Oph The Record 2017 by OPHTEC

OPH the RECORD Published by OPHTEC BV /// 2017/2018 edition /// #13

OPHTEC presents

CPMA

Comprehensive Platform Management of Astigmatism

“Over 10,000 ArtiLens PIOLs” Dr Choe Chul Myong:

AND MORE: 8 Precizon Toric IOL

Results in Focus

14 Precizon Presbyopic IOL

/// Visit us during the ESCRS congress, booth # P136

Interview with Alex Lee

21 Special Cases

Artisan Aphakia 4.4/7.5 | +40.0D

www.ophtec.com

>> Events & Congresses 2017 / 2018 Sept. / Oct. 28-1

Berlin

Germany

DOG

October 7-11

Lisbon

Portugal

ESCRS

November 3

Groningen

The Netherlands

ArtiLens Training

November 3-5

Seoul

South Korea

KOS

November 11-14

New Orleans

USA

AAO

November 22-24

Brussels

Belgium

Nov. / Dec. 29-2

Rome

Italy

SOI

December 7-9

Vilamoura

Portugal

SPO

February 1-4

Johannesburg

South-Africa

OSSA

February 8-11

Hong Kong

China

APAO

February 9-11

Belgrade

Serbia

W-ESCRS

February 15-17

Dresden

Germany

DGII

March 13-17

Düsseldorf

Germany

AAD

March 21-23

Groningen

The Netherlands

NOG

April 13-17

Washington, DC

USA

ASCRS

May 5-8

Paris

France

SFO

June 14-16

Nürnberg

Germany

DOC

July 19-21

Chiang Mai

Thailand

APACRS

September 22-26

Vienna

Austria

ESCRS

Colofon OphTheRecord is published by OPHTEC BV E-mail: r.den.besten@ophtec.com Lay-out: www.mennoschreuder.nl Print: Scholma Druk, Bedum Photo front: Vasco da Gama bridge, Lisbon All rights reserved. © OPHTEC BV 2017 PO Box 398, 9700 AJ Groningen, The Netherlands T: +31 50 5251944 F: +31 50 5254386

www.ophtec.com

In this issue

Dr Choe Chul Myong

Dr Choe Chul Myong, Nune Eye Hospital Seoul, Korea, has implanted more than 10.000 ArtiLenses. In this interview he tells us why, and why he keeps on going.

CPMA

OPHTEC’s Comprehensive Platform Management of Astigmatism (CPMA) offers you all you need + innovative know how for the entire Toric lens implantation procedure.

Precizon Presbyopic IOL

This brand new CE Approved Presbyopia correcting IOL has a unique Continuous Transitional Focus (CTF) optic. We asked Alex Lee, (OPHTEC’s Director Sales and marketing of the Asia / Pacific Region) to tell us about this new optic, how it works and what it brings to the patient.

Precizon Toric IOL

The Precizon Toric IOL has been available for 4 years now. In ‘Results in Focus’ you can read about its excellent performance.

ArtiLens Official Training Courses

OPHTEC educates surgeons on why and how an iris claw lens should be implanted. Therefore we organize many Training Courses every year, all over the world.

Looking back: Jan Worst’s appropriate Technology Together with Anneke Worst, we collected some drawings from Jan Worst’s Appropriate Technology Manual. A Manual put together in 1986 to help ophthalmologist in poor countries to make their own ophthalmic instruments.

Special Cases

Dr Mariano Royo from Spain sent us this special case about a microphthalmic eye.

Sandra’s Lisbon Tasting T(r)ips

Sandra Bayan runs OPHTEC’s Portuguese office. Next to her skills as a business woman she has great knowledge of her countries history and culture. We asked her to share some short Lisbon tasting T(r)ips.

OPH//THE//RECORD 3

over 10,00 ArtiLens PI “Why I have implanted

and keep on going”

Interview with Dr Choe Chul Myong of Nune Eye Hospital Seoul, Korea

Can you tell us about the Nune Eye Hospital? Nune Eye Hospital is in Seoul and Daegu, Korea. We are a comprehensive eye hospital with specialists covering all the subspecialties including cornea and refractive surgery, cataract, retina, glaucoma, strabismus, oculoplastics and neuro-ophthalmology.

refractive surgery for 2 years. I began doing private practice afterwards and from 2006 started the Nune Eye Hospital. In the early days refractive surgery was mainly PRK or LASIK with microkeratomes. Opacity after PRK and flap complications was not uncommon and most of the refractive surgeons wore glasses and avoided getting surgery on themselves. Phakic IOL was not readily available so clear lens extraction was the main procedure for high myopes.

We are also a certified ophthalmology training centre with residency and fellowship programs. There are 30 eye doctors, 3 medical doctors, 2 anaesthesiologists, and 250 staff members. Every year we have roughly 170,000 outpatient treatments, 67,000 surgery cases, 32,000 refractive surgery patients including ArtiLens.

