VOLUME 17 ISSUE 2 FEBRUARY 2012
ESCRS convenes 16th Winter Meeting in PRAGUE
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FEBRUARY 2012 Volume 17 | Issue 2
Cover Image: Franz Kafka statue located near the Spanish Synagogue in Prague
This month... Newsmaker Interview 4
ESCRS president Peter Barry talks about his plans for the society
Cataract & Refractive 6
Experts debate impact of femtosecond laser on cataract surgery
Latest generation femtosecond laser improves LASIK outcomes
8 High patient satisfaction with new multifocal IOL 9
Laser surgery market and the recession
10 Correcting postoperative astigmatism with laser 12 Early detection of endophthalmitis is crucial 13 Hydrogel bandages can enhance cataract wound stability 14 Solid results with solid-state laser 15 Corneal inlay good for patients who have undergone LASIK
Cornea 17 Successful visual outcomes with IOL scaffold 18 Steep learning curve with DALK procedures 19 Conjunctival autografting best procedure for treating recurrent pterygium 20 New immunosuppression protocols give better results, according to expert
Glaucoma 22 Understanding role of risk factors for glaucoma progression 23 New implant can reduce need for medications in POAG
24 New device appears safe and effective for IOP reduction 25 Lifestyle factors should not be overlooked in combatting glaucoma
Retina 26 Study shows promising results for geographic atrophy patients 27 Ranibizumab effective for DME treatment 28 Overcoming diabetic vitrectomy nightmares
News 29 ESCRS continues to support ORBIS and Oxfam 30 New technology 32 ESCRS funds multicentre CME study 33 ESASO outlines projects for 2012 34 Young ophthalmologist talks about his first night on duty; Sir Eric Arnott obituary 36 John Henahan Prize 2012; EuroTimes wins award
29 editorial staff
Published by The European Society of Cataract and Refractive Surgeons Publisher Carol Fitzpatrick
Managing Editor Caroline Brick
Executive Editor Colin Kerr
Production Editor Angela Sweetman
Editors Sean Henahan Paul McGinn
Senior Designer Paddy Dunne
Features 38 Outlook on Industry
44 Industry News
39 Book Review
46 Eye on Travel
42 Ophthalmologica Highlights
Assistant Designer Janice Robb
Seamus Sweeney Gearóid Tuohy
Circulation Manager Angela Morrissey
Colour and Print Times Printers
Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin
Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: firstname.lastname@example.org
Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post
Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.
ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983
As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2010 and 31 December 2010 is 32,019.
Volume 17 | Issue 2
WELCOME TO PRAGUE
16TH ESCRS Winter Meeting features an exciting and varied programme
by Pavel Studeny MD
International Editorial Board
would like to thank the members of ESCRS and readers of EuroTimes for giving me the opportunity of welcoming you to Prague for the 16th ESCRS Winter Meeting. I believe this meeting is a major landmark for ophthalmologists in our country and also in our neighbouring countries. We have experienced many changes since 1993 when the Czech and Slovak Republics were established as independent countries and we have faced, and continue to face, many challenges. But with every challenge comes a new opportunity and I am delighted to say that the practice of ophthalmology in our countries is continuing to develop as we closely follow the latest trends in ophthalmology worldwide. It is very important that we are able to discuss new ideas with our colleagues from Europe and the rest of the world and that is why it is very important that the ESCRS has decided to hold this prestigious meeting at the Hilton Hotel in Prague. Because of our economic situation, it is not always possible for us to attend international meetings outside of the Czech Republic so by bringing the winter meeting to our capital city, the ESCRS is helping us to learn about new technologies while saving us the expense of having to travel long distances. We are also very grateful that the ESCRS agreed to a reduced fee for members of the Czech and Slovak societies which will make the meeting more accessible. Already, there has been a lot of interest in this meeting from national delegates and as we also expect many other delegates to join us from outside the Czech Republic, we are looking forward to a very successful meeting. The ESCRS Winter Meeting is a very important educational event and while my more experienced colleagues will have a lot of information to share, the meeting also offers our young ophthalmologists the opportunity to benefit from discussions at the meeting. On a personal level, I look forward to the main symposia that will discuss Lens Surgery in Glaucoma Patients, Anterior Segment Complications, Correction of Irregular Astigmatism and the Evaluation of Visual Performance. Other attractions include the Annual Cornea Day on Friday 3 February organised by ESCRS and EuCornea and didactic courses in Basic Optics, Cataract Surgery, Refractive Surgery and Cornea. On Saturday 4 February, Live Surgery, organised by the Czech Society of Cataract and Refractive Surgery, will be transmitted from The Department of Ophthalmology, Faculty Hospital Kralovske Vinohrady and the Department of Ophthalmology at the Central Military Hospital, Prague. The meeting will conclude on Sunday 5 February and one of the highlights on our final day will be the Czech and Slovak Society Session which will feature presentations from some of our leading ophthalmologists.
EUROTIMES | Volume 17 | Issue 2
Emanuel Rosen Chairman ESCRS Publications Committee
Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE As you will see from our programme, we have a very busy schedule but I also hope that our visitors and guests will spend some time before and after the meeting exploring our historic city. February is a time of year when you can see Prague at its best so please visit our theatres and concert halls, our cafes and restaurants and make a wish as you walk across the Charles Bridge. To conclude, I wish you a very warm welcome to our meeting and hope that you enjoy our hospitality and friendship.
