction. With contemporary LASIK, the goal is spectacle independence of 20/20 or better and accuracy to within 0.25 D of intended refraction. Up until recently, cataract surgery targeted functional vision of 20/40 or better and within 1.0 D of intended refraction. With premium toric and multifocal IOLs, however, the goal is now spectacle independence of 20/30 or better at distance and near and we need much tighter tolerances in the range of 0.50 D,” said Dr Steinert. Dr Steinert said that the real challenge now is to find ways for cataract surgeons to move towards “LASIK-like” outcomes. “The high-profile patient is paying for the premium IOLs and that patient expects a perfect refractive outcome. While there are things we can do such as checking and double checking the keratometry readings, axial length measurements and all the IOL power formulae and so forth, we still have some refractive outcomes that are off target despite all this,” he said. Dr Steinert said that the biggest variable that could affect the refractive outcome is the effective lens position (ELP). “The standard IOL formulas assume an effective lens position based on the preoperative measurements, but these assume that the IOL will be positioned at the same plane in all eyes. It has been shown that the prediction of that post-op IOL plane is a dominant source of error in IOL power calculation,” he said. For instance, Dr Steinert said that if the IOL were positioned 0.5mm posterior to the assumed plane, a 21 D lens would produce only 20.0 D of correction, whereas if the IOL were 0.5mm anterior to the assumed plane, a 21 D lens would produce 22.0 D of correction. Dr Steinert cited a study by Cekic et al. showing that the size of the capsulorrhexis affects effective lens position, adding that controlling this variable that should help improve refractive outcomes in cataract surgery. “Does capsulotomy size affect refractive outcomes? A 4.0mm capsulorrhexis results in longer postoperative ELP than does a 6.0mm capsulorrhexis for the same type of IOL used. So we ought to have a round, centred, reproducible capsulotomy that is smaller than the IOL’s optic to ensure

View from surgical microscope after laser capsulotomy and lens fragmentation demonstrating anterior capsule elasticity with free floating capsule disk

that the IOL’s position in the bag matches the anticipated formula. And we have the potential to do that with the femtosecond laser,” he said. In a study performed by Zoltan Nagy MD in Budapest, capsulotomies created with the LenSx system had significantly better centration at one week and one month postoperatively compared to those created by manual capsulorrhexis. Additionally, the IOL overlapped with the capsular opening better in the LenSx group than in the manual group. “This improved accuracy may reduce the risk of IOL decentration as the capsule contracts over time, although this still has to be proven in clinical studies. Laser capsulotomy promises to produce a more constant effective lens position and better centration, which makes it advantageous for premium IOLs. Our refractive outcomes should improve with the precision of a laser procedure that replaces most of the manual, variable steps of cataract surgery,” he added. The importance of precise anterior capsulotomies in premium lens performance was also stressed by John Vukich MD. “The anterior lens capsule is a dynamic structure and all of the current lens models that are attempting to provide an accommodative result rely on some biomechanical translation of forces at the level of the ciliary body translated onto the anterior capsule. It is plausible to consider

Courtesy of John Vukich MD

he precisely round, well-centred, accurate diameter capsulotomy achieved by femtosecond lasers demonstrates less variability in effective lens position after IOL implantation, which should lead to improved predictability in refractive outcomes, especially in refractive IOL patients, according to Roger Steinert MD. “We are in the early days of clinical use but the indications are that femtosecond laser technology may become an indispensable tool in refractive cataract surgery,” said Dr Steinert, professor of ophthalmology and biomedical engineering, chairman and director of the Gavin Herbert Eye Institute at the University of California, Irvine. Dr Steinert noted that cataract surgery, despite being an immensely successful and safe procedure for millions of patients, still has its limitations. “The overall complication rate of cataract surgery is about ten times higher than LASIK. Surgeon confidence is going to be necessary for widespread adoption and market growth of this technology and the reality is that in lens surgery the accuracy is about half of what we achieve with LASIK in terms of the predictability of the visual outcome. We are still struggling somewhat with accurate astigmatism correction and presbyopia correction as well as the effective power of the implant,” he said. Dr Steinert compared the current performance of cataract surgery as being at a similar level as early LASIK technology. “Early on with PRK and LASIK our goal was functional vision and we were happy with 20/40 or better with a deviation

Precise laser capsulotomy and intraocular lens at one month post-op

that the consistency of the shape of the capsulotomy and its size and location are the last uncontrolled variables in terms of how we refine this technology and utilise it to its full extent,” he said. Dr Vukich’s study looked at capsulotomies created with the OptiMedica femtosecond laser in 23 eyes of 23 patients, followed by ultrasound phacoemulsification after lens fragmentation with the femtosecond laser and IOL lens implantation. The study found that the achieved diameter and shape of computer-controlled femtosecond laser capsulotomies were highly predictable and reproducible and that the elastic properties of the anterior capsule and the programmed incision diameter influence the final resulting diameter of the capsular opening.

contact

Gunther Grabner - g.grabner@salk.at

Update

Refractive Lens

Inlay shows promise

Corneal implant for presbyopia appears to sharpen near vision with only small sacrifice of distance vision in treated eye by Roibeard O’hEineachain in Paris

Promising results in FDA trial

Dr Grabner presented the results achieved in a series of 32 patients who underwent the procedure as part of a multicentre FDA study that is taking place at centres in the US, Europe and Asia. The patients in the study were presbyopic emmetropes aged between 45 and 55 years of age. All had a spherical equivalent within half a dioptre of emmetropia, required a reading add between 1.0 D and 2.5 D with uncorrected visual acuity 20/20 in both eyes. None had undergoneprior eye surgery or had any other eye disease. At 36 months of follow-up Dr Grabner’s cohort achieved a mean gain of 4.6 lines of uncorrected near visual acuity and the mean uncorrected distance visual acuity was 20/20. He noted that one of the FDA’s criterion for approval of the device as a treatment for presbyopia was that 75 per cent must be J5 or better. In fact, 98 per cent of patients in the study achieved J3 or better and half achieved J1, he pointed out. In addition, uncorrected intermediate visual acuity was 20/32 or better in 95 per cent of eyes and 20/ 20 or better in 50 per cent of eyes. Preoperative uncorrected distance visual acuity was 20/20 or better in all eyes. However, at six months’ follow-up it was 20/20 in two-thirds of eyes, 20/25 or better in 88 per cent, and 20/32 or better in all eyes. However, binocular distance visual acuity remained unchanged and uncorrected near and distance visual acuity remained stable throughout follow-up. “The loss of uncorrected distance visual acuity in this trial is less than that reported with older inlay designs. This may be due to the enhancing effect of its design on distance visual acuity which may be an advantage to EUROTIMES | Volume 16 | Issue 3

“

The AcuFocus KAMRA inlay is effective, minimally invasive and well tolerated with stable results Gunther Grabner MD

this technology,” Dr Grabner said. Complications included one case of epithelial ingrowth that required a repeated flap lift plus suturing. There were also two cases with decentred inlays. In those patients, Dr Grabner lifted the flap and re-centred the inlay about half a millimetre towards the line of sight. Over the following two years, near and distance visual acuity steadily improved to acceptable levels. There were also a couple of patients who had problems with dry eye after the procedure. “The inlay is mainly used in older patients, who will therefore be more prone to dry eye problems, especially women. It is important to test for and counsel patients about dry eye before surgery. For example, a patient who has a poor Schirmer’s test score should be advised that they will require eye drops for a minimum of six months,” he said.

Improved design now available

The current inlay measures 3.8mm in diameter with a central 1.6mm aperture and is five microns thick. It is composed of an opaque polyvinylidene fluoride material with 8400 laser etched micro-perforations designed to allow for optimal nutrient flow. An earlier inlay design was used in this study. It was 10 microns thick and had 1600 holes. The implantation procedure involves creation of a pocket or a flap in the nondominant eye with a femtosecond laser. The procedure takes less than 30 minutes to complete. Other developments include the KAMRA AcuTarget™ System, a device to assist surgeons with precise inlay centration guidance and assessment. It identifies both the 1st Purkinje reflex and the pupil centroid preoperatively and provides a visual guide for placement of the

inlay during surgery. Postoperatively, the AcuTarget System identifies the actual inlay placement versus the preoperative target. Laser manufacturers have also developed new technologies to support corneal inlay implantation within a pocket, for example the Ziemer femtosecond laser is now capable of reliably creating a pocket or flap at a target depth of 200-220mm. The IntraLase also has new pocket software that looks very promising, Dr Grabner said. He added that the deeper placement of the inlay should protect against complications of the anterior cornea such as corneal thinning that have happened with older inlay designs that resulted in removal. “Although I have not taken one out in over 80 patients, some with over four years of follow-up, I like the fact that I can take it out if need be. In my opinion, this is an advantage over other presbyopia-correcting technologies,” Dr Grabner added.

Courtesy of Gunther Grabner MD

he KAMRA™ (AcuFocus, Inc) corneal inlay, which uses a small aperture to improve near and intermediate vision in presbyopes, has produced promising results in a series of patients taking part in an international FDA trial, reports Gunther Grabner MD, University Eye Clinic, Paracelsus University, Salzburg, Austria at the XXVIII Congress of the ESCRS. “The AcuFocus KAMRA inlay is effective, minimally invasive and well tolerated with stable results,” he said.

At 36 months of follow-up there was a mean gain of 4.6 lines of uncorrected near visual acuity and the mean uncorrected distance visual acuity was 20/20

The current KAMRA inlay measures 3.8mm in diameter with a central 1.6mm aperture and is five microns thick. It is composed of an opaque polyvinylidene fluoride material with 8400 laser etched micro-perforations designed to allow for optimal nutrient flow

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Immediately preceding the XXIX Congress of the ESCRS

Abstract Submission Deadline: March 15th 2011

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Update

CORNEA Biometry connected …

Biomechanics

Key to optimising efficacy and safety of corneal diagnostics by Cheryl Guttman Krader in Paris

ew techniques for quantifying biomechanical properties of the cornea now entering the clinic offer significant potential for the diagnosis of keratoconus and other corneal diseases, reported investigators at a clinical research symposium at the XXVIII Congress of the ESCRS. The Ocular Response Analyzer (ORA, Reichert) is already available for measuring corneal biomechanical parameters. Research has shown there are differences in corneal hysteresis (CH) and corneal resistance factor (CRF) values between normal eyes and those with keratoconus. However, the diagnostic specificity is not sufficiently high. New software, which is commercially available in countries outside the US, analyses the CRF and six waveform parameters to generate a keratoconus match index (KMi) that indicates the probability the eye falls into one of five diagnostic categories: normal, keratoconus suspect (forme fruste), mild keratoconus, moderate keratoconus, or severe keratoconus. “Initial experience with this keratoconus scoring system suggests it is a promising technique for helping to confirm early keratoconus in eyes with suspicious topography and perhaps even for keratoconus detection in cases where topographical abnormalities are not yet present,” said Damien Gatinel MD, University Paris VII, Paris, France. Dr Gatinel was one of several clinicianscientists who provided expert input and clinical data used to develop the software. The analyses were performed by David Luce PhD, inventor of the ORA and chief scientist at Reichert, and were based on 42 parameters computed from ORA signals. Cynthia Roberts PhD, The Ohio State University, Columbus, OH, discussed another technique, dynamic rasterstereographic corneal topography (d.RCT, Vision Optimization, LLC) that is being developed to detect spatial asymmetry in corneal stiffness. “Dynamic corneal surface topography is based on the idea that keratoconus progression is driven by a focal reduction in the modulus of elasticity in the cornea, rather than by an overall weakening, and that this localised change in the spatial distribution of biomechanical properties would be the first detectable feature of keratoconus, preceding changes in curvature EUROTIMES | Volume 16 | Issue 3

and thickness,” explained Dr Roberts. The system is not sensitive to errors of alignment or low surface quality, and so one of its advantages is that it can be used intraoperatively on a bare stromal bed. Since the ESCRS Congress in September 2010, the system has been calibrated and the software for calculating stiffness has been completed. William J Dupps MD, PhD, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, discussed the development of OCT elastography as an approach for obtaining micron scale information on corneal strain in order to differentiate and localise abnormalities in tissue stiffness specific to keratoconus. The technique involves OCT imaging of the cornea’s dynamic response to externally applied stimuli and is part of a custom swept-source OCT platform that has a scanning rate of more than 100,000 A/ scans per second. “Our OCT elastography device is designed to provide both three-dimensional shape information and a depth-resolved analysis of corneal properties in the same sitting. We are combining these measurements with finite element modelling to simulate refractive procedures and collagen crosslinking with the goals of predicting and optimising treatment outcomes,” said Dr Dupps. David Touboul MD, reviewed supersonic shear wave imaging, another non-invasive elastography mapping technique for dynamic measurement of corneal biomechanics. The technology was developed at the Langevin Institute, Paris, France, and is commercially available in an ultrasound system for breast lesion imaging (Aixplorer, SuperSonic Imagine). “Positive results were achieved in proof of concept studies performed in ex vivo models and animal eyes to evaluate this technology for corneal elasticity mapping. Now as we work to transfer the platform to ophthalmology, we are developing eye interface and imaging optimisations. Then we will begin clinical trials and ultimately plan to apply the technology for real-time measurement during laser surgery,” said Dr Touboul.