Why did you start using ArtiLens phakic lenses? One of my colleagues, Dr You, went to OPHTEC in 2003. He joined the first Korean team to receive ARTISAN training and we started with this surgery in 2003. The early results were amazing compared to the clear lens extraction, so I had my wife get ARTISAN lens implanted on both eyes. She was -11.0D in both eyes and really wanted surgery but I couldn’t recommend CLE to her. After the ARTISAN lens surgery she said “I have never seen the world clearly like this in my whole life!” and was so excited and satisfied. Later I also implanted ARTIFLEX lenses on my daughter. I recommend ArtiLens PIOLs to all my myopic patients with -7.0D or more and hyperopic patients with +2.0D or more.

When did you start your career as an Ophthalmologist? I started my career as an ophthalmologist in 1997 as a medical officer in the Korean army. After 3 years of service and retiring as an army captain I entered fellowship in Yonsei University for cataract and

4 OPH//THE//RECORD

How many ArtiLens PIOLs lenses have you implanted? I have implanted over 10.000 ArtiLens PIOLs and keep on going. The satisfaction comes from my patients. Nearly all of my patients thank me for giving them a new life. >>

00 IOLs ‘Nearly all of my patients thank me for giving them a new life’

OPH//THE//RECORD 5

™

ONE SIZE FITS ALL

LARGE OPTICAL SIZE • REVERSIBLE • CONTROLLED POSITIONING SUFFICIENT DISTANCE FROM ENDOTHELIUM & CRYSTALLINE LENS

IRIS FIXATION ••

LONG TERM RESULTS • FDA APPROVED*

HIGH POWER RANGE & VARIOUS APPLICATIONS * ARTISAN MYOPIA, 2004

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Nune Eye Hospital, Seoul, Korea

High myopic patients with corrected vision less than 20/20 never imagined that they would see so clearly. I never had loss of best corrected vision and uncorrected vision was mostly the same or better than their best corrected vision before surgery. The important thing is precise preoperative examination and patient selection. During surgery a safe surgical technique is the most important. ArtiLens implantation has a learning curve, having an experienced surgeon nearby really helps. Our operating room is built with laminar flow and hepa filtration. It is also monitored for bacterial contamination on regular basis. Above all the most important thing is regular follow up. I recommend yearly follow up after surgery. You could prevent events leading to endothelial cell loss if the patient comes to the clinic every year.

Can you describe one of your most special / interesting cases? The patient I will always remember is my first case. He was -10.0D high myopia in both eyes and had a perfectly normal cornea. The unbelievable thing was he had had PRK in both eyes 15 years ago. At first I didnâ&#x20AC;&#x2122;t believe him because his cornea topography was perfectly normal with no signs of previous laser surgery. So I asked him to bring me his previous medical record. His record showed previous PRK of -10.0D. His eyes had been regressed to the preoperative state in 15 years. Best corrected vision was 20/30 in both eyes and after surgery he achieved uncorrected vision of 20/20. His results really gave me confidence for the ARTISAN lens and following surgeries. What do you do in your spare time? On a busy day I have to perform surgery on 10 patients until lunch time that will be 20 eyes. After lunch 40 follow up patients and 8-10 laser surgeries. This is quite exhausting both to the mind and body. So I work out but do not limit my meals because I am not trying out for the body building contest. I like to travel and visit new places, try out the local cuisine and play golf on the famous local courses.

OPH//THE//RECORD 7

Transitional Conic Toric IOL

Results in Focus

1 line better than competitive toric IOLs

Precizon Toric results published 2014/2015/2016.

8 OPH//THE//RECORD

// Study review

Getting 1 line better 1. Visual and optical outcomes of a new monofocal toric intraocular lens by: Tiago B. Ferreira, MD; ” ESCRS 2015 Purpose: To evaluate the visual and wavefront outcomes of patients who underwent cataract surgery with the implantation of a new transitional toric monofocal intraocular lens (IOL) - Precizon Toric IOL (model 565, Ophtec BV). Methods: This prospective case series included 50 eyes with cataract and regular corneal astigmatism between 1.00 and 4.00 diopters (D) submitted to phacoemulsification with implantation of a Precizon Toric IOL. Over a 4-month follow-up period, the main outcome measures were uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), spherical equivalent (SE) refraction, residual astigmatism, rotational stability of the IOL (OPD-Scan III, Nidek) and higher order aberrations (HOA) (OPD-Scan). Results: Mean UDVA was 0.05 ± 0.09 (0.3 to -0.15) LogMAR (P<.001) and mean CDVA was -0.02 ± 0.08 (0.05 to -0.15) (P<.001). UDVA was 0.3 logMAR or better in 49 (98%) eyes and 0.1 LogMAR or better in 43 (86%) eyes. Mean SE refraction was -0.18 ± 0.39 D (-1.12 to +0.50), with 47 (94%) eyes within ±0.50 D of the attempted spherical correction. Mean refractive cylinder was -0.34 ± 0.46 D (-1.00 to 0). Mean toric IOL axis rotation was 1.59 ± 2.15° (0 to 7°). Ocular aberrometry improved after surgery (for HOA RMS p=.002). Conclusions: The implantation of the Precizon toric IOL in patients with cataract and corneal astigmatism provided excellent visual outcomes, predictability of refractive results, rotational stability and good optical performance.