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
PAVEL STUDENY Pavel Studeny is a co-opted member of the ESCRS Board
Roberto Zaldivar ARGENTINA Oliver Zeitz germany
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A GREAT HONOUR
The president of the ESCRS talks about his hopes and plans during his two-year term of office
have been associated with the ESCRS since the early 1990s and am honoured and delighted to be elected president of the society. Over the last 20 years ESCRS has become a strong and successful society. Our annual congress is one of the largest on the global ophthalmology calendar. Because of my long association with ESCRS, I have a good understanding of how the society operates and a very good understanding of its many strengths. I also see many opportunities for us to use our strengths for the benefit of our members and the ophthalmic community. Young ophthalmologists are the future of our society. As I get older, one of my greatest pleasures is seeing one of my trainees carry out a cataract operation from beginning to end without my assistance and then moving onto more difficult cases. ESCRS must continue and increase its support for young ophthalmologists. From this year membership of ESCRS, including all member benefits, is free to all trainee ophthalmologists. At present we are providing bursaries for trainees from across Europe to attend the ESCRS winter and annual congresses. The Observership Programme provides 40 places for young ophthalmologists annually to benefit from a €1000 grant which allows them visit a European cataract or clinical refractive centre. I think the time has come for ESCRS to establish a Young Ophthalmologists’ Committee to direct further programmes aimed at their generation. In addition to having their own committee these young doctors will be seconded to other ESCRS committees. Here they will learn how the ESCRS is organised and they will contribute fresher new ideas to our discussions. Continuing medical education is a legal requirement in almost every European country. ESCRS must enhance its educational programme for cataract and refractive surgeons to meet this growing need. Distance learning is an important part of the future for CME education and at the ESCRS winter meeting in Prague we will launch iLearn, the ESCRS’s online elearning platform. This platform, which EUROTIMES | Volume 17 | Issue 2
ESCRS president Peter Barry
has been over a year in development, will complement and expand in a didactic format on the education provided at our two annual meetings. The iLearn platform will be available free of charge to ESCRS members. We must have a strong commitment to research. I had the good fortune to be chairman of the ESCRS Antibiotic Prophylaxis of Endophthalmitis Following Cataract Surgery Study which was completed in 2006. The successful completion of this clinical study has achieved an international and academic reputation for the society. Following on the results of this study, in 2012 ESCRS will commission a European-wide survey on the use of intracameral cefuroxime as prophylaxis before cataract surgery. The European Registry of Quality Outcomes for Cataract and Refractive Surgery – EUREQUO Project – co-funded by the EU and the ESCRS, is coming to a conclusion after three years. This project funded the establishment of a European-wide database for the collection of data on the outcomes of cataract and refractive surgery. By the end of this year ESCRS will have collected data on
the outcomes of 750,000 surgeries. The purpose of all surgery is the achievement of a safe, successful, quality visual outcome without complications. This will never be achievable in all cases but by collecting data through EUREQUO we can provide benchmarks for people to judge themselves and the performances of their clinics. ESCRS will continue to support the EUREQUO project for a further three years. After a call for new research project proposals in 2010, ESCRS have recently agreed to fund a three-year clinical trial proposed by the University Group in Maastricht, Netherlands on the prevention of cystoid macular edema following cataract surgery. ESCRS has earmarked a sizeable fund to support research projects and will be issuing a new call for projects in 2012. In addition to providing financial support it is my intention that ESCRS fund a research officer in the Dublin office to oversee the current projects, set up and develop a strong central system for judging and vetting research projects and provide expertise to those seeking funding from ESCRS and other sources. We need an Endophthalmitis Registry. Sweden is one of very few countries who have an endophthalmitis registry. We should take the Swedish model and develop a European-wide ESCRS Endophthalmitis Registry. This would be for intraocular surgery specifically but it could also cover other areas because the cumulative risk of endophthalmitis for any patient receiving multiple injections of anti-VEGF agents is now greater than the risk of endophthalmitis following cataract surgery. I would have loved the opportunity 25 years ago to have learned about practice development. I was very impressed by the presentations I heard when I attended the recent ESCRS Practice Development Workshops and Masterclass in Dublin in November 2011. Education in the principles of business and management is not available to trainees in their national training programmes but all professionals and especially those in the healthcare field will have to pay more attention to the business of their practices in the
Peter Barry - email@example.com
future. There will be courses on practice management and development at the ESCRS Congress in Milan in 2012 and a second Workshop and Masterclass in Dublin next November. Collaboration is important but we must not forget who we are and what we do. We are all aware of the explosion of meetings in the ophthalmological world. ESCRS has sought in recent years to develop strategic partnerships with other sub-specialty societies and to partner our meetings to take advantage of the synergies which exist between us. These relationships are very important but we must also be careful to stress that we are all independent organisations which do excellent work representing our own members. We value the support of industry but we must remain independent. Cataract and refractive surgery is relatively unique in the symbiotic relationship it has with the medical device and pharmaceutical industry. We will continue building on this relationship and are grateful for the support we receive but we will also continue to preserve our clinical independence and freedom so that the scientific content of our meetings is doctor-led rather than industry sponsored. Charitable initiatives are very important for the society. Our support of Oxfam and ORBIS has been very rewarding. We should continue working with these organisations and funding their projects by perhaps introducing an optional levy to the annual ESCRS registration fee. The society should also continue to donate some of its own funds to the projects. Finally, I think it is important that while we look to the future we recognise the contribution of all the giants on whose shoulders we stand. With that in mind, I would like to see the publication of an official history of the ESCRS. This project has been discussed for several years and on the 30th anniversary of our first congress, I think this would be an excellent time to record our achievements in print. As a doctor and an ophthalmologist nothing can match the experience of meeting a patient on the first postoperative day with a smile on their face because they are seeing what they could not see before. This is a joy I share with all of my colleagues. The presidency of the ESCRS comes at the pinnacle of my career and I look forward to the next two years and a time of further growth and success for the ESCRS.
n a l i M
XXX Congress OF THE ESCRS 8-12 September
15 March 2012 Submission Deadline: Abstract
Ridley Medal Lecture
Anti-VEGF in anterior segment disease
Femtosecond laser cataract surgery
M. Lundstrรถm SWEDEN
Chairpersons: R. Nuijts THE NETHERLANDS, H. Dua UK (EuCornea)
Chairpersons: P. Rosen UK, M. Piovella ITALY
Quality Outcomes in Cataract Surgery: The Real Story
Saturday 8 September
Monday 10 September
Cataract surgery and macular disease
Innovations in IOL power calculation
Chairpersons: P. Barry IRELAND, G. Richard GERMANY (EURETINA)
Chairpersons: T. Kohnen GERMANY, R. Mencucci ITALY
Saturday 8 September
Tuesday 11 September
Refractive surgery in children
I am a perfect cataract surgeon: but how can I be better?
Chairpersons: D. Epstein SWITZERLAND, K. Nischal UK (WCPOS)
Sunday 9 September
Sunday 9 September
Chairpersons: M. Lundstrรถm SWEDEN, R. Bellucci ITALY
Wednesday 12 September
for Preliminary Programme visit
cataract & refractive
Zoltan Z Nagy – firstname.lastname@example.org Takayuki Akahoshi – email@example.com
Will the femto laser be a revolutionary advance or expensive, unnecessary technology? by Cheryl Guttman Krader in Vienna
eading cataract surgeons agree that the femtosecond laser improves the precision of multiple steps of cataract surgery. However, the impact of its use on clinical outcomes and its place in clinical practice are more controversial, stressed two noted surgeons in a debate held during the XXIX Congress of the ESCRS. According to Zoltan Z Nagy MD, the increased control afforded by femtosecond laser-assisted cataract surgery translates into increased efficacy and safety and will make the laser especially useful for improving outcomes with premium IOLs. He acknowledged that many questions need to be answered. Nonetheless, patients are already asking for the laser, and he predicted market demand would drive its uptake. Responding that he prefers manual surgery, Takayuki Akahoshi MD, said that he believes that some of the benefits of the laser are being overstated and that its limitations, particularly its cost, cannot be overlooked. Dr Nagy, professor of ophthalmology, Semmelweiss University, Budapest, has been involved in the development and clinical evaluation of the LenSx femtosecond laser (Alcon LenSx). He reviewed data from studies evaluating the LenSx laser for optimising lens fragmentation and improving the reproducibility of incision creation and capsulotomy, along with evidence showing how its use translates into measurable improvements in clinical outcomes. Results from one comparative study showed use of the laser for pre-phaco lens fragmentation reduced ultrasound use for completing nucleus removal. In eyes with grade 2-4 cataracts, fragmentation with the femtosecond laser decreased average phaco power by 51 per cent and effective phaco time by 43 per cent compared with standard phacoemulsification. Studies have also shown that corneal incisions created with the computerprogrammed femtosecond laser are more architecturally reproducible and better selfsealing with exact wound edge apposition compared with those made manually with a blade. In a study evaluating integrity of two-plane incisions, stromal hydration was needed to close 85 per cent of manually created incisions but in none of the eyes that had femtosecond laser incisions. “Increased consistency in surgical and arcuate incisions will improve our
EUROTIMES | Volume 17 | Issue 2
understanding of incision outcomes, make surgically-induced astigmatism more predictable, and make astigmatic correction more accurate,” Dr Nagy said. The ability of the laser to create capsulotomies that are more regularly shaped, accurately sized, and centred has also been shown in a clinical trial where eyes undergoing manual capsulorhexis were the control. This advantage of the laser was shown to translate into increased refractive outcome accuracy in a study where the achieved SE was within 0.25 of intended in 77 per cent of eyes that had a femtosecond laser capsulotomy compared with 54 per cent of eyes having a manual capsulotomy. “Refractive outcome is more predictable after laser capsulotomy because final resting position of the lens is determined by capsule diameter, shape, and centration. With its advantages for more reproducible incision creation, enabling creation of a freefloating capsulotomy, and reducing manual manoeuvres, phaco time and energy to remove lens material, the femtosecond laser will facilitate and improve microincision cataract surgery,” Dr Nagy said.
