EuroTimes Vol. 20 - Issue 5 by EUROTIMES

SPECIAL FOCUS CORNEA RETINA

SHEDDING LIGHT ON THE ROLE OF GENETICS AND ENVIRONMENT IN AMD May 2015 | Vol 20 Issue 5

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CORNEA 4 Cover Story: Applied

biotechnology and its crucial role in treating ocular surface disease

7 CXL – long-term effects and predictability remain uncertain

9 Treating cataracts in

keratoconus patients can be a long and challenging process

10 Simultaneous

topography-guided PRK with CXL shows promise

11 Endothelial versus

penetrating keratoplasty – examining the data

FEATURES CATARACT & REFRACTIVE 12 Measurements in aphakic

23 ‘Genetic self testing

14 The treatment axis – how it is crucial to achieving optimum surgical outcomes

16 Presbyopia correction

18 ‘Growing body of

evidence pointing to refractive sweet spot’

P.47

is rarely useful for glaucoma diagnosis’

24 Successful eye

drop instillation – overcoming the various obstacles

RETINA 28 Swedish registry

shows very low endophthalmitis rates after IVT

29 Report from the 5th

EURETINA Winter Meeting at the University of Oxford

31 Dexamethasone

implant therapy can benefit patients with refractory DME

PAEDIATRIC OPHTHALMOLOGY 34 CXL is safe and can

arrest keratoconus progression in children, studies suggest

32 The complex role

of genetics and environment in AMD

eyes may improve power predictability

using a small aperture intracorneal inlay – positive outcomes

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2014 and 31 December 2014 is 42,957.

GLAUCOMA

REGULARS 36 Innovation

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38 ESASO update 39 Practice Management 41 Book Reviews 42 Eye on Technology 44 JCRS Highlights 45 Industry News 47 Travel 48 Calendar

EUROTIMES | MAY 2015

EDITORIAL A WORD FROM FRANÇOIS MALECAZE MD, PhD

THE LEARNING CURVE

EuCornea has gone from strength to strength and is now firmly established as a major point of reference for cornea specialists

e must never stop learning. These are exciting One of the major aims of EuCornea is to encourage young times for corneal surgeons and I am delighted ophthalmologists to attend our meetings and play an active to have been given this opportunity to write the part in the society. The training of young cornea specialists is editorial in this month’s EuroTimes. essential and I look forward to welcoming my younger colleagues Our cover story focuses on the advances in to Barcelona in September. It is also important that our more biotechnology that have helped to improve established members work closely with young cornea specialists corneal and epithelial healing. As my colleague Sheraz Daya by helping them with their training. points out, different centres will use different techniques so there This year’s EuCornea Congress will be partnered with the XXXIII is a need for collaboration among these centres to discuss the best Congress of the ESCRS. It is very important that EuCornea should way forward. continue its collaboration with ESCRS as we are still a young Collaboration, of course, is one of the key goals of organisation and it is important that EuCornea and as president of the society I would like to that we have a spirit of partnership Barcelona holds special encourage the co-ordination of cornea research projects with ESCRS and other societies. in Europe and the organisation of multicentre studies Another important initiative memories for all of us in the between different centres of cornea in Europe. that we are working on is the society as EuCornea, a new We had a very successful Cornea Day organised by establishment of a new international subspecialty organisation EuCornea and the ESCRS at the 19th ESCRS Winter journal dedicated to cornea Meeting in Istanbul, and we are now busy preparing for specialists, which I believe will be of dedicated to the specialty the 6th EuCornea Congress in Barcelona, Spain. major benefit to the society. of cornea and ocular surface Barcelona holds special memories for all of us in the Finally, I would like to say disease, was launched in society as EuCornea, a new subspecialty organisation that even in this age of advanced dedicated to the specialty of cornea and ocular surface communications where we can talk Barcelona in 2009 during the disease, was launched in Barcelona in 2009 during the to each other by phone and email XXVII Congress of the ESCRS XXVII Congress of the ESCRS. I was one of the founding on a daily basis, nothing can replace members of the society along with Harminder Singh the face-to-face conversation. For Dua, José Güell and Vincenzo Sarnicola and I am honoured to be that reason, I would urge all my colleagues attending our Congress serving as president this year and in 2016. to talk to me and let me know what we can do to make EuCornea Six years ago, we started from a blank canvas with a shared even more successful. Best wishes and I look forward to meeting commitment and enthusiasm. Due to the hard work of all our you in Barcelona. members the society has gone from strength to strength and it is now firmly established as a major point of reference for cornea specialists. Our biggest challenge every year is to organise a Congress with an excellent scientific programme and we have lined up some excellent speakers to discuss issues such as crosslinking, cataract surgery in ocular surface disease and posterior lamellar keratoplasty. This year’s programme will include three invited symposia, eight Focus Sessions, Instructional Courses and Skill Transfer Courses, and six Free Paper Sessions. The EuCornea Medal Lecture will be * Dr François Malecaze is president of EuCornea and Chef du presented by John Dart, focusing on “Cicatrising Conjunctivitis Service d’Ophtalmologie – CHU Toulouse-Purpan, France Update: Translating Research into Effective Therapies”.

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Bill Aylward (UK), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), Hiroko Bissen-Miyajima (Japan), John Chang (China), 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)

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COVER STORY: CORNEA

OCULAR SURFACE RECONSTRUCTION Applied biotechnology continues to advance the treatment of ocular surface disease. Roibeard O’hEineachain reports

reatments for conditions like limbal stem cell deficiency, epithelial defects and neurotrophic keratitis have been raised to a new level by the advances in biotechnology that now permeate all fields of medical practice. The technologies include ex vivo stem cell expansion techniques and new pharmacological agents designed to enhance corneal and epithelial healing. But barriers remain to their wider accessibility to the patients who need them and some treatments may require further clinical validation before they are adopted into mainstream ophthalmic practice. EUROTIMES | MAY 2015

EX VIVO STEM CELL EXPANSION The use of limbal epithelial stem cells culture for eyes with severe limbal stem cell deficiency is based on the identification of the limbus as the epithelium’s stemcell repository and on the success achieved with keratolimbal grafts and transplantation of a small portion of the limbus from the fellow eye. Ex vivo expanded stem cell transplants have the advantage that they enable a large amount of tissue to be cultured from a tiny biopsy from the patient’s fellow eye or from a donor eye. Studies have shown that cultivated limbal stem-cell grafts give good and stable long-term clinical results, even in

eyes with severely damaged ocular surfaces and total limbal stem cell deficiency. The surgical procedure is not difficult for an experienced anterior segment surgeon. The technique of isolating stem cells from a limbal biopsy specimens and expanding them into sheets of cells requires specialised laboratories. In an interview with EuroTimes, Sheraz Daya MD, FACS, FRCS (Ed), UK, noted that different centres use slightly different techniques for insuring that stem cells cultures retain their stem cell properties and that the cell sheets are easily transferred to the patient’s eye. Therefore, as yet there is no single standard technique but rather a parallel

COVER STORY: CORNEA

Courtesy of Sheraz Daya MD, FACS, FRCS (Ed)

evolution of techniques with a lot of crossover of methodologies. “There seems to have been a plateau in the development of this technique, however there are still some questions that need to be answered. In terms of standardisation, as there has been an exchange in technology, there are ‘lineages’ of techniques which include culturing cells on amniotic membrane as a carrier, a contact lens carrier and free cell culture and transfer of sheets directly to the eye – our preference and learnt from deLuca and Pellegrini in 1997 and modified by using an amniotic membrane to retain the stem cell sheet. “Other carriers are being evaluated and things look promising in terms of 3D printing and the use of a variety of biopolymers. As usual, funding research is an issue, with fortunately so few patients requiring this type of treatment it is hard to make convincing arguments to the industry, and much development will continue in university research laboratories,” he added. Apart from the biotechnological aspects of these approaches, Dr Daya emphasised that the host eye environment must be rendered as hospitable as possible if the epithelial stemcell sheets graft is to be successful. “What requires more evaluation is how to optimise success of the ex-vivo technique. There are a large number of variables with each patient being quite unique. There is much to consider when deciding how to proceed. We demonstrated that conjunctival inflammation can be a major problem and this must be controlled prior to proceeding. Ocular surface restoration in terms of lid closure, elimination of keratinisation and the creation of decent fornices is also of vital importance and even after surface restoration, this requires constant maintenance along with repeat procedures,” he said. It is very useful to have to hand the skills and expertise of a good oculoplastic surgeon who understands the need for good lid closure. One unresolved question is whether immunosuppression is needed in the long term with expanded stem cell allografts. Dr Daya noted that his findings suggest donor epithelial cells are replaced by host epithelial cells over time, which would make longterm immunosuppression unnecessary. Ultimately, the greatest challenge may be to make the use of expanded limbal stem cell technology more accessible to patients, Dr Daya noted.

“As these are tissue engineering techniques, they need to be performed in accredited laboratories with dedicated staff, with ‘Designated Individuals’ overseeing and ensuring regulations are met. The cost is quite prohibitive and it would be a waste of resources having this duplicated in too many institutions. Supply of tissue to other corneal surgeons from central laboratories should be the goal and research into transport mechanisms is necessary,” he said.

TOPICAL TREATMENTS For epithelial defects and corneal healing problems, biological agents such as autologous serum platelet-enriched plasma and amniotic membrane transplants have proved very useful. Now there are also biotechnological agents designed to enhance the natural healing process in a less cumbersome way. Among them is Cacicol® (Laboratoires Théa), a structural analogue of the heparan sulphate glycosaminoglycans, which has been commercially available for clinical use in most European countries since last year. The compound is intended for the management of chronic corneal wound healing, such as persistent epithelial defects, neurotrophic keratopathy and persistent anterior corneal dystrophies with associated pain. “The heparan mimetic stimulates extracellular matrix healing process,

There seems to have been a plateau in the development of this technique, however there are still some questions that need to be answered... Sheraz Daya MD, FACS, FRCS (Ed)

and is a possible alternative therapy to heavy and invasive treatments such as autologous serum or amniotic membrane transplantation. Applied topically to a damaged corneal surface it penetrates into the damaged extracellular matrix, where it substitutes the endogenous heparin sulphate and binds to collagen and fibronectin. This mechanism protects the corneal matrix growth factors and cytokines against degradation,” said Ewa MrukwaKominek MD, PhD, Silesian University of Medicine, Katowice, Poland. She cited a study in which 80 per cent of patients with persistent epithelial defect or corneal ulcers resistant to usual treatments had a rapid decrease in pain and a reduction in the area of ulcerated ocular surface after instillation of Cacicol eye drops. Another study showed that in a small group of patients with neurotrophic keratitis, 72 per cent had a complete healing of the ulcer, after receiving the agent for a mean period of nine weeks. “In all these cases, a clear improvement of corneal healing, demonstrated by a decrease in the ulcerated ocular surface or complete tissue regeneration, was observed within a few weeks with Cacicol therapy at a dosage of one-two drops a week to one-two drops every two days. No local or systemic side effects were observed. Patients are very satisfied with this treatment,” Prof MrukwaKominek said.

NERVE GROWTH FACTOR Another new topical agent for ocular surface regeneration is recombinant human nerve growth factor (rhNGF, Dompé). Preliminary results from the phase I REPARO trial showed that most patients receiving the agent achieved healing of neurotrophic ulcers resulting from various causes. EUROTIMES | MAY 2015

COVER STORY: CORNEA The randomised, double-masked study included 18 patients. Fourteen received rhNGF at concentrations of 10mg/ml or 20mg/ml and the remaining four patients received vehicle eye drops. All patients were instructed to instil their drops six times a day for eight weeks. Overall, the corneal lesions completely healed in 73 per cent of eyes, and around a third of eyes had improvements in their Schirmer and corneal sensitivity scores. Visual acuity was decreased in two patients, and improved in 11 at the end of treatment. Treatment was well tolerated. The REPARO study group, headed by Prof Stefano Bonini at the BioMedico Campus of Rome, are currently conducting a phase II trial with rhNGH involving 39 centres in nine European countries and a parallel phase study is also under way in the US. In addition, Dompé are conducting clinical trials evaluating the efficacy of rhNGH in the treatment of dry eye, retinitis pigmentosa and glaucoma. Dr Daya told EuroTimes that he has as yet no experience with Cacicol, but that he regards rhNGF as very exciting, although it is very difficult to acquire at this point. “Platelet rich growth factors (PRGF, BTI Technology Institute, Spain) are also very promising. We have to date used 100 per cent plasma, however there is good evidence that the platelet fraction of plasma along with inactivation of complement provides a high concentration of growth factors that may be a great adjuvant in the context of ocular surface restoration and ex-vivo stem cell allograft transplantation,” he said.