2. Evaluation of optical performance of 4 aspheric toric intraocular lenses using an optical bench system: Influence of pupil size, decentration, and rotation. By: Kim MJ, Yoo YS, Joo CK, Yoon G. Cataract Refract Surg. 2015 Oct;41(10):2274-82. doi: 10.1016/j.jcrs.2015.10.059 Purpose: To evaluate the effect of pupil size, degree of intraocular lens (IOL) decentration, and rotation of 4 aspheric toric IOLs on the image quality. Methods: Four aspheric toric intraocular lenses (IOLs)-the Precizon (transitional conic toric IOL), AT Torbi 709M (bitoric IOL), SN6AT4 (posterior toric surface IOL), and ZCT225 (anterior toric surface IOL)-were evaluated using the optical bench metrology system. Measurements included changes in spherical aberrations, relative spherical equivalent (SE), and image quality at different pupil diameters and image quality degradation due to decentration and rotation of the IOLs. Results: Change in relative SE with pupil size in aberration-free toric IOLs (transitional conic toric and bitoric IOLs) was greater than in negatively aspheric toric IOLs (posterior toric surface and anterior toric surface IOLs). In contrast, the aberration-free IOLs showed higher contrast than the negatively aspheric IOLs. When IOLs were decentered by 1.0 mm, the contrast reduction rates at 17.6 cycles per degree for the transitional conic toric IOL, bitoric IOL, posterior toric surface IOL, and anterior toric surface IOL were 5.1%, 3.1%, 12.2%, and 15.8%, respectively. Rotation-induced deterioration of contrast to 0.5 required a much higher rotation for the transitional conic toric IOL than for the other 3 IOLs. Conclusions: The transitional conic toric IOL and bitoric IOL provided superior image quality despite pupil size changes and the presence of decentration. The transitional conic toric IOL demonstrated maximum rotation tolerance compared with the other IOLs.

3. Evaluation of a new toric IOL optic by means of intraoperative wavefront aberrometry (ORA system): the effect of IOL misalignment on cylinder reduction. By: Erik Mertens ESCRS 2014, Purpose: To intraoperatively compare the effect of misalignment of the Precizon™ and Lentis toric (Oculentis GmbH Berlin Germany) intraocular lenses (IOLs) on refraction by means of the ORA system and to compare postoperative outcomes. Methods: Prospective, randomized, comparative study in which patients with cataract and pre-existing corneal astigmatism underwent routine cataract surgery with bilateral implantation of a toric IOL model. Intraoperative wavefront aberrometry (ORA system) was used to assess the effect f IOL misalignment on cylinder reduction after which the lenses were rotated to the intended axis and surgery was completed. Analysis: Toric IOL implantation in 10 eyes in each subgroup resulted in an average of 1,6° rotation with the Precizon IOL and an average of 2,2° with the Lentis Toric IOL.For every degree of error in a toric IOLs rotational misalignment, there is a 3.3 percent decrease in the correction of astigmatism. If a toric IOL is misaligned by 10 degrees, the astigmatism will be 33 percent under-corrected. If the toric IOL is misaligned by 30 degrees, there will be no astigmatism correction. As indicated in previously published papers, we found the same under correction with misalignment with the Lentis Toric IOL by deliberately misaligning 10° and 5°. Conclusion: The new toric optic IOL Precizon™ gave similar results in terms of rotation one month postoperatively but performed significantly better in astigmatism correction and was less sensitive to misalignment in respect to the Lentis Toric IOL.

4. Astigmatism management in cataract surgery with Precizon toric intraocular lens: a prospective study By: Vale C, Menezes C, Firmino-Machado J, Rodrigues P, Lume M, Tenedório P, Menéres P, Brochado MC Clinical Ophthalmology 19, January 2016 Purpose: The purpose of this study was to evaluate the visual and refractive outcomes and rotational stability of the new aspheric Precizon® toric intraocular lens (IOL) for the correction of corneal astigmatism in cataract surgery. Patients and methods: A total of 40 eyes of 27 patients with corneal astigmatism greater than 1.0 diopter (D) underwent cataract surgery with implantation of Precizon® toric IOL. IOL power calculation was performed using optical coherence biometry (IOLMaster®). Outcomes of uncorrected (UDVA) and best-spectacle corrected distance visual acuities (BCDVA), refraction, and IOL rotation were analyzed at the 1st week, 1st, 3rd, and 6th month’s evaluations. Results: •The median postoperative UDVA was better than preoperative best-spectacle corrected distance visual acuity (0.02 [0.06] logMAR vs 0.19 [0.20] logMAR, P0.001). •At 6 months, postoperative UDVA was 0.1 logMAR or better in 95% of the eyes. •At last follow-up, the mean spherical equivalent was reduced from -3.35±3.10 D to -0.02±0.30 D (P0.001) with 97.5% of the eyes within ±0.50 D of emmetropia. •The mean preoperative keratometric cylinder was 2.34±0.95 D and the mean postoperative refractive cylinder was 0.24±0.27 D (P0.001). The mean IOL rotation was 2.43°±1.55°. None of the IOLs required realignment. Conclusion: Precizon® toric IOL revealed very good rotational stability and performance regarding predictability, efficacy, and safety in the correction of preexisting regular corneal astigmatism associated with cataract surgery.