An alternate view Providing his perspective, Dr Akahoshi, director of ophthalmology, Mitsui Memorial Hospital, Tokyo, Japan, noted that while the laser performs each of its surgical steps efficiently, overall procedural efficiency is decreased because of the requirements for docking, alignment, imaging, planning, and transporting patients between the laser and operating rooms. The extra time can be a significant drawback for busy surgeons. “I perform 50 to 55 cases daily, six days a week. With an average surgical time under four minutes, I can manage 10 cases an hour moving between two operating theatres. Using the femtosecond laser would increase my case time 4- to 5-fold and lead to a long waiting list for my cataract surgery patients,” he said. Dr Akahoshi acknowledged that capsulotomies created with the femtosecond laser are more accurately sized and regularly shaped than a manual capsulorhexis, and that the laser may be beneficial for novice cataract surgeons. However, these younger practitioners will also be unable to afford the laser, and considering posterior capsule opacification development, there should be
Fig 1: As long as the capsulorhexis edge is on the optic, there is no difference in the PCO formation even if the shape of the CCC is not perfect
Fig 2: Breaking the posterior plate and periphery of the nucleus is the key point of pre-chop to facilitate safe and quick phacoemulsification
Fig 3: Using a pre-chopper manually, the posterior plate of the nucleus can be divided completely
Fig 4: By femtosecond laser, the size of the capsulorhexis is limited by the pupil size, while manual procedure can make a capsulorhexis larger than the pupil
Fig 5: Femtosecond laser cannot manage a case with small pupil. Laser procedure after pupillary dilatation by iris retractors will not be possible
Fig 6: Manually we can attain complete pre-chop of the nucleus through a small pupil after making a capsulorhexis larger than the pupil
no difference between procedures performed with a femtosecond laser or a manual technique as long as the anterior capsular rim overlaps the optic (Figure 1). Addressing femtosecond laser incision creation, Dr Akahoshi characterised the idea of using it to make limbal relaxing incisions (LRIs) as “ridiculous”. “LRI is an old-fashioned procedure with poor predictability and that may induce irregular astigmatism. Excimer laser correction or toric IOLs are better alternatives for treating corneal astigmatism,” Dr Akahoshi said. He agreed that the femtosecond laser has benefits for pre-chopping dense cataracts and minimising ultrasound use in these more difficult cases. However, to avoid posterior capsule rupture, current laser lens fragmentation algorithms leave a significant posterior plate of lens, and so manual prechopping may still be needed. “Using an appropriate mechanical
nucleofractis technique and instruments, surgeons can successfully manage cataracts of all grades and reduce ultrasound energy consumption and total phaco time. The key is to not only crack the nucleus, but to achieve complete division of the nuclear fragments,” Dr Akahoshi said. Finally, he pointed out there are situations where the femtosecond laser cannot be used. For example, capsulorhexis creation and pre-chopping are not possible in eyes with a small pupil, and there may be problems with docking in small, deep-set eyes, which are common in the Asian population. “What the femtosecond laser can do is just make incisions, capsulorhexis and pre-chop which can be done much faster and more easily by hand. Even if I may get a free laser machine, I will not use it, because it’s more time consuming and less efficient. Maybe after 20 years later when I’m old enough to have difficulties in manual surgery, I may consider to use," Dr Akahoshi said.
Courtesy of Takayuki Akahoshi MD
cataract & refractive
The moment flapless surgery becomes clearly visible: in a smile. This is the moment we work for.
Better outcomes with reverse femto side cut for LASIK flaps by Dermot McGrath in Vienna
EUROTIMES | Volume 17 | Issue 2
Corneal sensation is vital for maintaining epithelial integrity. Corneal nerves are cut during LASIK and result in a temporary reduction of corneal sensation.
Allon Barsam MA, FRCOphth observer-masked study included 49 patients who had a horizontal corneal flap created in both eyes using the IntraLase 150 kHz femtosecond laser using a nasal hinge set at an arc length of 50-degrees. All flaps were 8.5mm round and 110 microns in depth and energy levels were standardised for the planar cut and the side cut. One randomly selected eye of each patient received a 30-degree side cut and the other eye received a 140-degree side cut when creating the flap. Each patient applied the same postLASIK, open-label treatment medications to both eyes. Six months after surgery, the uncorrected visual acuity (UCVA) was found to be 20/15 or better in 38.9 per cent of eyes with the 140-degree side cut and 25 per cent of eyes with the 30-degree side cut. The figures for those attaining UCVA of 20/20 or better were 91.7 per cent in the 140-degree side cut group and 72.2 per cent in the 30-degree side cut group. Changes in best-corrected visual acuity (BCVA) showed that 5.6 per cent lost up to one line of vision in the 140-degree group compared to 22.2 per cent in the 30-degree cut group, while 38.9 per cent gained one line in the 140-degree cut group compared to 25 per cent for the 30-degree cut group. Corneal sensation was also found to be significantly lower in the 30-degree side cut eyes than in the 140-degree cut eyes in three of the five areas tested. Schirmer’s and tear break-up tests were also significantly better for the 140-degree treated eyes compared to the 30-degree cut treated eyes.
