The Michael Blumenthal Award in the 2013 Video Competition went to Makoto Kishimoto,

Japan, for “New type torsional phaco tip advantages”.

Dr Kishimoto described how a close examination of the physics of ultrasound phacoemulsification inspired the design of new phaco tip that is less likely to cause disruptions of flow and scattering of lens fragments. The aim of the new design is to prevent cavitation, a phenomenon that can occur when a sudden reduction of pressure reduces the boiling point of water.

In an experiment using a piece of Gouda cheese, Dr Kishimoto was able to demonstrate how cavitation alone can generate a very strong flow. That led them to design a tip in which flow would switch from positive to negative in a way that the pressure differentials averaged out within a very short temporal frame.

Educational Sheraz Daya, UK, received First Prize in

the Educational Category for “Femtosecond deep anterior lamellar keratoplasty,” which provides a demonstration of donor and host preparation using the “modified mushroom” trephination profile created with the laser in a DALK procedure. The Second Prize went to Soosan Jacob, India, for “And the Twain shall meet: retinal and corneal convergence Descemet membrane detachment – new classification and management,” and Third Prize to Renato Ambrosio Jr, Brazil, for “Thin or thinned, thick or thickened: that is the question”.

Innovative First Prize in the Innovative Category went to Ronaldo Badaro, Brazil, for “RKology”, in which he describes a novel suturing technique that he used to even out the contours of the cornea of a patient who developed a progressive loss of spectacle corrected vision many years after undergoing radial keratotomy. Pavel Stodulka, Czech Republic, took Second

Prize for “Simultaneous laser assisted cataract surgery and silicone oil removal through laser posterior capsulotomy”. The Third Prize went to Yichieh Shiuey USA for “Femtosecond implantation of a foldable artificial cornea”.

Scientific In the Scientific Category, First Prize went to Hisaharu Suzuki, Japan, for “Temperature in the anterior chamber during phacoemulsification”. Special Cases First Prize in the Special Cases Category went to Fernando Trindade, Brazil for “Customize me”. In his video, he presents two very different cases where customised lenses brought about successful outcomes that could not have been achieved with the usual commercially available variety. The Second Prize went to Partha Biswas, India, for “Spherophakia with corneal endothelial adhesion: challenged to the limits”. Third Prize went

to Milan G J Izak, Slovakia, for “Challenging cataract surgery”.

Young Ophthalmologists Denise Wajnsztajn, Israel, received First Prize in the Young Ophthalmologists category for “Surgical approach to post-

traumatic epithelial ingrowth in visual axis area two years after LASIK surgery: a challenging case”. The Second prize in the category went to Soumya Nanaiah, India, for “Techniques of Scleral-fixated capsular tension segment implantation”.

Continuing the strong upward momentum of recent years, over 7,400 delegates from all over

the world gathered in Amsterdam, The Netherlands for the XXXI Congress of the ESCRS.

Addressing the Opening Ceremony, Peter Barry, president of the ESCRS, welcomed delegates to Amsterdam and stressed the strong links between the society and the Netherlands.

“These links between the ESCRS and Amsterdam and the Netherlands are particularly strong. It was in 1982 when Cornelius Binkhorst founded the EIIC in The Hague and I understand there were 160 delegates at that congress, some of whom are still with us today. We returned in 1995 for the 13th annual congress where the number of delegates increased to 1,100 and six years later we held the 14th annual congress in Amsterdam with 2,300 delegates. Now, 12 years on, I am delighted to

report that the number of delegates attending this congress is over 7,000,” he said.

Reflecting on his term of office, Dr Barry said that youth, education and research have been

the thematic cornerstones of his presidency.

“For young ophthalmologists we offer free membership for any three years of their training, bursaries to the annual congress and the winter meeting, and we also have the Observership grant programme which enables them to visit clinics in Europe for a period of one or two weeks,” he said.

In terms of support for research, Dr Barry highlighted initiatives such as the ESCRS PreMed study on macular oedema after cataract surgery, a new femtolaser-assisted cataract surgery study and the EUREQUO patient outcomes register which has recorded almost two million cataract surgeries in its database. An Endophthalmitis Registry has also been instituted to track patterns of bacterial breakthrough and microbial resistance, and a new 2013 version of the Endophthalmitis Guidelines has been made freely available to all delegates.

Dr Barry also emphasised the society’s ongoing commitment to supporting the excellent work of Oxfam and ORBIS in their various projects in the developing world.

ESCRS treasurer and chairman of the Netherlands Intraocular Implant Club, Rudy Nuijts, welcomed delegates to Amsterdam. “It was in 2001 when the last ESCRS meeting was organised in Amsterdam and it is my great pleasure on behalf of the Netherlands Intraocular Implant Club and the Dutch Ophthalmological Society, to welcome you to this year’s congress in this wonderful city,” he said.