OPH//THE//RECORD 9

What these studies tell us: // Study 1*

>> Precizon Toric IOL provides at least 1 additional line of uncorrected vision compared to leading toric IOL brands*. Vision without glasses LogMAR

Precizon Toric > Leading Brands >

Snellen

(metric)

(Imperial)

Decimal

-0.30

6/3

20/10

2.00

-0.20

6/3.8

20/12.5

1.60

-0.10

6/4.8

20/16

1.25

0.00

6/6

20/20

1.00

0.10

6/7.5

20/25

0.80

0.20

6/9.5

20/32

0.63

0.30

6/12

20/40

0.50

0.40

6/15

20/50

0.40

0.50

6/19

20/63

0.32

Type

Tecnis

Acrysof

Precizon Toric

Rotation (2-4 mo.) 3.5˚ ± 2.62˚ (range 0 to 10˚)

3.25˚ ± 2.04˚ (range 0 to 8˚)

1.59 ± 2.15° (range 0 to 7°)

UDVA

0.12 ± 0.06 (0 to 0.2)

0.13 ± 0.10 (0 to .0.4)

0.05 ± 0.09 (0.3 to -0.15)

Snellen (US)

20/25 - (20/20 to 20/32)

20/25 - (20/20 to 20/50)

20/20 - (20/15 to 20/50)

CDVA

0.02 ± 0.04 (0 to 0.1)

0.04 ± 0.05 (0 to 0.05)

-0.02 ± 0.08 (0.05 to -0.15)

Sphere (D)

0.11 ± 0.72 (-1.25 to +1.00)

0.06 ± 0.64 (- 1.25 to +0.75)

-0.02 ± 0.40 (0.75 to + 100)

Cylinder (D)

- 0.56 ± 0.35 (-1.00 to 0)

- 0.41 ± 0.32 (- 1.25 to 0)

-0.34 ± 0.46 (-1.00 to 0)

SE (D)

- 0.19 ± 0.74 (- 1.38 to 0.88)

-0.14 ± 0.64 (- 1.62 to +1.50)

-0.18 ± 0.39 (-1.12 to +0.50)

* The data from study 1 combined with other study data from the same surgeon (using same pre-op equipment, same technicians doing refraction, etc.) (‘Comparison of the Visual Outcomes and OPD-Scan Results of AMO Tecnis Toric and Alcon Acrysof IQ Toric Intraocular Lenses’) Tiago B. Ferreira, MD; Ana Almeida, MD.

// Study 2

>> Image contrast with aberration free IOLs was better than those with negatively aspheric IOLs.

>> Aberration-free toric IOLs had better tolerability to decentration than negatively aspheric ones.

>> The aspheric transitional conic toric IOL showed better rotation tolerance than the other 3 aspheric toric IOLs; this is attributed to its optical design involving the transitional conic toric surface. Image contrast according to degree of IOL rotation

Image contrast according to degree of IOL rotation 0.8

with the 4.0 mm pupil at 17.6 cpd

0.8

0.3

Contrast

0.4

Transitional conic toric IOL

0.2

Bitoric IOL

0.1

Anterior toric surface IOL

0.3

0.2 0.1

Posterior toric surface IOL

Anterior toric surface IOL

0.4

Rotation (degree)

with the 4.0 mm pupil at 17.6 cpd

0.8

Contrast

0.4

Transitional conic toric IOL Bitoric IOL Anterior toric surface IOL

0.20

10 OPH//THE//RECORD

0.40

Posterior toric surface IOL Anterior toric surface IOL

0.4 0.3

0.2 0.1

Posterior toric surface IOL

Bitoric IOL

0.5

0.1

Transitional conic toric IOL

0.6

0.3

Rotation (degree)

with the 4.0 mm pupil at 35.2 cpd

0.7

0.2

Image contrast according to degree of IOL decentration

Contrast

Posterior toric surface IOL

0.5

Bitoric IOL

0.6

0.8

Transitional conic toric IOL

0.7

with the 4.0 mm pupil at 35.2 cpd

0.60

Decent ation (mm) r

0.80

0.20

0.40

0.60

Decent ation (mm) r

0.80

// Study 3

>> Transitional conic surface provides a greater tolerance for misalignment and improved outcomes. Precizon Toric vs Lentis Toric IOL Cylinder Loss Per Degree Of Rotation

Precizon Toric vs Lentis Toric IOL Cylinder Loss Per Degree Of Rotation

Cylinder Loss Lentis Toric IOL

Efficiency Loss

150% 125%

100%

100% 68%

75% 52%

50%

35%

25% 0%

141%

129%

7.2˚ 0˚

5˚

14.5˚

10˚1

5˚

20˚

Residual error of the axis

38.5˚

22.1˚ 25˚

30˚

35˚

40˚

45˚

Axis Shift Remaining Astigmatism from Preoperative

Remaining Astigmatism Magnitude as a Percentage of Preoperative Magnitude

Cylinder Loss Lentis Toric IOL

45˚ 40˚ 35˚ 30˚ 25˚ 20˚ 15˚ 10˚ 5˚ 0˚

Rotation of Astigmatism 40.0˚

37.5˚

35.0 ˚ 30.0˚ 25.0 ˚

22.5˚

0˚

5˚

10˚1

5˚

20˚

Residual error of the axis

25˚

30˚

35˚

40˚

45˚

// Study 4: >> UDVA was equal or better than preoperative BDCVA in all eyes. >> SE remained stable after one week.