Allon Barsam - firstname.lastname@example.org
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sing the latest generation femtosecond laser to create a reverse 140-degree side cut significantly improves flap stability, reduces the incidence of dry eye and corneal irritation and delivers greater visual outcomes in LASIK procedures, according to a study presented here. “The inverted bevel-in reverse side-cut angle is designed to provide better wound healing for enhanced biomechanical stability of the post-LASIK cornea, as well as increased flap adhesion postoperatively for optimal wound healing,” Allon Barsam MA, FRCOphth told delegates attending the XXIX Congress of the ESCRS. Dr Barsam’s study evaluated corneal sensation and the signs and symptoms of dry eye in eyes receiving either a 30-degree side cut or a 140-degree reverse side cut in bilateral femtosecond flap formation with LASIK. Discussing the rationale behind the study, Dr Barsam, a corneal, cataract and refractive surgery fellow at Ophthalmic Consultants of Long Island in Rockville Centre, New York, noted that a basic neurosurgical premise of repairing a severed nerve is to optimise the apposition of the two sides of the severed nerve. “Corneal sensation is vital for maintaining epithelial integrity. Corneal nerves are cut during LASIK and result in a temporary reduction of corneal sensation. We considered the 30-degree side cut as an exaggeration of what used to be achieved with the fourth-generation IntraLase femtosecond laser (AMO) and similar to what might be achieved previously with a microkeratome and postulated that these flaps might not bed down so perfectly and result in an increased distance that the nerve needs to travel in order to eventually regenerate,” he said. By contrast, Dr Barsam said that the 140-degree reverse side cut that is now possible with the fifth-generation IntraLase laser seems to result in a better apposition between the flap and the stromal bed. “It fits together much like a tongue-andgroove joint with potentially less distance that the corneal nerves need to travel in order to regenerate. This may be why we are seeing less dry eye and better visual acuity outcomes with this approach,” he said. Dr Barsam’s multicentre, randomised,
cataract & refractive
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EUROTIMES | Volume 17 | Issue 2
Courtesy of Max Rasp MD
he new Diffractiva®-aA multifocal intraocular lens provides good far, near and intermediate vision, according to the results of a study presented at the XXIX Congress of the ESCRS. “The level of patient satisfaction with this new multifocal lens was high due to very low spectacle use and minimal photic phenomena at night,” said Max Rasp MD, University Eye Clinic, Paracelsus University, Salzburg, Austria. He noted that the Diffractiva-aA (HumanOptics) IOL is a one-piece hydrophilic acrylic multifocal lens (see image). It has a diffractive aspheric aberration-free anterior surface with a 3.5 D near add and a spherical posterior surface. The implant also has a square edge and a 360-degree epithelial cell barrier on the posterior surface. The lens may be implanted through a microincision. It has been commercially available in Europe since September 2010. The prospective multicentre study involved 60 eyes of 30 cataract patients that underwent bilateral implantation of the new Diffractiva-aA multifocal lens. At the time of his presentation at the ESCRS Congress, 17 patients (34 eyes) had completed six months of follow-up. To be included in the study patients had to have corneal astigmatism no greater than 1.0 D and no ocular pathology other than age-related cataract. Dr Rasp noted that at their most recent follow-up, the postoperative mean spherical equivalent was 0.12 D. Two-thirds of patients (69 per cent) were within 0.25 D of emmetropia and all were within 0.75 D. In addition, mean uncorrected distance visual acuity was 0.91 when tested monocularly and 1.0 when tested binocularly. Furthermore, monocular uncorrected distance visual acuity was 20/20 or better in 79 per cent of eyes, 20/22 or better in 93 per cent, and 20/30 or better in all eyes. In addition, patients' mean uncorrected near visual acuity was 0.86 when tested monocularly and 0.93 when tested binocularly. Monocular uncorrected near visual acuity was 20/20 or better in twothirds of eyes, and 20/25 or better in all eyes. Moreover, mean uncorrected intermediate visual acuity was 0.72 when tested monocularly and 0.82 when tested binocularly. Monocular uncorrected
The Diffractiva-aA MIOL
intermediate distance visual acuity was 20/20 or better in 38 per cent of eyes, 20/25 or better in 77 per cent of eyes, and 20/32 or better in 85 per cent of eyes. The good intermediate vision was also reflected by the monocular defocus curve, with the lowest point being in average at 0.20 logMAR (20/30). As regards photic phenomena, 53 per cent reported never seeing haloes around headlights at night, 13 per cent said they saw them sometimes, 27 per cent said they saw them very often and seven per cent said they always saw them. In terms of seeing glare around headlights at night, 80 per cent said they never noticed it, seven per cent said they rarely noticed it, three per cent said they sometimes noticed it, and only 10 per cent said they noticed it very often, Dr Rasp noted. Importantly, none of the patients reported being severely disturbed by these photic phenomena, when present. In response to a questionnaire, 93.3 per cent of patients said they never wore glasses and the remaining 6.7 per cent said they wore them only very rarely. In addition, all patients said they were satisfied with the lens and 87 per cent said they were very satisfied, he said. Dr Rasp has no financial interest in the Diffractiva®-aA multifocal intraocular lens.
Max Rasp - M.Rasp@salk.at
cataract & refractive
recession & LASIK
Laser eye surgery market will bounce back by Priscilla Lynch in Southport
he UK market for laser eye surgery should bounce back in the next few years, according to Tony Veverka, chief executive of Ultralase. During a presentation at the United Kingdom and Ireland Society of Cataract and Refractive Surgery (UKISCRS) XXXV Congress, Mr Veverka discussed the commercial reality of the laser surgery market and how it has been affected by the recession Looking at the UK market, he said it grew from approximately 80,000 patients in 2004 to just fewer than 140,000 at its peak in 2007. During that time it was a very consolidated market dominated by three big players. However, 2008 saw a major drop off in the market following the recession, with those opting for laser eye surgery decreasing to approximately 110,000 customers, and further declining in the last two years to an estimated 95,000-100,000 this year. “There is a real correlation between consumer confidence and consumer appetite to spend, particularly on relatively big ticket items and volumes in our industry,” he said, acknowledging that it has been a challenging few years. Despite the recession, Mr Veverka was optimistic about the future of elective laser surgery in the UK market, given the cyclical nature of the market. Discussing the public’s perception of the risk involved in laser eye surgery, he said there was confusion over the difference between risk and fear. “Fear is a basic emotion which is really disproportionate to the risk. For example, parents are generally more afraid of child abduction than they are of child obesity, yet obesity statically has a far greater effect to well-being. People are also much more afraid of flying than driving, despite driving having a greater risk. So when consumers think of laser eye surgery they hugely overplay the risk because of those factors. The risks are actually very small but the impact of the fear is great [on business] and we as an industry need to attack that issue as best we can,” Mr Veverka maintained. Comparing laser eye surgery to a lottery, he said it was similar in that the chances
EUROTIMES | Volume 17 | Issue 2
trast supremseitciovnity sen
People are also much more afraid of flying than driving, despite driving having a greater risk. So when consumers think of laser eye surgery they hugely overplay the risk because of those factors.
of a win/complication were very small but the public overplayed their chances of winning/something going wrong. “It’s the opposite of the lottery logo ‘it could be you’” really,” said Mr Veverka who also said that the industry as a whole must continue to reassure patients. He said potential market penetration rates in the UK's general population for laser surgery are “fairly modest” at about four per cent, approximately 1.3 million people, “so there is plenty of runway”. “There is also a growing acceptance of laser surgery, from the medical community, the optical community in general and consumers. The scare stories and the horrible websites about difficult experiences are much less, and dwarfed in comparison good news stories from successfully treated patients. We do good work, and we often forget that. We transform people’s lives for the better through enhancing their vision. We should be proud to work in this industry,” he commented. Mr Veverka concluded that while the public overplays the risks of laser eye surgery, LASIK comes out much better than other elective procedures with strong satisfaction ratings. This coupled with the cyclical nature of the market means that it is here to stay and the UK will see market expansion again in the coming years.