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Biometry

contacts

William Dupps Jr - bjdupps@sbcglobal.net Cynthia Roberts - roberts.8@osu.edu Damien Gatinel - gatinel@aol.com David Touboul - toubould@gmail.com Lenstar_Eurotimes2010_½-vert-Webinar.indd 1

25.01.11 13:56:18

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contacts

Franz Grehn - f.grehn@augenklinik.uni-wuerzburg.de Lutz E Pillunat augendirektion@uniklinikum-dresden.de Anastasios G P Konstas f.grehn@augenklinik.uni-wuerzburg.de Robert N Weinreb - rweinreb@ucsd.edu

Update

Glaucoma

IOP monitoring

normal tension glaucoma patients, but all patients with glaucoma. In fact, many of the patients that we think have normal tension glaucoma do not have it. When evaluated over 24 hours, there are very few patients with normal tensions throughout the day. Look for the revolution that will come to glaucoma management with continuous IOP monitoring, particularly when it is linked with drug delivery,” he said. Anastasios G Konstas MD, PhD, Aristotle University, Thessaloniki, Greece, agreed that single, infrequent IOP measurements are often inadequate for making therapeutic decisions in many patients. However, the practicalities and limitations of most centres generally restrict the use of 24-hour IOP monitoring to only a selected group of glaucoma patients. “There are the three groups I focus on for daytime, or 24-hour measurements. They are patients who progress despite apparently good IOP control in the clinic with single measurements, patients at risk with worse 24-hour characteristics (eg, exfoliative glaucoma), younger glaucoma patients, because I think that they need more attention since they have longer to live, and also I focus on patients with advanced glaucoma,” Dr Konstas said.

Panel of glaucoma experts put the clinical utility of 24-hour monitoring under the microscope by Roibeard O’hEineachain in Madrid

rowing evidence suggests that continuous or 24-hour IOP monitoring can improve the detection of peak pressures and pressure spikes and the degree of IOP fluctuation in glaucoma patients and glaucoma suspects. It could therefore be important in both diagnosing the condition and assessing treatment efficacy. How the data obtained in this way should be applied in clinical practice was the subject of a panel discussion led by Franz Grehn MD, University Eye Clinic, Wurzburg, Germany, at the 9th European Glaucoma Society Congress. Several studies where glaucoma patients have undergone 24-hour IOP monitoring have shown that peak pressures often occur outside of office hours. However, IOP-lowering treatment strategies that have proven successful in the past have been based on IOP measurements obtained during office hours. That raises the questions about whether night-time IOP measurements are necessary in all patients and how the measurements should influence therapeutic decisions, Dr Grehn said.

Subgroups that need closer monitoring Panellist, Lutz E Pillunat

MD, University of Dresden, Germany, said that diurnal IOP monitoring measurements are probably not needed in all glaucoma patients or glaucoma suspects, but should be used primarily in normal pressure

glaucoma patients and those with aberrant IOP behaviour. “We observe patients whose IOP always increases at night, completely independently of the body position, whether they are sitting or lying. The same happens to other people whose IOP increases around noon whether they are in a supine or sitting position. In these patients, I think it’s very necessary to get diurnal measurements to choose the right treatment,” he said. Robert N Weinreb MD, University of California, San Diego, said that 24-hour IOP measurements can be useful for all glaucoma patients and those who are suspect for the disease. He added that the measurements could be particularly helpful in patients who progress despite apparently good IOP control during the day. However, he pointed out that without a dedicated sleep laboratory or appropriate 24-hour pressure sensor the measurements obtained might not be very useful. On the other hand, there are several technologies currently under development aimed at providing continuous 24-hour IOP monitoring, Dr Weinreb said. They include contact lens-based IOP strain gauges and implantable sensors. The IOP-monitoring contact lens may be the first to become available for clinical use. “I think we are very fortunate because we are on the threshold of a transformative event for glaucoma diagnosis and management. Continuous IOP monitoring will redefine how we manage not only our

Influence of 24-hour measurements on treatment One

of the ways that continuous monitoring could influence treatment decisions would be in cases where extreme 24-hour IOP fluctuations might be a concern. Dr Konstas noted that research has shown that surgical procedures like trabeculectomy significantly reduce 24-hour IOP fluctuation, far more effectively than medical treatment. “We compared pressure over 24 hours in patients who had undergone successful trabeculectomy to that of patients who were receiving apparently successful maximal medical therapy and there is no question that one benefit successful trabeculectomy can bring is a very narrow fluctuation (less

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than 3 mmHg). This is significantly better than medical therapy. Of course then we have to consider how narrow fluctuation has to be in each stage of glaucoma,” he said. However, Dr Weinreb countered that in his research with John Liu PhD, involving hundreds of glaucoma patients who underwent IOP monitoring in a sleep laboratory, there has been no relationship between glaucoma progression and fluctuation. He also cautioned against following the advice of some authors, who suggest that at night patients should prop their heads up in bed with a pillow in order to reduce nighttime IOP. “There is no question that you lower intraocular pressure as you elevate the head. However, you’re changing so many other things. You’re changing the perfusion pressure, you’re changing the blood flow, and you’re changing the intra-cranial pressure. So, until we understand how all of these things interact, until we can measure all of these things continuously, I suggest that it still is acceptable for your patients to be sleeping supine without extra pillows,” he said. Dr Weinreb added that future generations of ophthalmologists will consider the current practice of taking just one IOP measurement for diagnostic purposes to be just as absurdly inadequate as most of the current generation of ophthalmologists now consider the digital palpation technique to be. “I would predict that 20 years from now, when many of you will be sitting in a conference hall like this at the 19th European glaucoma conference, someone on the podium will be reminiscing that in the year 2010 clinicians measured IOP just once in their office and then based much of their clinical decision making on that solitary measurement. Everyone in the congress will laugh, because it is so absurd and primitive,” he said.

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Update

Glaucoma

Genetic research

A new era of research is beginning to reveal glaucoma’s hereditary factors

by Roibeard O’hEineachain in Madrid

“I

t’s a very exciting time to be in glaucoma genetics with large, interesting new studies being published almost daily,” Ananth C Viswanathan MD, PhD, National Institute for Health Research (NIHR) Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital/UCL Institute of Ophthalmology, London, UK, told a session of the Ninth European Glaucoma Society Congress. In the past, traditional family linkage studies have revealed many causative genes for glaucomatous disease. However, their findings have tended to be specific to the pedigree investigated and have shed little light on glaucoma’s hereditary factors in the general population. Advances in genetic research are enabling researchers to switch to a cohort-based approach, in the form of genome-wide association studies, he reported. Genome-wide association studies provide a meticulous comparison of the genome of large cohorts of patients affected by the disease of interest with the genome of a large cohort of control patients. They can reveal the locations of subtle variations in the chromosome’s nucleotide sequences, called single nucleotide polymorphisms (SNPs). “Instead of looking at classical familybased linkage, we are now looking for the association of genetic signals involving literally millions of markers in each individual and doing that across thousands of individuals. So we are seeing the nature of this scientific endeavour change from family-based linkage to cohort-based association,” Dr Viswanathan said. Dr Viswanathan is the principal investigator for glaucoma in a research group funded by the Wellcome trust that has been conducting genome-wide association studies. The Wellcome Trust Case-Control Consortium 2 (WTCCC2) established in 2008 is composed of multiple research consortia across the world that are investigating the genetic basis of 15 common diseases, including glaucoma. The WTCCC2 has identified several SNPs that may have an influence on glaucoma’s aetiology. However, those findings must be confirmed in a separate cohort of patients

before they can be published, he emphasised. In the meantime, other groups conducting genome-wide studies have completed both the discovery and confirmation process with some genetic variants that could have a role in the diseases, he said. For example, an Australian group has found associations between variations in the ATOH7 gene and variations in optic disc size (Macgregor et al, Hum. Mol. Genet. 2010; 19 (13): 2716-2724). Animal studies have shown that the gene plays a key role in retinal ganglion cell formation. The findings have been replicated by another multinational research consortium studying several population cohorts, Dr Viswanathan noted (Ramdas WD, van Koolwijk LME, Ikram MK, Jansonius NM, de Jong PTVM, et al. (2010) A Genome-Wide Association Study of Optic Disc Parameters. PLoS Genet 6(6): e1000978. doi:10.1371/journal. pgen.1000978). Another research consortium led by an Icelandic group has identified an association between glaucoma and an SNP in close proximity to the CAV1 and CAV2 genes (Thorleifsson et al, NatureGenetics2010;42:906–909). Both genes are expressed in the trabecular meshwork and retinal ganglion cells. The research group’s findings were replicated in separate cohorts in Sweden, UK, Australia and China. Another recent development has been the initiation of the European Glaucoma Society’s GlaucoGENE project. The initiative involves a consortium of experts from across Europe, including specialists in phenotyping, complex genetics and basic ophthalmic biology. The aim of the project is to create a European genetic epidemiology research network, using detailed and standardised phenotyping, to better elucidate the multifactorial nature of glaucoma’s genetics (Founti, P., Topouzis, F., van Koolwijk, L., Traverso, C. E., Pfeiffer, N. &Viswanathan, A. C. (2009). Biobanks and the importance of detailed phenotyping: a case study--the European Glaucoma Society GlaucoGENE project. Br J Ophthalmol 93(5): 577-81).

contact

Ananth C Viswanathan - vis@doctors.org.uk

Don’t miss Outlook on Industry, see page 33 ad_cornea_protect 120x300 EUROTIMES | Volume 161101v1 | Issuejmo 3 Eurotimes.indd

28.01.11 12:06

Update

retina PROVEN SAFETY

Retinal implant

Restoring some visual function to patients with advanced photoreceptor degeneration

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he pilot clinical trial of a subretinal electronic implant (Retina Implant AG) indicates that the device is safe, well tolerated and is capable of restoring some measure of useful visual function in blind retinitis pigmentosa patients, reported Eberhart Zrenner MD at the 10th EURETINA Congress. “It is still early days and we still have to improve on the device, but I think we have established proof of concept and shown that our subretinal approach can give these patients the ability to distinguish shapes and identify objects, which is already huge progress for these patients. We have now started a second trial of the device in Germany and will be expanding the trials to other centres in Europe in 2011,” said Prof Zrenner, director of the Institute for Ophthalmic Research in Tubingen, Germany. Prof Zrenner said that electronic prostheses currently represent the best hope of restoring some visual function to patients with total photoreceptor degeneration. “The aim is to restore useful visual process by implanting a subretinal electrode implant in patients that are blind from utter retinal degeneration, and to give them back the possibility of recognising or localising objects and achieving self-sustained mobility,” he said. Discussing the properties of the device, Dr Zrenner explained that the core of the implant is a microchip, approximately 3.0mm x 3.0mm in size and 0.1mm thick, in which 1,500 pixel fields are arranged, including circuitry for amplification, brightness adjustment and safety switching. The size of one pixel is 70 µm x 70 µm. This produces a field of view of 12 degrees, a window of the size of a laptop screen in one meter distance which is already sufficient to enable mobility and the orienting recognition of objects. Each pixel cell is assigned one photodiode, an amplification circuit and a stimulation electrode. Each photocell takes the light entering the eye and converts it into the electrical energy that is required to stimulate the intact nerve cells in the retina next to the electrode. The nerve impulses from these cells are relayed to the brain via the optical nerve and ultimately lead to visual perception. Prof Zrenner explained that the implant is placed in the subretinal space in the area where the light-sensitive sensory cells are located in healthy persons.