>> The refractive astigmatism remained stable after one week.

Visual outcomes and refraction UDVA 0.1 LogMAR or better

95 %

0.0 LogMAR or better

42.5 %

UDVA was equal or better than preoperative BCDVA in all eyes.

Within ± 0.50 D from emmetropia

97.5 %

SE remained stable after 1 week.

Within ± 0.75 D from emmetropia

100 %

Spherical equivalent

Refractive astigmatism ≤ 0.50 D

95 %

≤ 1.00 D

100 % Mean IOL rotation

2.43° ± 1.55°

The refractive astigmatism remained stable after 1 week.

None of the IOLs required realignment. OPH//THE//RECORD 11

OPHTEC presents

COMPREHENSIVE PLATFORM MANAGEMENT ASTIGMATISM

‘If you want to travel fast, go alone; If you want to travel far, go together’ African proverb

>> 12 OPH//THE//RECORD

Crossing the t’s and dotting the i’s for an astigmatism correction

Precizon Toric 1 line better than competitive IOLS* Transitional Conic Surface (TCS) • Aspherical cylinder • Pupil independence • Enhanced tolerance to misalignment • Proven stability *data on file

By focusing on a perfect lens and on the equipment for preoperative measurements and cornea marking, OPHTEC is the first company to deal with astigmatism correction in the widest sense of the word. We cooperate with specialists in every aspect of astigmatism, because professional knowledge is the key to astigmatism correction! More than 25 years ago, Kimiya Shimizu implanted the first toric lens. It was a three-piece PMMA lens that went into the eye through a 5.7mm incision. The outcome in terms of distance visual acuity was not too bad for a first-generation lens - 20/25 or better in 77% of the eyes, but unfortunately the results for rotation were less impressive. More than 20% of the lenses rotated 30° or more, and nearly half rotated more than 10° 1). We have moved on with a fair few toric-lens generations and the results have improved enormously. Besides using better lens models and materials, digitising pre-operative measurements has also produced gains. Improved equipment offers more accurate topographic measurements of the cornea and its curvature. However, treating astigmatism continues to be precision work and a proper match and coordination of every part of the process affects the outcome. With its Comprehensive Platform Management of Astigmatism (CPMA), OPHTEC now offers everything you need and advanced cross-disciplinary know-how for the entire toric-lens implantation process. We joined forces by working together with the people who developed the Cassini corneal shape analyser and ophthalmologist Dr Alan Brown who developed his own perfect cornea marker, the Robomarker, to be able to offer patients the best results. CPMA is the next step in the battle against astigmatism in cataract surgery. Shimizu K, Misawa A, Suzuki Y. Toric intraocular lenses: correcting astigmatism while controlling axis shift. J CataractRefract Surg 1994; 20:523–526

Cassini REAL Equivalent Keratomy Readings (EKR) • Unique multi-colored led technology; • REAL Equivalent Keratomy Readings (EKR): direct values for optimized IOL calculations, from the posterior and anterior corneal surfaces; • Cassini Total Corneal Astigmatism (TCA) uses specular reflection technology to reconstruct the shape of both the anterior (1st Purkinje image) and the posterior (2nd Purkinje image) surface of the cornea.

Robomarker Corneal Marking System • Integrated fixation light; • Pre-inked and disposable tips; • 1st automatic corneal maker to mark both axis of reference and implantation; • Infrared tips for FEMTO Phaco.

OPH//THE//RECORD 13

Presbyopia correction reinvented CE-approval for Precizon Presbyopic IOL The CE-approval of OPHTEC’s new Precizon Presbyopic IOL was announced on 7 May. Another mile stone for OPHTEC. With a new developed Continuous Transitional Focus optic, this new presbyopia correcting IOL offers “natural vision” to the patient. Alex Lee, Director Sales and marketing of the Asia-Pacific Region, answers the 4 most frequently asked questions. Alex Lee

What makes the Precizon Presbyopic IOL different? The current Presbyopia - correcting IOLs are largely based on lens platform that were designed for monofocal IOLs hence limited by their successes. While, the Precizon platform was designed to fill the unmet needs in presbyopia correction from day 1 of the start of the project. The total development time took more than 5 years! We waited until we came out with something that was clearly different and that will bring benefits to both the surgeons and the patients. Current multifocal IOLs are highly sensitive to ocular aberrations. The most commonly cited reasons for patient dissatisfaction from the literature are due to ametropia; dry-eye syndrome; posterior capsule opacification (PCO); or photic phenomena due to IOL decentration, retained lens fragment and large pupil. The Precizon Presbyopic IOL addresses ocular aberrations due to IOL decentration and large

14 OPH//THE//RECORD

pupil by taking in considerations the optics of the human eye as a whole in the choice of lens material, haptics and patent pending optics that we termed Continuous Transitional Focus (CTF). Can you explain Continuous Transitional Focus (CTF)? The challenges that presbyopia patient present are two folds. Firstly, the human crystalline lens is losing “accommodation” and secondly, the cornea is developing positive aberration to increase the depth of focus to naturally compensate the diminishing vision range and eventually the presbyopic eye losing the ability to see images up close. Continuous Transitional Focus (CTF) delivers optimal depth of focus and the subjective adaptation to defocus during near vision. CTF blending the light transmitted through the aging cornea to enrich the depth of focus delivered by the optics of the IOL. Unlike the defocus curve of other MIOL, defocus curve from CTF does not have peaks and valleys. An analogy can be drawn from the early days of motion pictures: the pictures seem to be jerky motion (16-24 frames per second) due to the limited frame per second. Modern motion pictures have optimal frame per second (48-72 frames per second) to minimize the perceived flicker to the visual cortex. The brain does not have to work extra hard to choose the images that it wants to see (CTF).