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cataract & refractive
I think that this approach will remove many of the inconsistencies of the procedure and will improve understanding and accuracy of not only LRIs, but of all our corneal incisions
by Dermot McGrath in Vienna
emtosecond laser technology is giving a new lease of life to incisional techniques for correcting postoperative astigmatism, according to a study presented here. “There has certainly been something of a rebirth of these techniques in recent years thanks to advances in laser technology,” Eric D Donnenfeld MD told delegates attending the XXIX Congress of the ESCRS. “The advantages of laser femtosecond incisions are that they are customisable and adjustable, meaning that refractive incisions are no longer an art form as they were in the past – they are now a science with the ability to place incisions of the exact size and exact depth and in the exact place you want them every single time,” he said. Dr Donnenfeld, in private practice at Ophthalmic Consultants of Long Island, New York and clinical professor of ophthalmology at New York University, noted that limbal relaxing incisions (LRIs), the traditional mainstay of surgical astigmatism correction, offer many advantages to surgeons. “They are inexpensive, easy to perform, and use minimal instrumentation. They can be done at the same time as cataract surgery, they have no impact on the cataract healing process and they can be repeated postoperatively if necessary,” he said. The downside of LRIs includes the fact that the surgeon must have a topographer and be able to interpret topography. They may also induce irregular astigmatism when greater than 2.0 D, they carry the risk of perforation, and they are less precise than laser vision correction, he said. In using LRIs, one of the major challenges facing an ophthalmologist is where to place them during cataract surgery, said Dr Donnenfeld. “Do we place them on the refractive axis, the keratometric axis or the topographic axis? And the answer is ‘none of the above’,” he said. A critical step in obtaining accurate astigmatic correction is being able to calculate the surgically induced cylinder from the incision, said Dr Donnenfeld.
Eric D Donnenfeld MD
A femtosecond LRI
While there are several ways to achieve this, the problem is that the measurements are all based on an assumed incisional induced astigmatism, which in reality can be very variable. “Therefore the only true way to measure postoperative astigmatism accurately is to do it intraoperatively and I think this is the future of cylinder correction,” he said. Dr Donnenfeld said that preoperative planning for LRI procedures has been greatly facilitated thanks to online calculators such as AMO’s LRIcalculator. com which allow surgeons to input the preoperative information in order to obtain better postoperative results. “It uses the Donnenfeld and the Nichamin nomograms, you insert the preoperative Ks, the incision location, and it gives you a prediction of where to place your incision which is very useful to bring to the operating room with you,” he said.
Don’t miss Eye on Technology, see page 30 EUROTIMES | Volume 17 | Issue 2
Eric D Donnenfeld - firstname.lastname@example.org
Age-guided femtosecond laser cataract surgery will regenerate interest in corneal incisional techniques
Courtesy of Eric D Donnenfeld MD
Dr Donnenfeld said that he typically uses LRIs for small amounts of cylinder, between 0.50 and 0.75 D, and he also uses the phoropter to locate and centre incisions on the steep axis and further refine the postoperative astigmatism. To take LRIs to an even higher level of precision and accuracy, however, the femtosecond laser represents a major advance for incisional techniques, said Dr Donnenfeld. “The true rebirth of incisional technology is the advent of arcuate incisions with the femtosecond laser. The early results with the LenSx femtosecond laser (Alcon) have really been quite interesting and I think represents the future direction for astigmatic correction,” he said. The incisions are essentially dragged and dropped onto the eye using on-screen technology and surgeons can measure pachymetry intraoperatively using
the onboard OCT. More reproducible cataract incisions create more predictable postoperative astigmatism, he explained. “I usually preset the depth of my incisions to 85 per cent and then these incisions can be opened and adjusted on the table as required. One of the nice aspects of these incisions is that they have very minimal effect until the incisions are open, which allows you as a surgeon to manipulate these incisions postoperatively or intraoperatively to predict better astigmatic results,” he said. Dr Donnenfeld said that using intraoperative aberrometry (Wavetec ORange) can also be used to titrate results in the operating room. “The patients can also be examined the next day with topography and refraction and the incisions can then be opened, if needed, to increase the effect of the incision and adjust the refraction,” he said. The results of the first case series of 14 patients treated with arcuate incisions showed that 86 per cent of eyes had postoperative astigmatism of 0.50 D or less and 71 per cent of 0.25 D or less, said Dr Donnenfeld. Summing up, Dr Donnenfeld said that image-guided femtosecond laser cataract surgery looks set to regenerate interest in corneal incisional techniques. “I believe this will bring the 80 per cent of ophthalmologists who do not perform LRIs at the present time into the ability to perform incisional surgery. It is computer controlled and it is faster, safer, easier, customisable, adjustable and repeatable. I think that this approach will remove many of the inconsistencies of the procedure and will improve understanding and accuracy of not only LRIs, but of all our corneal incisions,” he said.
Symptomatic VMA A Disease That’s Gaining Traction
Symptomatic vitreomacular adhesion (VMA) is an increasingly recognized sight-threatening disease of the vitreoretinal interface 1
VMA: » May lead to symptoms such as metamorphopsia, decreased visual acuity, and central visual field defect2 » Can cause traction resulting in anatomical damage, which may lead to severe visual consequences, including3,4 • •
Macular hole3 Retinal tear/detachment4
RefeRences 1. Schneider EW, Johnson MW. Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review. Clin Ophthalmol. 2011;5:1151-65. 2. Steidl SM, Hartnett ME. Clinical pathways in vitreoretinal disease. New York: Thieme Medical Publishers; 2003. Chapter 17; 263-86. 3. Gallemore RP, Jumper JM, McCuen BW 2nd, Jaffe GJ, Postel EA, Toth CA. Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina. 2000;20(2):115-20. 4. Mitry D, Fleck BW, Wright AF, Campbell H, Charteris DG. Pathogenesis of Rhegmatogenous Retinal Detachment: Predisposing Anatomy and Cell Biology. Retina. 2010 Nov–Dec;30(10):1561–72. 11/11
ThromboGenics, Inc. | 1560 Broadway, 10th Floor, New York, NY 10036 - U.S.A. | ©2011 ThromboGenics, Inc. | All rights reserved.
