VOLUME 17 ISSUE 6 JUNE 2012

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Special Focus: Glaucoma 4 Cover story: Risk factors in pathophysiology of glaucoma explored8 New tonometers for iOP measurement on the market9 Current unmet needs and targets in glaucoma management identified10 should cataracts be removed in glaucoma patients?12 Making follow-up visits for glaucoma patients more efficient

Cataract & Refractive 14 Value versus benefit when considering femtosecond lasers for cataract surgery15 More understanding needed to efficiently treat endophthalmitis17 Advances in laser technology ensures safety of presbyLAsiK 18 Pathogenesis of presbyopia analysed24 study shows positive results for multifocal toric iOL25 Treating higher order aberrations not without restrictions26 study shows high degree of spectacle independence with iOL27 Management of vitreous loss in cataract surgery patients28 Cost a concern with femto cataract surgery

Cornea 30 Preserving the endothelium in cataract surgery31 New variation on crosslinking discussed34 Understanding visual complaints of dry eye syndrome patients35 New device helps detect early dry eye36 Combined treatment could give more predictable refractive results

Retina 38 New approach to measuring the impact of macular oedema39 Technical advances in photoreceptor replacement highlighted

Ocular 43 some risks may become more apparent with generic products 44 Live contact lens fitting session a success at annual congress

Paediatric Ophthalmology 45 Regional variation in childhood blindness in Eastern Europe apparent

News 48 Research shows corneal transplants becoming more mainstream50 iOL scaffold technique discussed52 Two innovators receive AsCRs honours52 From the Archive53 EsCRs partnership with Oxfam has helped prevent spread of disease

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June 2012 Volume 17 | Issue 6

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Features 54 Practice Development55 industry News56 Book Review57 JCRs

58 Eye on Travel59 Resident’s Diary 60 Calendar

Publisher Carol FitzpatrickExecutive Editor Colin KerrEditors sean henahan Paul McGinn

Managing Editor Caroline BrickProduction Editor Angela sweetmanSenior Designer Paddy Dunne

Assistant Designer Janice RobbCirculation Manager Angela Morrissey Contributing Editors howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon schuyler Eisele stefanie Petrou-Binder Maryalicia Post

Leigh spielberg Pippa Wysong Gearóid TuohyColour and Print Times PrintersAdvertising Sales EsCRs, Temple house, Temple Road Blackrock, Co. Dublin, ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org

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.ISSN 1393-8983

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Published byThe European Society of Cataract and Refractive Surgeons

As certified by ABC, the EuroTimes aver-age net circulation for the 11 issues distributed between 01 January 2011 and 31 December 2011 is 32,332.

by Keith Barton

in september 2011, the EsCRs held its inaugural Glaucoma Day in Vienna, in partnership with the European Glaucoma society (EGs). Following the success of that meeting, the 2nd EsCRs Glaucoma Day will be held in Milan on Friday september 7,

2012. The programme has been put together by Prof Carlo Traverso (italy), president of the EGs, Dr Fotis Topouzis (Greece) of the EGs Programme Committee, and myself.

The 2012 programme will differ in format and content from last year’s meeting. instead of focussing solely on glaucoma surgery and its various aspects, this year’s meeting will cover a wide range of topics related to glaucoma that we believe will be of broad general interest to practitioners.

The format will consist of 10 focussed discussions around key topics, including imaging, visual function, neuroprotection, iOP measurement and various aspects of surgery. Each area of focussed discussion will be guided by three brief introductory talks by experts in the respective areas and will be designed to set the scene for subsequent discussion. The names of the speakers will be announced shortly pending confirmation of their availability. We envisage that the focussed discussion format will permit much more audience participation and interaction than the standard lecture-style format.

The meeting will start with an introduction and welcome by Prof Traverso. The first sessions of the morning will focus on the sensitivity and specificity of diagnostic testing in the detection of glaucoma and glaucoma progression, followed by a discussion around the dilemma of comparing optic disc and retinal nerve fibre structure with visual function.

This will be followed after a short break with discussions on medical therapy, including the generic prescription of glaucoma medications, a topic of increasing factor in glaucoma practice. An update on neuroprotection and a discussion of iOP measurement will follow. The first of these sessions will update the audience on recent advances in the basic science of neuroprotection, stem cells and genetics. The latter session will discuss, among other things, the relative merits of the new instruments for measuring iOP.

Before lunch, the keynote lecturer Leonardo Mastropasqua, professor and chairman of the University Eye Clinic at the University of Chieti, will talk about “Trans-scleral outflow in glaucoma”. Prof Mastropasqua has a distinguished track record in glaucoma research and we are very grateful that he has kindly agreed to give the keynote lecture.

After lunch, the afternoon sessions will all be dedicated to the surgical management of glaucoma. We hope to cover a range of aspects of glaucoma surgery, from the “old chestnuts” such as cataract surgery in glaucoma and angle closure, to the new minimally invasive surgical devices and more modern cataract-related considerations in patients with glaucoma, such as multifocal iOLs.

While a number of the expert speakers will be from italy, reflecting the location and audience, we have invited a selection of speakers from across Europe. The meeting will finish with closing remarks from myself. We anticipate that the programme will be interesting and stimulating and will provide attendees with a useful update on progress in glaucoma research as well as practical advice on management of glaucoma in everyday practice.

EUROTIMES | Volume 17 | Issue 6

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Editorial

2ND EScrS GlaUcOMa DaYUpdate on progress in glaucoma research and practical advice on management of glaucoma

José Güell

Clive Peckar

Emanuel RosenChairman

ESCRS Publications Committee

Ioannis Pallikaris

Paul Rosen

Medical Editors

InternationalEditorial Board

EUROTIMESESC

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Noel Alpins AUSTRALIA

Bekir Aslan TURKEY

Bill Aylward UK

Peter Barry IRELAND

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

Rudy Nuijts THE NETHERLANDS

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

Keith Barton MD, FRCP, FRCS, is co-director, with Prof Carlo Traverso and Fotis Topouzis, of the 2nd ESCRS Glaucoma Day

KEITH BARTON

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by Roibeard O’hEineachain

BEYOND IOP

While there is a consensus that reducing intraocular pressure (iOP) in glaucoma patients can reduce the

progression of the disease, research also suggests that elevated iOP is not glaucoma’s only risk factor and may not even be the most important one in all cases.

The evidence that other factors than iOP are important in the pathophysiology of glaucomatous disease includes the observation that some glaucoma patients continue to progress despite good reductions in iOP and that, in patients with normal tension glaucoma, the disease progresses despite perfectly normal iOP. in addition, in the five-year OhTs study more than 90 per cent of patients did not develop glaucoma.

Therefore, intensive research is now under way throughout the world devoted to finding potentially modifiable risk factors other than iOP.

Neuroprotective strategies iOP reduction can prevent or slow the loss of retinal ganglion cells in eyes with glaucoma, including those with normal tension glaucoma. it therefore follows that the retinal ganglion cells in eyes with glaucomatous disease may have an increased sensitivity to iOP, said Jeffrey L Goldberg MD, PhD, associate professor of ophthalmology, Bascom Palmer Eye institute, University of Miami, Miller school of Medicine, Miami, Florida, Us.

“Formerly, glaucoma was thought of primarily as a disease of high intraocular pressure, but in recent years there has been a subtle but important shift in our understanding of the disease. We now think of glaucoma as a disease of susceptibility to insults, including intraocular pressure. so the disease isn't the outflow problem or the problem with pressure regulation up at the front of the eye. The disease fundamentally is that some people for unknown reasons are very

sensitive to some insults like pressure. At present, we don't understand the reasons for that susceptibility but we're making progress,” Dr Goldberg told EuroTimes in an interview.

There are numerous theories as to why retinal ganglion cells die in eyes with glaucoma. They range from such obvious possibilities as simple mechanical damage to the cells and hypoxia to more complex biomolecular and pathophysiological mechanisms. But all of the theories remain unproven and it is not clear if the cause of retinal ganglion cell death is the same in all cases, he said.

“We don't really understand yet how the pressure in the eye at any level translates into the insults to retinal ganglion cells that ultimately lead to their death. it could be any or all of a number of reasons, including pathways such as excitotoxicity, vascular dysregulation, hypoxia, or the cells being cut off from their target-derived trophic factors. it could be some transduction of that pressure that messes up the neuron/glial interaction in the optic nerve head or

interferes with synapse formation between the retinal ganglion cells and their partners in the retina or their partners in the brain. it could be that one patient is sensitive for one reason and another patient is sensitive for another reason,” Dr Goldberg said.

Failures and successes in clinical trials The best known clinical trial involving a proposed neuroprotective agent in glaucoma is the Phase iii memantine trial carried out by Allergan. Memantine is an NMDA glutamate receptor antagonist that has been FDA approved for the treatment of Alzheimer’s disease. The theory behind its use in glaucoma is that it could reduce glutamate excitoxicity in the optic nerve head, which is a proposed mechanism of retinal ganglion cell loss.

The international Phase iii trial involving 1,136 patients began in 1999 and concluded in 2006. Although the study showed that the progression of glaucoma was significantly lower in patients receiving the higher dose of memantine than in patients receiving the low dose of the drug,

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glaucomaSpecial Focus

New treatment strategies on the horizon which address other aspects of glaucoma’s pathophysiology

EUROTIMES | Volume 17 | Issue 6

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The disease fundamentally is that some people for unknown reasons are very sensitive to some insults like pressure. At present, we don’t understand the reasons for that susceptibility...

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Jeffrey L Goldberg MD, PhD

If you have primary vascular dysregulation you are more likely to have a disturbed autoregulation and that is why these people are at a higher risk for glaucoma

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Josef Flammer MD

there was no significant difference between the results in active treatment groups and the placebo group.

Another agent, brimonidine (Alphagan®, Allergan), is showing more promise as a neuroprotectant. it also has the advantage of already being approved for use in glaucoma patients because of its iOP-lowering properties.

in a randomised controlled trial involving patients with low-pressure glaucoma, 91 patients receiving topical brimonidine had significantly less visual field progression than 79 patients receiving timolol over a mean of 31 weeks of follow-up, despite similar reductions of iOP in both groups (Krupin et al. Am J Ophthalmol 2011 ;151:671– 681).

There are numerous theories regarding how brimonidine achieves its apparent neuroprotective effect. For example, it may enhance the function of brain-derived neurotrophic factors in the retinal ganglion cells, it may inhibit ischemia-induced release of glutamate, or it may activate the production of anti-apoptotic compounds, Dr Goldberg noted.

The prospects of brimonidine as a neuroprotectant may improve still further if it proves effective in trials where it is used in a biodegradable intravitreal implant formulation similar to that used in the Ozurdex implant, he added.

“it is unlikely that brimonidine will supplant prostaglandins as a first-line glaucoma eye drop but the Low Tension Glaucoma study Group’s data is probably strong enough to warrant using brimonidine, at a minimum, as a second agent for patients who are progressing or having difficulty despite good pressure control while receiving prostaglandins,” Dr Goldberg said.

Salvaging dysfunctional retinal ganglion cells A frequent finding of studies that have charted glaucoma progression over several years is that, in the earlier stages of the disease, visual field loss will sometimes precede detectable changes in the optic nerve head. Although this can be a result of measurement artefacts that in turn result from media opacity, patient inattention, and other neuroretinal tissues

masquerading as retinal ganglion cells, the finding may also represent retinal ganglion cells that are still alive but are dysfunctional.

“There is a lot of evidence from animal models of glaucoma and from the human disease that there is an interval between dysfunction and the actual death of the retinal ganglion cells. That suggests that, if we could intervene and give these dysfunctional cells a sort of booster shot, then we might acutely enhance function, in addition to preventing their eventual demise,” Dr Goldberg said.

One such cell-salvaging approach is the use of neurotrophic factors that could both enhance axon growth and enhance retinal ganglion cell survival. That is the rationale behind a phase i clinical trial that is currently under way in the Us involving the treatment of primary open-angle glaucoma (POAG) patients with intravitreal implants containing encapsulated cell lines expressing ciliary neurotrophic factor.

Another approach might involve the use of agents that block the inhibition of axon re-growth that normally occurs in the mature eye. such agents include antibodies to the oligodendrocyte-derived protein Nogo, and the Rho-kinase inhibitors, which also have iOP-lowering properties. Both agents are undergoing clinical evaluation for the treatment of spinal cord injury.

A third approach is to improve the function of retinal ganglion cells through electrical stimulation. One of the main hypotheses for how retinal ganglion cells die in glaucoma is that the loss of electrical activity and synaptic function sets in motion the biomolecular processes that ultimately lead to their death. Therefore, enhancing the retinal ganglion cells’ function could, in theory, yield the added benefit of improving their survival, Dr Goldberg said.

“The appreciation of glaucoma as a neurodegenerative disease has been increasing. We think that many of the neurodegenerative diseases throughout the brain and spinal cord also involve a loss of activity or synaptic function on the way to the cell’s death. if that's true in glaucoma as well, that would link glaucoma even more strongly to the pathology of other neurodegenerative diseases,” he added.

Improving ocular blood flow Among the many risk factors that research has identified for glaucoma onset and progression, one of the most significant is a low ocular perfusion pressure. Ocular perfusion pressure is estimated as blood pressure minus intraocular pressure, or better, as arterial pressure minus venous pressure. Both intraocular pressure and systemic blood pressure fluctuate over the course of 24 hours, with blood pressure generally rising in daytime hours and falling during the evening and intraocular pressure doing the reverse.

One school of thought suggests that an impaired autoregulation of ocular blood flow can play a role in the progression of glaucoma and that this impairment plays an especially important role in patients with normal tension glaucoma and in glaucoma patients who progress despite optimum iOP control. Patients with a condition called vascular dysregulation syndrome are especially prone to an impaired autoregulation, said Josef Flammer MD, professor and head, Department of Ophthalmology, University of Basel, Basel, switzerland.

“if you have primary vascular dysregulation you are more likely to have a disturbed autoregulation and that is why these people are at a higher risk for glaucoma. They are not automatically glaucomatous, the vast majority won't get glaucoma, just as the majority with iOP greater than 25 mmhg will never get glaucoma, but the risk is greater,” he told EuroTimes in an interview.

Unstable ocular blood flow can in theory contribute significantly to the retinal ganglion cell death and excavation of the optic nerve head that characterise glaucoma, he said. it can result from extreme fluctuations of iOP and from extreme

fluctuations in blood pressure. The result in either case is a fluctuation in the oxygen supply to the cells in the optic nerve head.

“We are pretty sure that in the end one major factor is oxidative stress. That is because we know that hypoxia, for example, might kill axons but does not normally kill the astrocytes in the optic nerve head. Whereas, we know that oxidative stress can damage the mitochondria, causing the optic nerve head to suffer, including the axons and therefore also the neurons they are attached to. At the same time, the oxidative stress in the first stage causes the astrocytes to produce more nitric oxide, but in the long run they also disappear because they cannot survive this oxidative stress in the long run,” Dr Flammer explained.

Weakened autoregulation may intensify the injurious effects of iOP and blood pressure fluctuations. Where a patient’s autoregulation is disturbed, even normal fluctuations of iOP and blood pressure can lead to the same kind of oxygen fluctuation as occurs with high fluctuations of iOP and blood pressure, Dr Flammer noted.

“in other words, high iOP, low blood pressure, disturbed auto regulation, they can all individually and combined lead to the same picture, namely oxidative stress,” he added.

The characteristics of patients with vascular dysregulation syndrome commonly include low blood pressure, low body mass index, cold hands and a tendency not to feel thirsty. They also have a tendency to take longer to fall asleep, are unlikely to work outdoors and are more sensitive to some systemic medication, Dr Flammer said.

he added at present he treats glaucoma patients who have very low blood pressure with salt, patients with dysregulation syndrome with magnesium and very low doses of calcium channel blockers and with

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“In other words, high IOP, low blood pressure, disturbed auto regulation, they can all individually and combined lead to the same picture, namely oxidative stress”Josef Flammer MD

EUROTIMES | Volume 17 | Issue 6

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glaucoma

Special FocusJeffrey L Goldberg – jgoldberg@med.miami.eduJosef Flammer – jflammer@uhbs.chHemin R Chin – Hemin@NEI.NIH.GOVCarlo Traverso – mc8620@mclink.it

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ginkgo. The sign he looks for as indications that the treatment is working is improved visual fields and improved regulation of ocular blood flow. if such techniques are not available the reduction of the condition’s symptoms is a good surrogate, he said.

he noted that he frequently finds that patients with vascular dysregulation syndrome who progress despite an iOP of 12 mmhg will stabilise once their dysregulation has been successfully treated, even if their iOP rises back up to 18 mmhg.

“Unfortunately, from a scientific point of view, we still lack good, big controlled studies although in my experience spanning over three decades – and i've used it in thousands of patients – i am very satisfied with the treatment. But the pharmaceutical companies will not sponsor that absolutely meaningful type of study because the agents i use cannot be patented,” Dr Flammer said.

he added that glaucoma in such patients is often only the tip of the iceberg and that their dysregulation syndrome can also result in other pathologies including migraine headaches, hearing loss and silent myocardial ischaemia and others.

“if a patient has a dysregulation he doesn’t only have a problem in his eye. i have had a number of patients with untreated dysregulation that had myocardial infarctions very early in their life or else sudden hearing loss. so while you treat the dysregulation you don’t only benefit the patient’s eyes. That is why patients often report an improved quality of life after they start their treatment,” Dr Flammer said.

New clues to glaucoma genetics since a family history of glaucoma is a risk factor for the disease it is likely that genetic factors play a role in its aetiology. however, the genetic factors involved appear to be much more complex than those that lead to colour blindness or eye colour, traits which can be linked to a single gene. instead, the genetic basis of glaucoma appears to resemble more closely diseases such as AMD and diabetes, which appear to involve the interaction of a number of different genes.

isolating the genes involved would therefore be almost impossible using classical family history analysis. however, in recent years geneticists have developed a cohort based approach called genome-wide association. studies using this approach compare the entire genome of large cohorts of patients to reveal the locations of subtle variations in nucleotide sequences on the chromosomes, called single nucleotide polymorphisms (sNPs), associated with specific traits.

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). The findings were replicated in a UK twin cohort and the Wellcome Trust Case-Control Consortium (WTCCC) cohort. Animal studies have shown that the gene plays a key role in retinal ganglion cell formation.

Another group has identified an association between glaucoma and an sNP in close proximity to the CAV1 and CAV2 genes (Thorleifsson et al, Nature Genetics 2010; 42:906–909). Both of the genes are expressed in the trabecular meshwork and retinal ganglion cells.

More recently, in the largest genome-wide association study of POAG conducted to date, a group of investigators funded by the Us National Eye institute identified two sNPs in two different chromosomes significantly associated with normal tension glaucoma and exfoliative glaucoma. Both sNPs were in the vicinity of genes associated with transforming growth factor beta (TGF-beta), a molecule that regulates cell growth and survival throughout the body and which plays an important role in the health and function of the optic nerve.

“This is the first indication that there is significant association between single

nucleotide polymorphism markers particularly on chromosome 9 and chromosome 8 with the normal tension glaucoma patients that is highly significant. But we don't yet know how much of the genetic risk that represents,” hemin R Chin PhD, associate director of ophthalmic genetics and program director, ocular genetics, National Eye institute, National institutes of health, Bethesda, Maryland, Us.

The study’s investigators analysed the complete genome of 6,633 participants, half of whom had POAG. The participants were part of two Nih-funded studies: GLAUGEN (Glaucoma Genes and Environment) and NEiGhBOR (NEi Glaucoma human genetics collaBORation), conducted at 12 sites in the Us. The findings were published in the journal PLoS Genetics, (April 26, 2012).

“in this study we used 3,000 cases and 3,000 managing controls and we were able to identify the most significant highly probable alleles. There may be many other genetic risk factors that will contribute to the disease to a smaller degree and we are now trying to get at those factors by combining forces with groups in Europe, Australia, singapore and all over the world,” Dr Chin added.

IOP reduction still essential While researchers continue to search for clues into glaucoma’s cause and ways to treat the disease, the best evidence-based approach to glaucoma therapy remains iOP reduction, said Carlo Traverso MD, University of Genoa, Genoa, italy.

“Agents that preserve visual function independently of iOP could be of great advantage so long as iOP is very low, but i don’t think there will ever be a neuroprotectant or something that works on the blood flow that will work if iOP is not lowered to an optimal level,” he told EuroTimes.

he noted for example that in the brimonidine trial, which showed an advantage of the alpha 2 adrenergic antagonist over timolol, the patients had achieved low iOP and that was an essential component of brimonidine’s neuroprotectant effect.

“in that study, the patients in the two treatment arms had well-controlled iOP – otherwise they would have been dropped from the study – and those receiving brimonidine had better optic nerve function. That doesn’t mean that iOP is irrelevant, brimonidine would not have achieved the neuroprotective effect unless it also controlled iOP,” he added.

Agents that preserve visual function independently of IOP could be of great advantage so long as IOP is very low

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Carlo Traverso MD

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There may be many other genetic risk factors that will contribute to the disease to a smaller degree and we are now trying to get at those factors by combining forces with groups in Europe... and all over the world

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Hemin R Chin PhD

Saturday, 8 SeptemberLive Surgery: Advancements in Surgical Techniques and TechnologiesGold Plenary – Milan Conference Centre

18:00 - 18:30 – Registration18:30 - 20:30 – Live Surgery Broadcast in High Defi nition

Host Surgeon: Dr. Lucio Buratto, ItalyModerator: Dr. Donald N. Serafano, USA

Sunday, 9 SeptemberNew Value Proposition: Laser Refractive Cataract Surgery and Advanced Technology IOLsSpace 1 – Milan Conference Centre

13:00 - 14:00 (lunch boxes will be provided)

Sunday, 9 SeptemberAdvancements in the Diagnosis and Treatment of Dry EyeSpace 3 – Milan Conference Centre

13:00 - 14:00 (lunch boxes will be provided)

Sunday, 9 SeptemberInnovations in Cataract and Refractive SurgeryAuditorium di Milano

18:15 - 19:00 – Registration19:00 - 20:00 – Symposium20:00 - 21:00 – Reception

Monday, 10 SeptemberImproving Predictability and Outcomes: Innovations in Glaucoma and Cataract SurgerySpace 1 – Milan Conference Centre

13:00 - 14:00 (lunch boxes will be provided)

Alcon in MilanSave the date for these symposia during the XXX Congress of the ESCRS in Milan.

© 2012 Novartis

Register Online:http://www.escrs.org/alconsatellites

EUROTIMES | Volume 17 | Issue 6

Goldmann Applanation Tonometer (GAT) has long been considered the gold standard for iOP measurement in glaucoma

management, but that privileged status is under threat thanks to a new generation of tonometric devices on the market, according to a number of presentations at the World Glaucoma Congress.

“Goldmann tonometry provided repeatable measurements that were less dependent on scleral rigidity and therefore more accurate than the schiotz tonometer that preceded it,” said Robert L stamper MD. “This allowed it to become the most commonly used tonometric technique in the world, and allowed comparability of readings. however, as several studies have now shown, the accuracy of Goldmann tonometry is seriously affected by factors such as corneal thickness, irregularity of the cornea and high astigmatism,” he said.

Dr stamper, professor of clinical ophthalmology at the University of California, san Francisco, Us, said that it is important to bear in mind that tonometry has limited use as a diagnostic tool given that only about 25 per cent of the population with intraocular pressure measurements over 35 mmhg actually have glaucoma.

“iOP is not such a good screening device even though it has been the traditional one, and the reason is clearly that false positives are frequent. Only about one per cent of people with elevated intraocular pressures per year actually develop glaucoma. And false negatives are also frequent with somewhere between 25 per cent and 50 per cent of people who ultimately develop glaucoma

recording a normal iOP on screening exam,” he said.

Dr stamper noted, however, that the importance of iOP measurement escalates dramatically when it comes to glaucoma management. “This is because we know from multiple studies that elevated iOP is a major, if not the major risk factor, for progression from ocular hypertension to glaucoma. Elevated iOP is also a major risk factor for progression of primary open angle glaucoma (POAG) and fluctuation of intraocular pressure is another known risk factor for progression of POAG,” he said.

Risk reduction The Advanced Glaucoma interventional study (AGis) showed that lowering iOP delays the visual consequences of glaucoma and reduces the risk of progression, said Dr stamper. “Therefore in chronic glaucoma it is very important to know the mean iOP, the maximum iOP, and the variability in iOP, and glaucoma management should be aimed at reducing all of those factors,” he said.

Dr stamper pointed out that the most accurate means of measuring iOP – manometry – is also unfortunately the least practical and least acceptable to patients since it involves sticking a needle directly into the eye.

Goldmann applanation tonometry, purportedly based on the imbert-Fick law which states that the force required to applanate the cornea is proportional to the iOP, is the most widely used indirect method of measuring iOP, said Dr stamper. Nevertheless, despite its ubiquity, there are a long list of factors that can impact on the

Goldmann tonometer’s accuracy including corneal thickness, corneal irregularity, astigmatism, excess or inadequate fluorescein, calibration errors, and observer bias, among others, he said.

Dynamic contour tonometry (PAsCAL, Ziemer Group), which works on the basis of contour matching instead of applanation, represents an interesting alternative to GAT, said Dr stamper.

“Dynamic contour tonometry is less dependent on corneal thickness than Goldmann devices and therefore provides more accurate readings in real-time. it can also calculate ophthalmic pulse amplitude, and no fluorescein is needed,” he said.

Dr stamper said that studies conducted by Dr Kniestedt and colleagues at the University of California have shown that dynamic contour tonometer readings are relatively independent of corneal thickness and provides the most accurate tonometric measurements in thin corneas. The device also provides accurate iOP in oedematous corneas, is relatively accurate after LAsiK, and is also independent of corneal radius of curvature, he added.

The enhanced accuracy and precision of dynamic contour tonometry compared to Goldmann tonometry was also stressed by Ted Garway-heath MD in a separate presentation.

“Accuracy is how close to the truth the measurements are, and precision is all about the repeatability of the measurements,” said Dr Garway-heath, iGA professor of ophthalmology at University College London and glaucoma theme lead at the NihR Biomedical Research Centre at Moorfields Eye hospital.

he noted that a number of published studies have shown how iOP measured by Goldmann tonometry varies with corneal thickness. “They are pretty much in agreement that for every 100 microns of cornea thickness difference there is about a 2.5 mmhg difference in measured iOP. But central corneal thickness is not the only factor of the cornea that affects the measurement accuracy. Corneal curvature,

and the material properties or stiffness of the cornea (Young’s modulus), and its viscoelastic properties, play a role as well,” he said.