RETURN OF THE BIOSYNTHETIC CORNEA One of the great unmet challenges in the treatment of corneal disease is maintaining the supply of donor corneal material. One potential solution for that may be a biosynthetic cornea, and that is a technology that is now entering its second generation. The cell-free constructs offer the prospect of eliminating the risk of infection from donor to recipient as well as the risk of immune rejection, which accounts for the majority of the 10 per cent of grafts that are lost within two years of transplantation. At the ESCRS Winter Meeting in Rome in 2008, Per Fagerholm MD of Linköping University, Sweden, presented the first case series of patients ever to be implanted with a biosynthetic cornea composed of human recombinant type III collagen crosslinked with water

LE before treatment

LE before treatment LE after treatment

LE after treatment Case 1 – Corneal melting ulcers, Sjögren’s Syndrome

soluble carbodimides. The implant was developed in a collaborative effort between Dr Fagerholm’s team in Sweden and the Eye Institute in Ottawa, Canada, under the direction of May Griffith PhD. Prof Griffith is now professor in regenerative medicine at Linköping University, Sweden. The series included 10 patients. In all cases, the epithelial surface barrier was established by two months, innervation of the implant was rapid and complete, and colonisation with host keratocytes was good but slower than in donor grafts. At 24 months’ follow-up, the biosynthetic implants remained stably integrated and avascular, and there were no cases of immune rejection. However, the results also showed that there was room for improvement. In a couple of patients there were problems with re-epithelialization, which in one case resulted in corneal melting. In addition, spectacle-corrected visual acuity at two years' follow-up had a mean value of only 20/110. “The results in the first 10 human implants were good, but not perfect. What we found was that some of the corneas became slightly opacified in different ways and we traced that back to the suture technique we used. We had overlying sutures and that seems to prevent the epithelium from resurfacing properly. And inflammation in the beginning causes the production of local enzymes

...inflammation in the beginning causes the production of local enzymes and inflammatory cells... Per Fagerholm MD EUROTIMES | MAY 2015

and inflammatory cells, so that had some effect on the implant,” Dr Fagerholm told EuroTimes in a recent interview. Dr Fagerholm and his associates in Ottawa suspended further clinical testing until they could develop and test new biomaterials. To make the biomaterial better able to resist enzymatic degradation and sturdy enough to be secured with a single-stitch suture technique, it has been strengthened using a double crosslinking technique. He noted that he and his associates have completed animal testing with the new material and are now seeking approval to commence testing it in humans. “Experiments with pigs tell us that the new implants work. You can suture them and they are otherwise as good as those with the older material. In March this year we sent our application to our MPA, which corresponds to the FDA in America, to be allowed to implant this construct and we expect to get everything in order this summer,” he added. Their application concerns not only the use of the new material, but also attempts at optimising the re-epithelialization through the use of limbal stem-cell sheets. Dr Fagerholm added that they will also be soon seeking approval for clinical testing with other new biomaterials. “There are more alternatives popping up, human collagen isn't the only one. We’re also testing pig cornea collagen and artificial collagen. We have many options to test, some are further ahead than others, we're going to apply for clinical testing with those also within this year,” Dr Fagerholm said. Sheraz Daya: sdaya@centreforsight.com Ewa Mrukwa-Kominek: emrowka@poczta.onet.pl Per Fagerholm: per.fagerholm@liu.se

Courtesy of Ewa Mrukwa-Kominek MD, PhD

SPECIAL FOCUS: CORNEA

CXL SAFETY

Effective for treating keratoconus, but long-term effects uncertain. Howard Larkin reports

large body of clinical evidence shows that traditional epithelium-off corneal crosslinking (CXL) is safe and effective for routine use treating keratoconus and post-LASIK ectasia. However, the longterm effects and predictability of CXL remain uncertain due in part to incomplete understanding of human corneal collagen ageing and how keratoconus progresses. Ironically, these fundamental questions may well remain unanswered specifically because CXL has been so successful in slowing keratoconus, François Malecaze MD, PhD, Purpan Hospital, Toulouse, France, told the XXXII Congress of the ESCRS in London. “We lack a large study to assess precisely the natural evolution of the disease. Now that corneal crosslinking is widespread this study will be difficult to conduct,” he said. Less evidence exists for other crosslinking approaches, including epithelium-on, and combining epi-on or epi-off with intracorneal ring segments, photorefractive keratectomy or phakic intraocular lenses. Therefore, additional precautions should be taken when using these procedures to protect patients and to generate additional data for assessing safety and efficacy, said Dr Hannah Patrick, Consultant Clinical Advisor to the Interventional Procedures (IP) Programme from the UK’s National Institute for Health and Care Excellence. However, ongoing research is needed to identify the optimum treatments for keratoconus treatment. Dr Patrick quoted IP guidance on the procedure (https://www.nice.org.uk/guidance/ ipg466). “NICE encourages further research into CXL using riboflavin and UVA for keratoconus and keratectasia, especially epithelium‑on CXL and the combination procedures,” she said. The NICE IP guidance on corneal crosslinking states that: “Current evidence on the safety and efficacy of epithelium off CXL for keratoconus and keratectasia is adequate in quality and quantity. Therefore, this procedure can be used provided that normal arrangements are in place for clinical governance, consent and audit.” But the evidence for epi-on and combination procedures is limited, so NICE recommends notifying institutional clinical governance leaders, clearly informing patients or their guardians of the uncertainty about efficacy and safety, and auditing and reviewing all patient outcomes. NICE also suggests clearly describing all CXL techniques used, and reporting visual acuity, corneal topography and quality of life outcomes. Reporting longterm outcomes for all types of CXL procedures, particularly how they affect progression to corneal transplantation and the frequency and efficacy of repeat procedures, would also improve understanding. Dr Patrick noted that NICE IP guidance is neither mandatory nor intended as a standard of care, but is designed to support innovation. Still, questions remain Dr Hannah Patrick about all forms of CXL due in part to limited

understanding of human corneal collagen biology, Dr Malecaze said. Animal models suggest corneal collagen synthesis ceases at the equivalent of young adulthood in mice, and about half of collagen fibres remain stable in corneal remodelling after injury in rabbits. But corneal stability cannot be studied directly in humans so its half-life is unknown, Dr Malecaze said. However, collagen in human cartilage is thought to last about 120 years while collagen in skin lasts about 12 years. In the cornea it is probably several years, Dr Malecaze said. Several studies also suggest keratometry stabilises as keratoconus patients age. An early study found the disease progresses in steps and stops progressing after age 30 (Amsler M. Ophthalmologica 1946; 104:96-111). More recent studies have found a linear progression (Tuft SJ et al. Ophthalmology 1994 Mar; 101(3):439444) and progression slowing sharply as age progresses (McMahon TT et al. Cornea 2006; 25:296-305). A handful of cohort studies also show CXL remains effective in adults for three to five years. However, the few prospective studies in children suggest that while CXL stabilises keratometry, keratoconus continues to progress in most cases, Dr Malecaze said. As a result, long-term CXL results cannot be precisely predicted, Dr Malecaze said. François Malecaze: malecaze.fr@chu-toulouse.fr Hannah Patrick: hannah.patrick@nice.org.uk

NICE encourages further research into CXL using riboflavin and UVA for keratoconus and keratectasia

EUROTIMES | MAY 2015

6th EuCornea Congress

BARCELONA 4–5 September 2015 Fira Barcelona Gran Via, Spain North Access, Hall 8

2 Days. 4 Symposia.

8 Focus Sessions.

4 Courses. 6 Free Paper Sessions.

EuCornea Medal Lecture

Saturday 5 September

Friday 4 September

13.00 – 14.00

16.00 – 17.00 (At the Opening Ceremony) Cicatrising Conjunctivitis Update: Translating Research into Effective Therapies

Linking Inflammation to Dry Eye Disease (DED) Moderator: C. Baudouin FRANCE

Sponsored by

John Dart UK

www.eucornea.org

/EuCornea

@EuCornea

SPECIAL FOCUS: CORNEA

KERATOCONUS reating cataracts in keratoconus patients can be a long process involving many twists and turns, as shown in a case study presented by Soraya Jonker MD, University Eye Clinic Maastricht, The Netherlands, at a Cornea Day session of the 19th ESCRS Winter Meeting in Istanbul. The case involved a 77-year-old woman with keratoconus in both eyes. From the time that she was first referred for INTACS implantation and cataract surgery in her right eye, she was hospitalised four times, underwent surgery eight times and visited the Maastricht clinic 42 times. At first presentation she had a visual acuity of 0.50 and 0.05 in her right and left eye, respectively. On 29 November 2009, she underwent femtosecond laserassisted INTACS implantation in her left eye. The surgeon noted that applanation was unsuccessful and suspected a possible vertical gas breakthrough.

Corneal topography at first visit

Courtesy of Soraya Jonker MD

Keratoconus patients present many special challenges to cataract surgeons. Roibeard O’hEineachain reports

THINNING At a follow-up of one week there were signs of minor irritation and a slight thinning of the corneal layer covering the inferior INTACS segment. On 16 December 2009, the corneal thinning led to the extrusion of the inferior INTACS segment, which was therefore explanted. On 17 March 2011, the patient underwent a deep anterior lamellar

Corneal topography at final visit

keratoplasty. A small perforation at 12 o’clock occurred during the dissection, which the surgeon attempted to remedy with air tamponade in the anterior chamber. However, by 4 April a double anterior chamber was detected. The patient was immediately hospitalised and scheduled for surgery. But later that day the double anterior chamber progressed until there was iridocorneal touch from three to seven o’clock, combined with acute glaucoma with an intraocular pressure (IOP) of 62mmHg. The Maastricht team extracted air from the double anterior chamber with a dissection needle and again placed an air tamponade in the anterior chamber. They also performed a peripheral iridotomy.

The patient responded well to the interventions: the graft was clear and the IOP was 17mmHg. On 20 September 2012, the patient underwent femtosecond laser-assisted cataract extraction with arcuate keratotomy. However, the keratotomy flipped the astigmatism and had to be closed with sutures. When the sutures were removed the eye was amenable to refractive correction. On 2 October 2014, the patient underwent a FLACS procedure with implantation of a toric intraocular lens (IOL) in her right eye. At her most recent visit in February 2015, the patient’s best corrected visual acuity was 1.0 in her right eye and 0.6 in her left eye. Soraya Jonker: soraya.jonker@mumc.nl Isabelle Saelens: isabelle.saelens@mumc.nl Rudy Nuijts: rudy.nuijts@mumc.nl

At first presentation she had a visual acuity of 0.50 and 0.05 in her right and left eye, respectively Both eyes at final visit

Soraya Jonker MD EUROTIMES | MAY 2015

SPECIAL FOCUS: CORNEA

PRK + CXL FOR ECTASIA May prevent PK for post-LASIK ectasia, but long-term results uncertain. Howard Larkin reports

imultaneous topographyguided photorefractive keratectomy (PRK) with corneal crosslinking (CXL) shows promise as an alternative to keratoplasty for treating post-laser surgery ectasia patients, Simon P Holland MB, FRCSC, FRCS, MRCP told Refractive Surgery Day at the 2014 American Academy of Ophthalmology annual meeting in Chicago. The procedure greatly reduces corneal astigmatism and irregularity, and patientreported outcomes have been excellent in several studies out to two years or more, he reported. “We can regard this modality as widening the scope of treatment, perhaps avoiding or postponing PK or DALK in post-LASIK ectasia,” said Dr Holland, of the Pacific Laser Eye Centre, Vancouver, British Columbia, Canada, and the University of British Columbia. However, as with any new treatment, PRK with CXL for ectasia presents new challenges. These include difficulty predicting refractive outcomes due to possible continuing hyperopic shift after crosslinking and uncertainty about how thinning an already thin cornea may affect long-term stability. Complications related to delayed corneal re-epithelialisation also can be quite serious, Dr Holland said. Therefore, further studies of the technique are indicated, and alternatives such as intrastromal ring segments with CXL also should be considered.

BUILDING A TRACK RECORD Pioneered as a treatment for keratoconus, several studies document that topographyguided PRK with CXL is also safe and effective for managing post-laser surgery ectasia, Dr Holland noted. He pointed to an early one-year follow-up on a single patient (Kymionis GD et al. Open Ophthalmol J. 2011 Feb 11;5:11-3) as well as a study of 26 patients followed for a mean of 25 months (Richoz O et al. Ophthalmology. 2013 Jul;120(7):1354-9). These generally found significantly reduced corneal astigmatism and higher order aberrations, and improved uncorrected and corrected visual acuity, both indicating restoration of a more regular and optically functional corneal shape. Dr Holland also reported preliminary results of his own experience with Dr EUROTIMES | MAY 2015

Courtesy of Simon P Holland MB, FRCSC, FRCS, MRCP

Ectasia case insert

David T C Lin, also of the Pacific Laser Eye Centre, treating 55 contact lensintolerant post-LASIK ectasia patients with simultaneous topo-guided PRK and CXL. All patients received transepithelial PRK using the Wavelight Allegretto platform running T-CAT software. Based on topographical data, this program guides tissue removal from an asymmetrical cornea to reshape it into a symmetrical aspheric cornea. The software allows control of the degree of asphericity and refraction. To minimise the impact of hyperopic shift often seen with CXL, they targeted -1.25 dioptres. To maintain sufficient corneal strength, a residual stromal depth of at least 300 microns was left. Outcomes were evaluated at regular follow-up intervals and included refraction as well as uncorrected and corrected visual acuity, and patient symptoms. In many cases very little ablation was required to regularise the cornea and restore sharp vision, Dr Holland said. For example, a 62-year-old female presenting with ectasia 15 years after LASIK required removal of just over 30 microns of stroma to improve uncorrected vision from 20/300 to 20/50, and corrected from 20/40 to 20/30, while reducing astigmatism from -5.50 dioptres to -1.5 dioptres. Similarly, ablation of 38.7 microns from a 21-year-old male improved his uncorrected vision to 20/30, and corrected vision to 20/20, and the improvements were stable at two years.