Dr Nuijts outlined the rich history of the Netherlands in IOL surgery and development, citing the major contributions of Cornelius Binkhorst and Jan Worst in laying the foundations for much of the progress that was to follow in the developing field of IOL surgery.

Youth, education and research driving progress

I

Douglas Koch (left), who gave the Binkhorst Medal Lecture pictured with Peter Barry, president of the ESCRS

Innovations in technology

Makoto Kishimoto, winner of the Michael Blumenthal Award in the Video Competition (left), with Peter Barry, president of the ESCRS

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In a minority of Fuchs’ dystrophy patients, corneal clearance after Descemetorhexis without

endothelial keratoplasty is possible, said Gabriel van Rij MD in the EU Cornea Medal Lecture. However, many questions remain, including appropriate patient selection and optimal follow-up to support endothelial cell regrowth, added Dr van Rij, who is ophthalmology chair at Erasmus Medical College, Rotterdam, The Netherlands.

Dr van Rij noted that transcorneal freezing has been shown to stimulate endothelial cell migration in monkeys and to a limited extent in humans. One monkey study freezing a 7mm zone also demonstrated that ROCK inhibitors doubled cell density.

However, Fuchs also involves deposition of an extracellular matrix which persists after freezing, Dr van Rij said. Descemetorhexis removes the endothelium and any remaining matrix. He noted that inadvertent Descemetorhexis

in cataract surgery followed by spontaneous corneal clearance has been reported in the literature.

Dr van Rij reported a study his group conducted involving eight consecutive Fuchs patients scheduled for Descemet-stripping automated endothelial keratoplasty (DSAEK). They instead received

standard phaco and IOL insertion and Descemetorhexis. Descemet’s membranes were scored just outside the area of corneal guttae.

Dexamethasone was administered after surgery and tapered over several weeks, though in hindsight, this may not have been a good idea, Dr van Rij

noted. “Corticosteroids inhibit cell migration and mitosis.”

At six months’ follow-up, three patients were considered successfully treated, with best spectacle-corrected vision of 20/25 or better and a mean central corneal thickness of 554 microns and mean endothelial cell density of 458 cell per square mm, though two had corneal oedema just outside the pupillary border. A fourth patient achieved 20/60 and further corneal clearance is awaited.

The other four patients had none or almost no corneal clearance with mean best spectacle corrected vision between 20/100 and 20/400 in two. One had an epithelial defect and one a burst bullae. Three of these patients went on to uneventful DSAEK, Dr van Rij said. The two patients with good visual acuity but corneal oedema also underwent DSAEK to relieve discomfort.

One patient, though, achieved 20/25 and cell density of 657 per square mm and pachymetry of

544 microns 3.5 years after surgery with only Descemetorhexis. The cornea was initially cloudy but has remained clear since six months after surgery, Dr van Rij reported. She even saw better with the eye receiving only Descemetorhexis than with her fellow eye, which had received DSAEK and phaco two years before the experimental procedure. Further, her cell count rose and pachymetry progressively declined from 584 at six months to 559 at two years and 544 at 3.5 years. “The cornea is thinning still. The patient is very pleased and we are pleased with it.”

Viable alternative Future study of the possible genetic basis of variation in endothelial cell migration and regeneration, and the possible role of drugs may also help make Descemetorhexis a viable alternative to lamellar corneal transplants with its complexity, supply problems and related risk of rejection. “Right now we mostly do endothelial keratoplasty. In the future we will prevent disease progression through gene therapy or SFN, delaying the need for surgery,” Dr van Rij said.

EuCornea may be a young society in comparison to some of the older, more established

ophthalmological societies, but in four short years it has made a major impact and there are exciting plans for its future development.

José Güell MD has been a driving force in the promotion and exposition of corneal research and surgery, in addition to his pioneering work in refractive surgery. Four years ago he helped found EuCornea, the first Europe-wide organisation devoted to the treatment of corneal disease so it was fitting that Dr Güell was given the opportunity as president of EuCornea to address delegates at the 4th EuCornea Congress in Amsterdam, The Netherlands.

Speaking at the Opening Ceremony, Dr Güell said the success of EuCornea was due to

the high calibre of the scientific programme. “I am pleased to announce that this looks set to be another successful congress,” said Dr Guell. “I would like to thank all the organisers and speakers for their invaluable role in creating such a high calibre scientific programme for the 4th Congress.”

This year’s congress, which was attended by over 700 delegates, featured an excellent programme with world leaders in the field of cornea and ocular surface disease speaking across 12 symposia, six courses and 12 free paper sessions. This included a joint ESCRS/EuCornea symposium on Refractive Surgery in Risky Cornea chaired by Beatrice Cochener and Rudy Nuijts with co-chairperson Roberto Bellucci.