Dr Garway-heath cited a study by Andreas Boehm and colleagues at the University of Dresden which showed that measurements with the Pascal DCT showed good concordance with intracameral iOP, and that corneal thickness exerted a statistically significant effect on measurements with the DCT, although the size of the effect is less than half that seen in Goldmann tonometry. Another population-based study, the Los Angeles Latino Eye study, also showed that measurements of DCT iOP are affected by corneal thickness, but to a much less degree than that seen with Goldmann applanation.

Excellent precision in another recent study carried out by Aachal Kotecha et al at Moorfields Eye hospital, the Pascal DCT showed excellent measurement precision and displayed better repeatability and reproducibility compared to the Goldmann tonometer and also the Ocular Response Analyzer (Reichert Ophthalmic instruments), said Dr Garway-heath.

Tests of another tonometric device, the icare rebound tonometer (icare Finland Oy), carried out by Martinez de la Casa et al, found that it tended to overestimate iOP compared with Goldmann applanation tonometry. Another study by Nakamura et al also demonstrated that the icare tonometer was also significantly more affected by corneal thickness than Goldmann tonometry.

summing up, Dr Garway-heath said that overall Pascal DCT and ORA measurements are less affected than Goldmann tonometry by central corneal thickness, while i-care measurements are more affected than Goldmann by corneal thickness. With respect to reproducibility, Pascal DCT measurements are as repeatable as, and more reproducible than GAT iOP measurements, while the Ocular Response Analyzer iOP measurements are less repeatable and reproducible than Goldmann iOP measurements.

Robert L Stamper – stamperr@vision.ucsf.eduTed Garway-Heath – David.Garway-Heath@moorfields.nhs.uk

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IOP cONtrOlGoldmann under pressure as new tonometers come on streamby Dermot McGrath in Paris

8 Update

glaucoma

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Practice Development

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9

EUROTIMES | Volume 17 | Issue 6

While much progress has been made in recent years in the management of glaucoma, there is still a long way to go

in addressing the significant unmet medical needs that remain in many aspects of current glaucoma care, according to Peng T Khaw MD, PhD.

“There have been a lot of advances in recent years but there are a lot of unmet medical needs in many areas of glaucoma management such as informatics, diagnostics, pharmacology and surgical interventions, among others. The good news, however, is that there are many exciting therapies beyond eye drops that could address many of these unmet needs in the future,” Dr Khaw told delegates at the World Glaucoma Congress.

Dr Khaw, professor of ocular healing and glaucoma and director of the National institute for health Research Biomedical Research Centre at Moorfields Eye hospital and the UCL institute of Ophthalmology, London, noted that glaucoma guidelines from around the world broadly agree on the principal goals of glaucoma management.

“The optimal treatments will ideally preserve visual function which is adequate to the individual needs of the patient, with minimal side effects and which will last for the expected lifetime of the patient. This should be achieved with minimised disruption to normal activities and at a sustainable cost,” he said.

Current unmet needs and targets identified by Dr Khaw include better prediction methods using intelligent informatics and new non-invasive diagnostic imaging methods, improved iOP control, precise control of tissue scarring and flow after surgery, and a greater understanding of the role of axon-neuronal support and regeneration in glaucoma.

While there are a large variety of medical agents available for the treatment of glaucoma, clinicians need greater guidance on the optimal means of delivering more targeted treatments for each patient.

“One of the issues with medical therapies is that we use different drops, we change them, and we don’t have any accurate predictors except our own experience as to what is the optimal therapy for that patient,” said Dr Khaw.

he noted that while there is a lot of data now available from large-scale glaucoma

studies conducted over the past decade, it is not always clear how the conclusions from such trials should be applied on a daily clinical basis. “We need pooled information and a sort of informatics crystal ball to give us an idea of the risk-benefit for medical treatment and what is best for individual patients. We need more advanced informatics systems to be able to integrate this information with advanced diagnostics so that we can actually better predict what is going to happen and enable better individualisation of treatment and prognosis,” he said.

“Using technology in the future such as the “OpenEyes” software program being developed at Moorfields Eye hospital will help in this respect,” said Dr Khaw.

“This free open source software is being designed to include the challenges of glaucoma management and will enable us to guide, based on individual patient characteristics, what treatments patients are more likely to respond to, what their best prognosis is and to orient our decisions about medical and surgical therapy,” he said.

“More accurate identification of change in the patient’s disease course is also essential for more effective medical therapy,” said Dr Khaw.

“We need improved methods of detecting structural and functional change and we need to be able to relate this to meaningful functional end points including patient- related outcome and experience measures. i think increasingly glaucoma therapy is going to have to be justified to governments, care organisations and patients in terms of functional outcomes for people, not just what their iOP is,” he said.

UNMEt NEEDSMore accurate identification of change in the patient’s disease course is essential for glaucoma careby Dermot McGrath in Paris

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Update

glaucoma

Peng T Khaw – p.khaw@ucl.ac.uk

...there are many exciting therapies beyond eye drops that could address many of these unmet needs in the future

“

Peng T Khaw MD, PhD

EUROTIMES | Volume 17 | Issue 6

While modern cataract surgery is widely recognised as being one of the safest and most effective surgical

procedures available, there is growing recognition that removing a cataractous lens might also be a beneficial intervention for patients with glaucoma.

The issue, however, remains controversial and there is far from universal recognition of if and when cataract removal should be performed in patients with co-existing glaucoma. At the 2011 World Glaucoma Congress, two leading glaucoma experts presented the arguments for and against the contention that cataract surgery is the best operation for glaucoma.

“Cataract surgery is unquestionably the best glaucoma operation currently available,” Reay h Brown MD told delegates. his counterpart in the debate, Carlo E Traverso MD, said that while he believed that cataract

surgery might be beneficial in certain specific glaucoma cases, it was nevertheless prudent to recall that 'all that glitters is not gold'.

Open-angle glaucoma Outlining the case for cataract surgery in glaucoma, Dr Brown, in private practice in Atlanta, Georgia, Us, said that he considered it “a very good operation for open-angle glaucoma

(OAG) and a great operation for angle-closure glaucoma”. The clincher, he said, is the fact that cataract surgery offers a far more convincing risk-benefit profile than any other glaucoma intervention.

“The problem with glaucoma surgery, as we all know, is risk, and this is what we are trying to avoid. Looking at the glaucoma surgery risks in the tube versus trabeculectomy (TVT) study, we see that complications occurred in 39 per cent of tube eyes and 60 per cent of trabeculectomy eyes after three years. The need for reoperation or loss of two or more lines of vision occurred in 22 per cent of tube eyes and 27 per cent of trabeculectomy eyes. Furthermore, there was failure at the end of three years in 15 per cent of the tube eyes and 31 per cent of the trabeculectomy eyes, which goes up to 33 per cent failure for tube and 50 per cent for trabeculectomy in the five-year data,” he said.

By contrast, cataract surgery both improves vision and has a very minimal risk of complications, said Dr Brown, adding that many studies show that cataract surgery lowers intraocular pressure (iOP). he cited one such study, the istent (Glaukos inc.) FDA trial, which compared cataract surgery plus istent implantation to cataract surgery alone.

“Cataract surgery alone lowered pressure at 12 months by 8.4 mmhg while cataract surgery plus istent insertion lowered iOP by 8.5 mmhg. Another study by Poley, Lindstrom and samuelson also concluded that phacoemulsification by itself lowered intraocular pressure almost as effectively as any other glaucoma procedure,” he said.

Cataract surgery is also beneficial in angle-closure glaucoma, said Dr Brown.

“This study of 83 patients from my own practice showed an average reduction in pressure of 3.3 mmhg and the overall reduction was 19 per cent. But if we stratify by preoperative pressure, we find the reduction is even greater. There were 19 patients with iOPs of 20 mmhg or above and the average was reduced from 22.3 mmhg to 17.1 mmhg, a reduction of 5.2 mmhg or 23 per cent. Anti-glaucoma medications also were reduced, so the true reduction was probably more in the range of 6 or 7 mmhg,” he said.

Conclusive evidence Outlining the case against cataract surgery being the best glaucoma operation, Dr Traverso, director of the Eye Clinic at the University of Genova, italy, said that clinicians should not rush to judgment on the issue until more conclusive evidence is brought to bear. Most of the cited POAG studies used only a single preoperative iOP, were retrospective, and did not include untreated patients.

“While some studies have indeed shown primary open angle glaucoma patients with higher preoperative iOP obtaining greater average reduction after phacoemulsification, most of the reduction can be explained by what statisticians refer to as regression to the mean,” he said.

Dr Traverso said that the story is very different for angle closure glaucoma and that while phacoemulsification may indeed be helpful as a pressure-lowering measure for angle-closure patients, there is little convincing evidence to suggest the same for POAG patients.

“in primary angle closure, lens extraction seems to have a beneficial effect on iOP control and it is especially indicated in more advanced cases. interestingly there was also some evidence in the literature that iOP reduction was proportional to the degree of angle closure,” he said.

Dr Traverso warned, however, that cataract surgery is more difficult to perform in patients with glaucoma, especially those patients with small pupils, exfoliation syndrome, poor mydriasis and weak zonules.

in his view, the best procedure depends on a number of factors, including the surgeon’s experience, the available technology, the patient’s willingness to undergo the procedure, and a host of clinical factors.

“We must remember that glaucomas are not all the same. We need individual care for individual patients, and surgery tailored to the needs of the individual. While phacoemulsification techniques have greatly improved glaucoma management, clear lens extraction is indicated only in selected cases of primary angle closure glaucoma. safe small-pupil phacoemulsification requires specific skills and phaco can decrease bleb function and increase permanently the iOP in eyes with functioning filtering blebs. There is currently no evidence of any quality to suggest that lens extraction routinely represents a clinically useful and generally applicable treatment for POAG,” he concluded.

Reay H Brown – reaymary@comcast.netCarlo E Traverso – mc8620@mclink.it

cont

acts

BESt OPtIONSIs cataract surgery the best operation for glaucoma?by Dermot McGrath in Paris

10 Update

glaucoma

Th e problem with glaucoma surgery, as we all know, is risk, and this is what we are trying to avoid

“Reay H Brown MD

We must remember that glaucomas are not all the same. We need individual care for individual patients, and surgery tailored to the needs of the individual

“

Carlo E Traverso MD

Don’t miss Research update, see page 48

ESCRSGLAUCOMA DAY

Friday 7 September 2012Milan, Italy

ChairpersonsCarlo E. Traverso (ITALY), Keith Barton (UK), Fotis Topouzis (GREECE)

IOP Home Monitoring12.30 – 13.30Room: Space 2

Moderator: J. Martinez de la Casa (SPAIN)

Programme includes

Keynote Lecture

Trans scleral outflow in glaucoma L. Mastropasqua (ITALY)

Scientific programme organised by

Registration: 2200Room: Space 1

www.escrs.org

More tests for better diagnosis – patient benefit or false economy?

Morphology and function: sense and non-sense

Medical treatment: new approaches and old problems

Neuroprotection downloaded

IOP measurements and clinical relevance

Surgery revisited: procedures individualised for target IOP

Surgery complications: is there a ‘plan B’?

Surgical devices

Phacoemulsification in glaucoma

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What can an ophthalmologist do to make follow-up visits with their glaucoma patients more efficient?

“Efficiency is not just about time or simply speeding things up. Efficiency is about getting the most out of the time that you have,” said Garfield Miller MD, assistant professor of ophthalmology at the University of Ottawa Eye institute in Canada. he spoke at the recent 51st Walter Wright Annual Ophthalmology and Vision sciences symposium in Toronto. he offered five key points to improve efficiency while maintaining a good quality of care.

One is knowing the patient’s Visual Field index Plot (VFiP) before walking into the examination room.

“Take a look at this plot before you see the patient. it gives you an idea not only of when changes occur but it also shows the rate at which it’s occurring. Knowing the details ahead of time leaves more time to examine the patient,” he said.

The second point is to know the target intraocular pressure (iOP) for that individual before walking into the examination room. “it’s nice to know target iOP before seeing the patient so you’re not making decisions on the fly,” Dr Miller said.

For the third point, start the patient encounter with the examination. This differs from what some physicians do, who maybe begin with a discussion. instead, consider greeting the patient, but inform them there will be time to discuss and answer questions at the end. Then, start the exam. he suggests doing it this way because it helps the ophthalmologist avoid having to repeat things to the patient.

“People tend to remember what is said at the end of an encounter better than what was said at the beginning. Also, for a glaucoma follow-up, you’re going to be doing the same examination of the eye to check iOP, gonioscopy, look at the nerve. sometimes you can avoid the redundancy of having a long discussion before and having a long discussion afterward and repeating some of the same questions,” he said.

Fourth, have a good electronic medical record (EMR) system in place. he notes

there are a variety of options available, including ones that are web-based. A web-based version is useful in that it makes it possible to review patient information off-site or even the night before. Advantages of EMRs is that all the patient information is in one place and is a great tool to help ophthalmologists with a plan for the patient.

“EMRs and glaucoma work well because you can compare images side-by-side rather than just looking through them on a chart. You can plot iOPs and compare iOP changes to events and treatment changes. With glaucoma, often minimal drawing is required and that works well with an EMR system. Also, prescriptions, letters and the like can be done quickly at the time of the visit,” Dr Miller said.

The final point is delegating the right tasks to the right people. some things, clearly, are delegated to technicians. But with respect to some of the patient education he suggests using educational material such as pamphlets, DVDs and specific websites. “This is important, especially since there may be only one or two visits per year for most patients.”

EUROTIMES | Volume 17 | Issue 6

12 Update

glaucoma

Don’t miss Practice Development, see page 54

FOllOW-UPDelegate the right tasks to the right people to ensure effi ciency and good patient careby Pippa Wysong in Toronto

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Take a look at this plot before you see the patient. It gives you an idea not only of when changes occur but it also shows the rate at which it’s occurring. Knowing the details ahead of time leaves more time to examine the patient

“

Garfield Miller MD

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Femtosecond (Fs) lasers are widely touted as the next big thing in cataract surgery. Early studies suggest that the technology has

the potential to improve precision and predictability while making some of the most difficult steps, such as capsulorhexis, much easier. it could also lead to a revolution in related fields such as lens design as the ability to manipulate the capsule to achieve reliable placement evolves.

Recognising this potential, half of surgeons polled at the opening session of the XXiX Congress of the EsCRs said they would use the technology if cost were no object. But in the real world, the costs are high – just how high no one really knows, said EsCRs past-president and Board member Paul Rosen FRCS, FRCOphth, MBA, London. Complicating the issue further, the clinical benefits of Fs laser-assisted cataract surgery have not yet been conclusively proven.

“Whenever we have a new technology we have to do a health technology assessment,” Dr Rosen said.

Questions include: Does the technology work? Which patients benefit? What is the benefit? What is the cost? And, importantly, how does it compare to current practice?

The review progresses in two stages. First is a review of published and unpublished literature. Then comes an economic evaluation – is the intervention cost effective

compared to the current technology?Often, reality overtakes this formal

process. Looking at the re-introduction of phaco in Europe in 1990, Dr Rosen noted that questions about cost and outcomes also were asked. he began a study in 1993 to examine the issues, and found that phaco produced better outcomes and improved throughput, and was therefore more cost-effective – but in the eight years it took to publish. “Within that eight years everyone had adopted phaco. so i can see certain parallels between what happened then and what is likely to happen now.”

Perceived value Cost-effectiveness analysis depends on the benefit achieved, and that benefit is different for different people. Providers may consider profit to be a benefit, while patients seek better individual outcomes that also benefit society. individuals may choose to spend more for a procedure that produces better outcomes, but the ideal is to come up with procedures that cost less but deliver the same or better outcomes.

For policy purposes, cost effectiveness is typically judged in terms of cost per quality-adjusted life years (QALY). Currently the cost per QALY in the Us for standard cataract surgery is roughly $2,700. however, the abstract value set for this exercise may have little to do with the value individuals place on an outcome such as spectacle independence. As a result, some will be willing to pay more

at the outset for the perceived benefit of a new technology. As costs come down and the benefits become clearer, others will try it. This phenomenon drives the product life cycle, in which risk-oriented innovators go first followed by early adopters. The lifecycle reaches maturity as the majority adopts it, Dr Rosen noted.

Dr Rosen believes there are two value propositions. For private practice, value is primarily related to quality while for public practice it is closely related to quantity and cost. These disparate concerns will likely drive how and when femto technology enters practice, Dr Rosen said.

On the quality side, Fs technology allows better wound construction, better rhexis and better astigmatism management for a potentially safer and accurate outcome. But whether it actually reduces infection risk, results in a more predictable lens position, reduces capsule complications and vitreous loss or reduces ultrasound-related endothelial cell loss remains unknown.

On the cost side, early estimates are that femto cataract systems will cost about €400,000 with maintenance running about €45,000 annually and per procedure fees and consumables in the €300 to €400 range. Also, how Fs technology will affect surgical process maps, staffing and procedure time is unknown. Extra time spent on surgery adds costs through other procedures forgone, Dr Rosen noted.

Adoption scenarios Factors influencing introduction of Fs cataract surgery vary by country, Dr Rosen said. They include demographics, wealth and disposable income, awareness and patient education, policies of government and private insurers, the ability to charge co-payments, and the drive for quality and lower costs.

in the private sector, surgeons who get in early would be at an advantage. Dr Rosen estimates that breaking even over five years would require charging an extra €500 per procedure for 128 eyes per month up to €900 for 25 per month. While this is substantial, it could work. he cited an estimate by marketer sharif Mahdavi in the Us that about 30 per cent of patients would opt for femto cataract surgery at a price of an extra $1,000. The inelasticity of private demand suggests that lowering the price would not increase volume, Dr Rosen said.

in the public sector, Fs cataract surgery could be adopted if it ends up saving money, including reduced costs for complications, or can demonstrate clearly superior outcomes, Dr Rosen said. he estimates the additional cost ranging from about €700 per eye for 25 cases a month down to €342 for 100-plus cases in the UK.

“it comes down to whether people are willing to pay that difference in a publicly funded system.”

Dr Rosen noted that it is too soon to judge the costs or the benefits of Fs cataract surgery. But it is developing rapidly and purchasers should try to protect themselves with contracts that include upgrades.

“its initial presence will be in the private pay market, but i expect there will be gradual introduction in to the publicly funded healthcare market over the next five to 10 years. i believe it is a powerful technology that is here to stay.”

HErE tO StaY?cost of technology may infl uence the use of femtosecond lasers in cataract surgeryby Howard Larkin in Vienna

EUROTIMES | Volume 17 | Issue 6

Paul Rosen – phrosen@rocketmail.com

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act

14 Update

catara ct & refra ctive

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Whenever we have a new technology we have to do a health technology assessment

“Paul Rosen FRCS, FRCOphth, MBA

Much of the time it is not known why certain patients are more prone to developing pseudophakic

endophthalmitis when the vast majority of others do not, noted Terrence O’Brien MD, Bascom Palmer Eye institute, University of Miami Miller school of Medicine, at the UKisCRs XXXV Congress.

he said that a more detailed understanding of the interactions between pathogen and host is needed to more efficiently treat endophthalmitis and improve visual outcome. For example, certain pre-existing diseases such as diabetes are known to increase risk, as are a number of preoperative issues.

“so there are host factors, organism factors and perhaps most importantly, in what is least well understood, is the interaction between the host and the organism and the cause.

“There is a paradox in that there is a significant number of microbes that are positive from anterior chamber taps recovered at the time of uncomplicated cataract surgery and yet the infrequency of endophthalmitis certainly suggests the potency of the ocular immune response to control invasion by a limited number of avirulent microorganisms,” he explained.

Discussing endophthalmitis risk factors, Prof O’Brien listed systemic immunosuppression, operative preparations, intraoperative complications such as vitreous loss, perioperative factors such as surface bacteria, wound leak or inferior wound placement, and chronic blepharitis.

he cited the results from a Us study, which showed that a high percentage of routine cataract patients operated on in the community had positive cultures from both the lid and conjunctiva, especially Gram positive species.

“however, what was most alarming was that nearly 50 per cent of the Staph. epidermidis isolates were methicillin resistant, and nearly 30 per cent of staph. aureus were MRsA.”

The question that now arises is which bacteria are the principal cause of pathogenesis. Clearly there are concerns about growing antimicrobial resistance, he commented, confirming that there is concern in the Us over the inappropriate use of topical antibiotics, which is “perhaps

selecting out resistant strains which are more virulent than conventional strains of bacteria”.

Outlining the results of animal research, he said S. epidermidis tends to produce a mild non-cavitary response with little tissue damage, accounting for relatively good prognosis.

S. aureus is the more virulent ocular pathogen with the putative virulence factors being adhesions, cytolytic toxins, and proteolytic enzymes that are controlled by a system of global transcriptional regulators called staphylococcal accessory regulator (sar) and accessory gene regulator (agr).

Prof O’Brien said further research has shown that globally regulated toxins, particularly the alpha-toxin, are key virulence factors in s. aureus endophthalmitis.

“Thus perhaps if we could arrest s. aureus toxin production by inactivating the global regulatory systems during the early stages of infection this may be a more viable therapy option than simply targeting the individual toxins alone.”

he concluded that successful endophthalmitis treatment is dependent on the rapid and aggressive recognition of the bacteria and referral for diagnosis and treatment, but treatment and outcomes will improve in the future if a more detailed understanding of the interactions between the pathogen and the host is achieved.

15

EUROTIMES | Volume 17 | Issue 6

Terrence O’Brien – tobrien@med.miami.edu

contactwww.oculus.de

Relying on Threshold Noiseless Trend (TNT) for effi cient progression analysis

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rISK FactOrSMore information needed on endophthalmitis pathogen and host interactionsby Priscilla Lynch in Southport

Update

catara ct & refra ctive

“So there are host factors, organism factors and perhaps most importantly, in what is least well understood, is the interaction between the host and the organism and the cause”

PRACTICE DEVELOPMENT WEEKEND

Practice Development

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Register online: www.escrs.org/practice-development/dublin2012/

FRIDAY 5 OCTOBER

Building Refractive PracticesKris Morrill, Medeuronet, FranceArthur Cummings, Wellington Eye Clinic, Ireland

Refractive outcomes Communication to patients and sta� Public relations to the community and referral network Valuing procedures and pricing

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Practice Development MasterclassStrategies and Tactics for a Successful PracticeKeith Willey, London Business School, UK

Strategies and tactics for a successful practice Planning for a successful future Commercial judgment Sharing success and failure

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Determine social media’s purpose in your business Speak with your target audience e� ectively Generate consistently valuable content Engage your community appropriately

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17

EUROTIMES | Volume 17 | Issue 6

Ongoing advances in excimer laser technology and the use of increasingly sophisticated ablation profiles makes

presbyLAsiK a safe and effective alternative for the surgical correction of presbyopia, Gustavo Tamayo MD told delegates attending the World Ophthalmology Congress.

“We are making advances all the time and are learning how to customise our presbyLAsiK treatments to ensure optimal outcomes for our presbyopic patients,” he told attendees.

Dr Tamayo emphasised that a greater appreciation of the effect of both positive and negative spherical aberrations induced in the cornea by a variety of presbyopic treatments – whether laser-induced, intrastromal inlays or multifocal iOLs – would ultimately enable surgeons to fine-tune their refractive outcomes according to the individual needs of the patient.

“Presbyopic treatments based on the creation of positive and negative spherical aberrations may be the future that guides us to find the best correction for every patient. We need to know more about the interaction of these aberrations in order to define the best treatment for each case and deliver optimal vision at all distances.”

Dr Tamayo noted that wavefront analysis of the multifocal corneas in presbyLAsiK has shown that the aberrations produced with excimer laser are similar to those created by corneal inlays and multifocal lenses.

A clear advantage of presbyLAsiK is the fact that the complication rate is low, said Dr Tamayo, and because it is not an intraocular procedure there is no risk of complications that do arise resulting in any permanent visual damage. There is also the reassurance of knowing that the procedure is reversible and that wavefront-guided ablation can be used to erase the multifocality of the cornea and return it to its previous state if required. Another bonus is that presbyLAsiK is repeatable, once the cornea’s biomechanical properties allow for a further enhancement, he said.

To illustrate its utility, Dr Tamayo showed a number of different ablation profiles for myopic and hyperopic patients and explained that delivering optimal visual outcomes depends on finding the

right balance of negative and positive spherical aberrations induced by the treatment.

“Multifocality has traditionally been defined as a topographic term meaning multiple and different powers on the surface of the cornea, but it can also be applied to wavefront maps based on the appearance of new negative spherical aberration or a decrease in positive spherical aberration. We need to see these different dioptric powers reflected in the aberrations that are mapped for the cornea, and we also need to see in a presbyopic treatment the combination of both positive and negative spherical aberrations. i am convinced that the right combination gives us the best results,” he said.

in response to a question concerning the long-term stability and follow-up of presbyLAsiK patients, Dr Tamayo said that he has been performing the procedure since 2001 and had experienced very high patient satisfaction levels.

“There is, of course, some regression of the effect over time. The correction of presbyopia is usually very good in the cornea but it is temporary and the procedure either needs to be enhanced after several years, or you need to decide on another option,” he concluded.

MUltIFOcal laSIKFine-tuning spherical aberrations for optimal presbyopic outcomesby Dermot McGrath in Abu Dhabi

Gustavo Tamayo – gtvotmy@telecorp.net

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The Ziemer FEMTO LDV Z Models are FDA cleared and CE marked and available for immediate delivery. For some countries, availability may be restricted due to local regulatory requirements; please contact Ziemer for details. The creation of a corneal pocket is part of a presbyopia intervention. Availability of related corneal inlays and implants according to policy of the individual manufacturers and regulatory status in the individual countries. Cataract procedures with the FEMTO LDV Z2, Z4 and Z6 models are not cleared in the United States and in all other countries. An upgrade possibility for these devices is planned once cataract options are available and cleared by the responsible regulatory bodies.