Overall, out of 35 cases followed six months or more, 19 (or 54 per cent) had uncorrected vision of 20/40 or better, and 23 (or 66 per cent) had improved corrected vision, with 10 (or 23 per cent) gaining two lines or more, Dr Holland and Dr Lin reported. Mean astigmatism was reduced 2.47+/-1.87 dioptres, with 28 patients reporting improvement in visual symptoms and three unchanged.

CHALLENGES However, three patients lost two lines of vision, and three experience delayed epithelialization. In one case, this resulted in haze that decreased vision more than two lines, Dr Holland said. “We think delayed epithelialization is our major problem. It is critical to get the epithelium healed up within a week, otherwise you stand a significant chance of haze,” Dr Holland said. Alternative treatments such as intrastromal ring segments with CXL might avoid this problem, he suggested. Other issues include questions about the effects of ablating thin corneas, Dr Holland said. While the efficacy of crosslinking has been shown for thin corneas, the impact on long-term stability of adding ablation is unknown. Simon Holland: simon_holland@telus.net David T C Lin: info@pacific-laser.com

SPECIAL FOCUS: CORNEA

RAPID DSEK ADOPTION Analyses of UK national data characterise outcomes differences and factors influencing outcomes. Cheryl Guttman Krader reports

ata from the National Transplant Registry show there was rapid and steady adoption of Descemet’s stripping endothelial keratoplasty (DSEK) by surgeons in the UK after the procedure was introduced. And, in 2013, almost three-quarters of patients needing a corneal transplant for Fuchs’ endothelial dystrophy or pseudophakic bullous keratopathy (PBK) underwent the partial thickness procedure rather than penetrating keratoplasty (PK), reported Frank Larkin MD at the 5th EuCornea Congress in London. Outcomes analyses for the two procedures using data from comparable six-year periods provide some evidence to support the current practice pattern, while findings from analyses of factors predicting surgical outcomes suggest targets for improving DSEK outcomes. The comparative analyses included first PK procedures performed from January 2000 through to December 2005 (1,243 PBK, 1,373 Fuchs’) and first DSEKs performed from December 2006 through to January 2011 (799 PBK, 1,275 Fuchs’). All eyes had two years of follow-up. Summarising the key findings, Dr Larkin reported that PK was associated with significantly better graft survival than DSEK. However, DSEK graft survival was improving as centres gained experience, and among patients with surviving grafts at two years, DSEK was associated with better visual and refractive outcomes compared with PK. Multivariate analyses conducted to identify variables affecting graft survival identified centre experience and donor endothelial cell density among other independent predictive factors. Speaking about the implications of the findings, Dr Larkin outlined several points to take away.

“Individual surgeons need to look at a new procedure and think about what advantages it gives over the procedure they are currently doing. Before transitioning to DSEK, surgeons getting good results with PK should consider how many procedures they will be doing and the length of their remaining surgical career,” he said. “In addition, it is perfectly clear from these data that in the UK the current arrangements for training in evolving lamellar surgical techniques and for donor cornea preparation are inadequate.” The UK National Transplant Registry provides an excellent source for comparing procedural outcomes because all grafts are registered centrally, and the time performing DSEK reached a plateau in 2010-2011. Data from Kaplan-Meier analysis of two-year graft survival rates showed outcomes varied by procedure and diagnosis, but the rate was significantly higher for PK vs DSEK for both eyes with Fuchs’ (94 per cent vs 81 per cent) and those with PBK (79 per cent vs 70 per cent). “These findings are consistent with every published study in showing that graft survival in transplant procedures for PBK are worse than for Fuchs’. The reasons for that difference are not understood,” said Dr Larkin, consultant ophthalmic surgeon, Moorfields Eye Hospital, London. “Considering the poorer graft survival with DSEK, one might wonder why patients in the UK are having endothelial keratoplasty. However, graft survival, which means a clear, functioning graft, is one thing, while data on visual outcomes for surviving grafts tells another interesting story.”

VISUAL OUTCOMES Analyses of the visual outcomes at two years among patients with surviving grafts showed that mean logMAR BCVA was significantly better for the DSEK group compared to the PK eyes both for patients with Fuchs’ (0.3 vs 0.4) and for those with PBK (0.6 vs 0.9).

In addition for the cohort with surviving grafts at two years, the proportion of eyes in which SE was within two dioptres of plano was significantly higher among DSEK patients than in the PK group, both in the Fuchs’ (75 per cent vs 51 per cent) and PBK (67 per cent vs 47 per cent) subgroups. In the multivariate analyses to identify predictors of surgical outcomes for the EK procedures in patients with Fuchs', lower centre experience and lower donor ECD were associated with poorer graft survival, along with existing glaucoma, male donor, older donor (age 75+), and preoperative BCVA worse than 6/60. Factors associated with poorer graft survival after DSEK in PBK eyes were lower centre experience, existing glaucoma and year of DSEK (2008-2009). Surgeon experience was not predictive of graft survival for either DSEK subgroup. “Our interpretation of these data is that surgeons starting DSEK and operating in a centre with experienced colleagues should likely have a shorter learning curve and encounter fewer complications,” said Dr Larkin. Focusing on some of the other predictors, Dr Larkin commented that, as with every type of corneal transplant, glaucoma at the time of DSEK is a significant predictor of graft survival. Likely patients with more advanced Fuch' had poorer outcomes because they have stromal disease rather than simply endothelial dysfunction. He noted that five-year outcomes will be analysed as those data become available, and future analyses may also include eyes undergoing DMEK should that procedure become more widely adopted. With that in mind and responding to an attendee’s comment about the potential for DMEK to provide patients with unaided driving vision, Dr Larkin noted that while the registry does not collect UCVA data, it is something to consider in the future. Frank Larkin: f.larkin@ucl.ac.uk

Türkiye TURKISH LANGUAGE EDITION ONLINE Visit: www.eurotimesturkey.org EUROTIMES | MAY 2015

CATARACT & REFRACTIVE

INTRA-OP OCT PREDICTIONS Measurements in aphakic eyes may improve power predictability. Roibeard O’hEineachain reports

ntraoperative optical coherence tomography (OCT) measurements of anterior chamber depth are more predictive of postoperative intraocular lens (IOL) position than are preoperative anterior chamber depth measurements, according to the results of a study presented by Sanaz Farrokhi, medical student, and conducted by Oliver Findl MD, FEBO, Hanusch Hospital, Vienna, Austria, at the XXXII Congress of the ECSRS in London. Ms Farrokhi noted that among the over one million cataract surgeries included in the EUREQUO database, the mean residual refractive error is 0.55D. In contrast to this, more than 50 per cent of patients with short eyes have a residual refractive error of more than 0.5D. “The main source of this deviation from the targeted refraction is that we cannot predict the lens position and that is the reason we carried out this study. We wanted to measure the anterior segment and specifically the anterior capsule position intraoperatively, and use this value to predict the IOL position,” she explained. The study included 170 eyes of 170 patients who underwent standard cataract surgery with a capsular tension ring to tauten the capsule. Ms Farrokhi and her associates used optical coherence biometry (Lenstar LS 900, Haag-Streit AG) to measure the patients’ axial length, anterior chamber depth and lens thickness, preoperatively, and one hour, one day, and three months postoperatively. The patients also underwent autorefraction and subjective refraction three months postoperatively.

POSITION In addition, the Vienna team performed intraoperative measurements of the anterior and posterior lens capsule position at different stages of the cataract procedure during cataract surgery using a prototype operating microscope with an integrated continuous OCT device (Visante attached to OPMI VISU 200, Carl Zeiss Meditec AG). Their findings showed that, of all the measurements taken, as expected the preoperative axial length was most predictive of postoperative IOL position, followed by intraoperative anterior lens capsule position after Irrigation/Aspiration of lens material. In addition, the reliability of additional intraoperative measurements made the predictability of postoperative IOL position less dependent on axial length than is the case with conventional IOL calculation formulas. That is, the r2 value with respect to axial length was below 0.001 for intraoperative anterior lens capsule measurement, but was -0.42 for the HofferQ formula, -0.5 for SRK/T, and -0.34 for Haigis. “The lower dependency on axial eye length means that short eyes especially would benefit from this technique. In the future we may be able to use intraoperative measurements for ray tracing and modern IOL calculation formulas,” Ms Farrokhi added. Sanaz Farrokhi, C/O Oliver Findl: oliver@findl.at EUROTIMES | MAY 2015

Less than % of cataract patients are currently treated for astigmatism during surgery. 1

1. Market Scope Annual Report, 2014.

CATARACT & REFRACTIVE

TREATMENT CENTRATIONS

Ophthalmic Imaging:

Choice of treatment axis key to optimum outcomes in refractive surgery. Roibeard O’hEineachain reports

from Theory to current Practice Organization : Michel Puech

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October 16th, 2015 Spoken languages: English/French (simultaneous translation)

12 Courses • Fiber and Optic Nerve OCT • Macular OCT • OCT Angiography • Intra Vitreal Injection • Lasers • Radiology

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Workshops • Ultrasound Imaging • UMB

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he optics of the eye may be described in terms of numerous axes. However, the question of which axis is most important to visual performance when planning cataract and refractive procedures is being debated, said Raymond Applegate OD, PhD, College of Optometry, University of Houston, Texas, US. “There are two key factors to consider when selecting the treatment axis that will provide the best acuity. They are the light passing through the pupil and the visual image quality at the fovea,” he told the XXXII Congress of the ESCRS in London. Dr Applegate said that on that basis he would recommend using the line of sight as the axis for centring refractive surgery. The line of sight starts at the fixation point and goes to the centre of the entrance pupil and from the centre of the exit pupil to the foveola. The angle formed by the intersection of the line of sight with the pupillary axis is the angle Lambda. However, it is often mistakenly referred to as angle Kappa, which more correctly refers to the angle formed by the intersection of the visual axis and the pupillary axis. He noted that the pupillary axis is the line that passes through the pupil’s centre and is perpendicular to the plane tangential to the point where the axis intersects the corneal surface. The visual axis is a theoretical construct and is typically defined as the line extending from the fixation target to the first nodal point of the eye, then from the second nodal point of the eye to the fovea. Importantly, there is no constraint that requires the visual axis to go through the eye’s pupil.

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The optical axis is a theoretical construct used more appropriate for centred model eyes since it is the line that connects the centres of curvature of all the optical surfaces. However, unlike the visual axis or the line of sight, the optical axis is conceived of as a line passing through a common centre of curvature of the eye’s refractive surfaces. It would be a rare eye for the refractive surfaces centres of curvature to fall on a straight line. The optical surfaces of the eye are typically tipped with respect to each other. Dr Applegate cautioned that treatment axes based on the pupil centre raise some additional considerations. The relationship of the pupil centre to the videokeratometric (VK) axis – the line that passes through the centre of the Purkinje image reflected from the corneal surface and is perpendicular to the plane tangential to that point – varies considerably among patients. He also noted that, although centring refractive procedures on the line of sight makes good sense in that in a well corrected eye it focuses the image on the most sensitive part of the retina, many surgeons have reported that they obtain better results by centring their treatment somewhere between the pupil centre and the VK axis. There could be several possible explanations for that finding. It could result in part from the curvature optimisation that is built into the laser refractive surgery platforms are optimised of corneal topography data as opposed to the centre of the pupil. Raymond Applegate: rapplegate@uh.edu

EUROTIMES | MAY 2015

AP-93X266mm-150305.indd 1

06/03/2015 11:39

Less than % of cataract procedures today are performed with femto technology. 1

1. Market Scope Annual Report, 2014.

CATARACT & REFRACTIVE

INTRACORNEAL INLAY Retrospective review of explantations supports reversibility. Cheryl Guttman Krader reports

utcomes data for presbyopia correction using a small aperture intracorneal inlay (KAMRA, AcuFocus) show excellent safety and efficacy that account for high rates of patient satisfaction and a low rate of removal. However, should any patient desire inlay explantation, the removal procedure is also very safe and results in rapid return to pre-inlay levels of near and corrected distance visual acuity, according to a retrospective analysis presented by Minoru Tomita MD, PhD, at the 2014 ARVO meeting in Orlando, US. Dr Tomita conducted a review of 63 patients who underwent inlay removal. All patients had the device placed into a femtosecond laser-created pocket at one month after LASIK to correct ametropia. Mean time to removal was 11.3 ± 7.4 months, and all patients were followed to six months. LogMAR UCDVA was 0.13 ± 0.26 pre-removal, decreased slightly at one week post-removal, but was 0.14 ± 0.26 at one month and stable thereafter. LogMAR UCNVA had returned to the pre-inlay level at one week and was unchanged through follow-up. Manifest refraction did not change significantly. Mean BCDVA was significantly lower at one week and one month post-removal compared to the pre-inlay level, but had recovered by three months and remained stable. BCDVA was

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≥20/25 in all eyes prior to placement of the inlay and in 97 per cent of eyes at six months; three eyes had a BCDVA loss of two lines at six months. “More than 20,000 inlays have been implanted worldwide, and after moving from a flap-based procedure to inlay placement in a femtosecond laser-created lamellar pocket one month after thinflap LASIK, the removal rate has decreased from six per cent to just 1.2 per cent,” said Dr Tomita. “During consultation, patients interested in the inlay are informed of the benefits and risks. They are told that 95 per cent of our patients are satisfied and only a small proportion use glasses occasionally for reading. However, we also discuss the possibility of removal, including the potential reasons and outcomes. Based on our experience, patients are told that their vision is expected to recover to baseline, but that an enhancement procedure may be needed for optimal vision, and they are also counselled that other treatment options will remain available to address the presbyopia after inlay removal.”