EUROTIMES | Volume 16 | Issue 3

“We have taken this approach because we think that photodiodes and electrodes correspond to the proper retinotopic localisation and we can also use the remaining information processing network of the retina there. Fixation is also easier in the subretinal space. Another plus is that natural eye movement helps to localise objects because the image received by the implant moves exactly with the eye, including the microsaccades, which help to refresh the image,” he said. In the pilot study of the implant, 11 patients were successfully implanted with the device under general anaesthesia. A subdermal cable was put in place from a small skin incision behind the ear and a small opening with a flap was made laterally near the equator of the eye. A small incision was then made into the choroid and the chip was then carefully advanced through these openings together with the tiny power line under the retina until it reached its destination near the fovea. “The implantation surgery went well and the chip was located where it should be in the posterior pole, with no problems of retinal detachment, haemorrhage, inflammation or vitreous traction,” he said. Triggering electric stimulation enabled patients to perceive light in particular shapes and patterns, said Prof Zrenner. Visual acuity tests showed that patients were able to recognise foreign objects and in some cases read letters in order to form words. In some cases, bright objects set against a dark background were perceived and localised. One patient, who had been blind for 15 years, surprised investigators when he told them that his name had been misspelled when asked to read it. Looking to the future, Dr Zrenner said that the European multicentre trial of the implant involving up to 50 patients would be an important step towards eventual commercialisation of the device. Retina Implant AG, the company responsible for marketing the device, is hoping to seek authorisation for a CE mark this year. n For further information see your browser under doi:10.1098/rspb.2010.1747.

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Update

retina

Inherited retinal disease

Current research is focusing on optimising the AAV delivery vector to enhance gene expression by Dermot McGrath in Paris

Robert E MacLaren – enquiries@eye.ox.ac.uk

“

Gene therapy for choroideremia is a logical future choice for clinical studies as the phenotype is readily identifiable

Robert E MacLaren MD, PhD

mportant advances in gene therapy research in recent years have opened the path for the first human clinical trials for choroideremia to begin in the near future, according to Robert E MacLaren MD, PhD, professor of ophthalmology University of Oxford and consultant vitreoretinal surgeon, Oxford Eye Hospital and Moorfields Eye Hospital. “Gene therapy for choroideremia is a logical future choice for clinical studies as the phenotype is readily identifiable. The preclinical data suggest that any eventual gene therapy will need to target both retinal pigment epithelium (RPE) and photoreceptor cells. If successful, it would represent the human correction of a 300-million-year-old error in the evolution of the X chromosome,” Dr MacLaren told delegates attending the 10th EURETINA Congress. Dr MacLaren explained that choroideremia is a rare inherited disease that occurs almost exclusively in males, with an estimated prevalence of one in 50,000 in Northern Europe. The disease is X-linked recessive and leads to the degeneration of the choriocapillaris, the retinal pigment epithelium and the photoreceptors of the eye. He noted that the pathogenesis of the disease is similar in many ways to retinitis pigmentosa (RP) with peripheral constriction and loss of the retinal layers.

Don’t miss Book Review, see page 35 EUROTIMES | Volume 16 | Issue 3

Choroideremia

“This means that patients tend to have relatively small functional areas of vision but maintain good visual acuity up until very late stages of the disease,” he said. One of the characterising elements of the disease evolution is the extreme wasting of the peripheral choroid, noted Dr MacLaren. Understanding the pathogenesis of this process is vitally important in identifying the target area for any eventual gene therapy, he said. “It is absolutely critical to know whether this degeneration of the choroid is a primary event or whether it is occurring secondary to the loss of the retinal pigment epithelium. We know that the choroid will thin in end-stage geographic atrophy and there is certainly good evidence that the choroid is dependent on the RPE. So in designing any form of clinical treatment, we need to know which layers to target: do we need to target the choroid or the RPE or both of them? And also since there will be a secondary degeneration of the photoreceptors we also need to know whether these cells are themselves affected by the disease process,” he said. Advances in OCT imaging technology have helped researchers to answer some of these key questions, said Dr MacLaren. “Looking at OCT scans, we can see in any choroideremia patients that the limit of the

RPE atrophy is slightly more central than the limit of the choroidal atrophy and that the degeneration of the choroid follows that of the RPE. These clinical observations point to the fact that the degeneration of the choroid is occurring largely secondary to the degeneration of the RPE and certainly the RPE would be the primary cell type in which we would wish to replace the defective gene in choroideremia,” he said. Further progress was made with studies of post-mortem retinal tissue specimens, which indicated that the process of degeneration in choroideremia also occurs independently of the RPE in photoreceptors, said Dr MacLaren. While there was some evidence that this was indeed the case, the real breakthrough came in collaboration with Dr Miguel Seabra of Imperial College London by creating a transgenic choroideremia mouse suitable for study. The research team used a conditional knockout mouse model in which the choroideremia REP1 gene, which is involved in protein modification within cells, was knocked out specifically in the photoreceptor layer and in the retinal pigment epithelium. “We found in our mouse models that knockout of the gene in the photoreceptors does result in photoreceptor thinning and more significantly a significant loss of

function in the electroretinogram (ERG) data in these mice. Using SLO imaging we observed that in the RPE knockout mouse there was a gradual progression of subretinal macrophages as the mouse ages. However, this process was accelerated in the photoreceptor knockout mouse, and again to an even greater extent where the gene was knocked out in both photoreceptors and the RPE,” he said. Bringing all the data together, it became clear that any clinical trial for choroideremia would need to target both the photoreceptors as well as the RPE, and that the most logical way to do this would be to use an adeno-associated virus (AAV) vector as the delivery mechanism for the replacement gene. The AAV vector has been used to date in four clinical trials worldwide to treat Leber’s Congenital Amaurosis, another inherited disease that typically results in blindness, and has shown promising results. Dr MacLaren said that the current research is focusing on optimising the AAV delivery vector to enhance gene expression and thereby increase the chances of the treatment successfully targeting both the RPE and the photoreceptor cells. “We know that by increasing the expression of the gene significantly we will then be able to reduce the dose of vector given to each patient, since ultimately it is more likely that the dose of vector will cause more problems than the gene itself,” he said. The delivery of gene therapy vectors to treat retinal disease is most commonly given by subretinal injection, said Dr MacLaren. “This has been shown in all clinical trials conducted thus far to be a relatively safe and reproducible procedure. The RPE and photoreceptor cells to be targeted in choroideremia are both exposed to the vector after subretinal delivery and the vector is constrained in the subretinal space, so we know that the method of surgical delivery itself will limit itself to the cell types that we wish to expose,” he said.

contacts

News

EBO

Vytautas Jasinskas – vytautas.jasinskas@kmu.lt Wagih Aclimandos – wagih@macunlimitedworld.net

European Board of Ophthalmology

sharing ideas

40 ophthalmology residents set to benefit from EBO Exchange Programme by Dermot McGrath

phthalmology residents across Europe have been applying in ever greater numbers for a place on this year’s European Board of Ophthalmology’s Residency Exchange Programme. For the 2011 programme, 40 residents in affiliated university eye clinics will be given the opportunity to train and study at an EBO-certified institution in Europe. “The goal is to give residents the opportunity to broaden their knowledge and deepen their experience within the countries of the European Union [EU] in order to achieve the highest standards of training

and education,” said Vytautas Jasinskas MD, FEBO, chairman of the EBO’s Residency Exchange Committee. The period of exchange is one month for a resident, with the chosen resident receiving an honorarium of €1,000 to help cover his/ her costs. The resident is expected to cover any additional expenses or to negotiate them with their home chairperson. In return for the grant, the EBO requests that participants provide a short written report of their experience at the end of their exchange. The mission of the EBO’s Residency Exchange Programme has been given added impetus by the expansion of the EU

in recent years to include many eastern European countries. As in previous years, the grant applications have originated from residents in over 20 EU member countries, with the majority coming from eastern European countries such as Romania, Bulgaria and Poland. “It is a continuous policy of the EBO to encourage ophthalmologists to share their knowledge within the countries of the EU in order to achieve the highest standards of training. This has become even more important since 10 new countries joined the EU in 2004,” explained Wagih Aclimandos, president of EBO. While the hosting centres need to be EBO certified to be part of the programme, the same criteria does not apply for the sending centres, which can participate so long as they have an established academic component to their ophthalmic training. The exchange of residents among EBOcertified institutions has been taking place since 2001. From that point on, both training and teaching ophthalmologists have

been offered the possibility of exchange in order to unify teaching practices. As well as facilitating the residency exchange process, the EBO also encourages teaching centres to apply for EBO Certification from the EBO Residency Review Committee and encourage their residents to attend the EBO Diploma Examination, scheduled to take place in Paris in May of each year. With so much forward momentum, the Residency Exchange Programme is set to encourage the next generation of ophthalmologists to participate in a vibrant network of exchange and collaboration, believes Prof Jasinskas. “The learning process is never finished and there are always new ideas and techniques that we can pick up and bring back to improve things in our own departments and hospitals,” he said. Further information about the EBO’s Residency Exchange Programme can be found online at: http://ebo-online.org/newsite/committee/ residency_exch/default.asp.

Key Note Lecturers • Wolfgang Drexler, Austria – Pushing the frontiers of retinal OCT • Anders Heijl, Sweden – Lessons from the early manifest glaucoma trial • Shigeru Kinoshita, Japan – Towards sophisticated therapeutic modalities for corneal diseases • Jonathan Trobe, United States – The management of optic neuritis: why is there so much controversy?

For Preliminary Programme and registration updates, visit:

www.soe2011.org

European Society of Ophthalmology

EUROTIMES | Volume 16 | Issue 3

Special Session: Stuart Fine – Lucentis vs Avastin for wet AMD. The CATT results in a European context.

News

Esaso

collaboration

European School in Lugano seeks to share ophthalmological learning and expertise

eneral ophthalmology is a well-recognised medical specialisation in all European countries, but Masters' degree programmes to provide further training and education are not yet fully developed. Consequently, ophthalmology graduates wishing to specialise need to find an institution or hospital which can offer them facilities for research or on-thejob training. Others may want to pursue a fellowship programme, but these are usually only available to US graduates. “ESASO was founded in 2008 to address both this challenge and the specific further education needs of training and practising clinicians, drawing on the skills of colleagues worldwide and the support of various universities. It seeks to facilitate the dissemination of new and effective ophthalmological learning and expertise through a dynamic combination of in-depth exposition of topics and direct face-to-face training, where experts show students how to deal with practical situations and problems,” according to Prof Borja Corcóstegui, president of ESASO’s Scientific Council. The school is based within the Università della Svizzera italiana (USI), Lugano Campus, Switzerland. This year the school will run a number of modules on topics including cornea, retina, cataract and refractive surgery and glaucoma. Students can choose from three types of education. Those who want to excel in their own subspecialty might only attend one module. Others who intend to go on a national career want to subscribe to the DiSSO (a diplom as Specialist Superior) and pass through all five modules. And those ophthalmologists who plan to go on an international career will subscribe to the Master’s programme which includes the DiSSO followed by a full year Fellowship at a prestigious institution or university. In 2010, ESASO opened its campus in Asia, the continent where more than half of the world’s blind people live and one where postgraduate training is practically nonexistent. “ESASO offers theoretical tuition as well as practical training, and has devised a detailed programme for the first few years featuring an expert team with recognised clinical and teaching experience. The theoretical curriculum and surgical practices EUROTIMES | Volume 16 | Issue 3

Trends in Surgical and Medical Retina

Second Module 2011 – Retina I

can be completed at the same university and those students who finish their education will receive their degree from that university,” said Prof Corcóstegui.