“At a time when we all have to choose carefully which congresses we attend, offering delegates more

than one meeting at the same time seems to be very valuable,” said Dr Güell.

Dr Güell said he was also pleased to announce that in September 2014, EuCornea will be partnered with the ESCRS and EURETINA congresses in London. “We hope that this alliance of related meetings will be highly beneficial for members and delegates from all organisations,” he said.

The Opening Ceremony was also addressed by Michel Zaal, president of the Dutch Cornea Society, and Donald Tan, president of the Asia Cornea Society and president of The Cornea Society.

Dr Güell said they were honoured to have Prof Gabriel van Rij present this year’s EuCornea Medal Lecture. Dr van Rij received the EuCornea Medal after his presentation on “The Cornea: How Many Endothelial Cells are Necessary?”

An alternative to endothelial keratoplasty?

Successful congress with excellent programme

José Güell, president of EuCornea, addresses delegates at the Opening Ceremony

EuCornea president José Güell with Gabriel van Rij, who delivered the EuCornea Medal Lecture

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EUROTIMES | Volume 18 | Issue 11

Radiotherapy has made major advances in recent years in offering a viable treatment

modality to patients with ocular tumours that were once deemed inoperable, according to Leonidas Zografos, who delivered the 2013 EURETINA Medal Lecture as part of the official Opening Ceremony at the 13th EURETINA Congress.

In a broad overview of the past, present and future of radiotherapy treatments in ocular oncology, Prof Zografos, honorary professor of ophthalmology and consultant at the Jules-Gonin Eye Hospital, Lausanne, Switzerland, told delegates that technology has come a long way since the pioneering German ophthalmologist Richard Deutschmann’s first successful treatment of uveal melanoma in 1915 with seven

episcleral applications of filtered mesothorium.

While the earliest treatment for uveal melanoma was removal of the eye, this has now been supplanted by radiotherapy as the standard of care for patients with uveal melanoma, offering preservation of an intact eye and, in many cases, preservation of visual function, said Prof Zografos.

Discussing other key moments in the history of the development of radiotherapy for ocular tumours, Prof Zografos highlighted the research of R Foster Moore, H B Stallard, and Martin and Reese, among others, in ushering in the modern treatment of ocular tumours.

While ocular brachytherapy has made major strides in recent years, there are still treatment limitations in terms of tumour height, position

and shape, said Prof Zografos.Much of Prof Zografos’ lecture

focused on the breakthrough provided by proton beam irradiation of intraocular tumours.

At present, there are more than 10 major units worldwide

performing this type of therapy, with an estimated 25,000 to 30,000 cases of uveal melanoma now performed. Over 6,000 cases have now been carried out at the Swiss treatment centres alone, said Prof Zografos.

Survival rates with this type of therapy are excellent. After 10 years, local tumour control is 98.8 per cent and eye retention probability around 95.6 per cent, he said.

While proton beam irradiation represents a step forward in the treatment of uveal melanoma, there is always scope for further progress, said Prof Zografos.

“The key challenges are the reduction of tumour-related mortality rate, the reduction of the irradiation induced side effects and the preservation of a low tumour recurrence rate,” he said.

Putting the evolution of radiotherapy in the treatment of ocular tumours over the past century into context, Prof Zografos quoted the Greek statesman and orator Demosthenes: “Bad things of the past benefit the future and this applies to our patients as well,” he said.

Retinal experts and researchers from all over the world converged on the

vibrant German port city of Hamburg for the 13th Congress of EURETINA.

At the official Opening Ceremony, Gisbert Richard MD, president of EURETINA, welcomed delegates to Hamburg for five days of stimulating exchange, scientific debate and education in the fast-moving field of retinal research.

“It is our great pleasure to welcome you to the 13th annual Congress of EURETINA in Hamburg. The success story of our society is of the kind that is probably unparalleled in European medicine. After starting in Hamburg 13 years ago with 300 attending guests, the meeting this year might be the largest retinological meeting worldwide,” he said.

Prof Richard said that while much has been achieved, there was no question of allowing the momentum to falter.

“Our task is to preserve what we have reached, to carry it forward and to develop it further, without losing sight of the unit of the whole field of ophthalmology. This is a challenge because the

general framework is rapidly changing,” he said.

Prof Richard said it was important to improve the exchange of ideas between European retinal specialists and to

give them a voice in Europe. “The progress in our subspecialty in the last few years has been immense, for example in the development of vitreoretinal surgery, the treatment of macular degeneration and many others. Other major advances are knocking on the door such as the development of the retinal chip, the application of stem cells, gene therapy and new drugs,” he said.

Education is another key priority for EURETINA, said Prof Richard. “One especially vital task is to support young talented and motivated scientists to become well-trained ophthalmologists and we achieve this by expanding the education programme and introducing new courses,” he said.