TECHNIQUE Dr Tomita said the inlay removal rate has decreased with use of the current inlay technique that is associated with more reliably predictable results, improved refractive stability, decreased recovery time and less dry eye. The primary reasons for inlay removal have been, in descending order, visual acuity, visual symptoms and adaptation failure. “Some patients have concerns about night vision in the first months after surgery and are encouraged to wait because these symptoms usually resolve by six months. However, some patients still want to have the inlay removed immediately despite having excellent visual acuity,” Dr Tomita said. Dr Tomita noted the inlay is easily visualised under the operating microscope because it is opaque, and the removal procedure is simple. “Removing the inlay is easier than the implantation procedure and definitely easier than implanting and removing a phakic or pseudophakic IOL,” he said. Since the inlay adheres well to the stroma, which virtually eliminates the possibility for unwanted migration, it must first be released using a spatula. Then, it is grasped with the insertion forceps and pulled out of the pocket. Post-removal, patients are placed on a medication regimen similar to that used post-LASIK. Dr Tomita also reinforced that, as with all surgical procedures, appropriate patient selection is a critical factor underlying success with the small aperture inlay. He suggested the AcuTarget HD is a useful screening aid for evaluating the optical quality of the eye and identifying early lens changes and ocular surface issues that can compromise short- and longer-term outcomes. The Kamra implant is available in Europe and Asia.

During consultation, patients interested in the inlay are informed of the benefits and risks Minoru Tomita MD, PhD

EUROTIMES | MAY 2015

Minoru Tomita: tomita@eyecanmedical.com

Less than % of people diagnosed with cataracts are getting surgical treatment. 1,2

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1. Market Scope Annual Report, 2014. 2. Visual impairment and blindness. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs282/en/. Accessed November 19, 2014. 3. Facts About Cataract. National Eye Institute website. https://www.nei.nih.gov/health/cataract/cataract_facts. Accessed February 26, 2015.

CATARACT & REFRACTIVE

THE SWEET SPOT Corneal vertex wins out for centring refractive procedures. Roibeard O’hEineachain reports

he ideal optical outcome and the means of achieving it with cataract and refractive surgery remain a source of heated debate, but there is a growing consensus that the ideal axis on which to base refractive procedures is a point close to the corneal vertex, said Damien Gatinel MD, Fondation Rothschild, Paris, France, at the XXXII Congress of the ESCRS in London. He noted that there is a growing body of evidence suggesting that refractive procedures should be centred on an axis somewhere between the centre of the entrance pupil and the corneal vertex, which is closer to the visual axis. Furthermore, research also suggests that the larger the angle of the line of sight to the pupillary axis, the closer to the corneal vertex the refractive treatment axis should be. The corneal vertex is visually evident in clinical photography as the projection of the centre of the first Purkinje image when a patient fixates on a light source that is coaxial with the camera. “Because by construction the nodal point is close to the centre of curvature of the cornea, you may assume that the visual axis is probably very close to the vertex,” he added.

FINDING THE LANDMARKS There are several types of diagnostic instruments available for determining the position of the corneal vertex, and other corneal anatomical landmarks important to vision, Dr Gatinel said. The iTrace® (Tracey), the OPD scan (Nidek) and the Acutarget™ (Acufocus) provide a measurement of distance between the pupil centre and the first Purkinje image. The Orbscan (Bausch and Lomb) provides measurement of the angle lambda, which is the angle of the line of sight – which extends from the fixation point to centre of the entrance pupil – to the pupillary axis, which is the line perpendicular to the cornea which passes through the centre of the entrance pupil. The Orbscan readings incorrectly refer to this angle as the angle kappa, which more correctly refers to the angle between the visual axis and the pupillary axis. Studies performed with these devices indicate Damien Gatinel MD

It is very important to try to match your pupil diameter with what you recorded with the topography system and pupillometry...

EUROTIMES | MAY 2015

that the centre of the entrance pupil is temporal in relation to the corneal vertex. The average angle lambda is 5.5° which correlates well with the average distance from the first Purkinje image to the centre of the entrance pupil, which is 300 microns. The studies also show that myopic eyes tend to have a lower angle kappa than hyperopic eyes, and that the position of the centre of the entrance pupil moves by about 100 microns as the pupil dilates and constricts. Furthermore, the pupil is not concentric with the limbus, and its centre is more nasal and superior and becomes even more so when the pupil constricts under high illumination. “However, there are eyes where the vertex is close to the pupil centre but there is a nasal pupil centre and other eyes where the corneal vertex is nasal but the pupil centre is close to the limbal centre, all of this is important for cataract and refractive surgeons,” Dr Gatinel pointed out.

CLINICAL IMPLICATIONS Knowing the position of the corneal vertex in an individual patient can be helpful not only for planning cataract and refractive treatments but also for correcting induced refractive errors after surgery. As an example, he described the case of a patient he had who developed visually disturbing symptoms such as ghosting and double-images after undergoing implantation of a Kamra inlay. Using Acutarget measurements he was able to determine that the implant was placed too far in the nasal direction with respect to the corneal vertex. When they accordingly re-centred the inlay the visual symptoms disappeared. In laser refractive surgery there is one inherent problem in centring treatments on the corneal vertex, and that is the intraoperative loss of specularity of ablated corneal surface, which means that there is no first Purkinje image to use as a reference for the corneal vertex. The laser system must therefore use other anatomical landmarks such as the pupil and the limbus and their relationship to the corneal vertex as determined by preoperative measurements. It is recommended to centre the photoablation midway or two thirds of the way between the pupil centre and the vertex. “It is very important to try to match your pupil diameter with what you recorded with the topography system and pupillometry. Then you can take into account any pupil centre shift which is assessed from the limbus, and add this X and Y shift to locate the intended laser centration. Then you can select the distance you want between pupil centre and the vertex and fire your laser,” Dr Gatinel added. Dr Gatinel noted that when performing cataract surgery, and especially when implanting intraocular lenses (IOLs) with complex geometry such as multifocal IOLs, he creates a temporally centred capsulorhexis. That seems counterintuitive, but it leaves a fairly large nasal capsule remnant allowing a nasal positioning of the IOL with good postoperative stability. Damien Gatinel: gatinel@gmail.com

XXXIII Congress of the ESCRS 5â&#x20AC;&#x201C;9 September 2015

Fira Barcelona Gran Via, Spain North Access, Hall 8

Binkhorst Medal Lecture Richard Packard UK

The Evolution of the Capsulotomy: From Crude Forceps to Precision Laser

Main Symposia Cataract Surgery in Ocular Surface Disease The Ageing Eye: Can We Delay or Reverse the Process? FLACS: What Have We Learned and What Can We Expect? Treating Presbyopia: From Concept to Evidence Late Dislocation of IOLs: Causes and Treatments

www.escrs.org /ESCRS @ESCRSOfficial

ESCRS

XXXIII Congress of the ESCRS 5–9 September

Saturday 5 September

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GLAUCOMA

GENETIC discover SELF TESTING Rarely useful for glaucoma diagnosis, home tests can cause needless worry. Howard Larkin reports

lthough genetic research suggests new potential treatment targets for glaucoma, genetic testing today is currently seldom needed for clinical diagnosis or treatment, Wallace LM Alward MD told Glaucoma Day at the 2014 American Academy of Ophthalmology annual meeting in Chicago. Indiscriminate testing can even do harm, said Dr Alward, of the University of Iowa, Iowa City, Iowa, US. Commercial genetic self-tests can be especially troublesome, he said, as they often confront patients with “risk” information that is almost meaningless outside a specific clinical context. The results can range from causing needless worry to generating unnecessary tests or even ill-advised prophylactic treatment, Dr Alward said. Therefore, he advised adhering to the AAO genetic testing task force recommendation to avoid routine testing for genetically complex disorders, including late-onset open-angle glaucoma (Ophthalmology 2012; 119: 2408-2410).

RISKS … Most glaucoma genetic markers were discovered through genome-wide association studies of large populations. So most are associated with increased disease risk rather than directly causing glaucoma, Dr Alward explained. But even when the association is strong, it may not be clinically relevant, Dr Alward added. For example, a gene association study of pseudoexfoliation found that patients homozygous for the highest risk variant of the lysyl oxidaselike 1, or LOXL1, gene were 700 times more likely to develop exfoliation glaucoma than those with the lowest risk (Thorleifsson et al. Science 317:1397-1400, 2007). “That’s pretty exciting – except that 25 per cent of the population is homozygous for the highest risk alleles.” And since most will never get pseudoexfoliation, testing is not very helpful, Dr Alward said. Indeed, research suggests multiple genetic and environmental factors contribute to pseudoexfoliation and most other glaucomatous conditions. But many factors and their interactions are unknown. So conventional clinical signs remain much more powerful glaucoma predictors than genetic tests in most cases, Dr Alward said.

… AND CAUSES However, a few genes apparently do cause glaucoma. These include myocilin for juvenile onset or primary open-angle glaucomas; optineurin and TBK1 for normal-tension glaucoma; CYP1B1 and LTBP2 for primary congenital glaucoma; and PITX2 and FOXC1 for Axenfeld-Rieger syndrome. “If you have these genes you are at very high risk for getting these diseases,” Dr Alward said. But these rare conditions combined make up only about five per cent of glaucoma cases – and are often evident without genetic tests, Dr Alward said. Genetic tests may be most useful in borderline cases, such as confirming PAX6 mutation in a patient with some but not all aniridia features, or screening offspring of patients with known genetic disease, he said.

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Wallace LM Alward: wallace-alward@uiowa.edu EUROTIMES | MAY 2015

GLAUCOMA

EYE DROP INSTILLATION

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onsistently getting one – and only one – eye drop onto the eye remains a significant challenge in treating glaucoma. Greater awareness of the obstacles patients face in effectively instilling eye drops, and better patient education, may help improve medication adherence and effectiveness, Alan L Robin MD, Baltimore, US, told Glaucoma Day at the 2014 American Academy of Ophthalmology annual meeting in Chicago. The problem is underappreciated, even among patients themselves, Dr Robin said. In a study he conducted, 92 per cent of patients said they never missed their eyes with eye drops, but observations showed 35 per cent missed at least sometimes and more than a quarter missed regularly. “The first thing is that you have to ask the patient if they are having problems. The second is perhaps you shouldn’t believe them, especially if they say they are having none. It’s not all that easy,” Dr Robin said. Squeezing out no drops or multiple drops, not washing hands before instilling drops, and contaminating the bottle tip are also common problems. Dr Robin’s research also suggests that ophthalmologists often do not offer much instruction on using eye drops, let alone assess whether patients are actually able to successfully instill them. To raise awareness, he outlined several obstacles patients face to successful eye drop use. Bottle design – Bottles can be difficult to open initially, prompting patients to use their teeth or a knife, risking contamination or even injury. Some bottle tips must be punctured by reversing the cap, but patients may find this difficult and simply cut off the tip, making drop control impossible, Dr Robin noted. Variation in the colour and size of bottles also has been shown to affect patient compliance. “We prescribe without thinking about the bottle,” he said. Hand strength – The pressure required to squeeze out drops varies widely by bottle type, and often exceeds what many patients can comfortably apply (Drew & Wolffsohn. ARVO 2014). “In the era of generics there is tremendous variability; try it yourself and you will see some are harder and some are easier. It can make a big difference in adherence,” Dr Robin said. Drop size – The size of drop extracted with each squeeze can vary significantly between branded and generic drugs. As a result, patients who have not previously run out of drops may run out when substitutions are made, Dr Robin said. Contamination – Some patients apply drops by putting the bottle directly on the eye surface, which can lead to infection. And while there is no one correct technique, instruction can help, Dr Robin said. He suggested an online video by Robert Ritch MD (https://www.youtube.com/watch?v=FhkRAaIbIuE). However, many ophthalmologists do little or no eye drop patient education. In a study involving 275 patients seen by 17 doctors at an initial or three-month visit only 30.9 per cent received verbal instructions, and only 9.8 per cent a technique demonstration. Written instructions were given only once at the patient’s request. “We really have to do a better job,” Dr Robin said. Alan L Robin: arobin@glaucomaexpert.com

EUROTIMES | MAY 2015

NICE 15th EURETINA Congress

17â&#x20AC;&#x201C;20 September 2015 Acropolis, Nice, France

11 Main Sessions 24 International Society Symposia 21 Free Paper Sessions 48 Instructional Courses 5 Surgical Skills Courses EURETINA Lecture Keynote Speaker: Alain Gaudric FRANCE The Broad Range of Cystoid Maculopathies

Kreissig Lecture Keynote Speaker: Bill Aylward UK A Logical Approach to Retinal Detachment

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EURETINA is delighted to announce the 4th Retina Race Date: Saturday 19 September (Registration opens at 6.30am)

Location: Promenade des Anglais, Nice Registration Fee: Ð30 in aid of Orbis N.B. Please note that according to French Law all race participants must submit a medical certificate dated from less than one year before the Race-Day signed by a doctor with the mandatory mention: “Mr/ Mrs X is conditioned to participate in the running competition” (French Law Buffet, March 1999) YOU WILL NOT BE PERMITTED TO PARTICIPATE IN THE RACE WITHOUT SUBMITTING THIS CERTIFICATE WITH YOUR REGISTRATION

RETINA

LOW ENDOPHTHALMITIS Swedish registry data shows very low endophthalmitis rates after IVT. Dermot McGrath reports

vidence from the Swedish national macula register shows a very low incidence of endophthalmitis of 0.02 per cent after intravitreal injections for the treatment of age-related macular degeneration (AMD), with rates comparable to that following uncomplicated cataract surgery, according to Inger Westborg MD. “The register focuses on adverse events with reports of endophthalmitis collected since 2007 and suspected systemic adverse events since 2010. We have a very low incidence for endophthalmitis per injection, with the risk increasing only slightly per patient to 0.065 per cent,” she told delegates attending the 14th EURETINA Congress in London. Dr Westborg, who serves as registry manager for the Swedish Macula Register, explained that it was one of the first national registers for AMD treatment set up in 2003. “Naturally at the time it was focused on photodynamic therapy which was the standard treatment for AMD at the time. The register has witnessed considerable evolution since then, becoming web-based in 2007 and seeing a large increase because of the widespread introduction of intravitreal anti-VEGF therapies,” she said. The Swedish national register collates a wide range of information concerning the results for AMD treatment, said Dr Westborg, including patient age, gender, type of lesion, number and type of treatments per clinic/county and number of follow-up visits. The medical outcome, visual acuity, near visual acuity and adverse events are also reported to the register. “We have around 80 per cent coverage of patients treated for AMD in Sweden, with 35 out of 37 eye clinics treating AMD connected to the register last year (2013). This year (2014) we have added Inger Westborg MD more clinics, included two

We have around 80 per cent coverage of patients treated for AMD in Sweden...

private clinics. In total, we have over 15,000 patients, more than 18,000 eyes, over 230,000 visits and 100,000 treatments recorded," she said.