Exciting initiatives Dr Giuseppe Guarnaccia, global executive director ESASO, says the school aims to improve the clinical and surgical practice of specialists in ophthalmology in order to promote and enhance professional skills. Its objective is to provide ophthalmologists with postgraduate education and hands-on training from an internationally renowned faculty. Last year, ESASO celebrated its first graduates who received their DiSSO in ophthalmology in Lugano. “This is a very exciting year for us,” said Dr Guarnaccia, “as we have a number of exciting new initiatives already in development. Last December we launched our first electronic newsletter eFOCUS which will be published every two months. The newsletter will offer regular updates on all of our activities. We are also looking forward to holding the 11th international AMD & Retina congress in Lisbon on November 4-5, 2011.” Fellowships Finally, said Dr Guarnaccia, ESASO would like to encourage ophthalmologists to take part in the ESASO Fellowship programme. This is an advanced specialist training programme in which the recipient can acquire a thorough, in-depth understanding of the specific subject and, accordingly, proficiency in the exercise of the clinical-surgical profession. “The Fellowship consists of a grant and a research project which is supervised by Prof Stanley Chang, New York,” Dr Guarnaccia said. “Students must publish their findings. The Fellowship curricula are planned in consultation with accredited departments of ophthalmology to ensure that the prescribed objectives are achieved. Fellows’ advanced training is conducted at one of the specialist teaching hospitals or university centres that have entered into a partnership agreement with ESASO and agreed on a training programme in a specialist branch of ophthalmology. A full list of these institutions is available on the ESASO website at: www.esaso.ch.

Live Surgery and Round Tables

Barcelona, 3 – 4 June 2011 Auditorium IMO (Institut de Microcirurgia Ocular)

Lugano, Switzerland 30 May – 4 June 2011

Faculty

A. Adán B. Aylward F. Bandello M. Berrocal A. Capone S. Chang C. Claes B. Corcóstegui P. Dugel C. Eckardt

J. García-Arumí A. Gaudric G. Guarnaccia C. Mateo R. Navarro K. Packo D. Pelayes S. Rizzo P. Stalmans

Institut de Microcirurgia Ocular Josep Mª Llado, 3 (Ronda de Dalt - Exit 7) 08035 Barcelona, Spain Tel. +34 93 253 15 00 Fax +34 93 417 13 01 Email comunicacion@imo.es

www.imo.es

B. Aylward S. Chang J. García-Arumí F. Holz D. Pelayes L. Yannuzzi Under the auspices of Euretina (European Society of Retina Specialists)

ESASO c/o Università della Svizzera italiana (USI) Via Giuseppe Buffi 13 6904 Lugano, Switzerland Tel. +41 (0)58 666 4629 Fax +41 (0)58 666 4619 Email info@esaso.ch

www.esaso.ch

contact Gabriella Skala – skala@skala-com.com ES_02-11 ESASO_IMO_Anz_120x300_RZ.indd 1

8.2.2011 13:44:48 Uhr

ESCRS Glaucoma Day Scientific programme organised by European Glaucoma Society

Immediately preceding the XXIX Congress of the ESCRS

Friday 16 September 2011

Reed Messe Vienna, Austria

Programme Chairpersons: Keith Barton, UK Anton Hommer, Austria

News

research

High-frequency ultrasound

In the latest article from the ESCRS Research Committee, we look at new applications of ultrasound in anterior segment surgery by Philippe Sourdille

Recent developments and clinical applications Aphakic IOLs: Pre- and

postoperative comparisons of capsular bag diameter (Marina Modesti, Rome, article under press) highlight surgically induced anatomical changes: frequent enlargement of the implanted capsular bag, possible tilt mechanisms, and retroposition of the IOL in 33 per cent of eyes. This will influence refractive precision and stability, as well as movements during accommodation. This information only provided by HFUS is a pre-requisite to improve pseudo and true accommodation. Posterior chamber phakic IOLs: Most complications of these devices are related to improper sizing based on white-to-white measurements. Since sulcus-to-sulcus measurements must be based on precise alignment a new 50 Mhz linear probe combined to size detecting software based on seven alignment criteria has been developed (STS UBM unit, Quantel Medical, Staar). Based on these measurements an ICL simulation software (Staar) will prospectively indicate the IOL EUROTIMES | Volume 16 | Issue 3

Ongoing research Measurement of corneal epithelium thickness profile for irregular corneas and keratoconus screening can be achieved with a repeatability of 0,58 micron across a 10mm diameter (Artemis 3, Arcscan) meaning that the epithelial thickness can be mapped to the nearest micron. The “doughnut pattern” of keratoconic epitheliums is characterised by epithelial thinning over the cone surrounded by an annulus of epithelial thickening. This additional information to front surface topography is a key element of differential early keratoconus diagnosis4 . 3D ultrasound is the next step to complete analysis of posterior chamber diameters, volumes and movements. The third dimension informs on the relative position of structures and creates a simplified visualisation of complex structures. It confirms the posterior chamber oval shape with a vertical diameter larger than the horizontal one (M Lamard, Faculté des Sciences, Brest). Comparison of 2D and 3D images of the same eye illustrate this and can be seen in the images above. Conclusion HFUS, as of today, is part of anterior segment analysis and is the only accurate way to image retro iridian structures. It is state of the art for posterior chamber phakic IOLs. Inter individual

measurements have to be completed by intra individual volume and sizes modifications during accommodation and pupillary changes (such as light reflex). Adaptability of phakic and aphakic IOLs to these changes is necessary to improve postoperative results. Further approaches to so-called accommodative lenses will also need a more precise anatomical knowledge.

This figure (2D) shows how one of the haptics (yellow circle) lies over the ciliary body, in the sulcus. The second haptic (blue circle) is more posterior, lying on the zonule

Courtesy of Philippe Sourdille

positioning in the posterior chamber. This improves the accuracy of phakic IOLs sizing and limits complications related to excessive or insufficient vaulting1,2. IOP lowering mechanisms after capsular surgery also benefit from HFUS: filtration bleb, and outflow channel volume and function are well defined by ultrasound. A hypoechogenic line in the suprachoroidal space around the filtration area had also been noted in the early postoperative period, corresponding to a newly formed aqueous resorption pathway. Recent work about mid- and long-term findings3 indicate frequent correlation of this hypoechogenic line with complete surgical success. This aqueous resorption pathway area would be more “physiological” than subconjunctival filtration, and would not be prone to the same iatrogenic complications.

Bibliography

1. Reinstein DZ, Archer TJ, Silverman RH, Rondeau MJ, Coleman DJ. Correlation of Anterior Chamber Angle and Ciliary Sulcus Diameters With White-to-White Corneal Diameter in High Myopes Using Artemis VHF Digital Ultrasound. J Refract Surg. 2009;25(2):185-194. 2. Arramberri J, ICL sizing, presented at ESCRS Paris 2010. 3. Bellicaud Thèse médecine Tours, 2009. 4. Reinstein DZ, Archer TJ, Gobbe M. Corneal Epithelial Thickness Profile in the Diagnosis of Keratoconus. J Refract Surg. 2009;25(7):604-610.

This image (3D) represents the same eye, with simultaneous and respective positioning of structures. For a phakic IOL it becomes possible to preoperatively determine the exact volume of the posterior chamber and to prospectively image the postoperative IOL positioning. This also leads to customisation of implants, phakic or accommodative, according to the exact posterior chamber anatomy

EUROTIMES

ESCRS

idden retro iridian structures such as ciliary sulcus, ciliary body, zonular system and lens equator are determining factors of accommodation, sulcus placement of intraocular lenses (IOLs), and precise positioning of phakic and aphakic IOLs. Optical imaging such as Scheimpflug devices and laser interferometry (OCT) will not penetrate iris pigment epithelium and will not provide proper information on these structures. High-frequency ultrasound (HFUS) currently is the only possible approach. Recent developments in 2D HFUS transducers and software are applied to accurate and reproducible sizing of the ciliary sulcus diameter for phakic IOLs, new information on implanted capsular bag dimensions and positions, and on IOP-lowering mechanisms of glaucoma filtration surgery. Ongoing research includes corneal epithelium thickness live measurements, with applications to refractive surgery and to ocular surface alterations. 3D HFUS will determine how a phakic IOL, or any device designed to accommodate, behaves in the posterior chamber.

Türkiye

Turkish language edition now online

Visit: www.eurotimesturkey.org

™

MAIN SESSIONs MAIN SESSION 1 THURSDAY 26 MAY 09.30 – 11.30 Research I: Vitreous Physiology & Disease Chairpersons: Z. Gregor uk, S. Binder austria, E. Stefansson ICELAND

LONDON 2011

26–29 May 2011

11TH EURETINA CONGRESS

QUEEN ELIZABETH II CONFERENCE CENTRE LONDON, UK

MAIN SESSION 2 THURSDAY 26 MAY 11.30 – 13.00 Research II: Drug Delivery to Retina Chairpersons: F. Holz germany, B. D. Kuppermann usa, D. Wong uk MAIN SESSION 3 THURSDAY 26 MAY 14.00 – 16.00 Imaging Chairpersons: S.Wolf SWITZERLAND, F. Holz germany

Thursday 26 May 08.00

MAIN SESSION 5

10.00 11.00 12.00 13.00

15.00

MAIN SESSION 6

17.00

FRIDAY 27 MAY 16.00 – 18.00 Uveitis Chairpersons: C. Pavesio UK, P. Lehoang FRANCE

18.00

saturDAY 28 MAY 08.00 – 10.00 Innovative Vitreoretinal Surgery Chairpersons: B. Aylward UK, D. Wong UK

MOUNT BATTEN

WESTMINSTER

MAIN SESSION 1 Vitreous Physiology & Disease MAIN SESSION 2 Drug Delivery to Retina

UVEITIS COURSE

RETINAL DETACHMENT COURSE

FREE PAPERS 1 AMD

FREE PAPERS 2 Vitreoretinal Surgery

14.00

FRIDAY 27 MAY 14.00 – 16.00 EURETINA Innovation Award Chairperson: E. Stefansson ICELAND

MAIN SESSION 7

whittle

09.00

MAIN SESSION 4 FRIDAY 27 MAY 08.00 – 10.00 Surgical Management of Diabetic Retinopathy Chairpersons: C. Awh USA, B. Aylward UK

CHURCHILL

MAIN SESSION 3 Imaging

EUROLAM

16.00 OPENING CEREMONY WELCOME RECEPTION

19.00 20.00

MAIN SESSION 8 saturDAY 28 MAY 11.00 – 13.00 Anterior/Posterior Segment Surgery Chairpersons: B. Aylward UK, D. Wong UK MAIN SESSION 9 saturDAY 28 MAY 14.00 – 16.00 Diabetic Retinopathy Chairperson: J. Cunha-Vaz PORTUGAL MAIN SESSION 10 saturDAY 28 MAY 16.00 – 18.00 Vascular Diseases Chairperson: F. Bandello ITALY MAIN SESSION 11 sUNDAY 29 MAY 08.00 – 10.00 AMD I Chairpersons: S.Wolf SWITZERLAND, J.F. Korobelnik france, F.Holz germany

friday 27 May 08.00 09.00 10.00

CHURCHILL

whittle

MOUNT BATTEN

WESTMINSTER

HENRY MOORE

ABBEY

MAIN SESSION 4 Surgical Management of Diabetic Retinopathy

COURSE 1 Macular Dystrophies

FREE PAPERS 3 Imaging

COURSE 2 German Retinal Society

COURSE 3 Diabetic Retinopathy

COURSE 4 Macular Oedema

11.00 12.00

KREISSIG LECTURE

13.00

AMSTERDAM RETINA DEBATE

16.00

sUNDAY 29 MAY 11.00 – 13.00 AMD II Chairperson: G. Richard GERMANY

arvo SYMPOSIUM

COURSE 5 Prolif. Diabetic Retinopathy

COURSE 6 Surgical Discussions

COURSE 7 Advanced OCT

COURSE 8 Electrophysiology of Vision

SATELLITE MEETING

MAIN SESSION 5 (EURETINA Innovation Award)

MAIN SESSION 12 17.00

COFFEE BREAK

ALLERGAN

14.00 15.00

PFIZER

SATELLITE MEETING

MAIN SESSION 6 Uveitis

EVI-RETNET SYMPOSIUM Translational Medicine & The Retina

18.00

MAIN SESSION 13

19.00

sUNDAY 29 MAY 11.00 – 13.00 Complications of High Myopia Chairpersons: A. Gaudric FRANCE, S. Chang usa

20.00

novartis

SATELLITE MEETING

EVICR.net

FRENCH ISRAELI ASSOCIATION

BAUSCH + LOMB

SATELLITE MEETING

FREE PAPERS 4 New Drug Treatment & Tech.