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Update

catara ct & refra ctive

We need to see these diff erent dioptric powers refl ected in the aberrations that are mapped for the cornea, and we also need to see in a presbyopic treatment the combination of both positive and negative spherical aberrations

“

Gustavo Tamayo MD

PRACTICE DEVELOPMENT WEEKEND

Practice Development

ESCRS

Register online: www.escrs.org/practice-development/dublin2012/

FRIDAY 5 OCTOBER

Building Refractive PracticesKris Morrill, Medeuronet, FranceArthur Cummings, Wellington Eye Clinic, Ireland

Refractive outcomes Communication to patients and sta� Public relations to the community and referral network Valuing procedures and pricing

SATURDAY 6 OCTOBER

Practice Development MasterclassStrategies and Tactics for a Successful PracticeKeith Willey, London Business School, UK

Strategies and tactics for a successful practice Planning for a successful future Commercial judgment Sharing success and failure

SUNDAY 7 OCTOBER

Social Media In ActionRod Solar, LiveseySolar Practice Builders, UK

Determine social media’s purpose in your business Speak with your target audience e� ectively Generate consistently valuable content Engage your community appropriately

ROYAL COLLEGE OF SURGEONS IN DUBLIN, IRELANDFRIDAY 5 OCTOBER – SUNDAY 7 OCTOBERDELEGATE FEES (INCLUDING GALA DINNER IN MERRION HOTEL, DUBLIN)

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EUROTIMES | Volume 17 | Issue 6

When viewed from an engineer’s perspective, the increasing stiffness of the crystalline lens

with age can account for most of the loss of accommodation that is present in presbyopic eyes, said harvey Burd MA, DPhil, MiCE, CEng, Oxford University, Oxford, UK.

“The picture that is emerging from our preliminary data is that the change in stiffness of the lens together with the reduced movement of the ciliary body contribute about 80 per cent of the loss of accommodation in presbyopic eyes. The remaining 20 per cent of accommodation loss is related to changes in the shape and bulk of the lens,” he told the XXiX Congress of the EsCRs.

in his analysis, Dr Burd used a technique called the finite element method to separate out the contribution of each of the factors involved in the loss of accommodation with

age. Engineers use the same approach to determine if an airplane will be able to fly, before it makes its maiden flight, he noted.

“The finite element method is one method of modelling engineering systems theoretically before they're actually constructed. so we thought, why not apply the system to understanding the human eye? if an accurate model can be devised, it becomes possible to look at the effect of different parameters and quantify their role in presbyopia,” he added.

Finite element eye model Dr Burd noted that the finite element method involves a very detailed mathematical modelling of the design and materials of the subject under investigation, based on the laws of physics. in the case of an airplane, the finite element model would include such parameters as the materials used in constructing the plane, the geometry of the wing, and the power of its engines.

“The idea is that the computer program simulating the performance aggregates the behaviour of all of these elements in order to give it a prediction of the behaviour as a whole. so it's a very neat way of assessing performance. Of course, if the performance is insufficient in the simulation model, it is very easy to adjust it at a computer design stage, compared to when you're actually in the air finding a problem with the wing,” Dr Burd said.

in the case of an investigation of accommodation and presbyopia in the human eye, the main parameters in the finite element model would be the mechanical, geometric and optical properties of the components of the eye that are involved in accommodation. These parameters reflect the various molecular changes that occur with age.

The schematic eye model Dr Burd and his associates used was based on the published literature regarding the shape and anatomical configuration of structures such as the crystalline lens, the lens capsule, the zonule and the ciliary body, as well as the changes that occur in these structures with age.

They also incorporated into their model the findings obtained through the physical testing of the stiffness of the crystalline lens at different ages. Their technique was to use a specially designed rig to spin the lenses and to define the measured amount of deformation that occurred in terms of a Young’s modulus of elasticity. They based the amount of stretch they imposed on the lens on the data obtained from MRi studies. The MRi studies also show a slight decline in ciliary movement with age, which they also incorporated into the finite element model.

“What we see is that in the young lens the nucleus is very, very soft, about a 10th of the stiffness of the cortex. They both stiffen with age. Between 29 to 45 years of age the stiffness of the nucleus increases by a factor of about 20 and the cortex by a factor of about two. At about 45 years, the stiffness of the cortex and nucleus are similar and then the stiffness of the nucleus

rockets off exponentially into older age. This is a key part of understanding the presbyopia story,” he said.

Using the stiffness measurements and the literature-based eye model, Dr Burd and his associates created finite element meshes of a 29-year-old lens and a 45-year-old lens. They then created an animation of the deformations that would occur in the different lenses and in related structures in response to an accommodative stimulus. The animation showed the change in thickness and curvature was very strong in the 29-year old lens. however, the 45-year-old lens, though still deforming, has smaller thickness variations, a reduced change of curvature and a reduced ciliary body movement.

Dr Burd noted that the 29-year-old eye accommodates, on average, by about 8 D. Between 29 and 45 years of age there is loss of about 5 D of accommodation. in the finite element model, the increased stiffness of the lens alone that occurs between those ages would cause a loss of 3 D of accommodation. The reduced movement of the ciliary body, which may itself be a result of the increased lens stiffness, accounts for another dioptre of accommodation loss, he said.

“The lens contains crystalline proteins in a compact globular form. With age they denature which means they open up. The denatured proteins form cross-links, which increases the stiffness of the lens substance. As a result, the lens which was very flexible in the young eye becomes increasingly less able to accommodate as one gets older,” he added.

Dr Harvey Burd – harvey.burd@eng.ox.ac.uk

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PrESBYOPIaFinite element model confi rms lens stiff ness as principal factorby Roibeard O’hEineachain in Vienna

18 Update

catara ct & refra ctive

Do you have more photos like this?

ESCRS is setting up an archive.Contact colin@eurotimes.org if you want to share your photos,

old ESCRS programmes and other historic items with us.

Finite element mesh for a 29-year-old lens in its accommodated form

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What we see is that in the young lens the nucleus is very, very soft , about a 10th of the stiff ness of the cortex

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Harvey Burd MA, DPhil, MICE, CEng

RIDLEY MEDAL LECTURE

M. Lundström SWEDEN

Quality Outcomes in Cataract Surgery:The Real Story

Sunday 9 September

During the Opening Ceremony, 10.00 – 10.50

REFRACTIVE SURGERY DIDACTIC COURSE

Saturday 8 September

08.30 – 17.00

YOUNG OPHTHALMOLOGISTS PROGRAMME

Saturday 8 September

09.00 –16.00

Chairpersons: O. Findl AUSTRIA

S. Morselli ITALY

VIDEO SYMPOSIUM ON CHALLENGING CASES

Saturday 8 September

16.15 –17.45

Chairperson: R. Osher USA

WORKSHOP ON VISUAL OPTICS

Sunday 9 September

08.15 – 17.45

Chairpersons: I. Pallikaris GREECE

M.J. Tassignon BELGIUM

JOURNAL OF CATARACT & REFRACTIVE SURGERY SYMPOSIUM

Controversies in Cataract and Refractive Surgery 2012

Sunday 9 September

14.00 – 16.00

Chairpersons: T. Kohnen GERMANY

E. Rosen UK

COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES

Monday 10 September

08.00 – 10.00

Chairperson: P. Barry IRELAND

SURGICAL VIDEO SYMPOSIA

Monday 10 & Tuesday 11 September

14.00 – 16.15

XXX Congress OF THE ESCRS

XXX Congress OF THE ESCRS

MilanMilan

8-12 September

2012

Scientifi c Programme Courses and Wetlabs

Congress Registration Hotel Bookings

www.escrs.org

SYMPOSIA

Saturday 8 September

11.00 – 13.00

ESCRS/EUCORNEA SYMPOSIUM:CORNEAL NEOVASCULARISATION

Chairpersons: R. Nuijts THE NETHERLANDS

H. Dua UK (EUCORNEA)

11.00 P. Fagerholm SWEDEN

Mechanisms of neovascularisation

11.15 D. Said UK

Clinical aspects and assessment of corneal vascularisation

11.30 Discussion

11.40 C. Cursiefen GERMANY

The medical management of corneal vascularisation

11.55 L. Fontana ITALY

The surgical management of corneal vascularisation in ocular surface disease

12.10 Discussion

12.20 J. Güell SPAIN

Pterygium and vascularisation: current concepts and therapeutic implications

12.35 B. Seitz GERMANY

Corneal vascularisation in HSV keratopathy: implications for transplantation

12.50 Discussion

13.00 End of session

Saturday 8 September

14.00 – 16.00

ESCRS/EURETINA SYMPOSIUM: CATARACT SURGERY AND MACULAR DISEASE

Chairpersons: P. Barry IRELAND

G. Richard GERMANY (EURETINA)

14.00 S. Wolf SWITZERLAND

Does cataract surgery accelerate conversion to wet AMD?

14.15 F. Holz GERMANY

Prophylactic anti-VEGF therapy in high risk dry and wet AMD at the time of cataract surgery

14.30 Discussion

14.40 J.F. Korobelnik FRANCE Are multifocal IOLs contraindicated in AMD?

14.55 F. Cuthbertson UK

Do blue filter IOLs work?

15.10 Discussion

15.20 F. Bandello ITALY

Diagnostics and treatment in diabetic macular oedema: an update

15.35 M. Wilkins UK The intraocular telescope for AMD

15.50 Discussion

16.00 End of session

Sunday 9 September

11.00 – 13.00

ESCRS/WCPOS SYMPOSIUM:CATARACT AND REFRACTIVE SURGERY IN CHILDREN

Chairpersons: D. Epstein SWITZERLAND

K.K. Nischal USA/UK (WCPOS)

11.00 R. Kekunnaya INDIA

Do study design and surgical technique influence paediatric cataract study outcomes?

11.15 E. Wilson USA

Infant aphakia treatment study

11.30 Discussion

11.40 C. Zetterström SWEDEN Clinical factors affecting target refraction in paediatric cataract surgery

11.55 M.J. Tassignon BELGIUM Which IOLs are best in children’s eyes?

12.10 Discussion

12.20 M. O’Keefe IRELAND

Is there a role for phakic IOLs in the treatment of amblyopia?

12.35 W. Astle CANADA Can the refractive surgeon help? PRK, LASEK and LASIK in children

12.50 Discussion

13.00 End of session

Monday 10 September

11.00 – 13.00

FEMTOSECOND-ASSISTED CATARACT SURGERY: WHERE ARE WE NOW?

Chairpersons: M. Piovella ITALY

P. Rosen UK

11.00 I. Pallikaris GREECE

Imaging and capturing technology: how does it work?

11.15 J. Stevens UK

Delivery systems: how do they function?

11.30 Real world clinical results and complications F. Bucci USA (LENSAR)

S. Daya UK (B&L VICTUS)

B. Dick GERMANY (OPTIMEDICA)

Z. Nagy HUNGARY (LENSX ALCON)

12.00 Discussion

12.10 R. Lindstrom USA

When will it work in private practice: what does it take to make it work?

12.25 Discussion

12.35 R. Bellucci ITALY

When and how will it work in public practice?

12.50 Discussion

13.00 End of session

Tuesday 11 September

11.00 – 13.00

INNOVATIONS IN IOL POWER CALCULATION

Chairpersons: T. Kohnen GERMANY

R. Mencucci ITALY

11.00 G. Auffarth GERMANY

The gold standards: IOLMaster 500 and LenStar

11.15 N. Rosa ITALY

IOL power calculation in premium IOLs: part I (accommodative/multifocal)

11.30 Discussion

11.40 J. Aramberri SPAIN

IOL power calculation in premium IOLs: part II (toric)

11.55 W. Haigis GERMANY

IOL power calculation after refractive surgery

12.10 Discussion

12.20 C. Carbonara ITALY

New tools for biometry

12.35 M. Mrochen SWITZERLAND The future: customised eye models

12.50 Discussion

13.00 End of session

Wednesday 12 September

11.00 – 13.00

I AM A PERFECT CATARACT SURGEON. HOW CAN I BECOME BETTER?

Chairpersons: R. Bellucci ITALY

M. Lundström SWEDEN

11.00 D. Spalton UK

How I avoid damaging the capsule

11.15 J. Holladay USA

How I always avoid refractive surprise

11.30 Discussion

11.40 R. Nuijts THE NETHERLANDS

How I avoid inducing astigmatism

11.55 C. Lobo PORTUGAL

How I avoid cystoid macular oedema

12.10 Discussion

12.20 L. Buratto ITALY

How I always avoid patient dissatisfaction with multifocal IOLs

12.35 K. Pesudovs AUSTRALIA

I always evaluate patient benefits after cataract surgery

12.50 Discussion

13.00 End of session

CLINICAL RESEARCH SYMPOSIA

Saturday 8 September

08.30 – 10.30

IOL POWER CALCULATIONS AND EYE MODELS

Chairpersons: D. Gatinel FRANCE

T. Olsen DENMARK

A. Langenbucher GERMANY

Tomography based IOL calculation model

P.A. Piers USA Spherical and chromatic aberration of IOL

G. Auffarth GERMANY Effect of toric misalignment

S. Marcos SPAIN

Effect of tilt and decentration of IOL

G. Yoon USA Optical performance of multifocal IOLs on an optical bench

T. Olsen DENMARK

The C-constant: new concept in IOL power calculation using ray tracing

11.00 – 13.00

IATROGENIC OCULAR SURFACE DISORDERS

Chairpersons: F. Kruse GERMANY

J. Murta PORTUGAL

B. Bachmann GERMANY

The tear film in iatrogenic ocular surface disease

J. Benitez del Castillo SPAIN

Ocular surface and preservatives

S. Kinoshita JAPAN Iatrogenic ocular surface inflammation: Stevens Johnson Syndrome

A. Denoyer FRANCE

Dry eye and refractive surgery

F. Kruse GERMANY

Iatrogenic limbal stem cell deficiency: the role of limbal stem cells in corneal epithelial maintenance

D. Balasubramanian INDIA

Cultivated limbal stem cell transplantation for ocular surface reconstruction

13.30 – 15.30

IOP LOWERING DEVICES

Chairpersons: P. Sourdille FRANCE

M. Tetz GERMANY

A. Crandall USA

Overview of suprachoroidal devices

R. Stegmann SOUTH AFRICA

How does viscocanalostomy influence aqueous outflow?

P.J. Pisella FRANCE

Suprachoroidal drainage after filtering surgery

A. Mermoud SWITZERLAND

Suprachoroidal flow after glaucoma surgery using Healaflowand Aquaflow

M. Tetz GERMANY

Other new glaucoma devices

P.Y. Santiago FRANCE

Five years plus aqueous outflow pathways after deep sclerectomy: biomicroscopical aspects, OCT and ultrasound imaging

15.30 – 17.30

PROGRESS IN OCULAR CROSS-LINKING

Chairpersons: F. Malecaze FRANCE

M.J. Tassignon BELGIUM

J. Marshall UK

Rapid cross-linking: does it matter?

P. Vinciguerra ITALY

Trans-epithelial cross-linking: scientific approach

C. Koppen BELGIUM

Safety aspects of cross-linking

Y. Rabinowitz USA

How to grade clinical success of cross-linking

V. Soler FRANCE

Cross-linking via iontophoresis: a new approach

D. Stulting USA

Recent advances in the biomechanism of cross-linking

XXX Congress OF THE ESCRS

Milan

www.escrs.org

Satellite Education ProgrammeXXX Congress of the ESCRS 8–12 September 2012

Lunchtime Symposia Sunday 9 September

13.00 – 14.00

New Value Proposition: Laser Refractive Cataract Surgeryand Advanced Technology IOLs

Room: Space 1Moderator: TBC

Sponsored by

13.00 – 14.00

Advancements in the Diagnosis and Treatment of Dry Eye

Room: Space 3Moderator: TBC

Sponsored by

13.00 – 14.00

Innovations In Refractive Surgery - Latest Advancements In Excimer And Femtosecond Laser Technology

Room: Brown Hall 3Moderator: J. Güell SPAIN

Speakers:C. De Courten SWITZERLAND

J. Güell SPAIN

D. Reinstein UK

R. Wiltfang GERMANY

E. Chansue THAILAND

Sponsored by

13.00 – 14.00

Leading Technology in Refractive Surgery

Room: Amber Hall 1 & 2Moderator: TBC

Sponsored by

13.00 – 14.00

Haag-Streit Satellite Meeting

Room: Amber Hall 4Moderator: TBC

Sponsored by

13.00 – 14.00

Newest Applications of Femtosecond Laser in Eye Surgery

Room: Amber Hall 5 & 6Moderator: P. Binder USA

Sponsored by

Lunchtime SymposiaSaturday 8 September

13.00 – 14.00

Merging the Refractive and Cataract Worlds

Room: Brown Hall 3Moderator: TBC

Sponsored by

13.00 – 14.00

The New FEMTO LDV Z Models: The Power of One

Room: Blue Hall 2Moderator: TBC

Sponsored by

13.00 – 14.00

Croma Satellite Meeting

Room: Amber Hall 1 & 2Moderator: TBC

Sponsored by

13.00 – 14.00

Challenging Cataract Cases –The Simple Truths

Room: Amber Hall 3Moderator: R. Osher USA

Speakers: C. Binder GERMANY

B. Malyugin RUSSIA

Sponsored by

13.00 – 14.00

Cataract Surgery – New Options for Optimizing Outcomes

Room: Amber Hall 5 & 6Moderators: O. Findl AUSTRIA, M. Piovella ITALY

Speakers: A. Assaf EGYPT

O. Findl AUSTRIA

P. Hoffmann GERMANY

E. Marques PORTUGAL

Sponsored by

13.00 – 14.00

Comprehensive Solutions for Cataract Diagnostics with New NIDEK Products

Room: Yellow Hall 1Moderator: TBC

Sponsored by

13.00 – 14.00

Ellex Satellite Meeting

Room: Yellow Hall 2Moderator: TBC

Sponsored by

13.00 – 14.00

Breaking News in OCT: New Tools for AMD and Glaucoma Management

Room: Yellow Hall 3Moderator: G. Staurenghi ITALY

Speakers: U. Schmidt-Erfurth AUSTRIA

G. Staurenghi ITALY

A. Augustin GERMANY

A. Ferreras SPAIN

Sponsored by

Evening Symposia Saturday 8 September

18.00 – 18.30: Registration18.30 – 20.30: Live Surgery Broadcast in HD

Live Surgery: Advancements in Surgical Techniques and Technologies

Room: Gold PlenaryHost Surgeon: L. Buratto ITALY

Moderator: D.N. Serafano USA

Sponsored by

EUROTIMES™

SATELLITE EDUCATION PROGRAMME

13 00 – 14.00

The Place of Dry Eye in Ocular Surface Disease

Room: Amber Hall 8Moderator: TBC

Sponsored by

13.00 – 14.00

Topcon Refractive

Room: Yellow Hall 3Moderator: TBC

Sponsored by

Evening SymposiaMonday 10 September

18.00

Intracameral Prophylaxis of Post-Operative Endophthalmitis in Cataract Surgery

Room: Amber Hall 5 & 6Moderator: TBC

Sponsored by

18.00

Total Keratoconus SolutionKeraring User Group Meeting

Room: Amber Hall 8Moderator: TBC

Sponsored by

18.00

The Future of Customized Laser Vision Correction

Room: Amber Hall 4Moderator: S. Schallhorn USA

Speakers:J. Stevens UK

M. Khalifa EGYPT

S. Schallhorn USA

Sponsored by

Lunchtime SymposiaMonday 10 September

13.00 – 14.00

Improving Predictability and Outcomes: Innovations in Glaucoma and Cataract Surgery

Room: Space 1Moderator: TBC

Sponsored by

13.00 – 14.00

STAAR Surgical Symposium

Room: Space 4Moderator: TBC

Sponsored by

13.00 – 14.00

Bausch + Lomb Satellite Meeting

Room: Brown Hall 3Moderator: TBC

Sponsored by

13 00 – 14.00

ZEISS Satellite Meeting

Room: Amber Hall 1 & 2Moderator: TBC

Sponsored by

13 00 – 14.00

Correcting Presbyopia at the Corneal Plane

Room: Amber Hall 4Moderator: D. Gatinel FRANCE

Sponsored by

13 00 – 14.00

High Speed, High Resolution Anterior Segment Imaging

Room: Amber Hall 5 & 6Moderator: TBC

Sponsored by

13.00 – 14.00

Zeiss Satellite Meeting

Room: Blue Hall 1Moderator: TBC

Sponsored by

13.00 – 14.00

Managing Patients Post Cataract Surgery – Maximising Visual Outcomes

Room: Blue Hall 2Moderator: L. Buratto ITALY

Speakers: J. Alio SPAIN

T. Aslam UK

E. Donnenfeld USA

Sponsored by

13.00 – 14.00

EVA, A New Dimension in Cataract Technology and Other DORC Anterior Highlights

Room: Yellow Hall 1Moderator: TBC

Sponsored by

13.00 – 14.00

Love At Second Sight; How Rayner Sulcoflex® Enhances Pseudophakic Vision

Room: Yellow Hall 3Moderator: M. Packer USA

Sponsored by

Evening SymposiaSunday 9 September

18.15 – 19.00: Registration & Pre Reception19.00 – 20.00: Symposium20.00 – 21.00: Reception

Innovations in Cataractand Refractive Surgery

Venue: Auditorium di MilanoModerator: TBC

Buses will depart from 18.00 outside the congress centre

Sponsored by REGISTER ONLINEwww.escrs.org/satellites

EUROTIMES™

SATELLITE EDUCATION PROGRAMME

EUROTIMES | Volume 17 | Issue 6

implantation of a multifocal toric iOL effectively reduces postoperative dependence on glasses in cataract surgery patients with moderate pre-

existing corneal astigmatism, according to the results of a single-centre, randomised, contralateral eye controlled clinical trial reported by Vinod Gangwani MRCOphth, at the XXiX Congress of the EsCRs.

The study was undertaken at Moorfields Eye hospital, London, UK, along with Mr Vincenzo Maurino and Mr Oliver Findl. 30 patients were enrolled in the study with 1.0 to 2.5 D of astigmatism in each eye. One eye was randomised to implantation of a commercially available multifocal toric iOL (M-Flex-T, Rayner) or to receive the multifocal only version of the same iOL platform (M-Flex, Rayner) combined with limbal relaxing incisions (LRis) to correct astigmatism. The +3.0 D add version was used for all of the iOLs, and the LRis were performed using a 600-micron steel blade based on the online Donnenfeld LRi nomogram and corneal tomography

(Pentacam, Oculus). Patients and examiners were masked to the surgical procedure performed in each eye.

Analyses of data collected after three months showed that implantation of the multifocal toric iOL was associated with

better refractive and functional outcomes than multifocal iOL implantation with LRis. Eyes with the multifocal toric iOL had significantly less mean manifest residual cylinder compared with the multifocal iOL-LRi group (-0.41 ± 0.47 D vs. -0.79 ± 0.60; p = 0.002) as well as significantly greater mean reduction in astigmatism (1.43 ± 0.63 D vs. 0.89 ± 0.77 D). in addition, a higher proportion of eyes with the multifocal toric iOL had less than 0.5 D of residual cylinder than the eyes with the multifocal iOL-LRi (59 per cent vs. 47 per cent).

Distance and near UCVA outcomes were good overall, but the outcomes were slightly better in the multifocal toric iOL group compared with the multifocal iOL-LRi group for both distance logMAR UCVA (0.12 ± 0.15 vs. 0.17 ± 0.15) and near logMAR UCVA (0.41 ± 0.1 vs. 0.37 ± 0.07). however, in this relatively small study, there were only trends for the differences between groups to be statistically significant.

Patient satisfaction was investigated with a 17-item survey. The key questions investigated the need for glasses. All patients reported they did not wear glasses most of the time. Nearly all patients, 95 per cent, said they wore weak reading glasses but only if they were reading for a long time.

“it is estimated that between 15 per cent and 29 per cent of cataract patients have more than 1.0 D of pre-existing astigmatism that contraindicates implantation of a standard multifocal iOL without some additional technique for correcting cylinder. Various options can be used for astigmatic reduction. Toric iOLs are generally considered to offer better predictability, long-term stability, and safety compared with LRis, whereas LRi surgery is logistically simpler and has lower cost,” said Dr Gangwani, who was an anterior segment fellow at Moorfields when he conducted the study.

“in our study, the clinical results and patient satisfaction with the multifocal toric iOL were excellent. Although ours was a pilot study with only 30 patients, we believe these results support the use of the multifocal toric iOL. however, we believe that patients need to be properly educated and selected for this type of implant. Dysphotopsias are a reality with multifocal optics, and patients must be fully aware of the limitations of multifocal iOLs and the problems arising from dysphotopsia.”

Night vision issues were common in the study population, with 41 per cent of patients reporting glare and 35 per cent of patients reporting haloes. however, the dysphotopsias were generally mild and none of the patients were bothered by the night vision disturbances.

“None of our patients was unhappy after the surgery, but they were all well-informed preoperatively and knew what to expect.

since we only have results from follow-up to three months, we cannot comment on whether their night vision problems improved over time,” Dr Gangwani said.

The patients in the study had a mean age of 76 years (range 62 to 88 years). Mean preoperative astigmatism was 1.85 ± 0.47 D for eyes implanted with the multifocal toric iOL and 1.67 ± 0.60 D for eyes that received the multifocal iOL with LRis. The difference between eyes was not statistically significant. Mean sphere at three months after surgery was also not significantly different comparing the multifocal toric iOL and multifocal iOL-LRi groups, 0.22 ± 0.52 D vs. 0.12 ± 0.53D.

Visual acuity outcomes were also analysed for the proportion of patients achieving different levels of UCVA. At three months, 65 per cent of eyes with the multifocal toric iOL compared with 53 per cent of eyes with the multifocal iOL-LRis had distance UCVA of 6/9 or better. Near UCVA was N8 (logMAR 0.40) or better in 82 per cent of eyes with the multifocal toric iOL, but in only 53 per cent of eyes that had the multifocal iOL with LRis.

Other evaluations included evaluation of mesopic and photopic contrast sensitivity, which was found to be below normal in all eyes. however, the results were not significantly different between the two groups, and there was also no difference between groups in results of glare testing.

The study also investigated rotational stability of the multifocal toric iOL using retroillumination images obtained at the slit-lamp at one hour, one month, and three months after surgery, and the results were very good. After three months, mean absolute rotation was 2.9 ± 2.3 D.

Dr Gangwani has no financial interests in any of the products mentioned above.