First Precizon Presbyopic Investigators Meeting (Copenhagen 2016). In the middle Erik-Jan Worst and Prof. Dr Holzer, main investigator of the European Multicentre Study of the Precizon Presbyopic IOL.

Graph 1: Binocular best distance corrected defocus curve*

Graph 2: Spectacle dependancy* 2% 0%

18%

How often do you wear spectacles? Never

80%

Occasionally Quite often Very often

Graph 3: Glare scores at 3M post-op*

What does it bring to the patient and the ophthalmologist? The Precizon Presbyopic IOL delivers persistence high quality images at all distances to the patients. The near vision limit is about 40 cm. The patients readily adapts to their new vision because of the continuous range of high quality images. We call it: natural vision. When prescribing presbyopia-correcting IOLs, surgeons are faced with difficult choices to anticipate the life-style needs of their patients. For example: patients that do a lot of close work, the surgeons may prescribe an IOL with higher plus power, say +3.5 D or it should be + 4.0 D? The process to prescribe Precizon Presbyopic IOL is quite straight forward: target emmetropia for both eyes by considering the lens powers calculated from two different formulas. It prevents guess work and therefore the surgeons can be more confident to treat presbyopia patients.

Graph 4: Halo scores at 3M post-op*

How are the results so far? The results we hear from the patients and surgeons are very encouraging. Most patients achieved good functional vision at all distances. We have started a post market study to collect more data and be able to “Focus on Perfection” with this unique new IOL. *Source: Precizon Presbyopic Multi Center Study. OPH//THE//RECORD 15

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The right option for complicated cases

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16 OPH//THE//RECORD

ArtiLens

Official Training Courses

By: Yvonne Hernández

Dr Mariano Royo (4 th right) and Yvonne Hernández (5th right) together with the participants of the Official ArtiLens Training Course in Madrid (May 2017)

A famous young man said some time ago: “Ask not what your country can do for you, ask what you can do for your country”. We at OPHTEC live with this message every day. We always ask what we can do for our customers. And we do it. One of the things we do is to continue the legacy of our founder, Jan Worst: we educate surgeons why and how an iris claw IOL should be implanted. Therefore OPHTEC organizes many ArtiLens Training Courses every year: all of them official as they all have a global protocol: the surgical steps and patient selection criteria of an ARTISAN & ARTIFLEX Phakic or Aphakic IOL, and also to train the surgeons to enclavate the lens into an artificial and / or animal iris. If you have a young spirit ready to learn and be trained, and ready to know the history of the Worst family, join one of our OPHTEC Official Training Courses and enjoy what OPHTEC and all our family can show you. You can find dates & locations of the ArtiLens Training Courses on www.ophtec.com

OPH//THE//RECORD 17

Looking back:

Jan Worst’s ‘Appropriate Technology’ By: Anneke Worst

Prof. Dr J.G.F. Worst

Over the last decades, cataract surgery has undergone many changes, particularly with the arrival of the phaco. This produced major problems in developing countries, as they became extremely dependent on donations. This inspired Jan Worst to start looking for methods that could reduce the costs for developing countries. He developed ways to produce cheap, but extremely sharp suture needles and knives, various surgical instruments and tools himself. He had the technique drawn up, filled a fishing box with basic materials and set up a system to use the techniques he developed in places where they were needed. In 1980 this led to the formation of ITIR (Intermediate Technology Information Ring). Its newsletters were distributed to more than 600 ophthalmologists and employees in ophthalmology clinics in Africa, India and Pakistan. With those ITIR newsletters, ophthalmologists were informed of the possibility to make the required products with locally available affordable material. The products needed to be easy to manufacture and needed to be sterilised properly too. Over the years, 34 different newsletters were sent out, each of them containing valuable information. In 1996, the newsletters were bundled and published in the form of a book under the name Appropriate Technology in Ophthalmology (ITIR publication).

>> At the time, Jan Worst created an instruction film for the

making of these instruments. You can view this film at YouTube.com/Ophtecbv (playlist: Historical videos).

We show you a few examples of the methods devised by Jan Worst to manufacture sharp micro knives and fine cornea scleral suture needles that were made with special bent pincers and produced enormous savings in all those clinics in developing countries. >>

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Microsurgical Needle & suture manufacturing By: J.G.F. Worst; N. Aponno | Drawings: Wim Velt

This chapter describes a do-it-yourself method to needle manufacturing under less privileged conditions than in ophthalmic hospitals in America and Europe. Equipment: a pair of prefabricated needle bending pliers, a pair of round tipped pliers, a needle holder, a 30 gauge injection needle, a bobbin with 50 mu soft stainless steel thread (or an other suturing material).