COURSE 9 PVR Management

COFFEE BREAK FREE PAPERS 5 Vitreoretinal Surgery

COURSE 10 Autofluorescence Images

COURSE 11 Vitrectomy In Diabetes

COURSE 12 ROP

WETLABS

SURGICAL SKILLS COURSES

EURETINA LECTURE

2011 KREISSIG AWARD

Thursday 26 may 16.15 – 16.35

Friday 27 may 11.00 – 12.00

Modern directions for the surgery of Diabetic Retinopathy

The Spectrum of Vitelliform Lesions in the Macula

Borja Corcostegui

Lawrence A. Yannuzzi

SPAIN

usa

instructional courses full day courses 1. Uveitis Course Organisers: C. Pavesio UK, C. Herbort Switzerland 2. Retinal Detachment Course Organiser: I. Kreissig Germany

instructional courses

saturday 28 May 07.00 08.00 09.00 10.00 11.00 12.00 13.00

CHURCHILL

16.00 17.00 18.00

MOUNT BATTEN

WESTMINSTER

HENRY MOORE

WETLABS

MAIN SESSION 7 Innovative Vitreoretinal Surgery

FREE PAPERS 6 Vascular Diseases & Diabetic Retinopathy

SATELLITE MEETING

fan club

NOVARTIS

MAIN SESSION 9 Diabetic Retinopathy MAIN SESSION 10 Vascular Diseases

COURSE 13 ARMD

ALCON

COFFEE BREAK MAIN SESSION 8 Anterior/ Posterior Segment Surgery

FREE PAPERS 7 Vascular Diseases & Diabetic Retinopathy

SATELLITE MEETING

FREE PAPERS 8

COURSE 18 Surgical Approach to Vitreoretinal Interface

Ant/Posterior Segment Surgery/ Uveitis/Intraocular Tumours

COURSE 14 Intravitreal Therapy

COURSE 15 New Strategies in Ocular Trauma

THEA

SATELLITE MEETING

COURSE 16 Avoiding Complications in Vitrectomy Surgery

COURSE 17 Uveal Melanoma

SURGICAL SKILLS COURSES

D.O.R.C

SATELLITE MEETING

COURSE 19

Bimanual Vitrectomy Techniques in MIVS Surgery

COURSE 20

Tips & Tricks in Minimal Invasive Vitrectomy

COFFEE BREAK fluid dynamics symposium

FREE PAPERS 9 AMD

COURSE 21 Managing Diabetic Macular Oedema

bayer

19.00 20.00

09.00

MAIN SESSION 11 AMD I

10.00

whittle

FREE PAPERS 10 Vascular Diseases & Diabetic Retinopathy

13.00

MOUNT BATTEN

WESTMINSTER

COURSE 22 Modern OCT Imaging

COURSE 23

Vitreoret complications Cataract Surgery

MAIN SESSION 12 AMD II

Screening for Diabetic Retinopathy Organiser: C. Egan UK

Macular Oedema Organiser: P. Tranos Greece

Proliferative Diabetic Retinopathy Organiser: A. Laidlaw UK

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

Advanced OCT Organiser: A. Polito Italy

Electrophysiology of Vision Organiser: G. Holder UK

Simple Approach to PVR Management Organiser: B. Corcóstegui Spain

10. How to Read Autofluorescence Images Organiser: F. Holz Germany 11. Vitrectomy in Diabetes Organiser: A. Laidlaw UK 12. Screening and Management of ROP Organisers: A. Kychenthal Chile, G.Caputo France

MAIN SESSION 13 Complications of High Myopia

FREE PAPERS 11 Vitreoretinal Surgery

COURSE 24 Fluorescein & ICGangiography

Full Programme Info

Membership Application

Courses and Wetlabs

Hotel Bookings

EURETINA Brief

17. Current Management in Uveal Melanoma 2011 Organiser: D. Pelayes Argentina

19. Bimanual Vitrectomy Techniques in MIVS Surgery Organiser: T. Nikolakopoulos Greece 20. Tips and tricks in Minimal-Invasive Vitrectomy Organiser: C. Pruente Austria

22. Modern OCT Imaging: Clinical Value and Scientific Perspectives Organiser: U. Schmidt-Erfurth Austria

Available at www.euretina.org: Congress Registration

16. Avoiding Complications in Vitrectomy Surgery Organiser: P. Sullivan UK

21. Managing Diabetic Macular Oedema: Pearls and Pitfalls Organiser: E. Midena Italy

14.00

15. New Strategies in Ocular Trauma Organiser: C. Forlini Italy, F. Kuhn USA

18. Surgical Approach to the Vitreoretinal Interface Organiser: P. Brazitikos Greece

COFFEE BREAK

11.00 12.00

14. Guidance in Intravitreal Therapy Organiser: U. Schmidt-Erfurth Austria

SUNday 29 May 08.00

Macular Dystrophies Organiser: E. Souied France

13. Important Diagnostic Features for Treatment of ARMD Organiser: G. Soubrane France

SATELLITE MEETING

CHURCHILL

2. ‘Wacker-Course’ German Retina Society Organisers: D. Pauleikhoff Germany, H. Heimann Germany

GENERAL ASSEMBLY

14.00 15.00

1. whittle

23. Vitreoretinal Complications of Cataract Surgery Organiser: B. Little UK

Application form available online until March 14 2011. For more information go to www.euretina.org

24. Fluorescein and ICG-angiography - Interpretation and Diagnosis of Macular Diseases Organisers: D. Pauleikhoff Germany, G. Staurenghi Italy

Friday 27 may

Saturday 28 may

Morning Symposia

10.00 - 11.00

Point - Counterpoint - Structure vs. Function in Diabetic Macular Edema

alcon satellite meeting

satellite education programme

Room: Whittle

Sponsored by

Room: mount batten

Sponsored by

10.00 - 11.00

lunchtime Symposia

Are nutritional supplements useful in AMD? Room: Westminster

13.00 - 14.00

allergan satellite meeting

Sponsored by

Room: Whittle

Sponsored by

lunchtime Symposia

13.00 - 14.00

Shining a Light on Innovation in Vitreo Retinal Surgery

Room: Whittle

Room: Mount Batten Moderator: C. Awh

USA

Sponsored by

novartis satellite meeting Sponsored by

13.00 - 14.00

D.O.R.C satellite meeting

evening Symposia 18.00 - 19.30

Room: Mount Batten

Sponsored by

novartis satellite meeting Room: Whittle

Sponsored by

evening Symposia 18.00 - 19.30

bayer satellite meeting Room: Mount Batten

Sponsored by

EURETINA EUROTIMES

â&#x201E;˘

SATELLITE EDUCATION PROGRAMME

contact

Berna Ozel – berna.ozel@vsy.com.tr

Feature

outlook on industry

improving patient outcomes

VSY Biotechnology’s AcrivaUD lenses offer premium multifocal, MICS and aspheric performance by Howard Larkin

stanbul-based VSY Biotechnology has been a leading ophthalmology supplier and manufacturer. With its line of AcrivaUD intraocular lenses, the firm has moved to the forefront of the global market for advanced cataract and refractive surgery. The firm’s multifocal, monofocal, and aspheric lenses, as well as advanced viscoelastics and injectors, match or better the performance of those supplied by major global players, says VSY Biotechnology CEO Dr Ercan Varlibas. “We are a progressive and innovative company that focuses on customer satisfaction by creating superior state-ofthe-art ophthalmology products designed and manufactured to greatly enhance and improve vision for our wide range of patients around the globe,” according to Dr Varlibas. “All our products are the result of rigorous and comprehensive research and development that ensures the highest optical quality and patient safety, as well as superb manufacturing consistency and efficiency that guarantees high reliability and service.”

Advanced materials and design

A combination of advanced materials and design make it possible to produce the AcrivaUD Reviol multifocal lens in powers from 0.00 D to +45.00 D in 0.50 increments – well beyond the 0.00 to +32.00 range typically seen. This makes multifocal lenses an option for highly hyperopic patients. Monofocal lenses are available from -20.00 D to +45.00 D. Biconvex design helps keep the lenses thin, as does an exclusive 360-degree “enhanced square edge” design that allows thinner lenses without sacrificing the PCO protection of a square edge. The lenses are made of a pure acylate monomer with 25 per cent water content and a hydrophobic surface. “Hydrophobic is not the name of the material, but the resistance which the material shows against water,” Dr Varlibas explains. This unique material combines the calcification resistance of a hydrophobic lens with the superior flexibility, vacuole-free clarity and “memory” of a hydrophilic lens. In vitro tests of ability to return to initial shape after folding, as measured by optical point spread function, showed VSY Biotechnology lenses back to initial values within one hour, while conventional hydrophobic material lenses showed more EUROTIMES | Volume 16 | Issue 3

Foldable Scleral Fixation AcrivaUD HAF

light scatter after four hours than VSY Biotechnology lenses after two minutes. Advanced optics help AcrivaUD lenses make the most of their materials’ clarity. “The ultra-definition, or UD, aspheric optics correct for the positive spherical aberration of cornea, enhancing image quality and offering the patient high contrast sensitivity even at night,” Dr Varlibas adds. Smooth transition zones on the lenses’ polished surfaces, rather than sharp steps between diffractive zones, minimise light scatter, improving modulation transfer function performance across all spacial frequencies compared with more conventional multifocal designs.

“We deliver our technologies through two complementary product lines, each providing specific solutions to address a wide range of ophthalmologists’ and patients’ needs” Ercan Varlibas

In fact, a 20-patient prospective study comparing the multifocal AcrivaUD Reviol with the monofocal aspheric Acrysof IQ found that the multifocal delivered similar uncorrected visual acuity and better distance contrast sensitivity at higher frequencies three months after surgery. The study, “Comparison of visual acuity and contrast sensitivity between aspheric monofocal and multifocal intraocular lenses,” was presented at the XXVIII Congress of the ESCRS last September in Paris.