Vinod Gangwani – dr_vinod_g@hotmail.com

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tOrIc IOlNew study favours multifocal toric platform over multifocal IOl with lrIsby Cheryl Guttman Krader in Vienna

24 Update

catara ct & refra ctive

Rayner multifocal toric IOL

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Toric IOLs are generally considered to off er better predictability, long-term stability, and safety compared with LRIs, whereas LRI surgery is logistically simpler and has lower cost

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Vinod Gangwani MRCOphth

EUROTIMESESC

RS ™

Türkiye

TURKISH LANGUAGE EDITION NOW ONLINE

Visit: www.eurotimesturkey.org

Update

cataract & refractive25

EUROTIMES | Volume 17 | Issue 6

in theory, wavefront-guided LAsiK can correct not only spherico-cylindrical refractive errors, but also pre-existing higher-order wavefront errors. in practice, however, higher order aberrations (hOAs) cannot

be completely eliminated due to limits on the precision of measuring and treating them.

so the question arises: for myopes with less than 0.3 microns RMs total hOAs preoperatively, does wavefront-guided ablation offer any benefit over wavefront-optimised treatment, which may be simpler and preserve tissue? Evidence suggests benefits for both approaches, though the advantages gained with wavefront-guided ablation may be difficult to measure for patients with low pre-existing hOAs, according to presenters at Refractive surgery Day at the annual meeting of the American Academy of Ophthalmology. “Wavefront-guided is important, but it has no measurable advantage in improving visual acuity for eyes that have pre-existing higher order aberrations of low value,” said Ronald R Krueger MD, Cleveland Clinic, Ohio, Us. Wavefront guided is also of no benefit over wavefront optimised in higher myopes, with more than -4.0 D correction, and total hOAs of up to 0.4 microns RMs, he added.

While wavefront-guided ablation is clearly better for patients with more hOAs, there are several reasons why it does not benefit patients with low hOAs, Dr Krueger said. For one, successfully treating low-value hOAs requires extreme precision in controlling laser beam shape, size, and power; a high repetition rate; and perfect centration and eye tracking to stay precisely on target.

Level of precision The literature suggests this level of precision is difficult to achieve, Dr Krueger said. Decentration of more than 0.8mm measurably degrades retinal image quality (Bueeler M et al. J Cataract Refract Surg 2003; 29:257-263) and cyclorotation of more than 2.0 degrees induces aberrations – an event one study found occurred in 68 per cent of cases (Ciccio et al. J Refract Surg. 2005; 21:S772-S774). A 2003 study of 1,039 eyes found mean cyclorotation of 4.03 degrees. Plus, the track record of iris-recognition rotational eye trackers isn’t the best. in a study of 275 eyes, iris recognition failed after three attempts in 10.1 per cent of cases, and iris tracking failed in 31.3 per cent (Prakash G et al. Am J Ophthalmol 2010; 149: 229-237).

studies have shown that both wavefront-guided and wavefront-optimised LAsiK induce hOAs, and there is no difference in postoperative uncorrected visual acuity or spherical equivalent for patients with less than 0.3 microns pre-existing hOAs, Dr Krueger said (Perez-Straziota CE et al. J cataract Refract Surg. 2010 Mar; 36(3) 437-41. Yu J et al. J Refract Surg. 2008 May; 24(5) 477-86. ).

Another study showed no difference in post-op wavefront aberrations in patients with less than 0.3 microns hOA pre-op, but increased induced aberrations in wavefront-optimised patients with low myopia who had more than 0.3 microns pre-op, and patients with myopia higher than -4.00 D who had more than 0.4 microns pre-op (Stonecipher et al. J Refract

Surg. 2008; 24: S424-S430). A meta-analysis of seven studies with 930 eyes found no difference in uncorrected distance or best corrected visual acuity, or mean residual spherical equivalent and no difference in post-op induction of hOAs for those with preoperative hOAs of less than 0.3 microns, but found wavefront-guided eyes had significantly less post-op induced hOAs than wavefront-optimised eyes in patients with more than 0.3 microns hOA pre-op (Feng J et al. Optom Vis Sci. Sept. 2011).

Low-value hOAs may not affect vision, and may even be beneficial, Dr Krueger said. A study of the effects of Zernicke wavefront aberrations using adaptive optics, with an electromagnetically deformable mirror, found that measureable visual acuity decreases started at 0.3 microns RMs with major decreases at 0.9 microns spherical aberration (Rocah CM et al. J Refract Surg. 2007;23: 953-959).

he pointed out that one goal of wavefront-optimised ablation is maintaining the ratio of central and peripheral corneal power to each other before and after surgery, preserving the prolate profile of the cornea, which is generally more beneficial than removing all aberrations. “We need to

preserve the asphericity of the cornea, and i especially believe wavefront-optimised should be used with higher myopes.”

steve schallhorn MD, AMO consultant and global medical director for Optical Express, believes there are advantages to wavefront-guided ablation for eyes with low-value hOAs. he cited published studies that have found higher levels of induced hOAs in wavefront-optimised eyes than wavefront-guided eyes (Padmanabhan et al. J Cataract Refract Surg 2008; 34: 389-397. Yu J et al. J Refract Surg. 2008 May; 24(5) 477-86.)

his own research also shows advantages for a wavefront-guided ablation profile. Dr schallhorn presented a study comparing matched eyes, 194 with conventional LAsiK and 185 wavefront-guided where all eyes had a pre-op hOA <=0.30 microns and a 6mm wavefront pupil. The conventional group had a mean of 0.21 microns induced total hOAs compared with 0.09 for wavefront-guided (p<0.001), (Figure 1). But spherical aberration is not the only hOA induced by LAsiK. As can be seen, other non-spherical aberration terms (hOA rms – z12) show an increase after surgery and wavefront-guided reduces the induction of these other aberrations also. it is important to keep in mind that a wavefront-optimised procedure is only ‘optimised’ to reduce the induction of spherical aberration, not the other higher order terms. similarly, a comparison of matched eyes with low pre-op hOAs, 30 that received wavefront-optimised LAsiK had mean induced hOAs of 0.012 compared with 0.08 for 64 eyes receiving wavefront-guided procedures (p<0.05), (Figure 2). A major reason for the difference between wavefront guided and wavefront optimised is less induction of other non-spherical aberration terms (hOA rms – z12).

“We found a significant difference where there was less induced hOA with wavefront-guided compared to wavefront optimised.”

Dr schallhorn also believes that the advantages of lower induced hOAs with wavefront-guided ablation may sometimes be too subtle to pick up with casual visual acuity testing. he pointed to a study by David Tanzer MD for the Us Navy showing that while both approaches yielded similar 20/20 vision in patients, 67 per cent of guided eyes achieved 20/12.5 compared with 52 per cent of optimised eyes, while 10 per cent of guided eyes achieved 20/10 compared with only two per cent of optimised.

Wavefront-guided eyes also had better mesopic contrast sensitivity, and showed significantly less induced hOAs.

Another important consideration when contemplating wavefront-guided and wavefront-optimised procedures is that most surgeons agree that patients with a ‘significant’ amount of preoperative hOA are better off having a wavefront-guided procedure. That is because wavefront-guided surgery can measure and reduce hOA in these patients, he said.

Dr schallhorn conducted an evaluation of hOA in patients seeking LAsiK. in 5,371 consecutive eyes of patients with a 6mm pupil wavefront capture, he found that most of them (57 per cent, 3,079 eyes) had hOA rms of > 0.3 microns. Even when considering a higher hOA cutoff, fully 26 per cent of eyes had a pre-op hOA >0.4 microns.

Ronald Krueger – Krueger@ccf.orgSteve Schallhorn – scschallhorn@yahoo.com

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trEatING aBBEratIONWavefront-guided laSIK is important, but its advantage in patients with low levels of preoperative HOas is debatedBy Howard Larkin in Orlando

Figure 1: Comparison of mean pre-op to post-op change of HOA after LASIK in a matched group of conventional and wavefront-guided treatments where the pre-op HOA

was <0.3 microns and every eye had a 6mm wavefront capture

Figure 2: Comparison of mean pre-op to post-op change of HOA after LASIK in a matched group of conventional and wavefront-guided treatments where every eye had a

6mm wavefront capture

We need to preserve the asphericity of the cornea, and I especially believe wavefront-optimised should be used with higher myopes

“Ronald R Krueger MD

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EUROTIMES | Volume 17 | Issue 6

A new apodised diffractive multifocal iOL called the seeLens MF (hanita) can provide cataract patients with satisfactory near, intermediate and distance visual acuity and a high degree of

spectacle independence, said Roberto Bellucci MD, hospital and University of Verona, italy.

“We think that this lens is promising, because it provided our patients with excellent visual acuity for distance and for near. intermediate vision was also surprisingly high and the contrast sensitivity results are equivalent to the marketed iOLs, and independence from glasses was achieved despite small refractive errors,” Dr Bellucci told the 16th EsCRs Winter Meeting.

The new seeLens MF is a hydrophilic acrylic aspheric iOL with apodised diffractive optics. The diameter of its optic is 6.0mm. The central 4.00mm of the optic provides a near add of +3.0 D at the lens plane, which is equivalent to about +2.4 D at the spectacle plane (Figure 1). The iOL’s total length is 13.0mm and it can be implanted using an injector with a lumen 1.8mm in diameter, Dr Bellucci noted.

“The height of the steps determines how the light converges to the diffractive focus. The lens is apodised and pupil-dependent and the height of each step decreases with increasing diameter. in this way, the apodisation helps distribute energy in favour of near vision when reading in bright light, and in favour of distance vision when driving at night,” he said.

Good vision at all distances Dr Bellucci presented the six-month results achieved in 20 eyes of 10 cataract patients who underwent implantation with the new lens. The patients in the study ranged in age from 52 to 77 years and had a mean age of 67.4 years. The iOL power of the implanted lenses ranged from +17.5 D to +23.0 D and the target refraction was emmetropia in all eyes. in addition, all eyes had normal corneas with less than 1.0 D of regular corneal astigmatism.

At six months’ follow-up, the patients’ mean binocular uncorrected visual acuity was 0.15 logMAR at 4.0 metres and 0.14 logMAR at 40.0 centimetres. Their mean distance corrected visual acuity values were 0.0 logMAR at 4.0 metres and 0.07 logMAR at 40.0 centimetres. The results for intermediate vision were also very satisfactory, Dr

Bellucci said. For example, the mean uncorrected visual acuity was 0.18 at 1.0 metre and 0.16 at 0.63 metres. similarly, the defocus curve showed that the lowest uncorrected visual acuity was always better than 0.2 logMAR (Figure 2).

“This is similar to what we are finding with most of the modern multifocal iOLs, the 0.4 logMAR at intermediate distances is a thing of the past,” he added.

Satisfactory optical quality Contrast sensitivity curves were quite good both in photopic and in mesopic conditions (Figure 3), and very similar to the curves usually obtained with good quality multifocal iOLs. This good clinical outcome is due to the high optical quality of this lens.

Optical quality in implanted eyes as determined by the optical quality assessment system (OQAs) were within normal range for monofocal hydrophilic iOLs. The mean optical scattering index was 2.5, which indicated poorer optical quality than is achieved with a monofocal iOL, which usually have a value below 1.0. Nonetheless, it compares favourably with the values generally achieved by some of the other diffractive multifocal iOLs.

similarly, the width of the point spread function curve at 50 per cent of its height was 6.8 arc min, which while again indicating a poorer optical quality than is generally achieved with monofocal lenses – which usually have corresponding values below 5.0 arc min – was nonetheless quite acceptable for a diffractive multifocal iOL, Dr Bellucci said. The same was true of the mean modulation transfer function value, which was 94 (OQAs value) compared to values of around 130 (OQAs value) with monofocal lenses.

All patients reported having good vision without correction and said they no longer used spectacles for any activities. in fact, even patients with residual refractive errors of up to 1.0 D did not appear to perceive any visual deficit

without correction. Visual complaints included vitreous floaters in one patient and photic phenomena such as small haloes around lights in a few cases, Dr Bellucci said.

he noted that studies with longer follow-up will be necessary to determine the performance of the lens with regard to posterior capsule opacification. however, he pointed out that the lens has some design features that should minimise the incidence of the complication. For example, the optic has a sharp edge around its entire circumference and the five-degree angulation of the haptic presses the optic tightly against the posterior capsule preventing epithelial cell migration. in addition, the manufacturers of the lens do not polish the optic material, because polishing has a rounding effect on square edges. The lack of polishing also maintains optical properties of the diffractive steps, he noted.

“The new seeLens MF multifocal iOL yielded good results in this preliminary six-month study. This iOL combines the advantages of the hydrophilic material with those of apodised diffractive multifocality,” Dr Bellucci said.

Roberto Bellucci – robbell@tin.it

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DIFFractIVE MUltIFOcalGood results for vision at all distances with new lens in preliminary study By Roibeard O’hEineachain in Prague

26 Update

cataract & refractive

Figure 1: The Hanita SeeLens MF multifocal IOL Figure 2: Binocular defocus curve in 10 patients implanted with the SeeLens MF multifocal IOL

Figure 3: Photopic and mesopic contrast sensitivity in 10 patients implanted with the SeeLens MF multifocal IOL

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The height of the steps determines how the light converges to the diffractive focus. The lens is apodised and pupil-dependent and the height of each step decreases with increasing diameter

“Roberto Bellucci MD

27

EUROTIMES | Volume 17 | Issue 6

Femtosecond laser-assisted cataract surgery almost completely, but not quite, eliminates posterior capsule ruptures or vitreous loss, harvey s

Uy MD, Manila, Philippines, reported at the annual meeting of the American Academy of Ophthalmology.

in his first 500 cases the rate of posterior capsular rupture and vitreous loss was less than one per cent. The majority of these cases had dense (> LOCs iii Grade 4) nuclei. however, the greater tear resistance of laser-assisted anterior capsulotomies appears to better preserve the integrity of the capsular bag, which facilitates management of vitreous loss, he noted.

Dr Uy said that femtosecond laser assistance helps prevent capsular rupture in several ways. The precision of the corneal incision helps stabilise the anterior chamber during surgery, and when fragmenting the lens the device can be programmed to leave an epinuclear plate at the back of the lens that helps prevent inadvertent contact of the posterior capsule by the phacoemulsification tip (Figure 1).

Currently, he leaves a 1.0mm gap between the deepest laser cut and the back of the capsular bag. To further reduce the need for phaco power, Dr Uy often uses a pie-cut cutting pattern that allows insertion of a pre-chopper or other similar instrument to divide the nucleus into several pieces before it is evacuated (Figure 2).

in the event of a posterior breach, the robust nature of the laser capsulotomy, whose regular edges have been shown to resist radial tears better than those seen in manual capsulorhexes, makes the capsular bag better able to withstand the stress of additional procedures to manage vitreous loss, Dr Uy said. These include anterior vitrectomy and use of tensioning devices to rescue the capsular bag. in the case of weak zonules, the capsule can be suspended with capsular hooks and can be expanded with tensioning rings.

Dr Uy presented a case in which a patient suffered a large posterior tear during lens extraction. Because the capsular bag retained some structural integrity, he was able to support the bag and implant the lens in the bag despite the posterior tear. The surgery went well and post-op the patient did well with uncorrected visual acuity of 20/25, he said.

in response to questions, Dr Uy added that there are a few complications that are unique to femtosecond cataract surgery. One is that bubbles created by the laser during capsule disruption may lead to a transient increase in intraocular pressure. Another is that proteins released by lasering the lens can block the trabecular meshwork if the interval between softening the lens and removing it is too long, also resulting in increased intraocular pressure. When large amounts of laser energy are applied, and the targets are too close to the pupil edge, papillary constriction can also occur.

incomplete capsulotomies can also occur if the patient’s head is not oriented properly to the femtosecond laser cutting plane, though this is rare and can be avoided with tilt compensation imaging software to ensure proper positioning of the laser during surgery, Dr Uy said.

Overall, laser-assisted surgery may make managing complications easier, but it is not a panacea, Dr Uy emphasised.

“Laser-assisted cataract surgery is not fool-proof. it makes vitreous loss management easier, but we still need careful planning, vigilance and good surgical principles to get successful outcomes.”

VItrEOUS lOSSlaser-assisted cataract surgery requires careful planning and good surgical principlesby Howard Larkin in Orlando

Harvey Uy – harveyuy@yahoo.com

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Update

cataract & refractive

Figure 1. Planning screen capture demonstrating space between the posterior capsule and laser fragmented area that

serves as a protective epinuclear plate for the posterior capsule

Figure 2. Real time image of a laser lens fragmented cataract using pie-cut pattern

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EUROTIMES | Volume 17 | Issue 6

Femtosecond laser offers exciting possibilities for significantly improving cataract surgery precision and outcomes, the

XXXV United Kingdom & ireland society of Cataract & Refractive surgeons (UKisCRs) Congress heard.

The ongoing discourse in the profession over the revolutionary properties of the femtosecond laser and its increasing applications versus its costs and the potential unknown risks were the focus of a lively session during the second day of the meeting. it was argued that femtosecond laser should always remain in the hands of ophthalmologists as opposed to lower grade clinicians, and that it will probably never completely replace traditional phaco surgery.

Jorge L Alió MD, PhD, instituto Oftalmológico De Alicante, spain, spoke about his pioneering work using the new technology in microincision cataract surgery.

Explaining the difference between cornea and lens femtosecond laser applications, he said the femtosecond laser pulses to the anterior capsule and crystalline lens during cataract surgery and requires different parameters from those used by femtosecond laser for corneal surgery.

specifically, the newest intraocular femtosecond laser penetrates deeper into the eye: 7.500 microns vs. 1.200 microns for those used in corneal surgery.

“This is a dramatic change and why it is so difficult to have a laser that can make corneal flaps and emulsify them at the same time. And the main difference in the different technologies is the numerical aperture (NA). it defines the focal length of the application of the laser and also the amount of energy you focus on that,” he commented.

Elaborating, Dr Alió said the larger the NA, the smaller the focal spot volume, and the smaller the energy threshold. There are two ways to increase the NA; by increasing

the lens diameter or by decreasing focal length, and in either case accuracy is vital.

Looking at the technologies currently available, he noted that in 2010 the Us FDA approved femtosecond laser technology to be used in cataract surgery, unusually ahead of Europe. There are currently four companies working with it, though with some variance in imaging – Lensx/Alcon (optical coherence tomography (OCT)), LensAR (confocal structured illumination (scheimpflug)), OptiMedica (OCT), and Technolas (OCT).

highlighting what femtosecond surgical systems are capable of, Dr Alió explained they can create corneal incisions (so far only Lensx), perform capsulotomy and photodisruption of the nucleus.

Other applications that have been investigated include lens softening (unsuccessfully), while some models (Femtec 520) may also perform refractive presbyopic surgery (intraCor).

Advanced and reliable After studying femtosecond cataract surgery for six years and visiting surgeons with direct hands-on experience in the different technologies available Dr Alió believes Alcon Lensx is the “most advanced, complete and reliable laser of all i know”. (he acknowledged that he became a member of the Medical Advisory Board of Lensx in 2010, prior to its acquisition by Alcon.)

As one of the few surgeons using the technology as this level, Dr Alió discussed his own results of femtosecond laser clear cornea incisions.

he pointed out that the design is controlled and selected by the surgeon and the programming software allows customised geometry and positioning so there is excellent dimension reproducibility. All incisions are self-sealing, the incision quality is objectively excellent and neutral for the corneal optics and there are no surprises, he added.

“Corneal incisions created using a femtosecond laser compared with those using manual blades show laser incisions are more architecturally reproducible,” he maintained.

Discussing his experience with interior capsulotomy using Lensx, Dr Alió said it is highly precise and predictable. specifically it is more accurate, metered and consistent

than traditional surgery, it avoids the risk of anterior capsular tear, and is perfectly centred which is a crucial factor for premium iOLs, he noted. it also reduces the induction of higher order aberrations.

To support his own findings, Dr Alió quoted the results of a clinical evaluation study of intraocular femtosecond laser in cataract surgery (Nagy et al, J Refract Surg. 2009; 25(12): 1053-1060), which found 100 per cent of Lensx procedures achieved an accuracy of ± 0.25mm while only 10 per cent of manual procedures achieved an accuracy of ±0.2.

Looking at femtosecond laser’s ability to perform photodisruption of the nucleus, Dr Alió said it allows the surgeon to skip sculpting and chopping steps, using patterns of cuts to soften harder cataracts and help facilitate removal of the nucleus. The technology also reduces the number of instruments used, intraocular movements and manipulation of the lens, plus by minimising the amount of phaco energy needed, it reduces the risk of capsule complications and corneal endothelial injury.

in a nutshell, the technology is a perfect fit with the new premium iOLs he told the meeting and has exciting possibilities for better precision and results in this type of surgery. he reiterated the limitations of conventional cataract surgery compared to LAsiK – the poorer visual outcomes, the limits on astigmatism and presbyopia correction, and the higher complication rates.

Expense an issue however, despite his optimism for the potential of femtosecond laser in cataract surgery, Dr Alió acknowledged the “important concerns among surgeons and administrators about how to deal with the extra expenses to be generated by femto cataract surgery”. Currently it costs over €500 per eye in his practice.

he said he remains confident, however, that the price will come down eventually and better management of the costs will make the financial condition manageable. Packages combining premium lens and premium surgery are a likely development in the next couple of years.

Jorge Alió – jlalio@vissum.com

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cOSt BENEFIt aNalYSISconcerns among surgeons and administrators about how to deal with the extra expenses to be generated by femto cataract surgeryby Priscilla Lynch in Southport

28 Update

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Corneal incisions created using a femtosecond laser compared with those using manual blades show laser incisions are more architecturally reproducible

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EUROTIMES | Volume 17 | Issue 6

30 Update

cornea

For cataract patients with endothelial disease careful surgical technique and the timing of cataract extraction are crucial to preserve endothelium and restore vision, Friedrich E Kruse MD, University

hospital Erlangen, Bavaria, Germany, told an EuCornea/EsCRs symposium at the XXiX Congress of the EsCRs.

With new techniques such as Descemet’s membrane endothelial keratoplasty (DMEK), which produces more-predictable refractive results and quicker recovery than penetrating or Descemet’s-stripping keratoplasty, combining lamellar surgery with phacoemulsification and intraocular lens (iOL) implantation has become an increasingly attractive option, he noted.

“Over the years we have experienced a great variation in our understanding of the role of the endothelium and how we are going to preserve this endothelium in cataract surgery. And now that we have lamellar surgery we are again facing a change of concepts because some of us are paying less attention to the endothelium because we just have better techniques of keratoplasty,” Prof Kruse said.

Growing knowledge since the 1950s, a great deal has been learned about how different surgical approaches affect the endothelium, much of which has implications for how surgery is done today, Prof Kruse noted.

Endothelial cell loss is related to the degree of surgical trauma (Sugar et al. Arch Ophthalmol 1978 Mar, 96:449-50), and posterior chamber phaco produces about the same loss as intracapsular extraction (Kraff et al. Arch Ophthalmol 1980 Oct; 98:1782-4). Phaco and extracapsular extraction also produce similar endothelial cell loss, in the range of 10 per cent to 20 per cent (Bourne et al. Ophthalmology 2004 Apr; 111:679-685), and loss rates are similar for phaco and small-incision manual cataract surgery, in which the nucleus is expressed with viscoelastics (Gogate et al. J Cat Ref Surg 2010 Feb; 36:247-253). incision location and size can significantly influence the outcome, Prof Kruse noted.

Results for eyes with diseased endothelium are similar, Prof Kruse said. One study found that eyes with preoperative endothelial cell density between 500 and 1000 per mm² lost about the same percentage of cells as normal control eyes, but showed no significant difference in central corneal thickness at three months (Hayashi et al. J Cat Ref Surg 2011 Aug; 37:1419-1425). Results were similar for Fuchs’ dystrophy and other non-progressive pathologies. Another study found that in eyes that have undergone penetrating keratoplasty, phaco results in about a 20 per cent loss compared with about 13 per cent for ECCE (Acar et al. J Cat Ref Surg 2011 Aug; 37:1512-1516).

“in eyes with endothelial disease, there is certainly more impact, but again it is about the same in phaco and in ECCE,” Prof Kruse said.

Implications for surgery The fragility of the diseased endothelium and the high potential for comorbidities have several implications for cataract surgery technique and timing, Prof Kruse said. For Fuchs’ dystrophy in particular, he recommended placing incisions peripherally to avoid damaging the central cornea, where endothelial damage is concentrated. A viscoelastic should be used to protect the endothelium. Following capsulorhexis, Prof Kruse advised looking for dislocation of the capsule. A lot of these patients may suffer from other pathologies like pseudoexfoliation syndrome and might need some iris retractors to hold the capsule, he explained.

With a hard nucleus, Prof Kruse recommended a peripheral approach and manually dividing the nucleus as much as possible, saving phaco for the end of the procedure. A high viscosity viscoelastic should be used to protect the endothelium, and trypan blue can help visualise the cortex for these patients. he suggested using phaco to make one groove to divide the lens. Enlarging the incision allows a very hard lens to be extracted with forceps without harming the endothelium. Viscoelastics should be used on top of the

lens to protect the endothelium during extraction, and can also be used to help express the lens.

As for timing, “the big question is: should we perform a cataract surgery or should we perform a triple,” Prof Kruse said.

With PK, many studies suggest there is no difference in terms of visual acuity, astigmatism, central refraction or variation of correction between a classic triple and phaco following PK, Prof Kruse noted. however, visual results are poor, with best-corrected vision typically in the 20/60 range, with refraction varying from -10.0 D to +10.00 D. This might argue against combining the procedures when possible, except most patients develop cataract after PK, so the triple may be easier on the patient.

substituting Descemet’s-stripping automated endothelial keratoplasty (DsAEK) for PK – the “new triple” – significantly lowers risk. But visual outcomes are still hard to predict because the lamellar stroma attached to donor tissue changes the curvature of the posterior cornea.

Prof Kruse recommended the “newest triple,” which uses DMEK. DMEK differs from DsAEK in that no lamellar stroma is removed with the donor cornea, which eliminates the hyperopic shift often seen with DsAEK. it also results in stable endothelial cell counts three months after surgery, making the combined surgery an attractive option for avoiding a second surgery for cataract patients whose endothelial disease might otherwise progress (Kruse et al. Cornea 2011; 30(5):580-587).

Prof Kruse described a step-wise procedure for reliably preparing donor tissue and inserting it using an iOL injector and air bubbles to unfold the graft and hold it on the posterior cornea. he recommended performing DMEK after normal phaco, using an iOL with plate haptic to maintain stability of the capsule, which is stressed by the placement of the graft. Removing the epithelium and using methylcellulose can help improve visibility through clouded corneas.

Visual outcomes are nearly stable at three months and improve out to six months. in 80 cases Prof Kruse examined, mean best-corrected visual acuity was better than 20/30. Many patients reach 20/20 after surgery, he said.