cataract & refractive
Concurrent endophthalmitis and retinal detachment management is vitreo-retinal surgeon’s worst nightmare by Priscilla Lynch in Southport
hile endophthalmitis is one of the most devastating complications of intraocular surgery, it is quite possible to achieve unexpected good visual outcomes if it is identified promptly and treated correctly and aggressively, emphasised specialists during the Endophthalmitis symposium at the United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) XXXV Congress. Malhar Soni MD, FRCS, consultant vitreoretinal surgeon, London, UK discussed clinical presentation and management of post-cataract surgery endophthalmitis (POE). He noted that the incidence of POE is variable from 0.03 per cent – 0.15 per cent, “is rare but devastating for the patient”, and presentation can be either early onset within six weeks or delayed onset. In EVS [Endophthalmitis Vitrectomy Study, 1995] around 75 per cent of patients presented within 11 days of the surgical date, 69 per cent had positive culture growth and the most common organism was Staph. Epidermidis, he reported. The acute fulminant form of POE usually presents within two to four days. In EVS, the presenting signs or symptoms in order of decreasing frequency were blurred vision, conjunctival congestion, pain and lid swelling. Lid oedema could possibly differentiate from infective endophthalmitis, or at least from infections caused by less virulent organisms, Dr Soni noted, adding, although hypopyon is “sine qua non” of endophthalmitis, ophthalmologists should be aware that approximately one in four patients with POE do not present with hypopyon or pain, as shown in the EVS results. More virulent bacterial organisms, either Gram positive or Gram negative, are associated with earlier presentation of symptoms compared to less virulent organisms, Dr Soni stated. It is vital to remember that the current evidence of symptoms is not highly specific in predicting the nature of endophthalmitis, he stressed. Dr Soni stated that concurrent endophthalmitis and retinal detachment (RD) management is any vitreoretinal surgeon’s worst nightmare and the EVS incidence rate of RD in eyes with endophthalmitis was 8.3 per cent. EUROTIMES | Volume 17 | Issue 2
Every moment counts and any delay in diagnosis and treatment mean a disastrous and poorer prognosis Malhar Soni MD, FRCS
Acute postoperative endophthalmitis
Additionally, in any case of endophthalmitis, Dr Soni warned that “every moment counts and any delay in diagnosis and treatment mean a disastrous and poorer prognosis.” So, suspected or confirmed endophthalmitis cases must receive highest triage priority and must be seen immediately on arrival to the eye casualty clinic. Delayed onset recurrent uveitis following cataract surgery often poses a challenge to ophthalmologists. It is a different group of POE all together and generally P. acne is the responsible organism but it can also be caused by coagulase negative staphylococcus, gram negative bacteria or fungi. Also, ophthalmologists should be aware of the rare form of P. acne, he reported. Similarly, fungal endophthalmitis is generally a delayed onset, chronic form and can be masked by the use of topical steroids, but eventually leads to a dramatic increase in intraocular inflammation and ocular discomfort. Typical presentation includes indolent inflammation with mild symptoms, fibrinopurulent anterior chamber exudates and vitreous snowball opacities. Fungal POE may be difficult to distinguish from infection due to P. Acnes. He highlighted the role and importance of the ocular ultrasonography in managing eyes with endophthalmitis. Discussing follow-up clinical assessment, Dr Soni said surgeons should review early and repeatedly, noting, “Do not assume the patient will get better.” A reduction in pain and swelling associated with retraction of the anterior chamber fibrin and dilatation of the pupil are good signs. “I personally prefer to monitor the clinical course every hour once I start the treatment. I strongly recommend
objective documentation through slitlamp photography to avoid any subjective variation or any error, and don’t forget to repeat B-scan ultrasonography.” Summing up his approach, Dr Soni maintained that postoperative inflammation after uneventful cataract surgery is endophthalmitis until proven otherwise and should be treated accordingly with ophthalmologists erring on the side of over management rather than under management. Edward Hughes MD, FRCSOphth, consultant vitreoretinal surgeon, Sussex Eye Hospital, Brighton discussed the diagnosis and treatment options for acute postoperative endophthalmitis. He recommended surgeons should perform an immediate (under one hour) vitreous tap and start intravitreal antibiotics with or without dexamethasone. “I personally don’t take an anterior tap because the EVS and ESCRS studies found it to add little to the diagnostic yield. Taking an AC tap softens the eye which makes needle tap more difficult. So my personal view is just sample the vitreous as it just complicates it to take the aqueous as well,” he explained. Looking at how the vitreous sample should be taken, he said using a cutter “theoretically means less vitreoretinal traction than just sucking vitreous through a needle”, but the downside is the potential delay as a trip to operating theatre is needed in most cases. “The needle can be done any time, anywhere and it is fast. That’s why I think it has the advantage when there will be a delay in getting a patient to an operating theatre for a cutter biopsy,” Dr Hughes commented. Quoting the EVS study, he said there was no real difference between the needle group
Mahar Soni - email@example.com Edward Hughes - firstname.lastname@example.org
versus the cutter group in relation to retinal detachment rates, “so unless you can get a cutter tap with an hour the needle is the right thing to do”. He recommended chocolate agar as the most effective culture medium but pointed out that there is a higher positive rate (by about 10 per cent) when it is combined with broth (blood culture bottle), adding that a small volume of the sample should be saved for PCR. Looking at the antibiotic choices for treatment, Dr Hughes said study results prove Vancomycin is an excellent choice for Gram positives, while for Gram negatives Amikacin is his preferred choice. Amikacin has developed a bad name due to reports of macular ischaemia but Dr Hughes feels these reports are not conclusive and notes that the visual outcomes in the EVS, which used intravitreal vancomycin and amikacin, were relatively good. In comparison with ceftazidime, amikacin benefits from synergy with vancomycin, lack of precipitation in the eye and also a theoretically less inflammatory bacterial kill (ceftazidime targets the bacterial cell wall releasing endotoxin). Moxifloxacin and Linezolid also achieve excellent concentrations in the eye after oral administration. There is no evidence of benefit with sub-conjunctival/topical antibiotics and limited evidence for steroids, he stated. Summarising, he recommended using intravitreal Vancomycin 1mg and ceftazidime 2.25mg (do not mix) or Amikacin 0.4mg immediately, while he uses moxifloxacin orally 400mg OD. Topical/subconjunctival antibiotics can be used at the surgeon’s discretion and intensive topical steroid cycloplegia is required. Regarding steroids, Dr Hughes said he would avoid using oral prednisolone (1mg/ kg) or intravitreal dexamethasone (0.4mg) in traumatic cases or suspected cases of fungal infection. Weighing up the evidence in relation to carrying out a vitrectomy, Dr Hughes said his main concern is the potential treatment delay. However, as techniques have improved he believes an early vitrectomy, ie, within 48 hours, is justifiable for severe cases, even if visual acuity is better than light perception. He cautioned not to delay initial treatment of a tap and injection to arrange a vitrectomy. If there is no improvement or the signs are worse after 48 hours he advised re-injecting antibiotics and considering a vitrectomy. During the panel discussion, Dr Soni stressed the role of primary vitrectomy irrespective of visual acuity status in managing most cases of endophthalmitis. He concluded with a statement by Harry Flynn Jr, “EVS provides general guidelines, the clinician must decide on the best treatment strategy for the individual patient.”
John Hovanesian - email@example.com
cataract & refractive
28 grams of pressure causes seepage in most unsutured wounds by Howard Larkin in Vienna
ydrogel bandages, which have been shown to reduce fluid ingress and egress ex vivo and to stop microleaks in vivo, should be further studied as a way to enhance cataract wound stability and reduce the risk of endophthalmitis, John Hovanesian MD, UCLA Jules Stein Eye Institute, told the XXIX Congress of the ESCRS. “For many years the association has been made between wound leakage and endophthalmitis, with an increase in incidence with clear corneal incisions,” Dr Hovanesian noted. He cited a 2005 study of 27 cases of endophthalmitis that found leaky wounds to be the leading risk factor, increasing the chances of infection 44-fold (Wallin T et al. J Cataract Refract Surg 2005; 31:735-741). Studies also suggest that intraocular pressure fluctuations in the early postoperative period may challenge the integrity of clear corneal incisions, leading to wound leaks (McDonnell PJ et al. Ophthalmology 2003; 110:2342-8), Dr Hovanesian said. Eye rubbing, sneezing and even eye blinking have been shown to cause significant pressure spikes.
Dr Hovanesian conducted a study with Dr Samuel Masket that set out to assess clear corneal incisions for leakage due to pressure spikes. Working with Ocular Therapeutix, Inc., they used a recently developed calibrated force gauge that can apply measurable amounts of force to the eye. The foot of the applicator was placed near the clear corneal incision on the scleral side of the wound, and up to 28 grams of force was applied. The researchers examined the response to external pressure of 30 eyes with temporal clear corneal incisions sealed with stromal hydration. Mean incision width was 2.5mm; 14 were single plane and 16 biplane, constructed using a grooved technique. All main and paracentesis incisions were confirmed to be closed before pressure was applied using the Seidel test to detect leakage. After 28 grams of pressure was applied for two to three seconds about a half millimeter from the main incisions on the scleral side, 22 out of 30, or 73.3 per cent, leaked. Nearly 90 per cent of single plane and approximately 60 per cent of biplane incisions leaked. Also, 11 of 20, or 55 per cent of paracentesis ports leaked. No adverse events were reported.