AcrivaUD Reviol Balance Design

The result is reduced vision distortion, reduced glare, and improved intermediate vision quality. A prospective study of 60 eyes comparing the Acriva Reviol MFM 611 and Acri.Lisa 366 D implanted with a bimanual microincision technique found similar uncorrected distance and near vision, and MTF, but better uncorrected intermediate vision for the AcrivaUD lens six months after surgery. That study, “Clinical outcomes of two different small incision diffractive multifocal intraocular lenses: comparative study,” was presented at the 15th ESCRS Winter Meeting in February in Istanbul. Further contributing to the AcrivaUD Reviol’s low-light performance is its diffractive optic, which is distributed across the entire optic surface, enabling multifocal performance and depth of focus independent of pupil size. The Reviol, which features a +3.75 D add and a 6.0mm optic size, is available in three designs; modified C-haptic, balanced modified C-haptic that compensates for capsular contraction, and a plate-haptic microincision model that can be inserted through a 1.5mm to 1.8mm incision. In addition to AcrivaUD multifocals, VSY offers monofocal lenses in modified C-haptic, balanced C-haptic, three-haptic and MICS plate-haptic models. A foldable monofocal scleral fixated lens with a 6.5mm optic is also available in powers from -20.00 to +45.00 D. Injector systems customised for standard, MICS and scleral-fixation lenses, and ultra-pure viscoelastics in a range of densities for every stage of surgery are also offered. “We deliver our technologies through two complementary product lines, each providing specific solutions to address a wide range of ophthalmologists’ and patients’ needs,” Dr Varlibas says. Even the boxes and bar code inventory management system

were developed for maximum efficiency in surgeons’ offices. VSY Biotechnology’s success is driven by its commitment to research and development, and the highest standards of manufacturing precision and efficiency. “The chief goal of R&D is to make positive changes in human life. For this reason, our R&D Department’s scientists, biomedical engineers, industrial engineers, chemical engineers, chemists, biologists and pharmacists devote themselves to developing products that increase patients’ happiness,” CEO Dr Varlibas says. VSY works closely with ophthalmic surgeons across Europe to constantly improve its existing products and develop innovative designs that improve patient outcomes. The firm also adheres to the most stringent manufacturing quality standards to ensure product performance and consistency. All products are subjected to multiple stages of rigorous inspection and are produced in a state-of-the-art Class 10,000 clean room. The firm also adheres to Medical Device Directive 93/42/EEC and international standards such as ISO 13485 Medical Devices - Quality Management Systems. Dr Varlibas believes that VSY’s recent success in Europe and throughout the world will only increase. “With our superior product line and our sterling focus on our customers’ needs, we at VSY Biotechnology believe that the future could not be clearer.” VSY Biotechnology is proud to develop AcrivaUD Toric. The company is going to launch the new toric IOL in the summer. AcrivaUD Toric will reduce astigmatism by custom-made production. AcrivaUD Toric offers enhanced aspheric optic that is designed to improve vision and increase contrast sensitivity in astigmatism patients, Dr Varlibas says.

SYMPOSIA TOPICS n Cataract

and Endothelium (Joint Symposium with EuCornea) n Femtosecond Cataract Surgery n Refractive Adjustments after Ocular Surgery n Decision-making in Presbyopia n Anterior Segment Reconstruction

preliminary programme online at: www.escrs.org

17-21 SEPTEMBER REED MESSE VIENNA AUSTRIA

European Society of Cataract & Refractive Surgeons

Feature

Book review

Good, better, best

Improved outcomes with IOLs after refractive surgery Frank Joseph Goes, a Dutch ophthalmologist who directs the Goes Eye Centre in Antwerp, has edited this extensive and varied volume, in which a range of international contributors discuss topics related to lens surgery after previous refractive surgery. I Howard Fine, in his Foreword, writes of the growing issue of patients who have had refractive surgery many years or even decades before, and who are now presenting for cataract surgery. These patients often tend, Fine writes, to put a high premium on the functional improvements to vision which resulted from their previous surgery, and this means that ophthalmologists engaging in surgery in this population must particularly attend to these issues. I have often written of the process which new technologies, particularly medical and surgical innovations, go through in the public imagination. From medical miracle cure, to flawed but useful treatment, via scares and panics and media hyperbole both positive and negative; in the end, effective treatments that stand the test of time become part of the furniture, so to speak. This volume is an excellent illustration of one part of the process, in a way perhaps the end stage; the treatment becomes so taken for granted that concern shifts not just to the best possible functional impact, but to how to manage revisions and further interventions in patients who have had the treatment. With longer life expectancy, and improved functional outcomes, we see phenomena such as 100-year-old marathon runners and the Transplant Olympics – no longer is either being a centenarian or surviving transplant surgery seen as in some way miraculous in its own right, but is simply a prelude to further life. Goes, in his own preface, writes of the impact of the first PRK and LASIK procedures, and of the unknown future that faced refractive surgery at that point. He not only discusses the obvious popularity of these procedures, but also the learning curve that practitioners – including himself – embarked upon in the early days. Goes describes his own searches for reliable information on lens surgery after previous refractive surgery, and the lack of specific information. For instance, a Medline search for studies on IOL power calculation after previous refractive surgery only returned 31 papers at the time of Goes' search. The book was prepared so the ophthalmic surgeon (Goes specifies EUROTIMES | Volume 16 | Issue 3

in private practice, but I feel that the readership would extend to those in other practices too) would find answers to the following specific questions: What is the right time to replace the lens in an eye that had refractive surgery beforehand? How is this done? What are the pitfalls and the best way to avoid those pitfalls? How do we perform correct IOL power calculations in eyes developing cataract after earlier refractive corneal surgery? There are nine sections to the book. The first looks at the present situation. The second section is on IOL power calculations after previous refractive surgery. The third deals with the outcomes of IOL surgery after previous refractive surgery; the fourth addresses the limitations of phakic IOL surgery and other phakic procedures. The sixth, to me the most interesting, looks at decision making in this clinical cohort. A chapter entitled “Eyemaginations” introduces the reader to the Eyemaginations suite of products, which allow the clinician to take the patient through a series of visualisations of possible outcomes. As the authors of this chapter note, the management of expectations is one of the crucial components of the skill of medicine. The sixth section deals with the surgery itself and seventh with the specific point of choosing the lens. The eighth deals with the potential complications, and how to avoid them. Finally, there is a section looking at potential further developments. Overall, this is a handsomely produced, well illustrated book with many practical diagrams, which covers a somewhat neglected area extremely well.

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LDV Da Vinci (Ziemer)

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Nikica Gabrić, MD (Zagreb, Croatia) Board member of the ESCRS

books editor: Seamus Sweeney publication Lens surgery after previous refractive surgery

Gabrić N. Bohac M. Moria One Use-Plus SBK vs LDV femtolaser: clinical evaluation. 28th ESCRS meeting, Sept 5, 2010, Paris, France. Prof. Gabrić has no financial interest and is not a paid consultant for Moria.

Download long-version testimonials on: www.moria-surgical.com Roundtable with 7 international SBK experts, #66076A

BY Frank Joseph Goes, Jaypee 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

MORIA S.A. 15, rue Georges Besse 92160 Antony FRANCE Phone: +33 (0) 1 46 74 46 74 - Fax: +33 (0) 1 46 74 46 70 moria@moria-int.com - www.moria-surgical.com

Feature

industry news

Recent developments in the vision care industry

See the beauty! New instrument for 23G vitrectomy

New trocar locking forceps have been designed by Geuder, in cooperation with Prof BartzSchmidt, specially for 23G vitrectomy. “In the forceps’ open position, the size-adjusted tips are optimal for holding trocar heads,” said a Geuder spokeswoman. “Their dullness allow for atraumatic manipulations for example around the conjunctiva. In the forceps’ closed position, the tips fit ideally into the lumen of the trocar port, enabling the bulbous to be rotated and stabilised without injury. The thickening of the tips prevent them from penetrating too deeply within the lumen. In addition, the tips can also be used to close the valve, upon which a dynamic air-gas exchange can follow. The trocar system can then be removed without any need for further instruments,” according to the company. n www.geuder.de/geuder

New technique for iris enclavation

The Matterhorn, Wallis, Switzerland

AdvAnced to the MAxiMuM

Engineered in Switzerland

The new FEMTO LDV Crystal Line for Z-LASIK and corneal surgery

Seeing better

Ziemer ophthalmic Systems AG a Ziemer Group Company Allmendstrasse 11, 2562 Port, Switzerland

Z-LASiK, the obvious choice. www.ziemergroup.com

Artisan family lenses are fixated to the iris for more than 25 years and remain perfectly in place after so many years, according to OPHTEC. “The new VacuFix technique was recently added to the methods officially prescribed by OPHTEC, the enclavation needle and the enclavation forceps, to fix the lens to the iris,” said an OPHTEC spokeswoman. “The VacuFix comprises two holders with an aspiration tip that can be attached to the phaco machine. A vacuum is created to clip a precise and replicable amount of iris tissue between the haptics of the lenses. The advantages of this technique are precision for the patient and surgeon, speed and convenience and, accordingly, comfort for the patient,” she said.

In a recent global study to determine the hierarchy of vision-corrected patient needs, seeing better was the most important consideration for selecting eye care products. The Needs, Symptoms, Incidence, Global Eye Health Trends (NSIGHT) study surveyed 3,800 spectacle- and contact lens-corrected subjects, 15 to 65 years of age, from seven different countries (China, Korea, Japan, France, Italy, UK, US). The current analysis aimed to determine a hierarchy of patient needs in the selection of eye-related products, based on respondents’ scoring of 40 features representing eight categories of potential product features. The NSIGHT study revealed that product benefits relating to vision quality are highly important to patients all around the world. When patients are asked to trade off various functional needs relative to eye care products, comfort becomes only half as important as vision quality. “NSIGHT validated that clear, crisp vision is a top priority for our patients,” commented Carla Mack OD, FAAO, director, Global Medical Affairs for Bausch + Lomb. n www.bausch.com.

Don’t miss Eye on Travel, see page 43 eurotimes_mar2011_z-lasik_ad_120x300mm.indd EUROTIMES | Volume 16 | Issue 3

08.02.11 14:01

Review

JCRS Highlights Journal of Cataract and Refractive Surgery

Functional vision after Nd:YAG

Posterior capsule opacification (PCO) continues to be one of the most common complications following cataract surgery. Patients with symptomatic PCO typically undergo Nd:YAG laser capsulotomy. While this is known to improve visual acuity, what is the effect on day-today functional vision? Researchers at Keio University in Tokyo used a new system to assess functional vision in a group of patients before and after Nd:YAG laser capsulotomy. The new computerised SSC-350 functional visual acuity measurement system (Nidek) takes continuous measurements as the patient goes through Landolt chart testing. The study revealed that corrected distance acuity did not change significantly before and after Nd:YAG treatment, but there was a significant improvement in functional visual acuity. The researchers believe the new technique is a useful tool in assessing visual quality or justifying the need for Nd:YAG laser capsulotomy in patients with good vision but visual symptoms caused by PCO. n T Hitomi et al., JCRS, “Functional visual acuity after neodymium: YAG laser capsulotomy in patients with posterior capsule opacification and good visual acuity preoperatively,” Volume 37, Issue 2, Pages 258-264.

Comparing femtosecond flap edges How do LASIK flap edges made by various femtosecond lasers compare with those made with a conventional microkeratome? Korean investigators used Fourierdomain optical coherence tomography to compare the thickness and side-cut angle of laser flaps created by IntraLase (AMO), VisuMax (CZM), and Femto LDV (Ziemer) and an M2 microkeratome (Moria). The analysis showed that flap morphology differed according to the system used. The IntraLase and VisuMax flaps had relatively even flap configuration, while the Femto LDV flaps were meniscusshaped. The Femto LDV flaps had the best flap thickness predictability, while the IntraLase had the side-cut angle closest to 90 degrees. All of the lasers were superior to the conventional microkeratome. These findings could have significant implications for visual outcome and the development of postoperative complications following LASIK.