Friedrich Kruse – friedrich.kruse@uk-erlangen.de

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PrOtEctING DISEaSED ENDOtHElIUMcareful cataract surgery, new lamellar techniques improve resultsby Howard Larkin in Vienna

Pre DMEK surgery

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Over the years we have experienced a great variation in our understanding of the role of the endothelium and how we are going to preserve this endothelium in cataract surgery

“Friedrich E Kruse MD

Don’t miss Industry News, see page 55

31

EUROTIMES | Volume 17 | Issue 6

Ophthalmic surgeons should consider the benefits of significantly strengthening the cornea and treating keratoconus

with a new variation on crosslinking, delegates attending the United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) XXXV Annual Congress were told.

Discussing the new Avedro microwave system and crosslinking, John Marshall PhD, FRCPath, FMedSci, FRCOphth(Hon), Frost Prof of Ophthalmology, and Institute of Ophthalmology in association with Moorfields eye Hospital London, voiced his concern about the negative effect of all forms of refractive surgery on the strength of the eye.

The non-invasive, incisionless, Keraflex® procedure, performed with the Vedera® machine, thermally remodels the cornea without the removal of any tissue so the procedure induces refractive change without weakening the cornea’s biomechanical integrity, as happens with LASIK and other refractive correction procedures.

Explaining the background to the new system, Prof Marshall said he had been concerned about the loss of tissue following PRK and especially LASIK.

“And that worried me from an engineering standpoint. What worried me more was that the wound healing never actually brings those tissues back together with the previous mechanical integrity. That is the bed is stuck to the flap with fibronectin and tenascin (an extracellular matrix glycoprotein) as if it were biological glue.

“So over the years I’ve looked at the maximum dioptre rate of change per year as a function of refractive surgery, and all refractive surgery results with progress of time in a greater magnitude of dioptre change,” he commented.

Working with a number of other experts, Prof Marshall looked at a means of measuring stability and confirmed that cutting down through corneal fibres is what weakens the system, while delamination doesn’t interfere with overall strength.

“So wouldn’t it be wonderful if you could devise a system that would change the orientation of collagen without actually cutting, and the technique you use is a thermal one using microwaves,” he said.

The resulting new Avedro Vedera system

accommodates flattening or steepening of the cornea, and if coupled with crosslinking the change becomes more permanent; increasing rigidity by three to four times, in a very time-efficient fashion, Prof Marshall explained. However, all thermal processes seem to have a transitory effect and therefore a second component was needed in order to ensure longevity of the induced change.

Focussing on the second step of the procedure, Prof Marshall discussed the impact of beam profile and riboflavin shielding using the Avedro KXL treatment, an accelerated crosslinking system. Prof Marshall explained that photochemical reactions within similar time domains exhibit something called reciprocity which means that the relationship between power and time to deliver a given energy to tissue is constant. Classical systems use 3 mW power sources for 30 minutes, precisely the same energy will be delivered using a 30 mW system for three minutes.

For example, treating keratoconus a 10 minute presoak; three minutes at 30 mW/cm2, Prof Marshall said the top-hat beam of the KXL provides uniform, predictable distribution of UV energy. He also said that by using a shorter soak time very little riboflavin reaches the endothelium this removes a potential harmful complication typical of other treatment methods. He explained that, the concept of riboflavin protecting tissues is incorrect as absorption by old revile it into riboflavin is the fundamental process by which crosslinking takes place. Using the Avedro system ensures that the energy is delivered in a short time at high power with uniform energy distribution across the treatment area.

CROSSLINKINGApproach appears faster, more efficientby Priscilla Lynch in Southport

John Marshall – Eye.marshall@googlemail.com

contact

Update

CORNEA

What worried me more was that the wound healing never actually brings those tissues back together with the previous mechanical integrity

“John Marshall PhD.

FRCPath, FMedSci FRCOphth(Hon)

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New Developments in Dry EyeB.Cochener FRANCE , J. Merayo SPAIN

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OPENING CEREMONYEuCornea Medal Lecture

H. Dua UK

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Update on Keratoconus Management

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EUROTIMES | Volume 17 | Issue 6

Double-pass aberrometry performed with a commercially available platform (OQAS, Visiometrics) and specialised software shows promise as an objective method for evaluating

tear film quality and understanding the visual complaints of patients affected by dry eye syndrome (DES), said Pierre-Jean Pisella MD, PhD.

Speaking at the 2nd EuCornea Congress, Dr Pisella described the association between tear film quality and visual complaints of DES to establish the rationale for using double-pass aberrometry for dynamic analysis of the tear film. He also reported the findings from clinical studies investigating aberrometric evaluation as a diagnostic and monitoring tool for DES that showed the test result differed significantly depending on DES severity.

“This new objective technique may help us to quantify the blurry vision associated with DES and help us to detect and further understand tear film-related patient complaints, especially in individuals with moderate dry eye who may not yet present with clinical signs such as corneal surface staining. Furthermore, the measurements may be a new tool for evaluating the efficacy of new artificial tears and other treatments for DES and other ocular surface diseases,” said Dr Pisella, professor of ophthalmology, Bretonneau Hospital, University Francois Rabelais, Tours, France.

Although the definition of DES issued by the International Dry Eye Workshop in 2007 identifies symptoms of visual disturbance as a consequence of DES, there is not always good correlation between the symptoms of patients with DES and their clinical signs. This mismatch is particularly true in patients with moderately severe DES who may have significant subjective complaints, including visual disturbances, but without significant corneal staining and only moderate changes in tear film breakup time (TBUT). Compounding the difficulty of interpreting the results of clinical evaluation is the fact that some currently used tests are not highly reproducible, said Dr Pisella.

“For example, we know that the results of TBUT testing in the same individual can be different when the test is performed by two different examiners. Considering these issues, a reliable approach for functional evaluation of DES patients would be very helpful.”

The rationale for using double-pass aberrometry for this purpose derives from knowledge that mucin deficiency resulting from a decrease in the goblet cell population is a common feature in patients with DES. Mucin deficiency leads to tear film instability and irregularity that is functionally expressed as visual disturbances.

Dr Pisella explained that when the tear film thickness is normal, the refractive power of the cornea is 43.08 D. However, in patients with DES, the tear film thickness becomes irregularly decreased. Consequently, the anterior radius is reduced and the power of the cornea can be changed by up to +1.30 D while high order aberrations can also appear.

“Tear film quality plays a role in the optical quality of

the eye, and double-pass aberrometry allows analysis of the changes in both high order aberrations and light scattering associated with an irregular tear film,” Dr Pisella said.

In order to use double-pass aberrometry to evaluate tear film quality, special software was developed to quantify scattering and calculate an Ocular Scattering Index (OSI). Forty patients were enrolled in a study, of which 20 had mild DES, 13 had moderate DES, and seven had severe DES based on DEWS categorisation criteria. The testing was performed over a 20-second interval and repeated four times. A mean OSI value as a function of time, between blinks, was calculated for each patient and used to calculate subgroup means for statistical comparison.

The mean OSI value increased with increasing severity of DES, from 1.86 in the mild group to 5.22 in the severe group, and was significantly higher in the severe DES group compared with the mild and moderate groups.

Further analyses aimed to control for potential confounding factors associated with abnormalities in other ocular structures, including the cornea, crystalline lens and vitreous and to take into account the effect of blinking, which results in a temporary change in the OSI and is more frequent with increasing dry eye severity. Even with these adjustments, the mean OSI remained significantly higher in the severe DES patients compared to the other two groups.

Additional testing provided early evidence supporting use of the aberrometric evaluation for determining the effect of DES treatment. Dr Pisella described two patients, one with a low tear film osmolarity of 284 mosml/L and the other a DES patient with an elevated tear film osmolarity of 326 mosml/L. In the patient with low osmolarity, artificial tear instillation had no effect on OSI comparing measurements obtained at baseline and 15 minutes after the drop was instilled. However, the OSI decreased and was stabilised after instillation of the artificial tear drop in the DES patient.

DOUBLE-PASS ABERROMETRYTechnique allows analysis of changes in high order aberrations and light scattering associated with an irregular tear fi lmby Cheryl Guttman Krader in Vienna

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CORNEA

Th is new objective technique may help us to quantify the blurry vision associated with DES and help us to detect and further understand tear fi lm-related patient complaints...

“Pierre-Jean Pisella MD, PhD

35

EUROTIMES | Volume 17 | Issue 6

A thermography device capable of delivering highly reproducible measurements of the dynamic ocular surface temperature (OST)

could play an important role in helping to detect early dry eye disease or other ocular pathologies, according to a number of researchers.

“Our initial findings indicate that the TG-1000 Ocular Surface Thermographer (OST, Tomey Corp.) may serve as an appropriate device to detect early dry eye disease or corneal pathology. However, to establish its clinical use, the impact of tear film properties or corneal parameters has to be taken into consideration,” Sarah Moussa told delegates attending the 2nd EuCornea Congress.

Dr Moussa, Saarland University Medical Centre, Germany, noted that attempts to measure OST began in earnest in 1950 when Stoll and Hardy developed a contact technique for measuring OST with the use of topical anaesthesia, which resulted in low accuracy and poor resolution. A breakthrough of sorts, however, came in 1960 when Mapstone introduced infrared thermometry, a non-contact technique which allowed repeated measurements to be made.

Dr Moussa’s prospective, longitudinal, single-centre study set out to determine the zonal differences of corneal surface temperature in adults following blinking. OST was measured at three different time points in the day and was measured every second for 10 seconds immediately after blinking. The researchers measured and compared the OST at the corneal centre and at three peripheral quadrants at 3 o’ clock (temporal), 6 o’ clock (inferior) and 9 o’ clock (nasal) at the corneal limbus.

During the 10 seconds following eye opening and between the various time points, the observed corneal OST parameters did not change significantly. A significant difference was found, however, between temperatures in the nasal quadrant and the centre of the cornea when the eye was refrained from blinking for 10 seconds at each individual time point. In addition the temperature was found to be warmer nasally than temporally in the time interval between six and 10 seconds after blinking, she said.

In a separate presentation, Matthias

Klamann MD also lauded the potential benefits of using the TG-1000 to measure OST. “Temperature is one of the fundamental characteristics of tissue metabolism and is certainly of major interest to investigate ocular physiology. This non-contact device offers new options for a better understanding of both ocular surface physiology and pathology. It demonstrates excellent intra-observer reproducibility, so it may be used for dry eye screening, ocular surface inflammation and other potentially useful applications such as for filtering bleb function,” he said.

Dr Klamann, Department of Ophthalmology, University Hospital of Berlin, Germany, noted that the TG-1000 incorporates a touch panel, an infrared sensor and colour images, with an infrared wavelength of between 8 um and 14 um, a frame rate of 4 frames-per-second, and a temperature accuracy to within +- 0.1 Celsius in a target range of 30 to 40 degrees Celsius.

In Dr Klamann’s study the device was tested on 60 eyes of 30 healthy patients. The results showed that ocular surface temperature measurements were highly reproducible with a mean ocular surface temperature for this patient population of 34.02 Celsius.

Dr Klamann concluded that non-contact thermography provides valuable visual and qualitative documentation of temperature changes in the vascular tissues, and will play an increasingly important role in the field of ophthalmology in the future.

EARLY DRY EYEResearchers warm to thermography deviceby Dermot McGrath in Vienna

Sarah Moussa – sarah.moussa@uks.euMatthias Klamann – matthias.klamann@charite.de

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“This non-contact device offers new options for a better understanding of both ocular surface physiology and pathology”Matthias Klamann MD

EUROTIMES | Volume 17 | Issue 6

Combining corneal crosslinking (CXL) and surface ablation stabilises ectasia and improves vision by reducing irregular

astigmatism resulting from keratoconus. But for early keratoconus should crosslinking be done first and surface ablation after the cornea stabilises, or should the two be combined in a single procedure? There are advantages and disadvantages to each approach, according to presenters at the annual meeting of the American Academy of Ophthalmology.

The chief advantage of combining crosslinking and surface ablation is that it results in significantly better corrected vision in eyes with highly aberrated corneas, said John A Kanellopoulos MD of Athens, Greece, and New York University, US. “Topo-guided intervention is not a refractive procedure, it is a therapeutic procedure that attempts to improve best corrected vision in these eyes.”

Other advantages of same-day treatment include less pain and rehabilitation time for patients and reduced risk from eliminating a second surgical episode. The biggest disadvantage is that the uncorrected refractive outcome is unpredictable – though the cornea and the refraction remain stable for years, he noted.

Dr Kanellopoulos reviewed a study he published in 2009 comparing visual outcomes of keratoconus treated sequentially, with photorefractive keratectomy (PRK) performed six months to a year after crosslinking, with simultaneous treatment. Mean best corrected visual acuity in the simultaneous group was 20/30, compared with 20/40, for the sequential group (p<0.001) (J Refract Surg 2009; 25(9): S812-818). The simultaneously treated group showed less PRK-related scarring.

In eyes that were so severely abberated that they were candidates for penetrating keratoplasty, more than half had improved best corrected vision and 98 per cent achieved 20/40 or better. No eyes lost vision and 75 per cent gained at least one line, with 25 per cent gaining two or more lines.

There is a dramatic difference in the variability of elevation and distribution of astigmatism, Dr Kanellopoulos said. This results in greatly improved corrected vision, which is a better way to evaluate outcomes in highly aberrated eyes than uncorrected

visual acuity or keratometric change.The “Athens protocol” involves a partial

topography-guided PRK combining myopic and hyperopic treatment zones that flatten the apex of the cone while steepening the central cornea. No more than 40 microns of tissue are removed, but this does help normalise the shape of the cornea, Dr Kanellopoulos said. This is followed by application of mitomycin C 0.02 mg/ml for 30 seconds, immediately followed by corneal crosslinking.

He believes that regularising the cornea improves its biomechanical properties, resulting in a more even distribution of intraocular pressure across its surface, which may contribute to a more even-thickness healing.

The figure above depicts published data on UV absorption by normal Bowman’s and elucidates to the potential advantage of having it removed prior to CXL. Additionally left is the cornea of the same patient that has had CXL alone and right the cornea OCT of the other cornea of the same patient that has undergone the Athens Protocol for KCN. It is obvious that the right picture shows deeper and broader hyper-reflectivity suggesting more efficient and broader CXL. Renato Ambrosio of Rio, Brazil has confirmed using the CORVIS system that CXL with the AP appears to provide better biomechanical response of corneas than CXL alone (personal communication), Dr Kanellopoulos said.

But since both crosslinking and PRK

flatten the cornea, and the flattening continues for months after surgery, combining the two makes for an unpredictable refractive result, Dr Kanellopoulos said. However, it does result in a more-regular corneal topography, which makes best spectacle corrected outcomes much more predictable than with sequential approaches.

“It is normal for refractive surgeons to fear a PRK intervention in an ectatic cornea and prefer to do so maybe at a later time. Our experience has proven to us that the contrary is a better option: Combined same day approach. We have published this work in 2009 and it includes a very large cohort of patients in either group, with a significant follow-up time of several years,” he said.

“The advantages for the population that we treat (South Eastern Europe) is based on the poor tolerance to RGP and other ‘specialty’ contact lenses. I always like to make the point that the ‘PRK’ treatment applied in our protocol is not a refractive treatment. It is based on the Wavelight topography-guided platform and aims to normalise the irregular cornea and improve CDVA and UDVA,” Dr Kanellopoulos said.

Osama Ibrahim MD, professor of ophthalmology and president of Alexandria University, Egypt, presented a different view. “It is mandatory to differentiate between frank keratoconus and topographically – suspicious keratoconus,” he said.

“For frank keratoconus, concurrent corneal crosslinking and PRK are not

justified. Not only as it removes tissues from an already very thin cornea which may aggravate the condition, but also due to the lack of refractive predictability. In frank keratoconus, only corneal crosslinking either alone or combined with intra-corneal ring segments is indicated," he said.

Dr Ibrahim prefers surface ablation only for patients with suspicious or forme fruste keratoconus, which he characterised as topographical aberrations with normal thickness and no posterior elevation on Scheimpflug imaging .

“In such cases, we use wavefront-optimised or topography-guided ablation profile and we aim at full correction. We have done more than 100 eyes with excellent refractive results and they did not show any progression into frank keratoconus. We believe surface ablation per se is a crosslinking procedure that helps to stabilise the condition.”

Therefore, for frank keratoconus with thinning of the cornea and a progressive course, Dr Ibrahim prefers crosslinking first. In 3,000 eyes he has followed for four years, all were stabilised after crosslinking. Moreover, corneal flattening occurs in 20 to 25 per cent, and it is significant, averaging about 4.5 D and ranging from 0.5 to 12.0 D. Nonetheless, patient satisfaction with crosslinking is higher than can be explained by objective findings, he said. “We believe there is not only flattening but also improvement in higher order aberrations.”

For patients who receive corneal crosslinking only, Dr Ibrahim waits six to 12 months for the cornea to stabilise and then if the condition necessitates does surface ablation to improve quality of uncorrected and best spectacle-corrected visual acuity. He may also add intracorneal rings for only selected cases with residual high irregular astigmatism and ametropia.

The advantages of waiting are more predictable refractive outcomes and better quality of vision, Dr Ibrahim said. Disadvantages include the pain, cost and additional rehabilitation from doing a second surgical procedure. But he believes the advantages of sequential treatment outweigh the risks, especially that the risks of simultaneous treatments has also to be considered.

“If you do crosslinking and PRK simultaneously there are advantages in ease, cost and some pain. But there are many disadvantages, including adding a variable to a procedure that is unpredictable already. Crosslinking causes flattening. If you combine it with another flattening procedure like PRK, you will get a decrease in accuracy and predictability of both, and a higher incidence of overcorrection. So I think the simultaneous approach is not justified, and I strongly recommend staging the two procedures if needed,” Dr Ibrahim said.

John Kanellopoulos – ajk@laservision.grOsama Ibrahim– ibrosama@gmail.com

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CROSSLINKING AND PRKSimultaneous treatment helps avoid corneal transplant, but sequential gives more predictable refractive resultsby Howard Larkin in Orlando

36 Update

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EUROTIMES | Volume 17 | Issue 6

In an address delivered at this year’s EURETINA Winter Meeting, Prof John Marshall, Institute of ophthalmology in association

with Moorfields eye Hospital, London, introduced a novel approach to measuring the impact of macular oedema by suggesting that visual acuity may be predicted more accurately by evaluating the vertical elements that pass between the plexiform layers, elements often resembling the columns of a cathedral. According to Prof Marshall, introduction of such techniques may be used prior to future trials of regimens for the treatment of macular oedema, thereby allowing clinicians to exclude patients that are unlikely to recover visual acuity, regardless of the mode of intervention.

Prof Marshall opened his address by suggesting that clinicians and researchers might consider viewing optical coherence tomography (OCT) as much as a device capable of producing hard numbers for analysis and research as it is already used as a clinical tool.

Prof Marshall presented visual acuity as having four major factors: image formation which is optical, image transduction which is based on the photoreceptor matrix, image transmission which is predominantly related to the bipolar cells of the retina and finally, image interpretation which occurs within the cortex. As the bipolar cells are the only connection between the photoreceptors and the ganglion cells, it follows that visual acuity will be a function of the connectivity and eccentricity of these cells.

In terms of retinal vasculature disease, Prof Marshall described the potential sources of fluid with a focus on the intra-retinal circulation, which supplies the inner retinal neurons, and the choroid, which supplies the photoreceptors and pigment epithelium. According to Prof Marshall, these are “two tight-junctional systems” and under normal circumstances are selective in what they release.

“Under normal circumstances there is diffusion of fluids from the retinal capillaries with a little bit draining back, predominantly the fluid is drained by the pigment epithelium into the choroid and a little bit leaks back,” explained Prof Marshall. “If this system goes wrong

significant changes can occur. For example, in diabetes, with the leaky capillaries predominantly pooling fluid in the inner retina. Because both histology and OCT section tissue by effectively cutting slices they give rise to the so-called cystic arrangement of oedema which is in reality an artefact. The fluid is usually within a single space and the apparent cysts arise because Muller’s fibre remnants are found passing through the fluid between the two plexiform layers and appear in sections to divide up the fluid-filled space into compartments.”

Prof Marshall further explained that by contrast, in conditions such as retinitis pigmentosa, where the pigment epithelium is a deficit, there is a pooling of fluid predominantly in the outer retina particularly in the macular region

where the fluid pools between the fibres within the fibre layer of Henle. Finally, in conditions like AMD the fluid goes through the pigment epithelium but now can’t get out through an aged, changed Bruch’s membrane and one sees things like pigment epithelial detachments.

Prof Marshall told delegates that the two plexiform layers act as areas of high resistance and fluid predominantly pools between them as can be seen on OCT and other image analysis tools. In the context of cystoid macular oedema, there’s nothing in the holes except fluid and so analysing the holes in terms of pattern location etc is a little pointless. What needs to be analysed is what tissue remains, and not more tissue has been lost. Any analysis of the system’s structure, and of the changes in the system in relation to disease, shows that the key

players to examine are the photoreceptor cells, bipolar cells and ganglion cells. As the bipolar cells provide the only through-put channel in the retina it follows that any damage that occurs here will have significant impact on visual acuity.

Prof Marshall proposed the analogy of a cathedral in describing the Muller’s fibres seen under conditions of macular oedema as being analogous to the columns supporting the roof of a Gothic cathedral. Just as the columns are the only element that passed between the floor and the roof and provide the ideal route for electrical cables allowing the lights to be switched on then the Muller’s fibres are the only structural component passing between plexiform layers providing passage and protection for the bipolar axons. Prof Marshall and his research group have a particular interest in the pillars and analysing them in terms of predicting potential outcome in terms of visual performance in cases of macular oedema.

Prof Marshall proposed that it is in the location of the pillars where any residual bipolar cells are going to be and that these bipolar cells will be essential for maintaining vision. The reason the literature reports a mild correlation with increasing thickness is because as the macula swells more of the bipolar axons are strained and eventually snap. Oedema pools between the two plexiform layers pushing them apart and eventually breaking the bipolar cell axons, unless they are protected by being adjacent to Muller cells. Protection by Muller cells is the key to the correlation between measurement of the structures and VA.

Prof Marshall described how his team analysed the OCT images “in a systematic fashion to see how many fibres there are, what is their minimum diameter and what is their eccentricity, because the number of fibres tell you the potential number of surviving bipolars, the minimum diameter tells you the maximum number of bipolar cells that could be there and their eccentricity gives you information as to their connectivity to the centre”.

John Marshall – eye.marshall@googlemail.com

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MACULAR OEDEMAOCT provides quantitative anatomic informationby Gearóid Tuohy PhD in Rome

38 Update

RETINA

Because both histology and OCT section tissue by effectively cutting slices they give rise to the so-called cystic arrangement of oedema which is in reality an artefact

“

Prof John Marshall

Scanning electron micrograph of a cystoid macular oedematous retina showing columns of tissue standing like columns in a cathedral around a continuous space of fluid pooling – the number and evaluation of such vertical columns passing between plexiform layers

provides information with respect to visual acuity

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EUROTIMES | Volume 17 | Issue 6

New in vivo experimental data support the idea that replacement of lost photoreceptors by cell transplantation should in time

represent a possible treatment option for affected patients, Dr Marius Ader, a principal investigator at the Centre for Regenerative Therapies, University of Technology, Dresden (CRTD), told delegates at the EURETINA Winter Meeting.

Dr Ader reported on experiments at his institute and explained that while photoreceptor transplantation has been on-going for 20 years, technical advances had moved the field forward considerably over the recent five years. His team routinely isolate primary photoreceptor cells from the peak of rod generation in donor animals and, when GFP (“green fluorescent protein”)-labelled, transplant the cells sub-retinally into recipient models. Results presented at the meeting showed green donor cells integrated in the outer nuclear layer with a morphology resembling mature photoreceptors.

Transplanted cells express photoreceptor specific markers, including recoverin. However, a key interest is to determine if transplanted cells can form outer segments. Dr Ader used an engineered reporter mouse in which rhodopsin is fused to the GFP label so that the signal represents the actual location of rhodopsin in the retina. Further modifications led to the development of a double reporter mouse which crossed a rhodopsin GFP mouse with an actin DsRed mouse, which, according to Dr Ader, allowed the researchers to see “the red fluorescence in the cell body and GFP in the outer segment of photoreceptors”.

The research group found that the double reporter allowed one “to follow both the integration of photoreceptors and outer segment formation following transplantation

using fluorescence microscopy without further staining procedures”.

“You can then go even further and use antibodies against GFP and label them with gold particles and look at the ultra-structure of the outer segments to examine the disc-filled outer segments,” he explained.

Using a correlative light and electron microscopy technique, Dr Ader showed the meeting that the transplanted cells’ outer segments are absolutely comparable with the wild-type endogenous outer segments, providing convincing evidence that transplanted cells integrated into the host retina and formed an outer segment.

While such results were encouraging, Dr Ader knew that if the technology were to be of real clinical value then it would need to be demonstrated in a disease model. His team used the available RP p347s disease model which had an almost non-existent ONL at the time of transplantation. However, following treatment, clear healthy cells were detectable in the recipient disease model including ultra-structure imagery showing proper outer segments with connecting cilia.

The transplanted precursor cells were able to mature and form disk filled outer segments.

The team pushed further to increase the rate and proficiency of the transplantation as they wished to focus on improving the low integration rate (<one per cent) seen in many of the experiments. Because the transplanted cells are a mix of photoreceptors, glial cells, retinal progenitors and immature bipolar and other neurons, Dr Ader explained that a selection and enrichment step would be required if the technology was to transfer to the clinic.

“Ideally you want to have selection done by way of a cell surface marker, not by any reporter [label],” Dr Ader explained.

As such, the challenge was to identify photoreceptor cell surface markers about which very little is known. Undeterred, Dr Ader’s research team analysed the expression profile of immature photoreceptors at post-natal day four, the optimal time-point for transplantation and, by a technique of flow cytometry, selected the photoreceptors with GFP from the retina. Analysis of GFP –ve and +ve cells allowed for the identification of different genes, some more than two-fold up-regulated in the GFP +ve photoreceptor cell population and others, down regulated by more than two-fold.

“When you look in detail at some of the genes you see that there is a really clear separation between the two groups of photoreceptor genes and other retinal genes.”

This allowed him to look for cell surface markers specific to photoreceptors. One of the cell surface markers that came up with a more than three-fold higher expression level in the photoreceptor cell population was a surface protein called “CD73”. As there was an available antibody, CD73 became the first candidate and could now be used to selectively isolate photoreceptors from a mixed cell population.

Using a technique known as MACS – magnetic associated cell sorting – Dr Ader’s research colleagues used CD73 to fish out photoreceptors and use these sorted cells to improve integration.