• The needle is broken off by multiple to-an-fro bending movements over a small angle, while grasping it with a needle holder. Note: do not bend over a large angle, otherwise a sharp burr will be formed which cuts off virgin silk sutures! • The broken off cone is slipped backwards over the suture.

• Straighten 25 cm soft stainless steel (or other) suture from the bobbin with the needle holder. Cut the straightened part of the suture of the bobbin. • Pass the straightened suture through the lumen of the needle, until the end disappears just inside the tip.

• One may now break off the needle a second time. This results in an ‘identification tag’. Compress the tag with the round tipped pliers.

• The 30 g needle is placed between the jaws of the needle bending pliers. The bevel of the needle tip should face the concave female side of the jaw.

• In case of a stainless steel suture: stretch it before use, to remove any kinks.

• The needle is compressed with the pliers. During compression, some counter pressure must be exerted on the needle in order to prevent it from slipping. Note that the rear part of the needle remains open.

Manufacturing ophthalmic surgical knives By: J.G.F. Worst; N. Aponno | Drawings: Wim Velt

• After bending, the needle is removed carefully from the pliers. Note: Take care that the tip of the needle does not touch the pliers, as this will inevitably blunt it.

Equipment: a 1.0 cc. tuberculin syringe, a 16 Gauge injection needle, 0.5 mm. steel wire, door hinge blade breaker and screw (prefabricated), non-breakable razor blades, a pair of scissors, a triangular file, a needle holder, a pair of round tipped pliers. • Position the razorblade between hinge with the edge of the blade aligned to the scratch.

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• Break the blade on hinge against table surface, with pushing and pulling movements. Result: Blade edge of 1.6 mm.

Preparation of the blade holder: • File a notch on the 16 Gauge needle, with a triangular file. • Break off the tip of the needle.

Fixation of the blade sliver: • Push the blade into the needle. Keep the sharp edge directed away from yourself to protect the sharp edge. • The blade is pushed deep into the needle and will fixate itself automatically. The blade should be held at a short distance from the needle when pushing it in, otherwise it will bend. • Cutting off the blade with high quality scissors (the cutting edges of the scissor should be about 90˚). Start cutting from the sharp edge of the razorblade, otherwise the tip will bend.

• Blunting the anterior part of the broken off needle. • Reaming the inside of the needle. The tip of the triangular file is used for this purpose. • Flattening the end of the needle (using the pair of flat tipped pliers), with 0.5 mm. wire inside cannula.

• Use the cut-off needle cover for protection of the blade (e.g. during sterilization or storage).

ARTISAN Ambassador 2016 Dr Matteo Forlini, (Institute of Ophthalmology, Academic Hospital Parma, Italy) received the ‘Artisan Ambassador Award’ from OPHTEC Director Erik-Jan Worst at the ESCRS conference in Copenhagen. Matteo received the award because he used the Artisan aphakia lens in an unusual manner in complex surgery and traumatology. In his speech, Erik-Jan also referred to Matteo’s father, Cesare Forlini, one of the early Artisan users who made a significant contribution to the promotion of the lens in Italy. A presentation about the Artisan Aphakia lens by Matteo Forlini is available on our YouTube channel: https://youtu.be/FVfzUgR4bNI

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Special Cases Artisan Aphakia 4.4/7.5 | +40.0D | Patient MJ | 46 yo In our series “Special cases” a contribution of Dr Mariano Royo from Spain (Hospital San Rafael & Instituto Oftalmologico, Madrid). Dr Royo implanted a small Artisan Aphakia IOL + 40 D (4.4 / 7.5) in a microphthalmic eye and a custom made Trimax IOL +48.5 D in the fellow eye of a 46 year old woman. He achieved great results.

May 2009 • Woman 46 years old; OS Rx (spectacle) +14.0D 1st surgery: pars plana vitrectomy + lensectomy preserving anterior capsula. Surgeon: Dr Carlos Mateo, retina surgeon from IMO, Barcelona

July 2010 • Calculation IOL by OPHTEC BV TrimaX Patient Design IOL +48.5D implanted in ciliary sulcus. Surgeon: Dr Mariano Royo Post op refraction -1.25 @ 155º

February 2016 • OD Rx (spectacle) +16.0 x -0,5@140º April 2016 • Surgery: VPP posterior vitrectomy + intracapsular (very weak zonula) lensectomy Surgeon: Dr Carlos Mateo, retina surgeon from IMO, Barcelona.

October 2016 • Implantation of Artisan Aphakia Calculation IOL by Ophtec BV • Artisan Aphakia Patient Design Optic diameter 4.4 mm, Overall diameter 7.5 mm, +40.0D Surgeon: Dr Mariano Royo

10 days Post op; Rx = +1.50@130º OPH//THE//RECORD 21

Ginginha

Ginginha is a sweet cherry liqueur that originated in Lisbon. A very old, small Ginginha bar is the traditional home of the drink. The bar provides visitor the opportunity to taste this wonderfully strong and sweet alcoholic drink. You can find this little bar next to the National Theater at the Praça do Rossio (Rossio square). You ask anybody where Ginginha is and everybody will tell you (standing with your back to the theatre it is on your left side). You can drink it with (with = ‘com’ and without = ’sem’) fruit.