The third focus for EURETINA is a political one, said Prof Richard, noting that the society needs to back-up innovations in diagnoses and therapies in guidelines, to draw up training curricula and to harmonise at a European level.

As part of the Opening Ceremony, the EURETINA

Medal Lecture was delivered by Prof Leonidas Zografos on the topic of “Radiotherapy in Ocular Oncology.”

First prize in the EURETINA Video Competition Awards was presented to Juan B Yepez from Venezuela for his video entitled “Illuminated chopper for phacovitrectomy in PDR”.

Second prize went to Antonio Valladares Moreno from Spain for “Ahmed valve implantation associated with 23-gauge phaco-vitrectomy – placement of valve tube directly into vitreous chamber by 23-gauge sclerotomy” and third prize to Mounir Lezrek from Morocco for “Pars plana vitrectomy incidents – management and prevention”.

Musical entertainment during the Opening Ceremony was provided by the Die Hamburger Klabautermänner Shanty Choir.

Francesco Bandello, president-elect of EURETINA, brought proceedings to a close by wishing delegates a productive and stimulating meeting.

Five days of stimulating exchange at EURETINA

Evolution in radiotherapy treatments for ocular tumours

Gisbert Richard, president of EURETINA, speaking at the Opening Ceremony at the 13th EURETINA Congress

Prof Gisbert Richard, president of EURETINA; Dr Dorothee Stapelfeldt, senator; Prof Leonidas Zografos, who delivered the Medal Lecture: and Dr F Green at the presentation of the certificate for the EURETINA

Medal Lecture

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José L Güell – güell@imo.es

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A new technique for manipulating endothelial grafts onto the posterior corneal stroma of eyes undergoing Descemet’s

membrane endothelial keratoplasty (DMEK) can speed up the surgical procedure and reduce the graft detachment and partial detachment rate, said José Güell MD, Autonomous University of Barcelona, Barcelona, Spain.

“This technique allows us to significantly reduce our intraocular membrane manipulation time, independent of donor age or preservation method, and also reduces our re-bubbling rate,” Dr Güell said at Femto 2013, an international meeting on anterior segment surgery.

The new technique involves the use of bimanual infusion with inferior iridectomy and transitory 20 per cent partial tamponade with sulphur hexafluoride (SF6) gas. As in air and gas tamponades in vitreoretinal surgery, the technique requires the postoperative cooperation of the patient, who, for the first postoperative week must position the head in three different positions, 15 to 20 minutes at each position, for two hours in the morning and two hours in the afternoon.

In a study involving 15 consecutive eyes of 15 pseudo-phakic patients who underwent the new technique, mean uncorrected and best spectacle corrected visual acuities were 0.4 and 0.85, respectively at one month follow-up. That compares to respective values of 0.20 and 0.52 preoperatively.

In addition, the mean time period between the main incision closure and final membrane positioning was four minutes and 10 seconds. That compares to a mean of 10 minutes and six seconds for the classic DMEK technique at his centre, Dr Güell said. Furthermore, re-bubbling was only necessary in one case (6.6 per cent) compared to a rate of 18 per cent in eyes undergoing classical DSEK.

Advances in endothelial keratoplasty He noted that endothelial keratoplasty has undergone a steady evolution since first introduced into clinical practice at the close of the last century, with endothelial grafts becoming thinner and thinner, up to the point where now, with DMEK, the graft consists completely of

endothelium and Descemet’s membrane.All of the endothelial keratoplasty

techniques have the advantages over penetrating keratoplasty of improved tectonic strength, minimal induction of astigmatism and speedier visual recovery. However, in all except DMEK, the best-corrected visual acuity patients can achieve with endothelial grafts is limited by the reduced corneal clarity caused by a stroma-to-stroma interface.

In addition, research shows that the immune rejection rate of DMEK grafts at two year’s follow-up is only one per cent, compared to 12 per cent for DSEK and 18 per cent for penetrating keratoplasty. There are also fewer posterior corneal higher order aberrations and visual distortions associated with DMEK.

However, classical DMEK is a more difficult technique than DSAEK, and the graft tissue has a higher rate of detachment or partial detachment postoperatively, necessitation re-bubbling procedures to manipulate the graft back into place.

Dr Güell said that as he gains experience with his new technique his results have continued to improve. In 30 eyes in which he has carried out the procedure since November 2012 up to April 2013, not a single case has required re-bubbling.

“Multicentre prospective long-term studies are needed to evaluate this technique and possible future improvements in research on substances to initiate and/or stimulate cellular proliferation will definitely improve this approach,” he added.

by Roibeard O’hEineachain in Verona

New endothelial keratoplasty technique facilitates graft positioning

DMEK ADVANCES

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CORNEA

This technique allows us to significantly reduce our intraocular membrane manipulation time...

“José Güell MD