TREATMENT PATTERN Dr Westborg noted that the mean age for start of AMD treatment in Sweden is 79 years, and 65 per cent of the patients are female. Intravitreal injections of anti-VEGF compounds account for around 90 per cent of all AMD treatments, with a change in the treatment pattern in recent years. “Initially almost 99 per cent of all anti-VEGF treatments were ranibizumab but since the landmark CATT study in 2011 we have witnessed a significant increase in the use of bevacizumab, and last year (2013) a first implementation of aflibercept. At the end of last year (2013) there was about one-third of each choice being used for AMD treatment,” she said. Focusing on the endophthalmitis cases that were added to the register in 2013, Dr Westborg said that all of the six cases concerned were women, with a mean age of 85 years. The mean number of intravitreal injections was eight and the operative routines included antibiotics for all patients on the day of treatment. The treatments were performed in the operating theatre in five cases and a sterile room in an office in one case. A recent survey of 41 clinics based on register data found that intravitreal injections were performed in the operating theatre in 93 per cent of cases and a sterile room in the ophthalmologist’s office in seven per cent. Antibiotics were used on the day of the injection in 39 clinics, with only two clinics not giving any antibiotics before or after intravitreal treatment, she said. Most clinics used chlorhexidine solution and alcohol, and two clinics used povidone iodine as their preferred antiseptic. Most clinics also use draping and blepharostat, said Dr Westborg. In terms of suspected systemic adverse events recorded in the register, 18 cases were judged to have a connection to intravitreal treatments in 2013, including six cases of myocardial infarction and 12 cases of stroke and transitory ischaemic attack. Summing up, Dr Westborg said that the registry shows a yearon-year increase in the number of AMD patients, treatments and follow-up visits, with a low incidence of endophthalmitis and serious systemic adverse events over the period covered by the registry. Inger Westborg: inger.westborg@nll.se

Courtesy of Swedish Macula Register Annual Report

EUROTIMES | MAY 2015

RETINA

5TH EURETINA WINTER MEETING Over 150 delegates gathered in University of Oxford, UK, for the event. Gearoid Tuohy reports

rofessor Jan van Meurs, of Rotterdam Eye Hospital and Erasmus University, The Netherlands, told delegates at the 5th EURETINA Winter Meeting that while anti-VEGF therapies may work well for a proportion of patients, there are specific groups for which anti-VEGF therapy does not work. According to Prof van Meurs, stem cell therapeutics, while of significant promise, continue to have serious challenges including both complex surgery and the quality of “product” that can be produced in the lab. The future for many stem cell therapies may involve the development of robust sheets of RPE derived from stem cells, however creating a reproducible and predictable quality control method for the production of such cells represents a significant engineering and biological challenge, he said. He showed data of recent surgeries with autolous transplants, emphasising that transplantation of both autologous and stem cell derived RPE sheets in patients with exudative AMD will be accompanied by trauma and tissue reactions to trauma (the danger model of Polly Matzinger). Prof James Bainbridge, of Moorfields Eye Hospital NHS Foundation Trust, London, UK, provided a brief update on the ongoing Octata Therapeutics (previously ACT Inc.) trial under way at centres in the EU. Prof Bainbridge provided details on the Phase I/II, open-label, multicentre, prospective study involving the subretinal transplantation of hESC-RPE cells in 12 subjects. The trial includes four cohorts of three Stargardt’s patients, each cohort receiving increasing doses of the RPE between 50,000 and 200,000 cells, together with immunosuppression medication withdrawn after 12 weeks. To date, Prof Bainbridge confirmed that the procedure appeared to be well tolerated, with areas of new pigmentation in the fundi of recipients suggesting survival of transplanted cells. While a number of speakers discussed successes and challenges with AAV gene therapy, alternative vectors for the delivery of therapeutic genes were presented by Dr Kyriacos Mitrophanous from Oxford Biomedica. According to Dr Mitrophanous, lentiviruses overcome a significant limitation of AAV, namely the size restriction on what size gene may be delivered. Lentiviral vectors can incorporate 9-10kb of DNA and can therefore comfortably accommodate the 6.8kb transgene required to treat Stargardt’s disease. Clinical trials, sponsored by the company, are currently under way and formal results are expected by the end of 2015. Dr Ursula Schmidt-Erfurth gave a presentation on computational image analysis, introducing the concept of utilising big data made possible from the thousands of patients seen at clinics. Computational analyses allow for a deeper understanding of disease mechanisms in all major indications. For the entire patient population seen over time, disease models allow to identify subgroups and disease patterns already at the initial presentation. Jan van Meurs: j.vanmeurs@oogziekenhuis.nl James Bainbridge: j.bainbridge@ucl.ac.uk Kyriacos Mitrophanous: enquiries@oxfordbiomedica.co.uk Ursula Schmidt-Erfurth: ursula.schmidt-erfurth@meduniwien.ac.at EUROTIMES | MAY 2015

Registration & Hotel Bookings Open

FOUR EVENTS

ONE VENUE Fira Barcelona Gran Via, Spain

North Access, Hall 8

XXXIII Congress of the ESCRS

6th EuCornea Congress

5–9 September www.escrs.org

4–5 September www.eucornea.org

WSPOS

3rd World Congress of Paediatric Ophthalmology and Strabismus

The 7th International Conference on Ocular Infections

4–6 September www.wspos.org

3–4 September www.ocularinfections.com

RETINA

REFRACTORY DME THERAPY DEX implants can improve VA when all else has failed. Sean Henahan reports

atients with refractory diabetic macular oedema (DME) can experience significant improvements in visual acuity with serial dexamethasone implant (DEX) therapy, David G Dodwell MD told the 2014 annual conference of the American Society of Retina Specialists in San Diego, US. Dr Dodwell, Medical Director, Illinois Retina Center, Springfield, Illinois, US, presented a study of 20 eyes of patients with refractory DME. Patients had persistent increased intraretinal fluid and had undergone multiple previous treatments including intravitreal anti-VEGF agents, triamcinolone acetonide, and focal laser therapy. Most, 95 per cent, were pseudophakic, and more than half had undergone prior vitrectomy surgery. Forty per cent had undergone internal limiting membrane peeling. Overall, the 20 eyes received 89 DEX implants (Ozurdex, Allergan). The patients underwent repeat implant treatment when recurrent increased intraretinal fluid was seen on OCT. Adjunctive anti-VEGF therapy was allowed. The mean DEX implant reinjection interval was 3.8 months, and the mean number of injections per eye was 4.5. Baseline central subfield thickness decreased from 490 to 281 microns two to three months after the first implant. This decrease was sustained with subsequent implants. Mean logMAR visual acuity increased from 0.64 to 0.33 following treatment. Visual acuity improved by three or more lines in 60 per cent of patients. Thirty per cent of eyes improved by five or more lines. Ten per cent David G Dodwell showed no improvement, and none worsened. Only one eye developed an intraocular pressure of more than 10mmHg above baseline, and was treated topically. Dr Dodwell described one dramatic case of a patient who presented with a central subfield thickness of more than 1,000 and visual acuity of 20/200. That patient had undergone multiple Avastin injections, and had developed sterile endophthalmitis following treatment with triamcinolone acetonide. The patient also had prior vitrectomy surgery with internal limiting membrane (ILM) peeling.

STEROID “This patient was told nothing could be done for him. We suggested he should try a challenge with 1.2mg of dexamethasone phosphate to see if he would respond to a non-particulate and more potent steroid. This showed favourable biological effects, but wore off after two weeks as would be expected given the short half life. The patient received a DEX implant, and two weeks later experienced a dramatic decrease in central subfield thickness, along with eventual improvement in visual acuity,” Dr Dodwell reported. “Our study supports the use of serial DEX implants as an effective treatment option in patients with refractory DME,” he said. David G Dodwell: ddodwell@illinoisretinacenter.com EUROTIMES | MAY 2015

RETINA

MAJOR EVOLUTION Shedding light on the complex role of genetics and environment in AMD. Dermot McGrath reports

arked progress over the past few decades in understanding the environmental and genetic underpinnings of age-related macular degeneration (AMD) has formed the scientific basis for the preventive management of the disease, according to Johanna M Seddon MD, ScM, who delivered the annual Kreissig Lecture at the 14th EURETINA Congress in London. “We have seen a major evolution in thinking from the time when everyone used to say that there is no evidence that AMD is a genetic disease, to the recognition today that we are dealing with a disease with genetic, nutritional and other environmental components. We now know that there are susceptible genotypes for AMD and the manifestation of disease may be modified by our behaviours and our lifestyle,” she said. AMD is a common cause of irreversible visual loss and the disease burden is rising worldwide as the population ages, said Dr Seddon, Professor of Ophthalmology at Tufts University School of Medicine, and Founding Director of the Ophthalmic Epidemiology and Genetics Service of Tufts Medical Centre, New England Eye Centre, Boston, US. While genetic factors lead to various levels of susceptibility for the development of AMD, the environment modifies the effects of this predisposition to varying degrees depending on the level of genetic risk, she explained. With this in mind, she noted that genotyping may become a useful tool for identifying individuals who are at high risk for disease and who may therefore benefit from increased surveillance and personalised treatment strategies. Reviewing the sea change in thinking that has taken place over the past decade or so, Dr Seddon said that numerous scientific publications now attest to the fact that both environmental and genetic factors contribute to the development of AMD.

ENVIRONMENTAL FACTORS Among environmental factors, Dr Seddon identified smoking, obesity and dietary factors, including antioxidants and dietary fat intake that have been shown to influence the onset and progression of AMD. Dr Seddon was one of the first researchers to pinpoint smoking as a clear risk factor for AMD. Her 1996 publication showed in a prospective analysis that smoking 25 cigarettes per day or more led to a 2.4 times greater risk of developing AMD over time compared to those who never smoked. Past smokers also had twice the risk of AMD. There are several possible mechanisms by which smoking may affect the healthy functioning of the eye, said Dr Seddon. First, smoking may adversely affect blood flow in the eye, decreasing high-density lipoprotein (HDL) cholesterol that may actually prevent atheroma formation, and increasing platelet aggregation and fibrinogen. Smoking also increases oxidative stress and lipid peroxidation, reduces plasma levels of antioxidants and increases inflammation. Dr Seddon and co-workers were the first to carry out a systematic study of diet and AMD, and discovered the beneficial impact of dietary lutein and zeaxanthin, contained in foods such as spinach, collard greens and kale. Studies published from 1994 to 2014 show the protective effect of a healthy diet with plenty of green leafy vegetables, fruit, fish and nuts with a high lutein/zeaxanthin content, and sufficient intake of EUROTIMES | MAY 2015