Pastel de Belém

You MUST go to Pastel de Belém to taste this famous pastry. Among the 50 best things to eat worldwide, the Pastéis de Belém were listed in 15th place by The Observer some years ago: “Creamy, flaky custard tarts - served warm with cinnamon - are one of Portugal’s great culinary gifts to the world.” The original recipe for the Pastéis de Belém is monastic and comes from the Mosteiro dos Jerónimos, the grand 16th century Hieronymites’ monastery located in Belém. You can find the bakery next to the Monastery in Belem. You can’t miss it. (Rua de Belém nº 84 a 92, 1300 - 085 Lisbon).

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Mercado da Ribeira (Time Out Market)

Traditional market and food court in Lisbon. You can find it near the river. It is a fashionable place to taste chef’s delicacies. You mustn’t miss it. Look at the beautiful tiles in the main entrance. Inside you can grab something to eat. I advise you to taste delicacies from Tarteria, Henrique Sá Pessoa, Asian Lab, Sea Me and Monte Mar. You also can buy good wines at nice and fair prices from Garrafeira Nacional and some typical Portuguese canned fish from Conserveira Nacional. (Avenida 24 de Julho - Cais do Sodré).

Ice Cream

Go to Praça do Rossio (Rossio square) and head on to Rua do Ouro. You’ll find Elevator de Santa Justa. This is a left from 1902 built by a student of Eiffel (that built the Eiffel tower in Paris). You can go up but there is always a line. If so, take the stairs next to the elevator and head left to Chiado, a fashionable district of Lisbon. You’ll find yourself in Rua do Carmo. On your right side you’ll find Santini where you can taste one of the best ice creams in Lisbon (Rua do Carmo, 9, Chiado).

Short Lisbon Tasting T(r)ips Sandra Bayan runs OPHTEC’s Portuguese subsidiary in Linda-a-Velha, a city near Lisbon, since its founding in 2012. Apart from her skills as a business woman she has great knowledge of her country’s history and culture. We asked Sandra to share some short Lisbon tasting trips. Short trips you can easily add to your busy ESCRS congress schedule. Short culinary trips to help make this Lisbon ESCRS unforgettable!

By: Sandra Bayan

Solar do Vinho do Porto

This classic bar opened in Bairro Alto in 1946 in an 18th century building facing Miradouro (view point) de São Pedro de Alcantara. You can look over all downtown towards São Jorge Castle and Tagus river. They serve over 300 labels of all kinds of Porto wine. A selection of Portuguese cheeses and hams may accompany the wines. Closed on Sunday, (Rua de São Pedro de Alcântara, 45). If you like great views: Lisbon has a lot of Roof top bars all over the city, search the internet for the ’10 best rooftop bars in Lisbon’.

Monuments: • • • • • • • •

Mosteiro dos Jeronimos (Jeronimos monastery) Praça do Império 1400 - 206 Torre de Belém (Belem tower) Av. Brasília, 1400 - 038 Padrão dos Descobrimentos (Discoveries Monument) Av. Brasília, 1400 - 038 Castelo de São Jorge (St Jorge’s Castle) R. de Santa Cruz do Castelo, 1100-129 Elevador de Santa Justa (Santa Justa Lift) R. do Ouro, 1150 - 060 Palácio Nacional da Ajuda (Ajuda’s National Palace) Largo Ajuda 1349-021 Convento do Carmo (Carmo Convent) Largo do Carmo, 1200 - 092 Panteão Nacional (National Pantheon) Campo de Santa Clara, 1100 - 471

Spots: Fresh fish and seafood

If you want to taste fresh fish and seafood the Portuguese way, there are a lot of places you can go. But NEVER eat in a place where you only find tourists. Look for places with local people. Always ask them to give you fresh fish, the same fresh fish they give to local people. And, don’t forget that there is no fresh fish on Mondays as fishermen don’t go out on Sundays!

• • •

Praça (square) do Rossio with our national theatre, Teatro D. Maria Praça dos Restauradores with the beautiful train station Praça do Comércio or commonly known as Terreiro do Paço, one of the most beautiful squares in Lisbon. Here it’s possible to see the square from Rua Augusta Arch.

Enjoy!

OPHTEC | Cataract Surgery

Treat astigmatism with confidence P ASPHERICAL CYLINDER P PUPIL INDEPENDENCE 1) Precizon Toric is part of OPHTEC’s

P ENHANCED TOLERANCE TO MISALIGNMENT 2) P PROVEN STABILITY 3) 1) Bench study Kim MJ, Yoo YS, Joo CK, Yoon G; (J Cataract Refractive Surg. 2015;41(10:2274-2282)) 2) Data on File - study report Dr Erik Mertens, ESCRS 2014 3) Vale C, Menezes C, Firmino-Machado J, Rodrigues P, Lume M, Tenedório P, Menéres P, Brochado MC; (Clinical Ophthalmology 19, January 2016) This product is not available in the US

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