Dr Ader showed the conference convincing data following transplantation of the CD73+ sorted cells demonstrating increased integration of photoreceptors. The team have additionally developed an

improved protocol where around 10,000 such cells have been integrated in the retinas.

He concluded his presentation by summarising the achievements of transplanting immature photoreceptors to allow for correct integration into the adult mammalian retina followed by the use of MACS enrichment by cell surface markers leading to increased integration.

“Such purification procedures may prove extremely important for the selection of in vitro generated stem-cell derived photoreceptors for transplantation studies and represent an indispensable prerequisite for possible future clinical applications”.

Marius Ader – marius.ader@crt-dresden.de

cont

act

PHOTORECEPTORPre-clinical photoreceptor transplantation into the adult retinaby Gearóid Tuohy PhD in Rome

39Update

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When you look in detail at some of the genes you see that there is a really clear separation between the two groups of photoreceptor genes and other retinal genes

“

Dr Marius Ader

Integrated photoreceptors following transplantation into an adult mouse retina. While the cell body of the donor cells are

labelled by DsRed (magenta) the outer segments are labelled by GFP (green) at the tip of the photoreceptor. INL: inner nuclear

layer; IS: inner segments; ONL: outer nuclear layer; OPL: outer plexiform layer; OS: outer segments

Cour

tesy

of D

r Mar

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Ader

MAIN SESSIONS

MAIN SESSION 1THURSDAY 6 SEPTEMBER 11.30 – 13.00OCULAR TUMOURSChairpersons: N. Bornfeld GERMANY,J. van Meurs THE NETHERLANDS

MAIN SESSION 2FRIDAY 7 SEPTEMBER 08.00 – 10.00PVR AND RETINAL DETACHMENTChairpersons: D. Charteris UK, D. Wong HONG KONG

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MAIN SESSION 4SATURDAY 8 SEPTEMBER 08.00 – 10.00DRY AMDChairpersons: P. Lanzetta ITALY, U. Schmidt-Erfurth AUSTRIA

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MAIN SESSION 8SUNDAY 9 SEPTEMBER11.00 – 13.00MANAGEMENT OF DIABETIC MACULAR EDEMA: WHAT YOU NEED TO KNOWChairpersons: F. Bandello ITALY, J. Cunha-Vaz PORTUGAL

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FREEPAPERS

MAIN SESSION 1Ocular Tumours

MAIN SESSION 2PVR and Retinal

Detachment

KREISSIG LECTURE

AMSTERDAMRETINA DEBATE

MAIN SESSION 3Imaging

US RETINASOCIETY

ITALIANRETINA SOCIETY

EVICR.NET+EUROVISIONNET

SYMPOSIUM

COURSE 10How to Read

Autofl uorescence Images

COURSE 11New Strategies in

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COURSE 16Managing Diabetic Macular Edema:

Pearls and Pitfalls

COURSE 12Proliferative

Diabetic RetinopathyFREEPAPERS

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COURSE 17Tips and Tricks in Minimal-Invasive

Vitrectomy

COURSE 13Management of

Intraocular Tumors

COURSE 18Retinal imaging: Revolutionising

Retinal Therapeutics

COURSE 14The Role of the

Vitreous in Retinal Disease

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COURSE 9Surgical Approach to the Vitreoretinal

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EUROLAMSYMPOSIUM

COURSE 1Current

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OCT Imaging: Indications, Features,

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08.00

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KREISSIG LECTURE

AMSTERDAMRETINA DEBATE

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US RETINASOCIETY

ITALIANRETINA SOCIETY

EVICR.NET+EUROVISIONNET

SYMPOSIUM

COURSE 10How to Read

Autofl uorescence Images

COURSE 11New Strategies in

Ocular Trauma

FRENCH/ISRAELISYMPOSIUM

ARVOSYMPOSIUM

FREEPAPERS

COURSE 16Managing Diabetic Macular Edema:

Pearls and Pitfalls

COURSE 12Proliferative

Diabetic RetinopathyFREEPAPERS

FREEPAPERS

COURSE 17Tips and Tricks in Minimal-Invasive

Vitrectomy

COURSE 13Management of

Intraocular Tumors

COURSE 18Retinal imaging: Revolutionising

Retinal Therapeutics

COURSE 14The Role of the

Vitreous in Retinal Disease

FREEPAPERS SHORT

PAPERSSHORTPAPERS

SHORTPAPERS

COURSE 9Surgical Approach to the Vitreoretinal

Interface

COURSE 8Bimanual Surgery in Small Incision

Vitrectomy (23g-25g-27g)

LUNCH BREAK

COURSE 7Current

Management in Uveal Melanoma

SURGICALSKILLS

COURSES

RESEARCHSYMPOSIUM

OPENINGCEREMONY

WELCOME RECEPTION

UVEITISCOURSE

COURSE 2What, When and How:

Surgical Discussions

COURSE 4Macular Edema

COURSE 6Macular Dystrophies

FREEPAPERS

SHORTPAPERS

SHORTPAPERS

SHORTPAPERS

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EUROLAMSYMPOSIUM

COURSE 1Current

Management of ROP and Pediatric

Vitreo-Retinal Diseases

COURSE 3State-of-the-Art in Anti-VEGF Therapy

COURSE 5Update in

OCT Imaging: Indications, Features,

Consequences

RETINALDETACHMENT

COURSESURGICAL

SKILLSCOURSES

THURSDAY 6 SEPTEMBER

FRIDAY 7 SEPTEMBER

* Please note this is a preliminary programme and is subject to change

SILVER PLENARY

REDHALL 1 & 2

BLUEHALL 1

BLUEHALL 2

WHITEHALL 1

WHITEHALL 2

YELLOW HALL 3

GREEN HALL 3

SILVER PLENARY

REDHALL 1 & 2

BLUEHALL 1

BLUEHALL 2

WHITEHALL 1

WHITEHALL 2

YELLOW HALL 3

GREEN HALL 3

COFFEE BREAK

LUNCH BREAK

COFFEE BREAK

NOVARTIS SATELLITE MEETING

SECOND SIGHT SATELLITE MEETING

BAUSCH+LOMBSATELLITE MEETING

NOVARTISSATELLITE MEETING

ALLERGANSATELLITE MEETING

NIDEKSATELLITE MEETING

ASIA PACIFIC VR SOCIETY

SYMPOSIUM

INNOVATIONAWARD

CEREMONY

COURSE 15Diseases Involving

VR Interface

07.00

08.00

09.00

10.00

11.00

12.00

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GENERALASSEMBLY

MAIN SESSION 4Dry AMD

MAIN SESSION 5Retinal Vein Occlusions

SPANISH VITREORETINAL

SOCIETY

FREEPAPERS

COFFEE BREAK

COFFEE BREAK

JOINTSYMPOSIUM

EURETINA/ESCRS

MAIN SESSION 6Neovascular AMD

FREEPAPERS

COURSE 19Steroids in

Retinal Therapy

FANCLUB

COURSE 22Vitreoretinal

Complicationsof Cataract Surgery

WCPOS JOINT SESSION

The Child’s Retina –Different Perspectives

WCPOS JOINT SESSIONPaediatric Uveitis

GERMAN RETINAL SOCIETY

SYMPOSIUM

COURSE 24Uveitis:

Standard Diagnostic and Therapeutic

Procedures

ITALIANBIO-ENGINEERING

SOCIETY

FREEPAPERS

COURSE 25Laser Therapy in Retinal Disease:

Indications & Procedures

US MACULA SOCIETY

COURSE 20Managing

Complications inVitreoretinal Surgery

COURSE 21Fluorescein and

ICG-Angiography - Interpretation & Diagnosis

of Macular Diseases

MAIN SESSION 7Innovative

Vitreoretinal Surgery

MAIN SESSION 8Management of Diabetic

Macular Edema: What you need

to know

RETINAWSSYMPOSIUM FREE

PAPERS

OPEN SESSIONScreening for

DiabeticRetinopathy

COURSE 28Simple Approach to PVR Management

FREEPAPERS

FREEPAPERS

COURSE 26Management of Retinal Vascular

Occlusion

COURSE 27Electrophysiology:

Principles and Practice

SUNDAY 9 SEPTEMBER

SATURDAY 8 SEPTEMBER

* Please note this is a preliminary programme and is subject to change

FREEPAPERS

SILVER PLENARY

REDHALL 1 & 2

BLUEHALL 1

WHITEHALL 1

WHITEHALL 2

AUDITORIUM

SILVER PLENARY

REDHALL 1 & 2

BLUEHALL 1

WHITEHALL 1

WHITEHALL 2

AUDITORIUM

GOLD PLENARY

COFFEE BREAK

LUNCH BREAK

ALCONSATELLITE MEETING

D.O.R.C.SATELLITE MEETING

NOVARTISSATELLITE MEETING

BAYERSATELLITE MEETING

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n Congress Registration n Full Programme Infon Membership Application

n Courses and Wetlab Bookingsn Hotel Bookingsn EURETINA Brief

Available at www.euretina.org:

12th EURETINA Congress

6-9 September 2012

EURETINA LECTURETHURSDAY 6 SEPTEMBER

16.15 – 16.35

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Phenotypic Variation in Early AMD

2012 KREISSIG LECTUREFRIDAY 7 SEPTEMBER

11.00 – 12.00

GISÈLE SOUBRANEFRANCE

Future Treatments Of Exudative AMD

The offi cial journalof EURETINA

Available to all members

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Morning SymposiaFriday 7 September

10.00 – 11.00

Focusing on the Patient:Individualized Treatment for Wet AMD

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Speakers:M. Larsen DENMARK

F. Holz GERMANY

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The Argus® II Retinal Prosthesis,the New Treatment Pathwayfor Retinitis Pigmentosaand Future Perspectives

Room: White Hall 1Moderator: TBC

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J.A. Sahel FRANCE

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EUROTIMES | Volume 17 | Issue 6

Within the next several years a large number of patents will expire on brand-name glaucoma

ophthalmic products in Europe and North America. While generics are beneficial in terms of cost, there are concerns in the ophthalmology community that generic drops of all types may come with risks not seen in the brand-name versions.

A key issue is that eye-drops have non-active ingredients in them, such as antimicrobial preservatives, and compounds that affect pH and tonicity. While a generic may contain the same drug as the brand-name, these other agents aren’t required to be the same, according to Cindy Hutnik MD, professor of ophthalmology and pathology at the University of Western Ontario. She spoke at the recent 51st Walter Wright Annual Ophthalmology and Vision Sciences Symposium in Toronto.

“Non-active ingredients can affect the bioavailability of the drug by interfering with its solubility and ocular penetration, and inactive ingredients may ultimately affect the drug’s effectiveness,” she said.

She noted that changes in non-active ingredients can affect the pH of the eye-drop to a patient, or affects its texture. Patients will stop using drops that sting or feel gritty, meaning compliance decreases and disease can go untreated.

According to the European Generic Medicines Association (EGA), “Generic medicines must comply with exactly the same standards of quality, safety and efficacy as all medicinal products.” However, while standards for production may be the same, some ingredients can vary, Dr Hutnik says, and this is where problems can occur.

For instance, the concentration of an active drug in eye-drops can vary between production lots. One study of glaucoma drops showed concentrations of active drugs in several products ranged from 85 to 120 per cent.

“Unfortunately, we can’t regulate eye-drops as much as we can regulate pills; liquid medications are harder to control,” she said.

Also, proving a generic gets to the part of the body where it is needed as well as the brand name is tough because testing for bioavailability is not possible with ophthalmics, said Dr Hutnik.

“With a pill, you take it, and it can be measured in the blood. But with an eye-drop there is no mechanism to make sure it has really gone in or how active it is. The definition of ‘equivalence’ has become very loose for these products by the regulating authorities. We really have no idea what patients are really getting with the generics,” she told EuroTimes.

In many places, physicians are required to

prescribe generics, unless there are specific problems with individual patients. It can be difficult for physicians to switch patients to a brand name, and sometimes pharmacies don’t carry brand-name products if a generic is available, she said. At least this is true in parts of Canada. Other factors such as dropper size, and how squeezable the bottle is can affect dose too.

Often, generic companies don’t have access to the original recipe or data pertaining to a brand-name drug, and have to reverse engineer products to figure out the ingredients and proportions, according to Richard Fiscella PharmD, MPH clinical professor emeritus of pharmacy practice at the University of Illinois. Generic companies make best guesses for some of the non-active ingredients, he said. Dr Fiscella has published a number of studies pertaining to ophthalmics and spoke to EuroTimes in a phone interview.

This is confirmed by a statement on the EGA Generics website which states: “Generic medicines applications do not make use of any data from the originator registration file. In fact, the data of originator products are never revealed to third parties, and so cannot be used by generic medicines researchers. Instead, generic medicines producers research and develop their own formulation of the product...”.

How much of a problem? How much of a problem this represents in clinical practice is hard to say, but there have been some worrying incidents, said Dr Fiscella. Generally, generics are of good quality and effective, but more scientific studies are needed to better determine safety and efficacy of generic ophthalmics, he said.

There were severe problems with the generic version of the NSAID diclofenac in 1999. After about a year on the market, there were case reports of corneal melting and some patients required corneal transplants. The product was removed from the market. Here, the solubizing agent and other inactive ingredients differed from the brand name and lead to serious problems, Dr Fiscella said.

Another example was with a generic form

of prednisolone acetate. Reports showed that in some generic versions the drug didn’t suspend well in the solution. This meant there were inconsistent amounts of steroid in each dose, Dr Fiscella said. The FDA in the US now requires studies of ophthalmic suspensions be performed before a generic is approved.

In another example, a generic version of latanoprost from India proved to be less effective than the brand name in lowering intraocular pressure in glaucoma patients. Adding to the confusion, there are multiple manufacturers who produce generic versions of latanoprost (there are at least seven in the US alone).

In addition, many ophthalmic products and many of the raw materials used in them are manufactured in other countries. With multiple sites located around the world, Good Manufacturing Practice (GMP) standards can be difficult to monitor, he said.

More research is needed in this area, in part because many reports of problems with ophthalmic generics are anecdotal, Dr Fiscella said. Conducting small, randomised clinical trials to compare safety and efficacy of brand name versus generic drugs before they are brought into the market would be useful. However, for many generic manufacturers doing this would be prohibitively expensive, and might discourage many companies from producing generics in the first place. This would lead to fewer affordable drugs on the market.

A post-marketing data gathering system would help – not just for tracking major side effects, but for minor problems too, such as redness or irritation. It’s important to pay attention to minor complications from drops because even slight differences can affect patient compliance, he said.

In the meantime, ophthalmologists and optometrists should ask patients to bring all their eye-drops in to appointments. Look for differences in effectiveness, comfort and side effects, he advised.

“See if the patient was switched from a brand to a generic. Note the manufacturer in the chart, so follow-up can be done, and if there is any concern,” Dr Fiscella said.

Cindy Hutnik – Cindy.Hutnik@sjhc.london.on.caRichard Fiscella – fi sc@uic.edu

cont

acts

OFF PATENT DRUGSGood Manufacturing Practice (GMP) standards can be diffi cult to monitorby Pippa Wysong in Toronto

43Update

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While generics are beneficial in terms of cost, there are concerns in the ophthalmology community that generic drops of all types may come with risks not seen in the brand-name versions

EUROTIMES | Volume 17 | Issue 6

The 41st annual meeting of the European Contact Lens Society of Ophthalmologists (ECLSO) in Istanbul played host to a

live contact lens fitting practice, which provided practical demonstrations of the assessment of unusual and difficult cases and was the first of its kind to take place at an international meeting, according to the organisers.

The idea behind the live fitting session was to have something similar to a live surgery session, but which would be devoted to contact lens fitting rather than surgery, said Tomris Şengör MD, president of the Turkish Contact Lens Society, who moderated the session with Dr Emrullah Taşındı.

“Live surgery sessions are a very popular part of ophthalmology congresses. However, as contact lens practitioners, we do not have surgery, but fitting. Consequently, I decided to put this idea into practice as ‘Live Fitting’ a sort of live surgery,” Dr Şengör, Istanbul Bilim University Ophthalmology Department, told EuroTimes.

The topic of the session was “How to fit contact lenses in difficult cases”. The session’s organisers selected 10 challenging cases. They presented patients who had previous difficulties obtaining a good quality of vision with spectacles and contact lenses because of irregular corneas resulting from refractive surgery, keratoplasty, advanced keratoconus, intracorneal rings and trauma.

During the live fitting session, the lecturers, Dr Tomris Şengör, Dr Canan Gürdal, Dr Ömür Uçakhan Gündüz, and Dr Banu Coşar, presented the biomicroscopic images and the data of the patients before contact lens fitting and described the difficulty involved in each case. Meanwhile, Dr Sevda Aydın Kurna and Dr Yelda Buyru Özkurt, who were with the patients in the examination room, explained their views of the best available solution to the problems each case presented, and fitted the contact lenses accordingly. The patients could also answer the questions from the session’s participants regarding their experience of the fitting process and their degree of satisfaction with the outcome.

Throughout the session, a video

link connected the auditorium with the examination room, where one video camera was connected to the biomicroscope and another enabled the audience to view the patient and the examiner. Dr Hilmi Or and Dr Ahmet Altun were responsible for the technical details of the communication. In this way, the attendees of the session saw the biomicroscopic view of the patients’ eyes with or without the contact lenses and they were also able to see the patients as they answered their questions.

“The session went very smoothly, almost absolutely perfectly, and it was almost like live surgery, both for the people who applied the lenses and for the people in the

audience,” Dr Şengör said. She noted that the Contact Lens Division

of the Turkish Ophthalmology Society had previously organised a similar live fitting programme at the first Practical Contact Lens Day held in Istanbul in 2010. “There are plans for similar sessions at other international congresses in the future”, she said.

“We would like to encourage all of our colleagues who are interested in contact lenses to organise such interactive practices in future that make the meetings more colourful and beneficial,” she added.

Tomris Sengör – tomris.sengor@gmail.com

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CONTACT LENS FITTINGLens specialists receive practical demonstrations on how to fit contact lenses in difficult casesby Roibeard O’hEineachain

44 Update

OCULAR

We would like to encourage all of our colleagues who are interested in contact lenses to organise such interactive practices in future that make the meetings more colourful and beneficial

“

Tomris Şengör MD

Pictures from the live contact lens fitting session at the 41st annual meeting of the ECLSO

EUROTIMES | Volume 17 | Issue 6

Childhood blindness in the Eastern European region is characterised by significant regional variation and a

worrying overall growth in retinopathy of prematurity (ROP) cases, according to a presentation here.

“Based on the available data there is a significant regional variation in childhood blindness in Eastern Europe, although there is a real lack of community-based data on prevalence, incidence, and causes of visual impairment in children,” Ilian Shandurkov MD told delegates attending the World Ophthalmology Congress.

“What is clear, however, is that the most important cause or preventable blindness in children in countries such as Bulgaria, Hungary, Poland and the Czech Republic is retinopathy of prematurity. It is very important to treat avoidable blindness if we are going to make a real difference in Eastern Europe,” he added.

Dr Shandurkov noted that an estimated 80 per cent of all visual impairment could be avoided or cured, according to the World Health Organization. The most common causes of vision impairment in

children globally include refractive errors without amblyopia, amblyopia, strabismus, congenital anomalies, and ROP.

The etiological profile for childhood blindness in Europe is somewhat different, depending on the region, noted Dr Shandurkov.

Lesions of the central nervous system, congenital anomalies, retinal disorders and dystrophies are the leading causes of childhood blindness in highly industrialised countries, while congenital cataract, glaucoma and ROP figure more prominently in middle-income countries. In less developed European countries, hereditary disorders and corneal blindness top the list, he said.

One of the first community-based surveys of blindness in Eastern Europe, the Sofia Eye Survey, found a rate of visual impairment of 1.32 per cent and a blindness rate of 0.49 per cent from a sample of 6,275 persons, with cataract implicated as the main cause of blindness.

A vision screening programme of 1,863 children in Bulgaria also revealed some interesting data.

“It was found that normally developed

children in orphanages had a much higher frequency of amblyopia and strabismus compared to children in families, probably due to late diagnosis in the case of institutionalised children,” he said.

Looking at data from other countries, a survey of 229 children in 10 primary schools for the visually impaired in the Czech Republic recorded an ROP rate of 41.9 per cent.

The data from Poland also confirmed the worrying rise in ROP-related blindness, said Dr Shandurkov. A 2001 study found that the number of visually disabled children in Poland had increased by 70 per cent in the previous decade, with optic nerve atrophy (22 per cent), retinopathy of prematurity (19 per cent), cataracts (14 per cent), high myopia (11.84 per cent), congenital abnormalities (8.65 per cent), retinal dystrophies (8.08 per cent) and glaucoma (6.42 per cent) cited as the leading causes.

In Hungary, a population-based study of children aged six to 14 in 1991 found congenital cataract (17 per cent), congenital eye abnormalities (15 per cent), high myopia (13 per cent), and ROP (11

per cent) as the leading causes of visual impairment in that age group.

In terms of ROP, which has been billed as a “third epidemic” by the World Health Organization, Dr Shandurkov said that improved neonatal care in Eastern Europe has led to greater survival of premature babies and consequently an increase in retinopathy of prematurity cases. The situation in the region has been aggravated by the lack of qualified ophthalmologists for early diagnosis and treatment, with only a few centres in bigger cities providing eye screening and treatment for ROP, he concluded.

Ilian Shandurkov – ilian_sh@yahoo.com

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REGIONAL VARIATIONSROP leads the list of preventable paediatric blindness in eastern Europeby Dermot McGrath in Abu Dhabi

45Update

PAEDIATRIC OPHTHALMOLOGY

Contact:

It was found that normally developed children in orphanages had a much higher frequency of amblyopia and strabismus compared to children in families, probably due to late diagnosis in the case of institutionalised children

“

Ilian Shandurkov MD

New engineered Biofi lmTM Coating

provides outstanding Benefi ts to enable

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State-of-the-Art

Online registration and hotel booking available

www.wcpos.org

KEYNOTE LECTURES SATURDAY 8 SEPTEMBER

WHAT’S NEW AND INTERESTING IN PEDIATRIC EYE TUMORS? Jerry Shields USA

Director of the Oncology Service at Wills Eye Institute and Professor of Ophthalmology, � omas Je� erson University, Philadelphia, USA

SUNDAY 9 SEPTEMBER

FORTY YEARS OF CLINICAL STRABISMOLOGY: LESSONS AND EXPERIENCES Emilio C. Campos ITALY

Professor & Chief of Ophthalmology at the University of Bologna S. Orsola-Malpighi Teaching Hospital, Italy

EUROTIMES™

SATELLITE EDUCATION PROGRAMME

Standard of Care for Antibiotic Therapy in Ocular Surface InfectionsSaturday 8 September 12.45 – 13.45Room: Brown Hall 1 & 2 Sponsored by:

Clarity Medical Systems Satellite SymposiumSaturday 8 September 12.45 – 13.45Room: Amber Hall 7 Sponsored by:

Ocular Surface Impairment in Paediatrics: New Outcomes

Sunday 9 September 12.45 – 13.45Room: Brown Hall 1 & 2 Sponsored by:

Satellite Education Programme

* Please note this is a preliminary programme and is subject to change

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NystagmusCh: R. Hertle USA,E. Kleinpaul BRAZIL

ExotropiaCh: D. Godts BELGIUM,

S. Olitsky USA

Strategies for Strab Re-OpsCh: C. Schiavi ITALY,

J. Manzitti ARGENTINA

Advances in understanding of the Anterior SegmentCh: A. Khan SAUDI ARABIA,

N. Schalij-Delfos THE NETHERLANDS

Paediatric CataractCh: A. Vasavada INDIA,

D. Plager USA

Botulinum Toxin for StrabCh: R. Gama PORTUGAL,

A. Scott USA

Early intervention & Habilitationof Children with impaired vision

Ch: L. Hyvarinen FINLAND,G. Dutton UK

STRABISMUS WORKSHOP

ESCRS/WCPOS SYMPOSIUM: Cataract and refractive surgery

in children Ch: D. Epstein SWITZERLAND, K.K. Nischal USA/UK (WCPOS)

WETLABSMy World My WayCh: M. Miller USA,

F. Martin AUSTRALIA

Paralytic StrabismusCh: L. Kowal AUSTRALIA,

K. Arnoldi-Jolley USA

WCPOS/EURETINA JOINT SESSION:Paediatric Uveitis

Ch: C. Edelston UK,A. Loewenstein ISRAEL

EsotropiaCh: M. Goldchmit BRAZIL,

P. Nucci ITALY

Strabismus TechniquesCh: R. Kekunnaya INDIA,

G. Ellis USA

Strabismus SyndromesCh: S. Ko HONG KONG,

E. Cumhur Sener TURKEY

Retinal MedicalCh: E. Silva PORTUGAL,

E. Traboulsi USA

WCPOS/EURETINA JOINT SESSION:The Child’s Retina –

Different PerspectivesCh: C.K. Patel UK, G. Richard GERMANY

KEYNOTE LECTURE J. Shields USA

KEYNOTE LECTURE E. Campos ITALY

Thyroid OrbitopathyCh: D. Granet USA,L. Baldeschi ITALY

Surgical Video SessionCh: D. Mojon SWITZERLAND,Y. Fong Choong MALAYSIA

Intraocular TumoursCh: A. Singh USA,

R. Sitorus INDONESIA

Pediatric Infectious Diseases Ophthalmology

Ch: N. Gangopadhyay INDIA,S. Isenberg USA

ALCON SATELLITE MEETINGStandard of care for antibiotic

therapy in ocular surface infections

Paediatric Orbital DisordersCh: Y. Abou-Rayyah UK,

D. Kikkawa USA

THEA SATELLITE MEETINGOcular surface impairment in paediatrics:

new outcomes

WCPOS/EUCORNEA Joint Session:Paediatric Cornea and Ocular Surface Disease: What’s what

Ch: A. Magli ITALY,V. Sarnicola ITALY

ElectrophysiologyCh: C. Westall CANADA,

S. Jalali INDIA

Anaesthesia and other issuesin the OR

Ch: C. Houck USA, A. Memmo ITALY

FREE PAPER SESSIONCh: C. Schiavi ITALY,

M.E. Arroyo-Yllanes MEXICO

FREE PAPER SESSIONCh: V. Paris FRANCE,

M. Jaafar USA

CLARITY SATELLITE MEETINGClarity Medical Systems

Satellite Symposium

Paediatric GlaucomaCh: N. Freeman SOUTH AFRICA,

A. Serra Castanera SPAIN

Paediatric External DiseasesCh: M.C. Dantas BRAZIL,

M. Fernandes INDIA

AmblyopiaCh: J. Holmes USA,

J. de Faber THE NETHERLANDS

Role of Anti-VEGF in Paediatric Ophthalmology

Ch: L. Gordillo PERU,G. Quinn USA

Reading & LearningCh: C. Donaldson AUSTRALIA,

S. Handler USA

Demyelinating Disease and Neuromuscular Disorders

Ch: P. Bianchi ITALY,H. Lim KOREA

Tele-learning & Tele-therapyCh: Dan Neely USA,

Rob Walters UK

IIH in Children:Visual pathway tumours

Ch: F. Triulzi ITALY,E. Mitchell USA

Non-Accidental InjuryCh: A. Levin USA,C. Sylvester USA

Technology Update Ultrasound/OCT/GDX/ Imaging etc.