Francesco Bandello, president of EURETINA, with Johanna M Seddon (centre) who delivered the Kreissig Lecture, and Ingrid Kreissig

zinc and vitamins C and E, resulting in a reduced risk of AMD of between 25-50 per cent, she said. The correlation between AMD and cardiovascular disease, in terms of risk factors and biomarkers, has been another key finding, contributing to the discovery of inflammation’s central role in both diseases, according to Dr Seddon. The importance of maintaining a healthy lifestyle is the key to reducing the risk of AMD and its progression in many cases, she said. “Do not smoke. Eat a healthy diet rich in dark green leafy vegetables and low in fat, eat fish twice a week, maintain a normal weight and waist size, exercise regularly, and control blood pressure and cholesterol,” she said. There are also several lines of evidence linking cardiovascular, immune and inflammatory biomarkers to AMD. Genome-wide association studies have revealed numerous common variants associated with AMD and sequencing is increasing knowledge of how rare genetic variants strongly impact disease. “While the evidence for interactions between environmental, therapeutic and genetic factors is emerging, elucidating the actual mechanisms of this interplay remains a major challenge in the field,” said Dr Seddon. About 30 common and rare AMD genetic loci have now been confirmed, gene-environment and gene treatment interactions are emerging, and both the genetic and lifestyle risk factors point to a central role for the inflammatory, immune, lipid, collagen extracellular matrix degradation, and angiogenic pathways in AMD. Dr Seddon said that the knowledge of non-genetic, modifiable risk factors along with information about heritability and genetic risk variants for this disease acquired over the past 25 years have greatly improved patient management and the ability of clinicians to predict which patients will develop or progress to advanced forms of AMD. Personalised medicine and individualised prevention and treatment strategies may become a reality in the near future, she said. Dr Seddon finished her lecture by paying tribute to the work of Professor Ingrid Kreissig for her immense contribution to ophthalmic training and research, particularly in the field of retina. Johanna M Seddon: jseddon@tuftsmedicalcenter.org

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PAEDIATRIC OPHTHALMOLOGY

CROSSLINKING BENEFITS Early treatment may arrest keratoconus in Down Syndrome patients. Howard Larkin reports

ecent studies suggest that corneal crosslinking (CXL) is safe and can arrest keratoconus progression in children and adolescents for 24 months or more, Farhad Hafezi MD, PhD told the 2014 American Academy of Ophthalmology annual meeting in Chicago. However, these studies also show conflicting results at 36 months. This may be because keratoconus is so aggressive in younger eyes that it may overcome CXL efficacy with time, said Dr Hafezi, Professor of Ophthalmology, University of Geneva, Switzerland and USC Los Angeles, US. But with progression likely in nine of 10 paediatric keratoconus patients, CXL treatment should be considered at initial diagnosis because it can prevent the need for later penetrating or deep lamellar keratoplasty to avoid severe visual impairment, Dr Hafezi said. Young patients also should be followed closely after CXL. Because CXL is so safe in patients with sufficient corneal thickness, retreatment is an option if progression resumes.

MUCH HIGHER While the general incidence of paediatric keratoconus ranges from about one in 1,500 in Europe to about one in 500 in the Middle East, risks are much higher in some subpopulations. At somewhere between one in 67 and one in 20, Down Syndrome patients are among the highest risk, Dr Hafezi noted. Yet historically, early keratoconus has been grossly underdiagnosed in Down Syndrome patients, Dr Hafezi said. This may be because sub-par performance on visual acuity tests in this cognitively challenged population is often attributed to poor patient communication or compliance.

Courtesy of Farhad Hafezi MD, PhD

Pictured at the opening ceremony of the Light for Sight reference site “www.ophthalmica.gr” in Thessaloniki, Nothern Greece (from right to left): Miltos Balidis (head of cornea unit, Ophthalmica), Farhad and Nikki Hafezi (founders of Light for Sight 21), Tsiflikis Stavros (vice chairman, Down Syndrome Organisation Greece), Nikos Kozeis (paediatric ophthalmologist) and Chrysanthi Basdekidou (paediatric ophthalmologist)

To raise awareness of the often overlooked risk of keratoconus in Down Syndrome, Dr Hafezi, together with his wife Nikki Hafezi MAS, IP, ETHZ, in 2012 founded Light for Sight 21, so named for the trisomy of chromosome 21 that causes Down’s. “My wife asked me how many Down Syndrome children I had treated with crosslinking, and I said ‘maybe two?’ We started to realise there was a big subgroup that doesn’t get treated.” Nikki Hafezi later expanded the voluntary organisation’s mission to combat preventable blindness from keratoconus for all children and renamed it lightforsight.org. It currently disseminates paediatric and Down Syndrome keratoconus information and develops best practice treatment models. Lightforsight.org also collaborates with referral sites in 25 countries where ophthalmologists can refer patients for keratoconus diagnosis, treatment and check-ups. “We were overwhelmed by the feedback from the [ophthalmic] community. This is a very nice initiative between countries,” Dr Hafezi said.

My wife asked me how many Down Syndrome children I had treated with crosslinking, and I said ‘maybe two?’... Farhad Hafezi MD, PhD EUROTIMES | MAY 2015

THE EVIDENCE Three large studies of the long-term outcomes of CXL for keratoconus in paediatric and adolescent populations have been published in the past two years, Dr Hafezi noted. In his own study, involving 46 eyes in patients aged nine to 19 years treated with CXL and followed from 12 to 36 months, Kmax values and corrected distance visual acuity showed significant improvement at 24 months, but not at 36 months (Chatzis et al. J Refract Surg. 2012 Nov;28(11):753-8). However, a phase II open trial involving 152 keratoconus patients aged 10 to 18 treated with CXL did show significant improvement in Kmax, corneal asymmetry index, and both uncorrected and corrected visual acuity at 36 months (Caporossi A et al. Cornea. 2012 Mar;31(3):227-31). A third study, involving 40 eyes in patients under the age of 18 undergoing CXL, found significantly improved keratometry and uncorrected and corrected visual acuity through 24 months (Vinciguerra et al. Am J Ophthalmol. 2012 Sep;154(3):520-6). As a result, no consensus yet exists on whether crosslinking should be initiated in otherwise eligible paediatric keratoconus patients without waiting for progression, Dr Hafezi said. Dr Farhad Hafezi can be reached at the ELZA Institute, Dietikon/ZH, Switzerland; www.elza-institute.com, info@elza-institute.com

World Society of Paediatric Ophthalmology and Strabismus

World Congress of Paediatric Ophthalmology and Strabismus Fira Barcelona Gran Via, Spain North Access, Hall 8 4–6 September 2015

Keynote Lectures Non-Strabismus Keynote Lecture Alex Levin USA

Friday 4 September 12.15 – 13.15

Strabismus Keynote Lecture Lionel Kowal AUSTRALIA

Clarity Satellite Meeting Sponsored by

Saturday 5 September Kanski Medal Helen A. Mintz-Hittner USA

12.45 – 13.45

Paediatric Management of Ocular Surface and Lids Moderator: D. Brémond-Gignac FRANCE Sponsored by

www.wspos.org /WSPOS @WSPOS

Expertise Resides ALL Around the World

INNOVATION

SUSTAINED RELEASE TECHNOLOGY Emerging delivery devices may cut intraocular injections, improve topical therapy. Howard Larkin reports

xtended release technologies now in development aim to tackle one of the most pervasive challenges of ophthalmology – consistently delivering ophthalmic drugs, whether topical or injected. The new technologies are designed not only to reduce the need for frequent intraocular injections, and reduce or even eliminate eye drops. They also smooth dosing spikes and troughs, enabling consistent delivery within the therapeutic range for all kinds of ophthalmic drugs over time periods ranging from hours to months.

NANOPARTICLES

Neurotech, based in Cumberland, Rhode Island, US, has developed Encapsulated Cell Therapy, or ECT, a miniaturised “cell factory” intravitreally implanted through a ≤3mm scleral incision and sutured to the scleral wall outside the visual axis. The implant contains a proprietary, immortalised, nontumorigenic RPE cell line that is genetically engineered to continuously produce a wide array of therapeutic proteins for two years or more with no immune impact in clinical trials to date, said Quinton Oswald, president and CEO. The ECT platform has many potential advantages over other long-term therapies. It can support the continuous and long-term delivery of proteins into the vitreous, singly or in combination with another drug(s). It can consistently deliver these large molecules for at least two years to treat a broad range of retinal diseases, although more recent explant data has suggested sustained delivery for up to five years. In addition, the relatively low sustained dose of drug emitted into the vitreous may minimise local and systemic adverse events that come from the current required bolus injections. Perhaps, most importantly, since the ECT implants are sutured to the sclera by a titanium clip they are easily removable, if necessary. Since the host has not been genetically modified in any way, as with gene therapy, the removal of the implant immediately stops any further exposure to the drug.

Position of the Encapsulated Cell Therapy implant in the posterior segment of the eye, outside of the visual axis

Ne uro tec h

EUROTIMES | MAY 2015

IMPLANTED CELL FACTORY

A proof of concept trial of Neurotech’s lead compound (NT-503) for wet AMD showed a mean gain of 13 letters with concurrent reduction of 200 microns in central foveal thickness at 12 months, Oswald said. A twoyear phase II trial comparing one NT-503 ECT implant with aflibercept dosed every eight weeks in patients with at least three previous anti-VEGF injections is scheduled to begin in early 2015. Another implant (NT-501 ECT), which produces ciliary neurotrophic factor (CNTF), has been shown to increase thickness of photoreceptor cells in retinitis pigmentosa, and is in a phase II trial for macular telangiectasia, with a phase I trial for achromatopsia in the works. Additionally, early pilot data from an investigator sponsored trial of NT-501 in patients with glaucoma suggest an improvement in

o sy rte Cou

Baltimore, US-based GrayBug has developed polymer-based drug delivery systems that enable customisable sustained release of all types of drugs, including small and large molecules. Using drug-loaded nanoparticles, microparticles and biodegradable implants, the devices can extend intraocular injection intervals to six months or more, GrayBug president and CEO Michael O’Rourke told the Ophthalmology Innovation Summit at the 2014 AAO annual meeting in Chicago. GrayBug’s lead compound is an antiVEGF and anti-PDGF agent targeting neovascular age-related macular degeneration (AMD). At the end of month three, vitreous drug levels were found to be 300 times higher than the 50 per cent maximal inhibitory concentration against VEGF-R and PDGF-R, and level release has been demonstrated to 120 days and longer. O’Rourke projects FDA clearance for human trials by the end of 2016. GrayBug also has

additional products targeting glaucoma and corneal transplant rejection in the pipeline.

INNOVATION

HYDROGEL TECHNOLOGY

said Robert Butchofsky, founder and CEO. The plug is inserted in the lower tear duct and phase II trials show the device lowers IOP 5.0 to 6.0mmHg for 12 weeks, reducing or eliminating the need for eye drops. Safety profile is good with mild lacrimation and eye pruritis the most common side effects, and retention at 92 per cent for 12 weeks with the latest design. A phase III study begins this year. Future applications include allergy and anti-inflammatory formulations. Michael Oâ&#x20AC;&#x2122;Rourke: Michael@graybug.com Quinton Oswald: q.oswald@neurotechusa.com Robert Butchofsky: info@matitherapeutics.com John Maroney: information@forsightv5.com Scott Corning, Ocular Therapeutix: scorning@ocutx.com

Cross-section of a cartridge in the Encapsulated Cell Therapy implant, depicting the selective membrane which allows oxygen and nutrients in and therapeutic proteins out

Courtesy of Mati Therapeutics

Ocular Therapeutix, Bedford, Massachusetts, US, is using its proven hydrogel technology in intracanalicular depots for surface delivery of anti-inflammatory steroids and glaucoma compounds, now in phase III and II trials respectively, said Amar Sawhney PhD, president and CEO. The firm is also conducting feasibility studies for six-month sustained release anti-VEGF intraocular injections. The anterior segment intracanalicular depots are easy to insert and absorb over time so there is no need for removal. The dexamethasone insert shows excellent clearing of anterior chamber cells and flare cells with significant reductions in ocular pain for a 30-day period, and is expected to be submitted for FDA approval for postoperative inflammation and pain in the second quarter of this year. The travoprost plug reduces intraocular pressure (IOP) 5.0 to 6.0mmHg for up to 90 days and is currently enrolling in phase IIb trials. Their intravitreal depot has demonstrated six-month release in vitro and is being tested in vivo. Assuming feasibility is demonstrated, the firm will pursue further collaboration with pharmaceutical firms to further develop the technology. The lead product for ForSight Vision5, Menlo Park, California, US, is Helios, a non-invasive polymer insert delivering glaucoma medications continuously for up to six months, said John Maroney, CEO. The product addresses problems with eye drops compliance, including inability to administer drops properly.

Designed to be replaced at normally scheduled office visits, the ring-shaped insert tucks under the eyelids, where it rests comfortably on the ocular surface. In tests, a non-eluting device remained stable and comfortable for two months in 95 per cent of 39 patients. Published phase I dosing studies showed therapeutically relevant IOP reduction for three months. A phase II randomised trial comparing an active insert eluting PGA with placebo drops to an inactive or placebo insert with active timolol drops in glaucoma and ocular hypertension patients has been completed. Results will be published later this year. A phase IIb dose ranging trial with a prostaglandin as compared to timolol is scheduled for this year. Applications for dry eye and allergies are in development. Mati Therapeutics, Austin, Texas, US, is developing Evolute punctal plugs for continuous delivery of glaucoma medications,

Courtesy of Neurotech

visual field and corresponding macular and nerve fibre layer volume as early as one month and lasting for at least 18 months. To date, NT-501 has been generally safe with approximately 1,000 person-years of cumulative exposure.