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“One ounce of pressure is adequate to simulate eye rubbing,” Dr Hovanesian noted. In a test of 21 eyes with clear corneal incisions with a mean width of 2.54mm closed with sutures, the overall leak rate was much lower at 23.8 per cent. Here again, single plane incisions were more likely to fail, with four, or 36 per cent, of 11 single plane incisions leaking compared with one, or 10 per cent, of 10 biplane incisions. No adverse events were reported. He noted an earlier study that found light and firm digital pressure caused average IOP to fluctuate between 27 and 58 mmHg respectively (McMonnies CW et al. Eye & Contact Lens 33(3):124-129, 2007). A test of the Ocular Therapeutix calibrated force gauge involving 30 eyes by Daniel Wee MD and Michael B Raizman MD of Boston, US, fell in the middle of that range. In this trial, applying 28 grams of pressure raised mean IOP by nearly 26 mmHg, from 17.5 mmHg to 43.5 mmHg, an increase of nearly 150 per cent.
Bandage a solution? The results suggest that clear corneal incisions may still place patients at risk because they often leak due to changes in IOP. “The study demonstrated to us that wounds closed by either stromal hydration or sutures are prone to leakage, and the forces leading to leakage are similar to those exerted by a patient in the postoperative period,” Dr Hovanesian said. “Biplanes were less likely to leak than single planes, and sutures represented an improvement as expected, but were still faced with a challenge. Nearly 24 per cent of
Hydrogel bandages may enhance wound stability. We look forward to further studies to show what the role of these bandages might be John Hovanesian MD
sutured incisions could leak when force is applied.” This raises the question of how surgeons can do a better job of ensuring that cataract wounds stay closed. Dr Hovanesian believes that hydrogel bandages may be the answer. In his own ex vivo study, Dr Hovanesian has shown that cataract wounds closed with polymerizing hydrogel bandages can prevent both ingress and egress of fluids (Hovanesian JA. J Cataract Refract Surg 2009; 35(5):912916). At least one recent study also has shown that that hydrogel bandages can stop microleaks of cataract incision in vivo, he noted (Calladine D et al. J Cataract Refract Surg 2010; 36:1839-1848). “We know that forces on the wound after surgery can cause the wound to become incompetent,” Dr Hovanesian said. “Hydrogel bandages may enhance wound stability. We look forward to further studies to show what the role of these bandages might be.”
cataract & refractive
David P Pinero - firstname.lastname@example.org Sunil Shah - email@example.com
This laser technology should be considered as an additional option for the correction of higher order aberrations
Solid-state platform studies indicate good outcomes with wavefront-guided treatments by Dermot McGrath in Vienna
Courtesy of Sunil Shah MD
Courtesy of David P Pinero PhD
David P Pinero PhD
Wavefront-guided LASIK in a case with significant amounts of primary coma due to a decentred ablative procedure (preoperative, top; postoperative, bottom). Right: changes in higher order wavefront map. Left: changes in the simulation of vision with an optotype
sing a solid-state laser platform seems to offer surgeons a safe, efficacious and predictable method of minimising the induction of ocular aberrations in both LASIK and surface ablation procedures, according to a number of studies. “The results from our preliminary study evaluating the results of wavefront-guided LASIK with a solid-state platform were very promising although the trends need to be confirmed in future series with larger sample sizes. This laser technology should be considered as an additional option for the correction of higher order aberrations,” David P Pinero PhD, told delegates attending the XXIX Congress of the ESCRS. Dr Pinero noted that the Pulzar Z1 solid-state laser (CustomViz) enables photoablation of corneal tissue using a
Our patients are leaving the clinic with a smile on their face, which I think may be down to the unique properties of this type of laser Sunil Shah MD
EUROTIMES | Volume 17 | Issue 2
wavelength of 213 nm, which produces a similar clinical and histopathology course to the excimer 193 nm laser. The 213nm wavelength is close to the absorption peak of collagen and has low absorption in fluid, which contributes to its high corneal ablation efficiency. The laser utilises a 0.6mm Gaussian shaped flying spot, a pulse rate of 300 Hz, and optimised, ocular wavefrontguided and topography-guided ablation profiles. “This approach delivers a high degree of accuracy and minimal damage to the adjacent areas as with LASIK, but the outcomes are less dependent on the hydration of the corneal surface,” he said. Surveying the scientific literature, Dr Pinero said that there were very few substantial studies assessing the performance of solid-state lasers in refractive surgery. One study from Tsiklis et al in 2007 reported excellent safety and efficacy for the treatment of low to moderate myopia using a solid state laser for PRK and LASIK treatments. However, there were no previous reported experiences with solid-state lasers using wavefront-guided ablation profiles. Dr Pinero’s retrospective case series included 13 eyes of seven patients ranging in age from 21 to 32 years who underwent ocular wavefront-guided LASIK for the correction of myopia or myopic astigmatism using the Pulzar solid-state laser and the M2
mechanical microkeratome. The mean postoperative follow-up period was almost nine months and the visual and refractive outcomes, as well as the aberrometric changes were evaluated during the follow-up by means of the iTrace system (Tracey Technologies). Dr Pinero reported that a significant improvement was observed in uncorrected distance visual acuity, changing from a mean preoperative LogMAR score of 0.99 (about 20/25) to 0.0 or better in 12 eyes (92 per cent). This visual improvement was consistent with a significant reduction in sphere and cylinder, with 92 per cent of eyes within 0.50 D of emmetropia and all eyes within 1.0 D. Furthermore, the mean postoperative higher order aberration RMS was 0.50 (± 0.41 microns), a difference that was statistically significant in spite of being of small magnitude, said Dr Pinero. In a separate presentation, Sunil Shah MD also highlighted the excellent refractive outcomes obtained in surface ablation procedures carried out using a solid-state laser platform. “The Pulzar Z1 solid state laser is a safe, reliable and effective tool for laser refractive surgery. Interestingly, because these were surface treatments these patients did not seem to feel the same levels of pain as they would have experienced had we been using
a standard excimer laser for LASEK. Our patients are leaving the clinic with a smile on their face, which I think may be down to the unique properties of this type of laser,” said Prof Shah. Discussing those properties in greater detail, Prof Shah noted that because there is no gas within the solid-state system, apart from the sealed laser chamber itself, hence there is theoretically less risk of toxicity with this device. He also echoed Dr Pinero’s suggestion that the wavelength of the laser should give it a theoretical edge over its excimer counterpart. “This was one of the key reasons to look at this particular wavelength where your results would never be changed even if you had excess water on the cornea,” he said. Prof Shah’s study included 244 eyes, 180 myopic and 64 hyperopic, that underwent surface LASEK performed by the same surgeon using the Pulzar Z1 laser at Jersey Vision Correction, St Helier, Jersey, with three months' follow-up. The mean preoperative spherical equivalent was -3.59 (range -0.75 to –10.50 D) in the myopic group and +2.78 (range +0.75 to +6.00 D) in the hyperopic group. The mean preoperative cylindrical refraction was 1.05 D (range 0 to 5.00 D) in the myopic group and 1.11 D (range 0 to 5.50 D) in the hyperopic group. Prof Shah said that 96 per cent of preoperative myopes achieved within 0.50 D of the target refraction and 100 per cent were within 1.00 D, while the results for hyperopia were 78 per cent of patients within 0.50 D and 93 per cent within 1.00 D of target refraction. The safety data was also very impressive, said Prof Shah, with corrected distance visual acuity remaining unchanged in 89 per cent of patients, with six per cent gaining one line of BCVA and four per cent losing one line of Snellen visual acuity (no patients lost more than one line). “If you consider the extremely wide treatment range of this patient population, this is a very acceptable result indeed. In our study we have 24 eyes with more than 2.5 D of astigmatism and despite that we are still getting 50 per cent of these patients within 0.13 D and 89 per cent within 0.50 per cent of target refraction,” said Prof Shah.