Ch: J. Schuman USA,S. Robbins USA

LidsCh: D. Bremond-Gignac FRANCE,

Milind Naik INDIA

Advances in ocular geneticsCh: H. Dollfus FRANCE,

E. Heon CANADA

FREE PAPER SESSIONCh: Y. Morad ISRAEL,M. Younis LEBANON

FREE PAPER SESSIONCh: M. Serafi no ITALY

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AUDITORIUM BROWN HALL 1 & 2 AMBER HALL 7 AMBER HALL 8

AUDITORIUM BROWN HALL 1 & 2 AMBER HALL 7 AMBER HALL 8 GOLD PLENARY

AUDITORIUM AMBER HALL 5 & 6 AMBER HALL 7 AMBER HALL 8 GREEN HALL 1

EUROTIMES | Volume 17 | Issue 6

Corneal transplants are the most widely performed and most successful type of transplant surgery, yet corneal blindness remains the fourth leading cause of blindness worldwide after cataract, glaucoma

and age-related macular degeneration (AMD). The causes of corneal blindness include lack of donor tissue, repeated graft failure, and ocular trauma and diseases. However, over the past few decades keratoprostheses have become available which can address most of those problems and their implantation is becoming a mainstream component of modern ophthalmic surgery.

Since Pellier de Quensqy first suggested the use of a piece of glass as a substitute cornea in 1789, many designs of keratoprostheses have come and gone, but only two have stood the test of time and are in wide use today. They are the Boston type 1 KPro, formerly known as the Dohlman-Doane keratoprosthesis and the osteo-odonto-keratoprosthesis (OOKP).

The two devices differ in design and indication, each filling distinct niches. The Boston KPro type 1 uses a donor corneal button as a skirt for the optic and is primarily indicated in eyes which have a history of repeated graft failure and which have normal tear and blink function.

The OOKP uses dental and alveolar bone overlaid with buccal mucous membrane as a carrier for the optic. Its primary indications are patients with bilateral corneal

blindness resulting from severe end-stage corneal disease, chemical burns and dry keratinised eyes.

The Boston keratoprosthesis The Boston KPro type 1 was originally developed by Claes Dohlman MD, Harvard Medical School, in the 1960s, but was not FDA-approved until 1992. The device has a collar button design with a PMMA front plate and optic, and a PMMA or titanium back plate which sandwich around a donor button of corneal tissue which is sutured into the recipient’s eye.

The device’s 5.5mm diameter front plate also includes a 3.35mm diameter stem, which is the optical portion of the keratoprosthesis and fits through the 7.0 or 8.5mm diameter back plate. The back plate has fenestrations to allow nutrition of the cornea, and is held in place with a titanium locking-ring.

In addition to repeated failed corneal grafts, other indications for the Boston KPro type 1 include vascularised corneas, aniridia and Peter's anomaly in paediatric eyes. The keratoprosthesis requires a wet blinking eye with good lid function and good tear film to preserve a healthy ocular surface and prevent degradation of the implant and infection.

Implantation of the Boston KPro is carried out in essentially the same way as a conventional keratoplasty, the only important additional step is the assembly of the keratoprosthesis/donor button complex.

Postoperative care includes lifetime treatment with topical antibiotics, usually a fluoroquinolone and vancomycin, to eliminate the possibility of endophthalmitis. In addition, all patients use a bandage contact lens over the keratoprosthesis to prevent the donor tissue from drying out and melting around the neck of the KPro.

In the major clinical trials reported to date, the average retention rate after a follow-up of one year has been 91 per cent, ranging from 82 per cent to 100 per cent. In eyes with at least one year's follow-up, two-thirds of patients have achieved a BCVA of 20/200 or better, and around 44 per cent have achieved a BCVA of 20/50 or better.

The major postoperative complication reported in the studies has been retroprosthetic membrane, which has occurred in about 40 per cent of eyes but has generally proved amenable to treatment with a YAG laser. The most serious complication to occur has been infectious endophthalmitis which has occurred in three per cent of eyes, overall. However, there have been no cases of endophthalmitis in the studies conducted since the adoption of lifelong vancomycin.

Another frequent complication is IOP elevation, the incidence of which can be reduced by preventive measures such as placement of a tube shunt prior to or during the implantation procedure. Less frequent complications have included stromal melt, retinal detachment and sterile vitritis.

Long in the tooth The osteo-odonto-keratoprosthesis is one of the oldest and most successful of artificial corneas. Originating from a design by Strampelli in the 1960s, and later improved upon by Falcinelli in the 1980s and 90s, a high proportion of the original patients implanted with the modified design (MOOKP) have obtained useful vision from their keratoprostheses for decades.

However, the OOKP procedure is very specialised and time-consuming, and must be performed in two stages. As a result, the use of the OOKP is generally restricted to patients with bilateral corneal blindness resulting from such conditions as severe end-stage Stevens-Johnson syndrome, ocular cicatricial pemphigoid, chemical burns, trachoma, and those with dry eyes.

In the first stage of surgery, the tooth and periodontal bone, with the optic in place, is sutured into a sub-muscular pocket to allow soft tissue to grow into it. The patient also undergoes suturing of the mucous membrane flap onto the sclera at this point.

In the second stage of surgery, which takes place two-to-three months later, the surgeon removes the implant from the sub-muscular pocket, reflects mucous membrane graft, trephines the cornea, removes the iris, lens and anterior vitreous, and then sutures the implant into place. The mucous flap is then reattached with a trephined hole through which the optical cylinder protrudes.

Falcinelli has reported a retention rate for the OOKP of 85 per cent at 18 years and BCVA ranging from 0.41 to 0.8. In our series of 32 patients, the retention rate at 3.9 years of follow-up has been 72 per cent, with resorption of the lamina the main cause for failure. The BCVA in our series was 6/60 or better in 78 per cent, and 6/12 or better in 53 per cent and 61 per cent of cases retained best-achieved vision throughout the follow-up period.

Aftercare of the OOKP is less intensive, particularly in terms of antibiotic usage. That is because the mucous membrane seals in the bone parts very well. Therefore patients only require a nightly application of antibiotic ointments. On the other hand, eyes with the OOKP are equally prone to complications such as glaucoma, retinal detachment as are eyes with the Boston KPro.

Future improvements in keratoprosthesis design and surgical technique are likely to lead to improvements in visual outcomes and retention of the devices. But already, modern keratoprostheses have revolutionised corneal surgery by enabling the restoration of vision in cases where it previously would have been impossible.

Christopher Liu – cscliu@aol.comJames Chodosh – James_Chodosh@meei.harvard.edu

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RESTORING SIGHTKeratoprostheses are becoming a mainstream part of corneal surgeryby Christopher Liu FRCOphth and James Chodosh MD, MPH

48 News

RESEARCH

Cross sectional anatomy of OOKP

Steps in buccal mucous membrane harvesting, preparation of the OOKP lamina, and appearance of the OOKP eye after completion of surgery.

Modern keratoprostheses have revolutionised corneal surgery by enabling the restoration of vision in cases where it previously would have been impossible

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EUROTIMES_June 2012 ads_Layout 1 5/3/12 3:32 PM Page 1

When a posterior capsule rupture (PCR) is noted prior to nucleus removal, the aim of the surgery

should be to try and remove the nucleus in a safe manner without allowing any pieces to drop into the vitreous (Fig 1A). Various techniques have been described to try and prevent a nucleus drop after PCR. This includes innovative techniques such as the HEMA lifeboat proposed by Dr Keiki Mehta, phacoemulsification using a Sheet's glide etc.

The IOL Scaffold described by Prof Amar Agarwal is a technique recently introduced for utilising in such a situation. This involves using an IOL as a scaffold beneath the nuclear pieces to prevent them from falling into the vitreous cavity. This technique is suitable for retained fragments up to hemi-nuclei or soft whole nuclei. In case of large hard nuclei, removal of the fragments via an extended corneal section is still preferred.

When a PCR is noted, it is essential not to reflexively pull out the phaco probe in a panic. The second hand should be used to instil a dispersive viscoelastic into the anterior chamber via the side port before withdrawing the probe. This prevents a sudden shallowing of the anterior chamber, extension of the posterior capsular rent and vitreous loss.

In case of a PCR with an intact anterior hyaloid face, a breach in the hyaloid face may be prevented by this simple step. The dispersive OVD is also instilled over the rent with the dual objective of preventing further vitreous loss as well as to act as a scaffold to prevent nuclear fragments from falling posteriorly into the vitreous cavity. The fragments may be further tackled by IOL scaffolding, depending on the size and density of the nucleus.

In this technique, the nuclear pieces are first brought up into the anterior chamber and placed temporarily over the iris prior to phacoemulsification. Preservative free triamcinolone acetonide is then used to stain the vitreous, and anterior vitrectomy is performed using low flow settings. Epinucleus and cortex aspiration are carried out using the vitrector probe, switching between cutting and aspiration modes (Fig 1B, C, D). Adequacy of capsular sulcus support is assessed.

The IOL is then pre-placed and utilised as a scaffold after coating the cornea with dispersive viscoelastic. This is done after enlarging the main port minimally to allow the

leading haptic of the IOL to be injected gently and in a controlled manner into the anterior chamber over the iris and under the nuclear fragments. While injecting, the injector tip should be placed within the anterior chamber and wound assisted implantation should be avoided to prevent uncontrolled entry and consequent drop of the IOL into the vitreous. A globe stabilisation rod may also be placed through the side port under the IOL optic to stabilise the IOL as it unfolds in the anterior chamber (Fig 2A).

In cases with a good pupillary tone and a pupillary size between 5.0 to 6.0mm, the second haptic may also be placed over the iris under the nucleus fragment (Fig 2B). If not, and in cases of floppy iris syndrome, the second haptic is allowed to trail outside the eye through the main port and the surgeon centres the optic over the pupil by engaging it at the haptic-optic junction using a dialler.

The nuclear fragments are then emulsified over the optic, which acts as a scaffold and prevents fragments from falling down while being emulsified (Fig 2C,D). The optic also compartmentalises the eye and prevents vitreous from further prolapsing into the anterior chamber or getting aspirated into the phaco probe during emulsification. It further acts to divert the irrigation fluid away from the vitreous cavity thus preventing hydration and prolapse of the vitreous. The torn posterior capsule is kept safely away from the phaco probe and chances for the anterior capsular remnants getting accidentally aspirated into the phaco probe are decreased. Once the fragments are emulsified, the IOL is dialled into the sulcus and any further anterior vitrectomy if required is performed.

If capsular support is not adequate for sulcus fixation of the IOL, the IOL scaffold technique can still be performed and the IOL can be secondarily fixated to the sclera via a glued IOL technique. In this case, diametrically opposite lamellar scleral flaps are created at the beginning of surgery and the IOL scaffold technique as described previously is then proceeded with. Once the nuclear fragments have been removed, 20-gauge sclerotomies are created under the scleral flaps and the haptics of the IOL are exteriorised under the scleral flaps using the handshake technique. They are then tucked using the Scharioth intra-scleral tuck into 26-gauge tunnels made at the edge of the scleral flaps and the flaps are sealed with glue.

EUROTIMES | Volume 17 | Issue 6

NUCLEUS DROPProper management of a posterior capsular rent is vital to avoid complicationsby Soosan Jacob MD

50 News

EYE ON TECHNOLOGY

Fig 1A: A posterior capsular rent is seen with retained cortex, epinucleus and a retained nuclear fragment. Flaps seen are for later fixation of a glued IOL due to the absence of an adequate

capsular support in this case

Fig 1C: The nucleus is supported by the vitrector and is brought forwards into the anterior chamber

by posterior assisted levitation

Fig 2C: The IOL acts as a scaffold supporting the pieces during emulsification and preventing drop into the vitreous cavity

Fig 2A: The IOL is injected gently over the iris while a globe stabilisation rod stabilises it from below. The leading haptic is

placed on the iris and the second haptic is allowed to trail outside the corneal incision

Fig 1B: The vitrector probe is used to perform anterior vitrectomy and remove cortex and epinucleus by alternating it

between cutting and aspiration modes. The vitrector may also be introduced through a corneal incision

Fig 1D: The nucleus is placed temporarily on the iris surface before proceeding with the IOL scaffold technique

Fig 2D: The IOL scaffold also acts as a barrier and decreases vitreous hydration and prolapse, vitreous aspiration into the phaco

probe as well as unintentional damage to the capsular remnants during emulsification. After nucleus emulsification, the haptics

are dialled into the sulcus or secondarily fixated depending on the degree of capsular support

Fig 2B: In case of pupils with a good tone and a size between 5-6mm, the second haptic may also be placed over

the iris underneath the nuclear fragment

Dr Soosan Jacob is a senior consultant at Dr Agarwal’s Group of Eye Hospitals, Chennai, India.

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EUROTIMES | Volume 17 | Issue 6

Bo Philipson and Jack Holladay were warmly welcomed by delegates attending the 2012 ASCRS Congress when they

received awards recognising their outstanding achievements.

In recognition of his prominent role advancing cataract and refractive surgery in Sweden and Europe, incoming ASCRS president David Chang MD welcomed Bo T Philipson MD, PhD, Stockholm, Sweden, as an Honored Guest .

“Dr Philipson also played a key role in

the development of the first OVD as well as heparin-coated IOLs, and the Technis diffractive multifocal IOL,” Dr Chang said.

Dr Chang also noted Dr Philipson’s service as a leader, founder and programme chair of the ESCRS, his extensive lecturing and surgery in more than 20 countries, his leadership of the Ophthalmology Department at Sweden’s prestigious Karolinska Institute and his founding of the Ögonklinik, now Sweden’s largest private eye clinic. “He has educated a generation of Swedish cataract surgeons and led the

efforts to adopt phaco emulsification, intraocular lens implantation and corneal refractive surgery in his home country.”

Accepting the honour, Dr Philipson expressed his gratitude for the opportunities he had to improve ocular surgery and those who supported his efforts. “I am very fortunate to be of the group to have experienced the evolution of cataract and refractive surgery from intracapsular surgery to the modern very advanced surgery. It’s been very fascinating. This shift of surgical technique and the improvement

of outcome have been made possible by the excellent teaching facilities that ASCRS and ESCRS have provided to us.”

Hall of Fame Internationally known for his pioneering work in optics, including brightness acuity tester for assessing the impact of glare on vision and widely used IOL power calculation formulae, Jack T Holladay MD, MSEE, FACS, was inducted into ASCRS’ Ophthalmology Hall of Fame. In an emotional address to the opening session of the ASCRS Symposium, Dr Holladay thanked colleagues for their support following high-risk aortic surgery in 2010.

Dr Holladay, who is a member of the EuroTimes International Editorial Board, has contributed immensely to improving the understanding of optics in ophthalmology, including glare testing, interpretation of corneal topography and the nature of astigmatism, said Douglas Koch MD, Houston, US. His IOL consultant power calculation software that takes into account factors such as corneal transplants and refractive surgery have improved vision outcomes for cataract patients around the world.

Dr Holladay spoke from the perspective of one who came close to death. His operation to correct an aortic aneurysm involved lowering his body temperature enough for him to survive cutting off blood flow to his brain for about 20 minutes during the procedure, followed by an eight-day coma, he said.

Though he is still a clinical professor at Baylor College of Medicine, he no longer treats patients. “After 37 years in ophthalmology I had to retire because I wasn’t quite the same after the operation. Looking back, the things I think about are not the patients, not the papers, none of those things, really, it’s the teaching,” said Dr Holladay.

ASCRS HONOURS INNOVATORSBo Philipson and Jack Holladay, two of the great innovators in ophthalmology, have been honoured by ASCRSby Howard Larkin in Chicago

52 News

ASCRS AWARD

From the Archive

A new diagnostic test using anterior chamber optical coherence tomography (AC OCT) can help to reduce the risk of pigment dispersion syndrome arising from the implantation of certain phakic intraocular lenses (IOLs),

according to a French ophthalmologist.Addressing the XXII Congress of the ESCRS, George Baikoff MD

said that pigment dispersion is one of the primary complications associated with implantation of a phakic IOL, especially in hyperopic patients.

"In our clinical experience with the Artisan-Verisyse lens (AMO

Inc), we observed very few cases of pigment dispersion in our series of myopes but quite a high percentage in our hyperopic patients. There are very few explanations for this in the published literature. The only real guidelines are that we have been advised to avoid implanting Artisan/Verisyse lenses in hyperopic patients with shallow anterior chambers or with irises that are described as ‘too convex’,” said Dr Baikoff, Clinique Monticelli, Marseilles, France.

* This article was first published in June 2005 in Volume 10 Issue 6 of EuroTimes.

Anterior chamber OCT device quanti� es risk of phakic IOL-related pigment dispersion system

Bo Philipson (left) and Jack Holladay (right) speaking at the 2012 ASCRS Congress in which they both received awards in recognition of their oustanding achievements

EUROTIMES | Volume 17 | Issue 6

The ESCRS has helped to prevent the spread of diseases such as cholera and trachoma in the Kitgum and Lamwo

districts of Uganda by developing new sustainable water supplies and empowering communities to manage these resources through training schemes and public health initiatives.

Oxfam Ireland’s chief executive Jim Clarken said: “The generosity of ESCRS members and the ESCRS Board has delivered real change to the communities of Kitgum and Lamwo. By supporting Oxfam and our partners in the Water, Sanitation and Hygiene Promotion (WASH) project, ESCRS has provided effective and sustainable water sources as part of a major investment in public health. On behalf of the individuals and communities of Kitgum and Lamwo, we are sincerely grateful for your continued support of Oxfam.”

Thanks to ESCRS, Oxfam and its WASH partners can help a community rebuild itself as families return following a 20-year conflict between rebels and government forces that forced them to flee and live in camps.

Poor access to latrine and sanitation facilities coupled with a lack of information about the importance of good hygiene lead to unnecessary illnesses and deaths from diseases such as cholera and diarrhoea. Investment by ESCRS has helped combat the spread of these water-borne diseases along with water-washed diseases that affect the eyes, such as trachoma and conjunctivitis.

Other achievements supported by ESCRS to date include: n Safe water coverage in Kitgum and

Lamwo districts now stands at 84 per cent and 91 per cent respectively – meaning both districts are well above the current national rural rate of 64 per cent;

n Oxfam has helped train and certify 150 male and female hand pump mechanics in skills required to operate and maintain solar-run systems. This ensures prompt, reliable and affordable maintenance of water sources;

n To support public health, 150 certified health policy monitors in Kitgum are now active in the local counties;

n The District Water Quality Laboratory is fully operational in Kitgum and serving both districts;

n A community-based water resource manager has been put in place in the two counties and they are developing water, sanitation and hygiene implementation manuals;

n A community-based sanitation and hygiene promotion has helped educate villagers about the importance of safe hygiene practices;

n Both districts have a new system in place to make hand pump spare parts available to the community at a reasonable price, ensuring the pumps are never out of use;

n In Lamwo, Oxfam worked with government staff to develop a community-based water resources management system. Following this, Oxfam trained and equipped 117 water user committees (with 48 per cent female membership).

This continuing collaboration between ESCRS, Oxfam and local community organisations has provided a successful model for similar projects that empower communities to independently manage key public health infrastructure, while also combating the spread of diseases.

Deirdre Miller – deirdre.miller@oxfamireland.org

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SUPPORTING OXFAMESCRS is providing public health information to communities in need, through partnership

53News

OXFAM

Successfully testing the water pumping system

A typical motorised water system in northern Uganda

A solar water pump house newly built in Lokung

Imag

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ourte

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f Oxf

am

Investment by ESCRS has helped combat the spread of these water-borne diseases along with water-washed diseases that affect the eyes, such as trachoma and conjunctivitis

EUROTIMES | Volume 17 | Issue 6

Manfred Tetz MD vividly recalls the day in May 2003 he opened his private practice in Berlin. “I saw one patient that

day. It is quite different these days.”Today, Eye Centre Spreebogen is staffed

by two full-time ophthalmologists in addition to Prof Tetz. There are also three part-time colleagues for specialised work such as retina and strabismus, and a few affiliated surgeons who use the clinic’s facilities for private patients. The practice sees a full range of patients, from cataract and refractive to glaucoma and retina. Payment for services comes from a variety of sources: Germany’s public and private insurance systems as well as domestic and international self-pay patients for non-covered services.

Despite an uneven economy, practice volume has grown steadily at about 10 per cent annually, says Prof Tetz, who recently joined the ESCRS Practice Development Committee. He believes his success is primarily the result of recommendations from previous patients.

“My philosophy on growth has always been organic, based on good quality service. We did a survey on what is most important to patients in terms of choosing a practice, and number one is word-of-mouth recommendations. It is very interesting, but not surprising. When I see a colleague in another medical field, it is usually based on a recommendation of someone I know,” Prof Tetz says.

A good website also helps, Prof Tetz adds. He believes that the most effective site provides easy access to information about eye conditions, procedures and the

practice, but isn’t too complicated. “The more educated patients will not go by the fanciest website with whistles and bells; they want a clean website that provides basic information and doesn’t drown them with too much information. It is a narrow line to walk between informative and innovative but not getting into overkill.”

But the best website in the world isn’t much good without satisfied patients, Prof Tetz says. “The old rules still hold. Good quality service and a good reputation attract new business.”

Full service spurs growth Prof Tetz believes that offering a full range of ophthalmic services has helped keep his clinic growing. “My approach to developing the business is to provide all segments of surgical, medical, and diagnostic ophthalmology, and not do a monoculture of laser, refractive laser or cataract. These monocultures may be very redeeming for a time, but they are very sensitive to changes in the legal system, changes in coverage by health insurance companies, and changes in the economy.”

Some surgeons who “retired” to refractive corneal surgery did well for a few years, but were forced to go back to general ophthalmology when the economy deteriorated, Dr Tetz notes. “Making the switch back from refractive surgery is more difficult than maintaining a full-service practice.”

In his own practice, laser refractive surgery has been a steady, but relatively small, business, Prof Tetz says. His growth area is lens-based refractive surgery, including toric, multifocal and phakic

IOLs, which have steadily grown in both absolute and proportional terms in recent years. These lenses got a boost in January, when a new law allowing surgeons to charge publicly insured patients extra for premium lenses took effect in Germany. Previously, regulations varied from state to state, but in general this was prohibited, and cataract services had to be paid entirely by insurance or entirely out-of-pocket, Prof Tetz notes.

Overall, private practice is growing in Germany, in part because many new technologies, including diagnostics such as HRT and OCT, are not covered by public insurers, who still cover about 90 per cent of patients, Prof Tetz says. He believes that Germany is moving toward a system in which public insurers provide basic coverage, but advanced services increasingly will be paid out-of-pocket.

“In Italy, Spain and Greece it is common knowledge that you needed to pay privately if you wanted better service, but in Germany we try to regulate everything as much as possible. Private practice always existed here, but the rules are getting more

permissive. It is very hard to get more money into the public system and it cannot cover all of the innovations in medicine and ophthalmology,” Prof Tetz says.

Flexibility required Of course, self-pay patients generally demand more for their hard-earned euro. “I think private practice is going to grow, but a lot of my colleagues do not like the extra time and effort of dealing with the patient. There is no way to do good refractive if you don’t spend extra time pre- and post-surgery, and extra chair time and extra follow up. If you are not willing to do it, you will not succeed,” Prof Tetz says.

To accommodate the greater demands of private pay patients, Prof Tetz sees them in a separate location, or at different times if two locations aren’t possible. He also separates surgical and non-surgical patients. “The worst thing for a patient who is going for an operation and hasn’t slept is to come into a waiting room with 30 people, and wonder when they will be called.”

Staff also must be trained to be more flexible in dealing with private patients, and to provide information on services and new technologies, Prof Tetz notes. This requires good “soft skills” of practice leaders to help shape the culture of the practice into a service-oriented team.

Willingness to change operations – and even partners – as practice needs change is also key for surgeons, Prof Tetz adds. Over time, he has brought in a clinic manager and outsourced private billing and other administrative functions to allow his staff to focus more on patient service.

“When I first started, I hired a team of good people and thought we would stay together until we died. The first thing I had to learn is there is always fluctuation on a team. Adapting to circumstances requires refreshing elements of the team, and it is quite natural,” Prof Tetz says. “You have to change steadily to remain stable. It is not guaranteed that things will get better if they change, but if you want things to get better, you have to change.”

Manfred Tetz – manfred.tetz@atk-spreebogen.de

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DECADE OF GROWTHDiverse services, excellent care, and word-of-mouth build private practiceby Howard Larkin

54 Feature

PRA CTICE DEVELOPMENT

A GLOBAL VIEW OFOPHTHALMOLOGY AT

www.eurotimes.orgOur new mobile website is designed for tablets and smartphones and includes content from the print edition of the magazine.

Over the coming months we will be enhancing and improving the digital version to help meet your needs.

Visit the new EuroTimes mobile website at

http://m.eurotimes.org

It is not guaranteed that things will get better if they change, but if you want things to get better, you have to change

“

Manfred Tetz MD

EUROTIMES | Volume 17 | Issue 6

109-year-old cataract patientRayner has announced that after enduring a decade of poor vision, 109-year-old Guo Liansheng has been given back the gift of sight. “Before implantation of a Rayner IOL, Madam Guo struggled to detect even the vaguest light changes. Afterwards, she was able to look into her eight-month-old great-great-granddaughter’s eyes for the first time,” according to a press statement released by the company.n www.rayner.com

SRD Vision Scientifi c Advisory BoardGeorge O Waring IV MD, has agreed to be a scientific advisor to SRD Vision, LLC. Dr Waring is an assistant professor of ophthalmology, the director of refractive surgery at MUSC Storm Eye Institute and serves as the medical director at Magill Vision Center. n www.srdvision.com

Th romboGenics re-submits BLA with US FDA ThromboGenics has resubmitted a Biologics License Application (BLA) with the US Food and Drug Administration (FDA) for ocriplasmin intravitreal injection, 2.5 mg/mL, for the treatment of symptomatic vitreomacular adhesion (VMA) including macular hole.