Don’t miss Calendar, see page 44 EUROTIMES | Volume 16 | Issue 3

n H

Ahn et al., JCRS, “Comparison of laser in situ keratomileusis flaps created by 3 femtosecond lasers and a microkeratome”, Volume 37, Issue 2, Pages 349-357.

Wavefront PRK vs. iris-fixated phakic IOL

While phakic IOLs are generally the choice for higher levels of myopia, debate continues on what to offer low to moderate myopes seeking refractive surgery. Dutch researchers compared the differences in visual acuity and residual refractive outcomes in patients who underwent either wavefront-guided PRK or Artiflex foldable phakic IOL implantation. Patients had a mean age of 40 years and were treated for -4.0 D to -7.0 D of myopia. At one year, the researchers found equal safety, efficacy, and contrast sensitivity with both procedures. However, no eye in the phakic IOL group lost lines of decimal CDVA, whereas 21.7 per cent in the PRK group lost one or more lines of CDVA. Endothelial cell loss has been a serious concern in anterior chamber phakic IOL implantation. Endothelial cell loss in the phakic IOL group was 4.7 per cent. The endothelium should be closely monitored after anterior chamber phakic IOL implantation, the researchers caution. n M Joosse et al., “Comparison of wavefrontguided photorefractive keratectomy and foldable iris-fixated phakic intraocular lens implantation for low to moderate myopia” Volume 37, Issue 2, Pages 370-377.

JCRS Symposium Femtosecond Laser Applications in Anterior Segment Surgery n

Wound Creation

– Samuel Masket, MD n

Astigmatism Correction

– William W.Culbertson, MD n

Continuous Curvilinear Capsulorhexis

– Roger F. Steinert, MD n

Softening the Nucleus

– Zoltan Z. Nagy, MD, PhD n

Presbyopic Correction

– Ronald R. Krueger, MD

Chairs: William J. Dupps Jr, MD, PhD Nick Mamalis, MD

Monday, March 28, 2011 1:00pm – 2:30pm Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

During the ASCRS Symposium on Cataract, IOL and Refractive Surgery San Diego, California

Housing Deadline

February 23, 2011 Don’t Miss... ASCRS Glaucoma Day 2011 Friday, March 25 www.ASCRSGlaucomaDay.org

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

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

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

Saturday, March 26 ASCRS Opening General Session San Diego Convention Center, 10:00 AM – 12:00 PM Includes presidential speeches, the Binkhorst Lecture Pediatric Cataract: The Compelling Quest, by Abhay R. Vasavada, FRCS, brief remarks by honored guests Gavin Herbert and Ulf Stenevi, MD. Inductees to the ASCRS Ophthalmology Hall of Fame will be introduced.

PROBE (Practice Revenue Optimization and Business Efficiency) San Diego Marriott Hotel and Marina, March 26-29, 2011 PROBE is a core selection of CME-designated courses that provide a comprehensive analysis of your practice to maximize revenue. This new business track is specifically designed for ophthalmologists to help them: identify areas of growth and streamlining; enhance profit diversification and develop a financial strategy; and analyze business models and productivity management. www.ascrs.org/11am/prob

Sunday, March 27 ASCRS Lecture on Science and Medicine San Diego Convention Center, 10:00 – 11:00 AM Best-selling author of the Emperor of all Maladies, Siddhartha Mukherjee, MD, PhD, will discuss the history of cancer treatment and research with program moderator Douglas Koch, MD and Joseph Noreika, MD, an ophthalmologist and cancer survivor.

Government Relations General Session San Diego Convention Center, 11:00 AM – 12:00 PM It’s About More Than Just a Checklist: What Every Clinician Can Learn From Capt. Sully and the Miracle on the Hudson. Steve W. Harden, President of LifeWing is the guest speaker. US Airways flight 1549, under the command of Capt. “Sully” Sullenberger, ditched in the Hudson River in New York City due to a catastrophic loss of thrust in both engines. By analyzing the lessons learned from the “Miracle on the Hudson”, clinicians can learn how to dramatically improve patient safety and quality of care.

Monday, March 28 ASCRS Innovators Session San Diego Convention Center, 10:00 – 11:30 AM Richard L. Lindstrom, MD, Thoughts on the Ophthalmologist’s Role in Education and Innovation. The Charles D. Kelman Innovator’s Lecture will review defining the problems and needs in the preservation, restoration and enhancement of vision for the individual and society as a whole.

Tuesday, March 29 ASCRS Clinical Carryout—Questions and Controversies San Diego Convention Center, 3:00 – 4:30 PM What are the most important things you'll take home from the Symposium? A panel of leading ophthalmologists will facilitate thoughtprovoking discussion, and audience response keypads will be used to further dialogue.

Feature

eu matters

Losing more control

Court rules patients have right to buy contacts over Internet and to bypass optician shops by Paul McGinn

he EU’s highest court has ruled that it is illegal to forbid patients from refilling their prescriptions for contact lenses on the Internet. In its ruling, the European Court of Justice found that a Hungarian law – which limited the sale of contact lenses to such shops – violated EU consumer law. In coming to its decision, however, the EU affirmed the role of the ophthalmologist in the ultimate clinical decision about contact lenses and supported the concept that EU countries could require patients to have their first set of contacts supplied by an optician. “Given the risks to public health which thus exist, a Member State may impose a requirement that contact lenses are to be supplied by qualified staff who are to alert the customer to those risks, carry out an examination of the customer and recommend or advise against the wearing of lenses, while inviting the person concerned, where necessary, to obtain the advice of an ophthalmologist,” the court wrote. “Because of those risks, a Member State may also impose a requirement that, where the wearing of lenses is not advised against, qualified staff are to determine the most appropriate type of lenses, check the positioning of the lenses on the eyes and provide the customer with information on the correct use and care of the lenses.” The court added that for the subsequent

supply of contact lenses there was no need to provide a patient with such services. The court said any additional information and advice required for prolonged use of contact lenses can be given to the customer by using the interactive features on the supplier’s Internet site or by a qualified optician designated by the supplier as able to provide that information at a distance. The case arose over a Hungarian regulation on medical devices, a provision of which requires that contact lenses only be sold by a specialist shop with a minimum area of 18 square meters and be staffed by an optometrist or an ophthalmologist qualified in the field of contact lenses. Curiously, the regulation allows the shop to deliver the contact lenses to the patient’s home. On the basis of that regulation, a district officer in the Hungarian National Public Health and Duty Doctor Service, banned a Hungarian-based company, Ker-Optika, from selling contact lenses on the Internet. Ker-Optika appealed the ban to a regional officer of the health service, but that officer, too, upheld the ban. Ker-Optika then appealed that appeal to a regional court in the city of Baranya. In that appeal, the company said that the Hungarian regulation violated the EU Directive on Electronic Commerce, which was transposed into Hungarian law in 2001. Under the directive, no EU country could

EUREQUO

require a company or individual to receive prior authorisation before commencing or continuing the provision of so-called “information society services.” The company argued that any product sold over the Internet came under that definition, and thus the protection of the directive. In its appeal, the company also argued that because the medical devices law allows the home delivery of medical devices, the Internet sale of contact lenses should also be permitted. The Hungarian National Health Service said that the sale of contact lenses fell outside of the directive on electronic commerce because it was an activity that cannot be carried out at a distance as it requires a physical examination of the patient. Because of the involvement of EU law in the case, the Hungarian court in Baranya referred the matter to the Court of Justice for a preliminary ruling on three questions: Does the sale of contact lenses constitute medical advice requiring the physical examination of a patient and thus not fall within the scope of [the] Directive [on electronic commerce]? If the sale of contact lenses does not constitute medical advice requiring the physical examination of a patient, must Article 30 EC be interpreted as precluding legislation of a Member State under which contact lenses may be sold only in specialist medical device shops?

What is EUREQUO?

European Registry of Quality Outcomes for Cataract & Refractive Surgery

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

The project aims to:

with the kind contribution of

EUROTIMES | Volume 16 | Issue 3

Improve treatment and standards of care for cataract and refractive surgery

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

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

Does the principle of the freedom of movement of goods laid down in Article 28 EC preclude the provision of Hungarian law which makes it possible to sell contact lenses solely in specialist medical device shops?’ In its judgment, delivered in December, the Court of Justice answered all three of the questions together, based on delineation between the sale and supply of contact lenses. “The answer to the questions submitted by the referring court is that the national rules relating to the selling of contact lenses fall within the scope of Directive 2000/31 since they concern the act of selling such lenses via the Internet; on the other hand, the national rules relating to the supply of contact lenses are not covered by that directive,” the court wrote. In regard to the sale of contact lenses, the court stated that the prohibition deprives traders from other Member States of a particularly effective means of selling those products and thus significantly impedes the access of those traders to the Hungarian market. Consequently, that legislation constitutes an obstacle to the free movement of goods in the EU. As regards the justification of that restriction, the court said that an EU country could, in principle, impose a requirement that contact lenses are to be supplied by qualified staff capable of providing the customer with information on the correct use and care of those products and on the risks associated with wearing lenses. Such a requirement, however, did not justify the blanket ban imposed by the Hungarian regulation, the court found. The court concluded that the Hungarian blanket ban on selling contact lenses via the Internet was not proportionate to the objective of protecting public health and must be held to be contrary to the longestablished EU rules that guarantee the free movement of goods.

Join the network EUREQUO gives a unique opportunity to monitor and compare results Quality registries create a sufficient basis for studying rare diseases, treatments and complications Collecting data will support you to make an audit report The collection of your data will facilitate the analysis of surgical outcomes and the development of evidencebased European Quality Guidelines

See www.eurequo.org for more information

contacts

Arthur Cummings – abc@wellingtoneyeclinic.com Ed Toland – ed.toland@wellingtoneyeclinic.com

Feature

PRACTICE DEVELOPMENT

a good service

ESCRS Practice Development Masterclass attendee finds value in focusing on basics by Howard Larkin

oing into the first ESCRSEuroTimes Practice Development Masterclass on entrepreneurship in September 2009, Arthur Cummings MB, ChB, MMed (Ophth), FCS(SA), FRCSEd, of Wellington Eye Clinic, Dublin, Ireland, and his clinic manager Ed Toland MBA were looking to expand a thriving refractive practice. One year later, facing a steep drop in demand for LASIK as Ireland and the rest of Europe plunged into recession, the clinic was looking for ways to cut costs while maintaining quality and improving service.

Nonetheless, the insights and strategic exercises that Masterclass course director Keith Willey MBA of London Business School presented proved invaluable in helping the practice navigate this unexpected shift, Dr Cummings says. “MBAs make you think outside the box. It helped us focus on what is controllable and what is not controllable. We can’t control the economy, and the number of people who will have LASIK will largely depend on the economy. What we can control is our cost. We can make better use of marketing and make better use of our time in the room with the patients.”

Mr Toland agrees that the Masterclass helped him take a step back and “work on the practice instead of in the practice.” He found particularly helpful Prof Willey’s insight that in differentiating a practice in the market, you can position yourself as primarily technology-driven, service-driven or pricedriven, but not more than one. “The more I thought about it the more I thought it was a useful concept,” Mr Toland says. “We felt we were strong in all three, but that our marketing would be more effective if we picked one. As a premium supplier, we are not interested in focusing on price, so we focus on service and adding value.” Service is what sets the clinic apart, Mr Toland explains. For example, while many visitors to the Wellington practice website frequently click on the website’s cost page, the clinic has made a conscious decision to focus on its level of service and intrinsic benefits of laser surgery to patients. The service approach carries over to cataract surgery, Dr Cummings adds. “We approach cataract surgery as an elective procedure. The time to do it is when it affects

that patient’s life.” He believes the clinic’s experience in meeting refractive patients’ demands for service and excellent outcomes, as well as its experience in guiding patients through the complex process of choosing a refractive option such as a multifocal lens or monovision, have helped it succeed as a premium provider in a tough market.