Graphic showing the Mati Therapeutics Evolute punctal plug, drug eluting core and where it is placed in the puncta

EUROTIMES | MAY 2015

ESASO

2015/16 PROGRAMME The one-year full ESASO Fellowship is an advanced subspecialty-training programme

ESASO Fellowships

ESASO Fellowships enable you to acquire knowledge and hands-on experience from leaders in a global network. The particular subspecialties are: • Anterior segment surgery • Glaucoma • Medical & surgical retina • Oculoplastic • Research Applications open for 2015/2016. Deadline 12.06.2015.

ince 2008, ESASO has been committed to developing a world-class educational programme in ophthalmology. The modular system makes it possible for practising ophthalmologists to combine advanced training with their existing work commitments. ESASO fellowships are the core of the school’s educational programme and are awarded annually on a competitive basis. They offer an invaluable opportunity for fellows to choose their fellowships in subspecialties such as anterior segment surgery, glaucoma, medical and surgical retina, oculoplastic and research. The school firmly believes that the quality of the learning environment is crucial to the overall value of a fellowship. For this reason, ESASO partners with some of the Stanley Chang foremost teaching hospitals and university departments throughout the world in cities such as Barcelona, Cambridge, Hamburg, London, Milan, New York, Rostock, Tel Aviv and Vienna. Stanley Chang, the Chairman of the Fellowship Committee, comments: “We continually monitor the quality of the programme and always strive to develop new connections with leading ophthalmic institutions globally.” The committee has called for young ophthalmologists to apply for the period 2015/16. The application deadline is 12 June 2015, followed by acceptance notifications and personal interviews in Lugano on 26 June 2015. This is a unique opportunity for young ophthalmologists to learn from the best teachers as they try to become ‘complete ophthalmologists’. In order to ensure that the programme is as accessible as possible to the most talented candidates, the ESASO Fellowship Committee provides a stipend of up to €40,000 to successful applicants. ESASO further offers a two-year clinical development fellowship programme, a four-week observership programme, and a full month visiting fellowship in cataract surgery. * For further information and application form, visit: www.esaso.org/fellowships

ESASO FELLOWSHIP COMMITTEE 2015/16

www.esaso.org

EUROTIMES | MAY 2015

Stanley Chang, US, Chair Maurizio Battaglia Parodi, Italy, Secretary Rupert Bourne, UK Borja Corcóstegui, Spain Giuseppe Guarnaccia, Switzerland Anselm Jünemann, Germany Anat Loewenstein, Israel Ramon Medel, Spain Ursula Schmidt-Erfurth, Austria Christoph Scholda, Austria Sobha Sivaprasad, UK Leonidas Zografos, Switzerland

PRACTICE MANAGEMENT

MARKETING VISION The ESCRS Practice Management and Development Committee is calling for entries for the second annual Marketing Case Study Competition

ith a prize of €1,000, the second annual Marketing Case Study Competition seeks to highlight the innovative ways that ophthalmologists are marketing their practices around the world today. To be judged by Paul Rosen, chairman of the ESCRS Practice Management and Development Committee, and marketing expert Kris Morrill, the winning submission will demonstrate a successful campaign that resulted in an increase in patient volume or practice revenue. Entries should consist of a three-tofour-slide presentation which illustrates the campaign, costs, as well as the results. The winning entry will be announced at the ESCRS Practice Management and Development Workshops on Sunday, 6 September, at the XXXIII Congress of the ESCRS in Barcelona, Spain.

PRACTICAL POINTS Entries should demonstrate examples of marketing campaigns executed in the 12 months prior to submission. They should also include the following: • Type of marketing campaign • Target audience, e.g. cataract-age patients • Cost of the campaign • Examples of the material used (photos) Submissions should also include metrics to demonstrate the effectiveness of the campaign. For example – how many new patients resulted from this campaign?

LAST YEAR’S WINNER Bilić Vision Ophthalmology and Orthopaedic Polyclinic, Zagreb, Croatia, was the winner of the first Marketing Case Study Competition at the Practice Management and Development programme during the XXXII Congress of the ESCRS in London, UK.

CALLING ALL MARKETING GURUS!

ESCRS

Practice Management

& Development 6–7 September 2015 Barcelona, Spain

Represented by its founder Nadežda Bilić MD, PhD, Bilić Vision’s entry focused on its successful radio education campaign to attract more cataract-age patients to the clinic. On an investment of €11,000, the clinic was able to generate an eight per cent increase in new patient visits based on the twice-weekly, two-minute health information series over a 12-month period. The clinic tracked if the new patients came via word of mouth, its website or the educational radio series. The judges felt that the Bilić Vision entry was an excellent example of a marketing campaign developed on a small budget with a good return on investment. “The four finalists gave compelling presentations of their marketing campaigns, but in the end we felt that Dr Bilić and her team demonstrated that they had put into practice what they had learned after attending previous ESCRS Practice Management and Development programme workshops,” said Dr Rosen.

ESCRS Practice Management and Development Marketing Case Study Competition BUSINESS

Winner of a €1,000 bursary will be announced during the XXXIII Congress of the ESCRS in Barcelona UTILISE BUSINESS

To enter email colin@eurotimes.org

INNOVATE UTILISE BUSINESS

Submission Deadline Friday 7 August 2015 LEADERSHIP INNOVATE UTILISE BUSINESS

Further details at www.escrs.org DEVELOPMENT LEADERSHIP INNOVATE UTILISE BUSINESS

EUROTIMES | MAY 2015

GET TO THE SOURCE Become an ASCRS member to receive the latest clinical advances, research, and information on issues affecting your practice. • Annual meetings, clinical reports, web seminars, and online daily discussions • Surgical videos, symposia, and paper sessions in the ASCRS MediaCenter • Post-refractive IOL and Barrett Toric Calculators, Toric Results Analyzer, and more online tools • Journal of Cataract & Refractive Surgery, Ophthalmology Business magazine, and EyeWorld News magazine

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BOOK REVIEWS

ART AND PRACTICE The increased safety of cataract surgery and the evolution of intraocular lenses (IOLs) and their implantation techniques have led many physicians to begin offering so-called “premium IOLs” to selected patients. But how does one get started? Where can one find PUBLICATION the information necessary to MULTIFOCAL INTRAOCULAR LENSES: select the right IOL for the THE ART AND THE PRACTICE right patients? Many books EDITORS on the topic have appeared, JORGE L ALIÓ AND JOSEPH PIKKEL but few seem to offer a comprehensive overview of PUBLISHED BY SPRINGER how to successfully eliminate pseudophakic presbyopia. Multifocal Intraocular Lenses: The Art and the Practice (Springer), edited by Jorge L Alió and Joseph Pikkel, has stepped in to fill this void. “Guidance is provided on types and models of intraocular lens, indications, selection of patients, implantation, neuroadaptation, and complications and their avoidance,” says the foreword. The treatment of pseudophakic presbyopia is highly science, from the design of the IOLs and their precise implantation, to the neuroadaptation required for patients’ adjustment to the new sensory input. This material is adequately covered in the early chapters. Despite the scientific design of the IOLs and complicated neurophysiology underpinning their performance, successful implantation often relies heavily on the psychology involved in satisfying the patient. Chapter 7, “Solutions for the Unhappy Patient”, addresses this complex manipulation of science and art. Most chapters, however, address the types, models and clinical use of the commercially available multifocal IOLs. This book is particularly useful for cataract surgery fellows, early-career ophthalmologists and experienced cataract surgeons who are interested in offering their patients the multifocal option.

BOOK

REVIEWS

ENDOTHELIAL KERATOPLASTY Endothelial keratoplasty has long since replaced penetrating keratoplasty for the most common endothelial diseases. A series of modifications, from DLEK to DSEK, have led to vastly improved surgical rehabilitation and outcomes. Standardized ‘no-touch’ DMEK is the next step for corneal surgeons, but attempting an entirely new technique is a daunting proposal. How to Get Started With Standardized ‘No-Touch’ Descemet Membrane Endothelial Keratoplasty (DMEK) (NIIOS/Sidestone Press), by Gerrit Melles & Isabel Dapena, is a good place to start. The text covers the entire process: surgical indications, tissue preparation, surgical technique, clinical outcomes, complications, repeat DMEK and clinical case examples. Particularly useful is the selection of surgical “Dos” and “Don’ts”. This book is intended for corneal fellows or specialists considering the next step in endothelial surgery. LEIGH SPIELBERG Books Editor

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

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EUROTIMES | MAY 2015

EYE ON TECHNOLOGY

PHOTOREFRACTIVE INTRASTROMAL CXL (PiXL) Collagen crosslinking has evolved since it was first described by Theo Seiler for the treatment of corneal ectatic conditions. Dr Soosan Jacob reports

TECHNIQUE

iXL, or Photorefractive Intrastromal CXL, was introduced clinically by John Kanellopoulos, Athens, who has also contributed a significant amount of other pioneering work in the field of corneal crosslinking (CXL) such as the use of higher fluence; use of nondextran containing riboflavin solution; introduction of the Athens protocol which uses a combination of CXL with topography guided excimer normalisation of ectatic corneas; prophylactic CXL in routine myopic and hyperopic LASIK, as well as in-situ CXL through femtosecond laser created corneal pockets. These and other significant developments in the field have allowed the corneal surgeon an expanded armamentarium of options in effectively planning treatment of ectatic corneas, as well as providing a potentially novel treatment technique for correction of refractive errors. PiXL refers to a customised, variable fluence CXL treatment to productively utilise the potential refractive changes derived from CXL differentials that may be generated within the same cornea. EUROTIMES | MAY 2015

RESULTS

PRINCIPLE OF PiXL Customisable, differential CXL application to specific corneal areas may induce predictable refractive changes. The Avedro team (Waltham, MA) pursued this principle in theory and groundbreaking device design. Spatially selective corneal stromal stiffening can modulate corneal curvature, resulting in the achievement of a planned refractive change. This theory has also been recently supported by computer simulation patterns innovated by BJ Dupps et al at the Cleveland Clinic Foundation. â&#x20AC;&#x153;PiXL may radically enlarge the use of CXL not just in the field of stabilising ectatic disorders, but also to refractive surgery by reshaping the cornea by means of localised, differential tissue strengthening. It could be used for healthy corneas of patients with small refractive errors up to 3 dioptres for myopia, hyperopia and/or astigmatic corrections as well as for mildly keratoconic patients where CXL is desired to be combined with customised refractive correction of myopia and/or cylinder without causing tissue

removal. We were fortunate to be trusted first with this fascinating technology and conduct the initial feasability clinical work,â&#x20AC;? says Dr Kanellopoulos.

TECHNIQUE The differential UV delivery system offered by the novel KXL II device (Avedro Inc, Waltham, MA) makes it possible to deliver differential and variable UV-A illumination, and therefore modulate the CXL effect. Custom-application may make myopic, astigmatic as well as hyperopic refractive change possible. A central circular pattern of UV-A application may be used for myopic correction, a bow tie pattern for astigmatic and a doughnut pattern for treatment of hyperopia. PiXL may be performed as epithelium-on (transepithelial) or epithelium-off. The epi-on may be advantageous in simplicity, minimal postoperative discomfort, rapid recovery and safety. Titration by retreatment may be done. The weaker biomechanical effect can be compensated for by using higher fluence

Courtesy of John Kanellopoulos MD

EYE ON TECHNOLOGY

Figure: A: Scheimpflug imaging data showing preoperative Figure B: Custom CXL pattern applied in three-step overlaid patterns, a circular, and Figure C: Postoperative map depicts significant ‘cone’ curvature data two single arcs. Exposure time and fluence (and consecutively, delivered energy) are reduction, and a postoperative cornea appearing a lot all customisable. The CXL ‘action’ was targeted on the thinnest cornea more ‘regular’

UV-A and by achieving higher riboflavin penetration via techniques that weaken the epithelial cell junctions and increase riboflavin penetration.

RESULTS Dr Kanellopoulos says: “Endothelial Cell Count (ECC) examination by confocal specular microscopy both preoperatively as well as one-month postoperatively is an integral part of our clinical protocol. Our data have not yet indicated any statistically significant difference in ECC. In-vivo biomechanical measurements show low specificity and sensitivity. “We have used objective biaxial stressstrain measurements which are likely to be superior to corneal strip extensiometry utilised in past experiments, considering the non-uniform topographic distribution of corneal strength profile. Studies show substantial ex-vivo evidence that significant corneal strengthening takes place even when UV-A light is projected through

the intact corneal epithelium, Bowman’s membrane and superficial stroma, to reach underlying riboflavin-soaked stroma in order to induce cross-linking. Predictability may be assessed by further studies, as currently we are conducting initial, proofing clinical evaluation. “Currently we have applied the PiXL application in more than 40 cases, over the course of more than 18 months. We have presented pioneering studies that achieved myopic refractive change. Astigmatic changes have also been reported, as well hyperopic changes."