In February 2012, the FDA indicated that it intended to assign a Priority Review designation to the original BLA submission for the same indication filed in December 2011. A company spokeswoman said the re-submission will allow ThromboGenics to meet the FDA’s Priority Review timelines and to manage the phasing of its resources to support both its European and US ocriplasmin filings. n www.thrombogenics.com

ILUVIEN marketing authorisation in Austria Alimera Sciences has announced that the Austrian Agency for Health and Food Safety, (Osterreichische Agentur fur Gesundheit und Ernahrungssicherheit (AGES), has granted marketing authorisation to ILUVIEN for the treatment of vision impairment associated with chronic diabetic macular edema (DME) considered insufficiently responsive to available therapies.

“We are excited to receive this marketing authorisation and pleased that DME patients in Austria will have this therapy available to them. We look forward to receiving the additional expected approvals from the UK and other concerned member states as we continue on track with our commercialisation plans in the EU,” said Dan Myers, president and chief executive officer, Alimera Sciences.n www.alimerasciences.com

55Feature

INDUSTRY NEWSRecent developments in the vision care industry

WaveLight EX500 Excimer LaserAlcon introduced its latest innovation in LASIK surgery technology, the WaveLight® EX500 excimer laser, during the 2012 American Society of Cataract and Refractive Surgeons (ASCRS) annual meeting in Chicago, Illinois. This is the first refractive surgery innovation that Alcon has unveiled since its merger with Novartis in April 2011.

“When Novartis acquired Alcon in 2011, we committed that our combined strength would provide additional benefits to our customers and their patients, delivering better services and bringing innovation to the market faster,” said Stuart Raetzman, area president, Alcon US. “The new WaveLight EX500 excimer laser is the first refractive surgery innovation to be offered by the new Alcon. It provides enhanced customisation for our customers – saving time and delivering excellent refractive outcomes.”n www.alconsurgical.com

Ocular Response AnalyserReichert Technologies has introduced the new all-in-one Ocular Response Analyser (ORA). A company spokesman said Reichert had pioneered the measurement of corneal biomechanical properties with the development of Corneal Hysteresis and Corneal Compensated IOP (IOPcc), and is now pleased to present the next generation ORA.

The improvements made to the new ORA will further enhance its clinical utility and relevance, said product manager David Taylor. “We have worked closely with opinion-leading ophthalmologists and optometrists around the world for a decade in the development and improvement of this device,” he said. “We are thrilled to incorporate what we have learned into the new model and look forward to bringing this exciting technology into many more practices.”

The new ORA is available directly from Reichert in the US and through authorised Reichert distributors internationally.n www.reichert.com

Coloured Ring OptionsVolk Optical is now offering its Digital Series lenses with new coloured ring options for easy identification and organisation. “The Digital Wide Field, High Mag and Clear Field can now be ordered in standard Volk blue, or with a choice of black, red, silver, gold, purple, or green finish.

Coloured rings can help practitioners easily distinguish their lenses from those of their colleagues or to identify one style of lens from another with just a quick glance. It’s also a convenient way to organise larger practices by colour coding the lenses in each exam room,” said a Volk Optical spokeswoman.n www.volk.com

Corneal collagen crosslinkingSCHWIND eye-tech-solutions says the company is the first and only manufacturer of excimer laser systems to offer the integrated SCHWIND CXL-365 vario system for corneal collagen crosslinking (CXL).

“CXL using ultraviolet A (UVA) light and riboflavin (vitamin B2) was introduced as a clinical application to stabilise the cornea by inducing crosslinks within and between collagen fibres. CXL has been investigated extensively and has been shown clinically not only to arrest the progression of keratoconic or post-LASIK ectasia but also to exert a moderately positive effect on visual status,” said a company spokeswoman.n www.eye-tech-solutions.com

56

EUROTIMES | Volume 17 | Issue 6

Cataract fundamentals Cataract surgery – it’s the procedure that unites nearly all eye doctors, and it’s the primary surgical task to master for every young ophthalmologist.

Every year, trainees across the world embark on a process of learning that will eventually allow them to operate independently. The learning process is complex, as the procedure itself is deceptively difficult. Becoming proficient usually takes several years, extending well into our professional lives after we have completed our training.

Experienced surgeons might take phacoemulsification skill for granted. After thousands of operations, the steps and the logic behind them, have become second nature. But residents, having diagnosed the many possible complications during call in the emergency room – capsular rupture, dropped nucleus, endophthalmitis – are understandably anxious when first offered the chance to introduce sharp or aspirating instruments into an eye.

Indeed, the old saying, “See one, do one, teach one,” does not seem to apply for cataract surgery as it does for the treatment of a chalazion. Most residents in surgical programmes will see 100 or more expertly performed procedures before being handed a scalpel. Then, they’ll be expected to perform a similar amount on their own before earning the title of ophthalmologist. Teaching comes much later, and then only to a select few who have truly mastered the procedure.

So how does one get started? The quick steps performed by mentors move so smoothly and look so easy that a trainee might miss a great deal of the sequence, precision and detail. That is, if they’re not prepared ahead of time with a basic mental map of the steps: What happens? When? Why? And it’s not only what’s going on inside the eye that counts.

How to set up and use the equipment – the operating microscope and the phaco machine and their respective foot pedals – is not self-evident, nor is the proper preoperative preparation of the patient.

This is where “Phaco Fundamentals: A Guide for Trainee Ophthalmic Surgeons” comes in. Written by Matthew Anderson and Jeremy Butcher, this book guides the reader through every stage of a cataract operation in an extremely simple, step-by-step manner. Covering the material in under 100 pages, with well over 100 intraoperative photographs and simple drawings, the book

treats each distinct step in its own chapter and is intended to equip the trainee with the knowledge required to complete his or her phaco from start to finish.

For example, “The Corneal Section” discusses the keratome, the multiplanar wound, and a few “helpful points” to remember. “The Capsulorhexis” introduces the reader to the various instruments available, the technique itself, and how to avoid potential pitfalls, like peripheral extension of the rhexis under the iris. Each of the steps is covered in this manner. The last chapter, “Final Steps,” reminds us to inform the patient that we are about to remove the speculum, so as to avoid startle, and to make sure that the patient’s hair isn’t yanked out when removing the drape. Each of the 13 chapters is about eight pages long – enough to cover the main points and get the reader closer to the goal of memorising and understanding the basics without getting bogged down by minutiae.

Thankfully, the authors avoid data, percentages, precise measurements, and other details unlikely to be of immediate use during the procedure itself. Further, theoretical and philosophical considerations are left for other texts, as are anatomical facts and figures. The authors assume that the reader has the knowledge expected of those who will be allowed to operate.

This book is useful for ophthalmology residents, fellows in the early part of their training, and surgeons responsible for teaching cataract surgery. For the latter group, a review of the very basic steps outlined in this book might give the teacher insight into just how little a beginning surgeon might know. Further, training programmes might be interested in acquiring a few copies as required reading prior to their trainees’ surgical rotations.

Visit our website http://youngophthalmologist.escrs.org

to fi nd out more about the new ESCRS Observership Programme.

n The ESCRS has developed a grant programme to support European trainee ophthalmologists who wish to observe clinical practice in a hospital or university setting.

n The society is currently seeking interest from centres willing to offer observerships of one-to-two weeks’ duration in cataract and/or refractive surgery.

n Those centres wishing to participate will be added to a database of centres available on this website.

Young Ophthalmologists’Resource Centre

Feature

BOOK REVIEW

BOOKS EDITORLeigh Spielberg

PUBLICATIONPHACO FUNDAMENTALS: A GUIDE FOR TRAINEE OPHTHALMIC SURGEONS

AUTHORSMatthew Anderson & Jeremy Butcher

PUBLISHED BY MATADOR

57

EUROTIMES | Volume 17 | Issue 6

CONTROVERSIES IN CATARACTAND REFRACTIVE SURGERY 2012

Sunday, September 9, 2012

14.00–16.00

Intraoperative Aberrometry: Of Value or Not Proven?

Pediatric Refractive Surgery:LVC or pIOL?

Femtosecond Cataract Surgery Outcomes:An Advance or Not?

Chairs: Emanuel S. Rosen, MD, FRCSEd,Thomas Kohnen, MD, PhD, FEBO

JCRS Symposium

During the XXX Congress of the ESCRS, Milan, Italy

System combines Scheimpflug and Placido topographerOphthalmic surgeons have an array of methods available for calculating the power of an intraocular lens (IOL) to be implanted in cataract surgery, including Placido-disk corneal topography, automated keratometry, Scheimpflug camera imaging, and dual Scheimpflug camera imaging combined with Placido-disk corneal topography. Researchers now report comparative results obtained with a new system that combines a Scheimpflug camera with Placido-disk corneal topography, Sirius (Costruzione Strumenti Oftalmici). They compared the system in 38 eyes of 38 patients having phacoemulsification and in-the-bag IOL implantation. The calculated IOL power using the Hoffer Q, Holladay 1, and SRK/T formulas; the axial length, as measured by ultrasound immersion biometry; and three corneal power measurements: validated topographer simulated keratometry (K); combined Scheimpflug camera–topographer simulated K (derived from anterior corneal curvature only); combined Scheimpflug camera-topographer mean pupil power (derived from anterior and posterior corneal curvatures through ray tracing). When the corneal power measurements from the combined Scheimpflug camera-topographer were used, the mean absolute error (MAE) ranged between 0.23 D ± 0.24 (SD) (simulated K and Hoffer Q formula) and 0.33 ± 0.23 D (mean pupil power and SRK/T formula). There were no statistically significant differences between the MAE generated by the simulated Ks of the two devices with any of the three formulas.n G Savini et al., JCRS, “Accuracy of corneal

power measurements by a new Scheimpflug camera combined with Placido-disk corneal topography for intraocular lens power calculation in unoperated eyes,” Vol 38, No. 5, 787-792.

Driving with blue toric IOLsEarly studies have suggested a benefit of non-toric blue light-filtering intraocular lenses (IOLs) when driving in glare conditions. Researchers investigated whether this also was the case for toric blue light-filtering IOLs. Using a driving simulator, researchers studied 18 patients with a toric ‘blue blocker’ and 15 patients with a non-toric ‘blue blocker’ IOL. The safety margin was defined as the time to collision less the time taken to turn at an intersection with oncoming traffic. In the presence of glare, patients with toric IOLs had significantly greater safety margins than patients with control IOLs, and significantly lower glare susceptibility (P<.05). In no-glare

and glare conditions, patients with test IOLs had significantly lower glare susceptibility than patients with control IOLs. The blue light-filtering toric IOL produced a significantly greater reduction in glare disability than the UV-only filtering non-toric IOL and increased the ability of drivers to navigate in low-sun conditions.n R Gray et al., JCRS, “Effects of a blue light-

filtering intraocular lens on driving safety in glare conditions”, Vol 38, No. 5, 816-822

Pinhole contactsThe Kamra intracorneal inlay (AcuFocus) increases depth-of-focus through small-diameter aperture optics to correct presbyopia. Questions remain about the optimal design of such systems. Accordingly, researchers evaluate the effects of four different contact lens-based artificial pupil designs on visual performance in 33 presbyopic patients. The mean uncorrected and corrected distance visual acuity ranged from 0.04 ± 0.05 (SD) to −0.01 ± 0.04 logMAR and from −0.02 ± 0.05 to −0.05 ± 0.03 logMAR, respectively. The uncorrected near visual acuity and distance-corrected near visual acuity ranged from 0.37 ± 0.11 to 0.42 ± 0.20 logMAR and from 0.35 ± 0.17 to 0.38 ± 0.12 logMAR, respectively. The difference in binocular distance contrast sensitivity was statistically significant between the pinhole systems and the control group (distance-corrected patients without pinhole lens) for six cycles per degree (cpd), 12 cpd, and 18 cpd. For near vision, differences were also significant for 3 cpd at the two luminance levels (P<.05). Stereoacuity values for near vision were not significantly different between the four pinhole systems (P>.05). The researchers conclude that soft contact lens apertures provide good visual acuity at distance, functional intermediate vision, and poor near visual acuity and stereoacuity. An improvement in visual performance with decreasing pupil diameter was not found.n S García-Lázaro et al., JCRS, “Visual function

through 4 contact lens-based pinhole systems for presbyopia”, Vol 38, No. 5, 858-865.

Thomas KohnenASSOCIATE EDITOR OF JCRS

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

Review

JCRS HIGHLIGHTSJournal of Cataract and Refractive Surgery

EUROTIMES | Volume 17 | Issue 6

La Scala La Scala has been a musical Mecca since it opened in 1778 on the site of a ruined church called Santa Maria alla Scala. The world's greatest artists have appeared here before an audience so famously expressive, it even dared to hiss the legendary Maria Callas during a performance of Medea. She quick-wittedly screamed the next words of the libretto directly across the footlights – “Oh cruel! Haven't I given you everything?” – and earned a prolonged ovation.

In the 18th century, a horseshoe-shaped hall was thought to offer the best acoustics. Sight lines were not a consideration because audiences came to the opera principally to see and be seen. When, in 2001, La Scala closed for three years for extensive renovation the already excellent acoustics were improved but nothing could be done about the sight lines. Views from many seats at La Scala, even expensive ones, are

restricted and some offer no glimpse of the stage at all. Today, La Scala's website offers a virtual view from each seat so that online ticket buyers at least, can avoid surprises.

The premiere of the ballet, Onegin, choreographed by John Cranko to music by Tchaikovsky, opens at La Scala on September 7th, with performances at 20:00 from 10 to 18 September. Tickets go on sale online from 9:00 on 28 June. The production stars the acclaimed Italian ballet dancer, Robert Bolle. You'll find a calendar of performances and online booking facilities at www.teatroallascala.org.

Behind the scenes If you love not only music of the opera but the costumes and sets as well, you'll want to take the tour of the Ansaldo workshops at Via Bergognone, 34. A specialist will guide you on a visit to the set design workshops and the areas devoted to costumes – their

creation, fitting, maintenance and storage. More than 60,000 garments belonging to over 280 productions are warehoused over a 1,400 square metre area. You'll also see the two practice rooms. One is for the chorus and the other, the same size as the theatre's stage, is where directors set up their first movements for new productions. Tours are on Tuesday and Thursday at 15:00 for individuals. Tickets costs €5. Booking is obligatory. Contact CIVITA at telephone +39.02.4335.3521 or by e-mail at servizi@civita.it.

Theatre museum An eclectic collection of memorabilia bequeathed to La Scala in 1952 by the writer and opera enthusiast Giulio Sambon is displayed here in an intimate setting. The entrance to La Scala museum is to the left of the theatre building

There are two floors of exquisite musical instruments, including the first spinet owned by Verdi, busts, statuettes and portraits of famous musicians and actors, theatre costumes, and a 40,000-volume theatrical library. It is also home to a variety of curiosities like Verdi's funeral mask, Puccini's watch, a lock of Mozart's hair, and a cast of Chopin's hand. When the stage of La Scala is not in use for rehearsals, you can enter a theatre box directly from the museum for a view of the theatre's gilded interior. A sign posted next to the entrance to the museum announces whether or not such a view is possible on the day.

The museum is open daily, with some exceptions. Opening hours are from 9:00 to 12:30, with the last entrance at 12:00 and from 13:30 to 17:30, with the last afternoon entrance at 17:00.

Music in the ari In Milan in September, music comes out to meet you. There's music in metro stations, in the streets, in piazzas, in parks, and in churches. Some of Milan's most spectacular venues open their doors to performances. This year, the annual event, MiTo SeptembreMusica, begins in Milan on 6 September with a concert by the National Orchestra of France

at La Scala. The name “MiTo" is derived from the names of the two cities that celebrate the festival simultaneously: Milano and Torino.

Music of every genre – from classical to rock – is on the programme, with four to five events daily featuring international artists and groups. Each year, the musical spotlight falls on a different country whose music becomes a mini-festival within the larger one. Exhibitions, discussion panels and film screenings round out the schedule. The programme is available online from 6 June at www.mitosettembremusica.it.

Delegates to the ESCRS congresses in Milan who show their badge when purchasing a ticket at the MITO SettembreMusica box office may avail of a special 10 per cent discount (not applicable on €5 concerts). The box office is located at MiTo's Milan Urban Centre, Galleria Vittorio Emanuele 11/12. Tel. +39.02.8846.4725.

Blue Note The first European franchise of the Greenwich Village jazz club, “Blue Note,” opened in Milan a few years ago and has been attracting international artists in blues, soul and jazz ever since. James Taylor, James Pizzarelli and Randy Becker figured in the Blue Note line-up earlier this year. Performances are about 75 minutes long. A candle-lit meal (with main courses costing €25 to €30) is served before the 21:00 show. For those who are dining at the venue, doors open at 19:30. A light snack menu is also available before the late session. The club is closed Monday and throughout the months of June, July and August. Ticket prices vary with the artist, but can be booked online. To discover who’s appearing when, check the calendar at the Blue Note website at: www.bluenotemilano.com.

MECCA OF MUSICMusic lovers who visit Milan in September are in for a special treatby Maryalicia Post

58 Update

EYE ON TRA VEL

Full / Part Time Laser and Intraocular Surgeons Required

opticalexpress.com

To apply, call David Carson on +44 (0)1236 723300 / +44 (0)7771 930423. Alternatively e-mail: davidcarson@opticalexpress.com or write to Optical Express, 5 Deerdykes Road, Westfield, Cumbernauld, G68 9HF, United Kingdom.

UK, Ireland and NetherlandsOptical Express is now recruiting laser and intraocular surgeons to treat in our state-of-the-art clinics.

In each of our clinics we use the world leading VISX S4 IR laserplatform with Advanced CustomVue Wavefront technology, IntraLase iFS 150 femtosecond laser. Our diagnostic equipment includes Oculus Pentacam, Zeiss Visante OCT and the latest generation of phaco instruments.

We are seeking to recruit dynamic, enthusiastic, laser and intraocular surgeons to lead our clinics into the new age of advanced laser and intraocular surgery techniques. We offer an excellent salary and remuneration package. Join our team of surgeons and become part of our forward thinking organisation.

Optical Express is now recruiting laser and intraocular surgeons to treat in our state-of-the-art clinics.

In each of our clinics we use the world leading

We are seeking to recruit dynamic, enthusiastic, laser and intraocular surgeons to lead our clinics into the new age of advanced laser and intraocular surgery techniques. We offer an excellent salary and remuneration package. Join our team of

The following congresses will be held in Milan in September 2012:3rd EuCornea Congress (6-8 Sept);2nd World Congress of Paediatric Ophthalmology and Strabismus (7-9 Sept);12th EURETINA Congress (6-9 Sept);XXX Congress of the ESCRS (8-12 Sept).

La Scala exterior and interior

EUROTIMES | Volume 17 | Issue 6

I had not anticipated the intense excitement that the birth of my daughter would generate among my co-workers. How animated the

people around me would become about my offspring is something that I had not even considered during the period leading up to her birth.

Nurses who I’d worked with once or twice in the operating room were interested in all the details – her birth weight, hair colour, sleeping pattern, and middle names were all fair game. Baby cards poured into our Dutch home and eventually filled the entire (tiny) baby room. Everyone wanted to see the latest pictures and iPhone videos. And with all the congratulations I received at work, you might think I had personally accomplished something particularly difficult and rare. I think my wife would beg to differ.

As an ophthalmologist-in-training, I had, of course, spent the whole pregnancy in a state of near-panic that she might be born with one of the rare ophthalmic conditions that I’d seen during my paediatrics rotations. Might she get congenital toxoplasmosis from our cat? Would she develop strabismus? Even retinal and optic nerve agenesis, which I had seen diagnosed in the OR, crossed my mind, although this was a possibility I couldn’t even consider without hyperventilating.

Fortunately, she was completely healthy at birth, so my attention has shifted to more realistic concerns. These primarily regard my ability to combine fatherhood, residency and that vague notion we call “life” into a productive and satisfying whole.

People say that parenting is a full-time job. A senior resident described it as “your core business.” However, both my work contract and my work ethic seem to say the same thing about my residency. Okay, so parenting and residency are both full-time

commitments. And what about “life”? A friend of mine, a cardiologist, has a motto that I am sure will keep his heart healthy and stress-free until he turns 100: “Sure, you have to work hard, but try not to let your job interfere too much with your life.” With these three views battling for supremacy in my mind, each claiming primacy above the rest, I suppose I’ll have to work out my own formula during the next three years of residency and potential fellowship(s) thereafter.

The main question is: Will I be able to combine working and studying with bottles and nappies and then still have time over for socialising, sports, travel, and culture? Will I be able to resist the temptation to bounce my daughter on my knee when I should be reading up on ophthalmic surgery? Will I be able to leave my books and my daughter at home while I myself go bouncing through the woods on my mountain bike? And will I be able to put my laptop away after hours of research work in order to play instead? Something tells me that these choices will rarely be mine to make, so I’ll have to recognise every window of opportunity and grab whatever comes passing by.

Fortunately, there are many similarities between residency and childhood, of which the most important seems to be opportunity. Both residents and children have the opportunity to learn, to make mistakes, to be supported by those with both greater experience and more extensive knowledge who are willing and able to solve big problems and fix big mistakes.

A second key factor is the advantage of exposure. Childhood, like ophthalmic training, benefits greatly from exposure to both what exists in real life and what has been written by others. Participating in varied travel, social and athletic activity is like examining lots of patients: they’re all different and potentially interesting, and the more you see, the better you’ll be able to recognise patterns, detect subtleties and appreciate the beauty and the significance of the details.

On a lighter note, several baby-to-ophthalmology comparisons have spontaneously come to mind. My presence during my daughter’s delivery was similar to my presence in the operating room for my first surgical rotations. “Great that you’re here. Remember as much as possible. Help

when you can, but make sure you don’t get in the way. And don’t drop anything.” A hysterical crying fit is like a corneal ulcer – both are horrible experiences, their aetiology is frequently unknown, and there’s relatively little you can do besides wait, hope and pray that they will get better soon. And changing a nappy is like removing a superficial corneal foreign body – easy to learn and easy to do, and something you can count on having to do daily for a long, long time.

Of course, there are more pleasant comparisons as well. Learning new baby-related skills – like installing the car seat, setting up the playpen, or building the crib – are just like any surgical skills. They’re generally a bit simpler, but no less important. Going for a walk outside is interesting and restorative, like a great lecture on an interesting topic. Seeing a baby smile creates the same feeling as telling a nervous patient that his eyes are perfectly healthy: a purely good sensation. And

presumably, the whole of parenthood is like the arc of an ophthalmologist’s career. You start your residency knowing nothing at all and feeling acutely incompetent, but there’s a steep learning curve early on and before you know it you’re doing more good than harm. You’ll make tons of mistakes along the way, but in the end you’ll end up with a happy child who’s ready for independent life and happy patients who are ready to see the world with as much colour and clarity as when they were children.

RESIDENT PAPAResidency – like childhood – affords chances to seek support from those with experience by Leigh Spielberg

59Feature

RESIDENT’S DIARY

Leigh Spielberg is an ophthalmology resident at the Rotterdam Eye Hospital in The Netherlands

Okay, so parenting and residency are both full-time commitments. And what about “life”?

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Reference

CALENDAR OF EVENTSDates for your Diary

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2012

2nd Joint International Congress Refr@ctive on-line and SICSSO 28-30 ROME, ITALYwww.rolandsicsso.org

11th Aegean Summer School in Visual Optics26-28 CRETE, GREECEwww.ivo.gr/summerschool

Aegean Cornea XI29-1JULY CRETE, GREECEwww.aegeancornea.gr

16th Afro Asian Congress of Ophthalmology & 5th Mediterranean Retina Meeting13-16 ISTANBUL, TURKEYwww.afroasian2012.org

ISER 2012XX Biennial Meeting of the International Society for Eye Research22-27 BERLIN,GERMANYwww2.kenes.com/iser/pages/home.aspx

3rd EuCornea Congress6-8 MILAN, ITALYwww.eucornea.org

12th EURETINA Congress6-9 MILAN, ITALYwww.euretina.org

ASCRS•ASOASymposium & Congress19-23 SAN FRANCISCO, CA, USAwww.ascrs.org

AAO•APAO Joint Meeting10-13 CHICAGO, IL, USAwww.aao.org

19th Annual Scientifi c Meeting of the MCLOSA and Regional Scientifi c Meeting of the IOSS30 LONDON, UKwww.mclosa.org.uk/annualmtg.html

European Society of Ophthalmology (SOE) 20138-11 COPENHAGAN, DENMARKwww.soe2013.org

17th ESCRS Winter Meeting15-17 WARSAW, POLANDwww.escrs.org

UKISCRS – XXXVI Annual Congress27-28 BRIGHTON, UKwww.ukiscrs.org.uk

8th Annual Congress of the Croatian Society for Cataract and Refractive Surgery5-7 DUBROVNIK, CROATIAwww.cscrs.hr

8th International Symposium on Uveitis19-22 HALKIDIKI, GREECEwww.ISU2012.org

Modern Technologies in Cataract and Refractive Surgery – 201225-27 MOSCOW, RUSSIAwww.mntk.ru

VI Congress of the Latin American Society of Cataract and Refractive Surgeons4-6 BUENOS AIRES, ARGENTINAwww.congresos-rohr.com/alaccsar2012

2nd World Congress of Paediatric Ophthalmology and Strabismus7-9 MILAN, ITALYwww.wcpos.org

XXX Congress of the ESCRS8-12 MILAN, ITALYwww.escrs.org

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9th Congress of Slovenian Society of Ophthalmology32nd Symposium of Ophthalmologists of Slovenia and Croatia28-30 PORTOROZ, SLOVENIAwww.zos2012.si

25th International Congress of German Ophthalmic Surgeons14-17 NURNBERG, GERMANYwww.doc-nuernberg.de

10th EGS Congress17-22 COPENHAGEN, DENMARKwww.eugs.org

SUPRACOR is CE marked. SUPRACOR for myopic, emmetropic, and post-LASIK patients is currently in clinical evaluation.SUPRACOR is NOT approved for use in the US. Technolas Excimer 217P is NOT approved for use in the US.Some of the products and/or speci�c 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 speci�cations are subject to change without prior notice as a result of ongoing technical development. Please contact our regional representative regarding individualavailability 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-031/05-2012©2012 Technolas Perfect Vision GmbH. All rights reserved.

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EuroTimes June 2012

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