The value of training Wellington also has focused on staff training and involving staff in making the practice more attractive to patients, Dr Cummings adds. Mr Toland, also found the ESCRS workshops on marketing helpful. “The research presented by Rod Solar [of Livesey Solar, London, England] on effectively answering your phone and how much it can affect your marketing success stood out. I came home with two or three pages of ideas to implement.” Dr Cummings believes that all ophthalmologists should participate in practice development programmes. “The economy is still under pressure and it will be difficult going for several years.”

5th International Symposium on Refractive Surgery, Cataract and Cornea

21-23 July 2011

CALL FOR ABSTRACT A wonderful opportunity for members of our profession from all over the world to meet and exchange ideas, along with a variety of cultural and spiritual attractions that Israel’s Dead Sea is known for. If you have a lecture topic that you wish to present, you are more than welcome to submit an abstract. Samuel Levinger Chairman Guest Speakers: H. Climenhaga, Canada

M. Daly, USA S. Daya, UK L. Grupenmacher, Brazil

EUROTIMES | Volume 16 | Issue 3

M. Kraff, USA

R. Krueger, USA Z. Nagi, Hungary T. P. O'Brien, USA

D. Rootman, Canada

K. Rosenthal, USA A. Slomovic, Canada M. Tassignon, Belgium

escrs on your time Symposia, free papers, videos and more from ESCRS Congresses in your home ngress o C I I I XXV , ESCRS e h t f o France Paris, nline Now O

escrs on demand Visit www.escrsondemand.org

Feature

eye on travel

Cruising London

Seeing London by boat on the Thames, London’s original highway, is fast and fun by Maryalicia Post

n 1802, the view from Westminster Bridge inspired Wordsworth to write a sonnet. Today's view might not inspire poetry, but most tourists will pause to take at least a couple of photos. In one direction, there’s the mighty tower housing Big Ben; in the other direction stands London Eye, the enormous observation wheel. On the South Bank side of the bridge, a number of key London sights lie along the river or just a walk of 10 minutes or so inland. The pedestrian route linking them starts here. Named “the Millennium Mile,” – although it's closer to two miles long – the route runs from the foot of Westminster Bridge to Tower Bridge. You can cover it all on foot in three hours if you have the time and energy and don't tarry at the museums. But better still, combine transportation to the sights that interest you with a mini-cruise. Buy a “hop on, hop off” River Roamer ticket for the Thames Clippers that leave from Waterloo Pier near the London Eye. For details, visit: www.booking. thamesclippers.com/river_roamer. Nine minutes after boarding the Clipper at Waterloo Pier you are at Bankside Pier. This is your stop if you want to visit the Tate Modern and Shakespeare's Globe Theatre. The Tate Modern, installed in an old power station, is worth exploring for the building alone, but its collection of modern art is exceptional and there's an espresso bar with two riverside balconies to enjoy. www.tate.org.uk/modern Shakespeare's Globe Theatre is an authentic reproduction of the destroyed 17th

Tower Bridge

EUROTIMES | Volume 16 | Issue 3

century original, or as authentic as modern scientific research can manage. Take a 90-minute guided tour of the theatre to learn all about it. www.shakespeare-globe.org. London Bridge City stop, reached in 13 minutes from Waterloo Pier, brings you within a walk of Southwark Cathedral. This church has welcomed worshippers since 606 AD. One of its four small chapels, St Andrew's, is specifically dedicated to people affected by AIDS. London Bridge City is also the stop for the Old Operating Theatre. Female surgical patients of the first St Thomas's hospital were operated on here in the attic of the hospital's church. Before 1822, operations were performed in the ward; the garret offered some measure of soundproofing, much needed before anaesthetics became available. The room was sealed in 1862 when the hospital moved to Lambeth and rediscovered in 1956. www.thegarret.org.uk Linger on the Clipper a few minutes longer and you'll reach Tower Pier, convenient for a visit to the Tower of London. The tower, repository of the crown jewels, is open every day. Come early to avoid the crowds. Buy a ticket up to seven days in advance of your visit online at: www.hrp.org.uk/TowerOfLondon.

More to see Greenwich, a 36-minute cruise from Waterloo Pier, is a World Heritage Site. An attractive village with a vibrant market (Wednesday to Sunday 10:00-17:30), Greenwich is home to the National Maritime Museum, the Royal Naval College and the Royal Observatory (where you can straddle the prime meridian – one foot in the western hemisphere, the other in the eastern hemisphere). Sadly, the Cutty Sark, the famous tea clipper that was once docked near here, won't be on view again until 2012. It was badly damaged by fire in 2007 and is undergoing restoration. www.oldroyalnavalcollege.org and www.nmm.ac.uk. Fans of modern British music will want to cruise a further 20 minutes to visit the “British Music Experience.” Installed in the 02 bubble, it features a retrospective look at British music since 1945. Interactive exhibits are arranged around seven time zones strung together along a giant timeline. It's digital, it's animated, and it’s crammed with facts and artefacts. Try the “Dance the Decades” booth:

London Eye

choose a dance style, get a short “lesson,” and then watch your efforts on film. Or make a recording in the Gibson interactive studio. If British Music is your thing, this is your place. www.britishmusicexperience.com.

The other side of Westminster Bridge The entrance to London Eye,

Britain's number one tourist attraction, is down the stairs to the left on the South Bank. The big wheel is designed for observation, not thrills, so a full turn takes a leisurely 30 minutes. If you plan to experience a “flight” on London Eye but don't know what day or time, buy a Flexi Fast Track ticket in advance. You'll bypass part of the queue and can check in 15 minutes before you want to climb aboard. Book online at: www.londoneye.com. Tickets are £29.70 per adult. The attractive old building you pass was once the County

Hall Now it houses a modest aquarium and some riverside eating-places. The Florence Nightingale Museum, (follow the signs to the right of Westminster Bridge) tells the incredible story of this privileged young lady fearful of “going mad for lack of something to do,” who was, at her death at 90, the second most influential woman in Queen Victoria's Britain. What she did and how she did it is skillfully told in this small museum that is more impressive than its size would suggest. Nightingales' two years as the “lady with the lamp” in Crimea form only a small part of a remarkable story brought alive with audio and visual displays and touching momentos like the medical chest she brought to the Crimean War. The museum building is in the grounds of St Thomas's Hospital. Open every day, 10:00-17:00. www.florence-nightingale.co.uk.

Journal Watch Does prostate cancer treatment boost cataract risk?

Prostate cancer patients treated with androgen deprivation therapy may be at a higher risk of developing cataracts, a new epidemiological analysis suggests. US researchers used data from the Surveillance, Epidemiology and End Results-Medicare database, to examine the risk of cataract associated with this treatment among 65,852 prostate cancer patients. ADT treatment was defined as at least one dose of a gonadotropin-releasing hormone agonist or orchiectomy within six months after prostate cancer diagnosis. Both gonadotropin-releasing hormone agonist use and orchiectomy were associated with an increase in cataract incidence. This is the first systematic investigation of the association between androgen deprivation therapy and cataract. The authors call for a prospective study to investigate these observations.. n Beebe-Dimmer J, et al., Annals of Epidemiology, “Androgen deprivation therapy and cataract incidence among elderly prostate cancer patients in the United States”, doi:10.1016/j.annepidem.2010.10.003.

Reference

Calendar of events Dates for your Diary

March

2nd World Congress on Controversies in Ophthalmology (COPHy) www.comtecmed.com/cophy

2011 Congress of the APAO www.apaosydney2011.com/

2011

3-6

Barcelona, Spain

11-12

Alicante, Spain

ARI Monographic 2011 – “Presbyopia… its treatment” www.alicanterefractiva.com

April

2011

20-24

25-30 CA, USA

ASCRS/ASOA Symposium and Congress www.ascrs.org

2011

6-10 Argentina 1-5 Mar del Plata,

May

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

2011

26-29 UK

VIII Congress of SEEOS And IX Congress of BSOS www.seeos-bsos2011.org

June

19-22 Germany 3 Nurnberg,

June

2011

Geneva, Switzerland

24th Intl. Congress of German Ophthalmic Surgeons www.mcn-nuernberg.de

PRESBYMANIA 2011 www.presbymania.com

24-26 UK

4-7

September

5-8 Porto Alegre, Brazil

vienna, austria

Birmingham

The Royal College of Ophthalmologists Annual Congress 2011 www.rcophth.ac.uk/annualcongress

2011

XXXVI Ophthalmology Brazilian Congress www.cbo2011.com.br/

Gothenburg, Sweden 8-9 1st World Congress on Surgical Training www.surgicon.org

23-24 Bordeaux, France Eurokeratoconus II www.jbhsante.fr

ARVO 2011 - Annual Meeting www.arvo.org

Istanbul,

11th EURETINA Congress www.euretina.org

2011

Florida, USA

19-22 Turkey

london,

May

Australia

SAN DIEGO,

May

2011

Sydney,

July

9-11

Milan, Italy

Retina in Progress present and future 2011 www.retina3000.it

GENEVA, SWITZERLAND

Joint Congress of SOE/AAO www.soe2011.org

2011

16-17 17-21

2011

2nd EuCornea Congress www.eucornea.org

29-2

PARIS, FRANCE

World Glaucoma Congress 2011 www.worldglaucoma.org

October 2011

6-7 Dublin, Ireland 13th International Paediatric Ophthalmology Meeting Dublin [See ad on page 17 for more details]

13-16 Seoul, Korea 2011 APACRS-KSCRS Annual Meeting www.apacrs.org

2011

1-3 Leuven, Belgium Leuven Retina Meeting www.leuvenretinameeting.eu

8-10 Crete, Greece 12th Aegean Retina Meeting www.aegeanretina.gr

21-23 Dead Sea, Israel Fifth International Symposium on Refractive Surgery, Cataract and Cornea www.dead-sea2011.co.il/

December

1-4

2011

vienna, austria

International Symposium on Ocular Pharmacology and Therapeutics www.isopt.net

22-25 ORLANDO, FL, USA American Academy of Ophthalmology Annual Meeting www.aao.org

XXIX Congress of the ESCRS www.escrs.org

Advertising Directory: Alcon Laboratories: Pages: 7, OBC; ASCRS / Eyeworld Pages: 20, 38-39; Benz Research and Development Page: 25; Croma-Pharma Pages: 22; D.O.R.C International BV Page: 23; Enaim Medical Centre Page: 41; ESASO Page: 27; Haag Streit International Page: 19; Katena Products Inc Page: 8; Medicel AG Page: 11; moria Page: 35; NIDEK Page: 14; Oculus Optikgeraete GmbH Page: 15; Oertli Instruments AG Page: 9; Rayner Intraocular Lenses Ltd Page: IBC; Schwind Page:IFC; SOE Page: 26; VSY Biotechnology Page: 3; Ziemer Page: 36

Please visit us on booth 923 at the ASCRS San Diego 2011

RAYNER IOL experts, the world over.

1.1

1.2

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Sulcoflex For when perfection is the only option

1.1 Sulcoflex® Aspheric 1.2 Sulcoflex® Multifocal 1.3 Sulcoflex® Toric

• The opportunity of multifocality to pseudophakic monofocal patients with

a safe and innovative surgical approach • Correction of post-surgical corneal astigmatism or spherical errors

without the trauma of IOL exchange • Specifically designed for ciliary sulcus fixation • Avoids the potential problems associated with conventional piggybacking • Unique, undulating, large diameter haptic design with 10° angle ensures

superb centration and stability • Excellent biocompatibility of Rayacryl® with the uveal tract

rayner.com

Sulcoflex ® Pseudophakic Supplementary IOLs are exclusively designed in collaboration with Professor Michael Amon (Vienna, Austria). Note: Sulcoflex® Pseudophakic Supplementary IOLs are not yet approved for sale in the US and Canada. 02/11 Copyright Rayner Intraocular Lenses Limited.