ADDRESSING KERATOCONUS WITH PiXL Customised patterns of delivered energy may be applied by customising UV-A patterns, fluence and exposure times to allow customised changes in topography of mildly keratectatic patients. Dr Kanellopoulos says: “In the example shown in Figures A-C, a keratoconic patient was treated with a customisable version of PiXL. Custom CXL

pattern was applied in three-step overlaid patterns, a circular, and two single arcs. CXL ‘action’ was targeted on the thinnest cornea. Comparison of preoperative to postoperative data indicate a significant ‘cone’ reduction, and a postoperative cornea appearing a lot more ‘regular’. This patient can now be managed with a spectacle refraction, as the postoperative astigmatism has been managed to significantly more regular, in comparison to the preoperative.” “The future lies in establishing and refining a nomogram, the optimal optical zone(s) and of course data that may be attempted and evaluated in future studies. We note, however, that the ease and essentially null morbidity that this procedure offers may additionally offer the possibility to titrate the effect through two or more treatments through time,” he says. * Dr Soosan Jacob is a Senior Consultant Ophthalmologist at Dr Agarwal’s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com

European Society of Cataract & Refractive Surgeons

Clinical

Call for Research Proposals Awards 2015

ESCRS has made available funding of €750,000 over three years for clinical research projects in the ﬁeld of cataract and refractive surgery

Additional information available at www.escrs.org Deadline for receipt of expressions of interest: 28 May 2015

EUROTIMES | MAY 2015

JCRS

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 4 MONTH: APRIL 2015

COST EFFICACY OF SAME-DAY BILATERAL SURGERY Same-day bilateral cataract surgery can provide both visual and economic benefits, suggest the results of a new prospective controlled non-randomised clinical trial. The trial compared the outcomes of 42 same-day patients and a matched set of separateday bilateral surgery. Benefits for same-day patients included less travel time, fewer office visits and quicker visual recovery. Overall reimbursement for physician and the ambulatory surgical centre were lower for the same-day cohort, while physician time was the same for both groups. SW Rush et al, JCRS, “Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States”, Volume 41, Issue 4, 732-739.

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Cataract surgery in eyes with previous herpes zoster ophthalmicus can be compromised by a number of chronic factors, a recent review indicates. The study evaluated 24 eyes with a history of herpes zoster ophthalmicus that had undergone phacoemulsification and intraocular lens (IOL) implantation. The mean CDVA improved from 20/112 preoperatively to 20/53 at one month postoperatively, improved to 20/44 at one year, but decreased to 20/71 at later visits. Eleven patients (45.8 per cent) had recurrent keratouveitis after the first episode, five before cataract surgery and six after cataract surgery. Three had penetrating keratoplasty for worsening corneal opacification. Two patients had tractional retinal detachment from chronic uveitis and required vitrectomy and retinal repair. Y He et al, JCRS, “Outcomes of cataract surgery in eyes with previous herpes zoster ophthalmicus”, Volume 41, Issue 4, 771-777.

CORNEAL ASPHERICITY Does anterior corneal surface asphericity affect the refractive outcomes in eyes having intraocular lens implantation after cataract surgery? Italian researchers believe so, suggesting that third-generation IOL power formulas be used to factor this in. Prior to surgery, IOL power was calculated using the Haigis, Hoffer Q, Holladay 1 and SRK/T formulas in 115 eyes. Asphericity (Q-value) was measured at 8.0mm with a Placido-disk corneal topographer (Keratron), a rotating Scheimpflug camera (Pentacam) and a rotating Scheimpflug camera combined with Placido-disk corneal topography (Sirius). All eyes received an Acrysof SA60AT IOL. Regression analysis showed a statistically significant relationship between the error in refraction prediction and the Q-value with all formulas and all devices. In all cases, a more negative Q-value (prolate cornea) was associated with a myopic outcome, whereas a more positive Q-value (oblate cornea) was associated with a hyperopic outcome. The researchers call for formulas to be updated. G Savini et al, JCRS, “Influence of corneal asphericity on the refractive outcome of intraocular lens implantation in cataract surgery”, Volume 41, Issue 4, 785-789.

THOMAS KOHNEN European editor of JCRS

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

INDUSTRY NEWS

INDUSTRY

NEWS

VISUAL FIELD TESTING At the American Glaucoma Society 2015 Annual Meeting in Coronado, California, ZEISS announced the worldwide launch of the new Humphrey Field Analyzer 3 (HFA3). “The HFA3 is designed to accelerate clinic flow while delivering the same gold-standard testing strategies and test patterns,” said a company spokesman. “The HFA3 upholds the Humphrey tradition of accuracy: test results on the new platform are equal to and interchangeable with results from prior generations of the HFA, providing continuity and certainty in the ongoing care of patients.” www.zeiss.com

STRONG RELATIONSHIPS

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NEW CEO Rick A Heinick has been named CEO and President of Calhoun Vision. “Rick’s experience and proven leadership ability is crucial to Calhoun as we focus on the vital task of obtaining FDA approval for the Light Adjustable Lens,” said Andy Corley, Chairman of Calhoun’s board of directors. www.calhounvision.com

HOYA Group has announced that it has closed financing in Salutaris Medical Devices (SalutarisMD®). “Our investment in SalutarisMD continues HOYA’s commitment to establishing strong relationships with companies developing next-generation products for medical care, particularly in the area of minimally invasive therapeutic technologies,” said Augustine Yee, Executive Officer, Chief Legal Officer and Head of Corporate Development and Affairs at HOYA Corporation. www.hoya.com

JOHN HENAHAN

PRIZE 2015

CALL FOR

ENTRIES Young ophthalmologists are invited to write a 900-word essay on

“How do I learn surgery?” and win a travel bursary worth €1,000 to attend the XXXIII Congress of the ESCRS in Barcelona, Spain

Closing date Friday 29 May 2015 For further information see www.escrs.org EUROTIMES | MAY 2015

TRAVEL

Motorbike Museum

Barcelona

TO TRY IN...

BARCELONA

CHANCE OF RAINFALL IN SEPTEMBER: 26% BARCELONA CARD: For unlimited public transport TAXI: Optional tip of 5% to 10% of the fare

The first floor of the enormous National Museum of Catalan Art (MNAC) is dedicated to Catalan Modern Art. Reopened in September 2014 after considerable renovation, the modern art display includes representative sculpture and painting, drawings and prints, photography, poster work, cinema, architecture and the decorative arts as far back as 1950. The museum also boasts an encyclopaedic collection of Romanesque, Gothic, Renaissance and Baroque art and houses the Catalan paintings from the Carmen ThyssenBornemisza collection. Long flights of stairs lead to the museum, worth the climb for the dramatic vistas. From May to September, open TuesdaySaturday: 10.00-20.00, Sundays and public holidays: 10.00-15.00. For full details visit: www.museunacional.cat If the glimpse of the motorbike in the Disseny Museum stimulated your curiosity, there’s more to see and to learn about Catalan’s motorbike industry… and the place to look into it is the Motorbike Museum in the Gothic quarter. Housed in the basement of the former Saint Felip Neri convent, this street-level museum is a wonderland of wheels and gears and bikes of all persuasions, 40 models in all. The permanent exhibition, “Catalan Motorbikes (1905-2010): the History of a Pioneering Industry”, pays tribute to the founders of the local motorbike industry which at one time numbered 150 manufacturers. For details visit: www.museomoto.com; Open Tuesday-Saturday: 10.30-14.30 and 15.30-19.30, Sunday: 10.30-14.30. Not all of Catalonia’s history is in museums. A moving demonstration of national culture can normally be seen on Saturdays and Sundays in the square outside Barcelona’s Cathedral, the Church of the Holy Cross and Saint Eulalia. A group of musicians will appear and unpack their instruments on the steps of the church, spectators will settle around them like a flock of birds and, as if by magic, people form circles in the square, link hands and wait for the Sardana to begin. The dance has been a badge of Catalan national defiance and pride since the 19th Century. Usually on Saturday at 18.30 and Sunday at noon in front of the cathedral. Read about the deceptively simple ‘People’s Dance’ at: www.barcelona-metropolitan.com

BARCELONA IN CONTEXT

Art and history define the Catalan capital, but its museums tell the story. Maryalicia Post reports CATALAN HISTORY The Museum of Catalan History traces the complicated relationship between Spain and Catalonia in a story that stretches from the Roman settlement of 2000 years ago to today. The section devoted to the Civil War, Franco and contemporary history helps put Catalonia’s recurrent demands for a referendum on independence in perspective. This sleek museum is housed in a 19th Century warehouse at the edge of the Old Port. You return to the present with a bump when you leave the softly lit exhibition halls to visit the rooftop terrace for a drink overlooking the harbour. Website: www.en.mhcat.net; Open Tuesday-Saturday: 10.00-19.00, Wednesday: 10.00-20.00, Sunday and public holidays: 10.00-14.30.

WORLD-CLASS EXHIBITS The Caixa Forum owes its origins to Puig i Cadafalch, a key figure in Barcelona’s art-nouveau movement who completed what was then known as the “Casaramona Textile Factory” in 1911. The brickwork, battlements and its two towers were the culmination of the local Gothic style. The banking firm La Caixa acquired the structure in 1963, returning it to the city as the Caixa Forum in 1992. An exhibition at Caixa Forum tells the story of the building and its place in Barcelona’s history. World-class temporary exhibits are listed on the website: www.fundacio.lacaixa.es; museum, restaurant and bookshop open Monday-Sunday and holidays: 10.00-20.00.

different exhibition on each of four floors. All exhibitions feature Catalan design in the textiles, fashion, graphics, ceramic and decorative arts. The museum houses 70,000 objects previously held by four different museums. Currently, 3,000 artefacts are exhibited, ranging from a Barcelona-made motorcycle to a Balenciaga nightdress. The building itself is worthy of the subject. Nicknamed the “Stapler”, it features escalators with a view. For details see: www.museudeldisseny.cat; Open TuesdaySunday: 10.00-20.00, closed Mondays.

CONTEMPORARY PAINTING Can Framis, a museum of contemporary painting, opened in the 22@ area of Barcelona in 2009. It is a collection of some 300 works by Catalan-based artists. Open Tuesday-Saturday: 11.00-20.00, and Sunday: 11.00-14.00. For details visit: www.fundaciovilacasas.com Design Museum

DESIGN MUSEUM Disseny Hub opened in the last days of 2014. The design museum is a short walk from Barcelona’s ‘Gherkin’ and a lynchpin of the 22@ centre for innovation. There’s a EUROTIMES | MAY 2015

CALENDAR

JUNE

OCTOBER

SOE 2015 Congress

Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology

6–9 June Vienna, Austria www.soe2015.org

↙

Retina in Progress 2015: Present and Future

LAST CALL

MAY 2015

6th Baltic Congress

ARVO Annual Meeting 3–7 May Denver, Colorado, USA www.arvo.org

5th Balkan Ophthalmic Wetlab Course 20–23 May Sofia, Bulgaria www.bow.bg

13th Meeting of European Society of Neuro-ophthalmology (EUNOS) 21–24 June Ljubljana, Slovenia www.eunos2015.org

53rd Symposium of International Society for Clinical Electrophysiology of Vision (ISCEV) 23–27 June Ljubljana, Slovenia www.iscev2015.org

29–30 May Barcelona, Spain www.imo.es/retinabarcelona2015

Maculart Meeting 28–30 June Paris, France www.maculart-meeting.com

JULY

3–4 July Siena, Italy www.ble-group.com

AUGUST

28th APACRS Annual Meeting 5–8 August Kuala Lumpur, Malaysia http://www.apacrs.org

EYE CONTACT

3–4 September Barcelona, Spain www.ocularinfections.com

6th EuCornea Congress

FEBRUARY 2016

NEW ENTRY 20th ESCRS Winter Meeting 26–28 February Athens, Greece www.escrs.org

4–5 September Barcelona, Spain www.eucornea.org

3rd World Congress of Paediatric Ophthalmology and Strabismus 4–6 September Barcelona, Spain www.wspos.org

NEW ENTRY Vitreoretinal Disorders

Trends in Surgical and Medical Retina 3rd Meeting

SEPTEMBER

International Conference on Ocular Infections (ICOI)

↙

1–3 May Kiel, Germany www.baltic-congress.de

11–13 June Florence, Italy www.symposiacongressi.eu

5–9 October Naples, Italy www.echography.com

XXXIII Congres of the ESCRS 5–9 September Barcelona, Spain www.escrs.org

15th EURETINA Congress

Berlin

17–20 September Nice, France www.euretina.org

OCTOBER

113th DOG Congress 1–4 October Berlin, Germany http://dog2015en.dog-kongress.de/

STUDIO INTERVIEWS with leading ophthalmologists at the XXXII Congress of the ESCRS EXCLUSIVE TO EUROTIMES!

Simultaneous Bilateral Cataract Surgery Oliver Findl interviews Steve Arshinoﬀ Available at www.eurotimes.org/eyecontact and the EuroTimes App

NEW ORLEANS

MAY 6–10

HOUSING NOW AVAILABLE BOOK EARLY TO STAY AT YOUR PREFERRED HOTEL.

ADDITIONAL PROGRAMMING ASOA WORKSHOPS TECHNICIANS & NURSES PROGRAM CORNEA DAY ASCRS GLAUCOMA DAY

AnnualMeeting.ascrs.org

How many of your cataract patients could benefit from the T-flex® Aspheric Toric IOL?

34.8% of cataract patients present ≥ 1.0 D corneal astigmatism1

rayner.com • Proven rotational stability2 • Excellent centration • Anti-Vaulting Haptic Technology® for excellent fixation within the capsular bag3 • Extensive range of sphere and cylinder powers

1. Ferrer-Blasco T1, Monlés-Micó R, Peixoto-de-Matos SC, González-Meijome JM, Cerviño A J Cataract Refract Surg 2009 Jan;35(1): 70-510 1016/j.jcr 2008.09.027 2. Alberdi R et al. J Refract Surg 2012; 28(10); 696-700. 3. Claoué C. Clinical and Surgical Ophthalmology 2008; 26(6): 198-200.

EC-2015-16 03/15