cataract & refractive
Small aperture inlay may provide solution for correcting presbyopia in patients after LASIK by Dermot McGrath in Vienna
ddressing delegates at the XXIX Congress of the ESCRS, Minoru Tomita MD, PhD, executive director of the Shinagawa LASIK Centre, Tokyo, Japan, said that the Kamra inlay (AcuFocus Inc.) provides excellent near and intermediate vision for patients without compromising their distance vision. “The initial results are very encouraging, although care must be taken when deciding the pocket depth in relation to the previous LASIK flap. On average, our patients gained six lines of uncorrected near visual acuity at 30cm with no changes in their uncorrected distance vision. Patient feedback was also very positive, with 95 per cent of the patients reporting that they were satisfied with their vision without reading glasses and 96 per cent of patients saying that their dependence on reading glasses had decreased,” he said. The key to the performance of the inlay lies in the central aperture of 1.6mm aperture, which increases the depth of field and enables the patient to achieve improved vision for near and intermediate distance with a minimal effect on distance vision. In Dr Tomita’s study, 741 post-LASIK presbyopes were implanted with the Kamra inlay in their non-dominant eye between November 2010 and August 2011. The surgical procedure is very straightforward, said Dr Tomita. First, a corneal pocket was created at a depth of 200 to 250 microns below the LASIK interface using the FEMTO LDV Crystal Line femtosecond laser (Ziemer Ophthalmic Systems). The Kamra inlay was then inserted into the corneal pocket. In almost one-fifth of cases, the prior LASIK flap was lifted and a laser touchup of SE +0.52±0.60 D was performed to achieve postoperative plano refraction. Inclusion criteria included patients aged between 40 and 65 with a corrected distance visual acuity in both eyes better than 20/25 and uncorrected near visual acuity in the implanted eye of J-3 or worse. Patients needed to be at least one month post-LASIK surgery, with a corneal thickness greater than 450 microns, regular topography, endothelial cell density of at least 2,000 cells/mm2 and no severe dry eye, or ocular or corneal disease or immune system disorders. Looking at the visual acuity results at three months postoperatively, Dr Tomita said there was no change in the mean uncorrected EUROTIMES | Volume 17 | Issue 2
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Thin, 100-micron, planar flaps Accuracy and predictability equivalent to Femto-SBK Smoother stromal bed No femto-complications
• … At a fraction of the cost distance visual acuity, which remained at 20/16. The mean uncorrected near visual acuity at 30cm improved six lines from preoperative J-11 to J-3. In terms of uncorrected distance visual acuity, 84 per cent of patients achieved 20/20 or better at three months. For uncorrected near visual acuity at 30cm, 31 per cent of patients achieved J-1, 42 per cent achieved J-2 and 78 per cent achieved J-3 or better. Subjective patient satisfaction was also very high, said Dr Tomita. Over 95 per cent of the patients reported being either satisfied (10 per cent) or highly satisfied (85 per cent) with their visual acuity, while 96 per cent reported a decrease in their dependence on reading glasses since having the implant. In a separate presentation, John Vukich MD discussed the two-year results from the United States FDA clinical trial of the Kamra inlay for the correction of presbyopia in emmetropes. He reported that the prospective, non-randomised study enrolled 507 patients at 24 sites worldwide, with the data from 99 patients available for inclusion at the two-year mark. The mean uncorrected visual acuity was J-3 for near, with an average 3.5 lines gain from baseline, said Dr Vukich. “There was a trend that we have observed from one year to around 18 months postoperatively showing a continued improvement in their ETDRS reading score over that period,” said Dr Vukich. Uncorrected intermediate vision showed a similar trend with a mean improvement to 20/25. For uncorrected distance vision, Dr Vukich said that there was an initial small drop in visual acuity followed by stabilisation to a mean of 20/20 at two years. He surmised that part of this drop might be due to the slight induction of astigmatism related to the creation of the corneal pocket for the inlay. The best-corrected distance visual acuity remained high with an average of 20/16 for these patients. The binocular uncorrected vision (UDVA) was unchanged from preoperative to 24 months postoperatively (20/16), and the binocular photopic and mesopic contrast sensitivity was all recorded as within normal limits, he added. Dr Tomita noted that the Kamra inlay is currently under investigational trials in the US but is available for use in Japan, and received the European CE mark in 2005.
Minoru Tomita - firstname.lastname@example.org John Vukich - email@example.com
SBK without compromise KERATOME
One Use-Plus SBK (Moria)
SUCTION RINGS USED
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« Moria One Use-Plus SBK is a safe and accurate automated microkeratome for the creation of 100-micron planar flaps. It allows refractive surgeons to provide high level of safety surgeries for patients with a unique 100% single-use solution.»
François Malecaze, MD, PhD (Toulouse, France) Malecaze F. Single-use Sub Bowman’s Keratomileusis procedure without a femtosecond laser: My first 1000 cases. 15th ESCRS Winter meeting, Feb. 2011, Istanbul, Turkey. Malecaze F. Utilisation du microkératome en chirurgie réfractive. Les Cahiers d’Ophtalmologie,mai 2011;150:49-50. Download long-version testimonials on: www.moria-surgical.com Roundtable with 7 international SBK experts, #66076A Ask for a demo: firstname.lastname@example.org
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MILAN 6 - 8 September 2012
3rd EuCornea Congress
Amar Agarwal - firstname.lastname@example.org Soosan Jacob - email@example.com
Novel technique enables successful PCR management while maintaining a small incision by Cheryl Guttman Krader in Vienna
There are several other methods that surgeons can use to prevent nucleus drop after PCR, including the phaco sandwich, posterior assisted levitation using a Sheet’s glide, or Keiki Mehta’s HEMA life boat. Amar Agarwal MD
EUROTIMES | Volume 17 | Issue 2
it is the only one in which the scaffold is the IOL itself and so allows the same IOL to be implanted into the sulcus after lens removal.” The IOL scaffold technique can be used after the nucleus pieces have been brought into the anterior chamber, but it should be limited to the management of PCR in eyes with soft to moderate nuclei, considering the risk of corneal damage if the cataract is very hard, Prof Agarwal said. In performing the technique, the first step is to adjust the infusion or fix an anterior chamber maintainer to prevent anterior chamber collapse. Then any vitreous that has prolapsed into the anterior chamber is removed by anterior vitrectomy. Next, the nuclear fragments are manoeuvred to lie above the iris in the anterior chamber. The IOL is introduced via the existing corneal incision and positioned beneath the nucleus with the leading haptic above the iris and the trailing haptic remaining just outside the incision. A dispersive viscoelastic is used to coat the cornea. “Using a dialler in the non-dominant hand, the surgeon should manoeuvre the optic-haptic junction on the trailing haptic side so that the IOL blocks the pupil. Keeping the trailing haptic outside the incision also enables adjustment of the IOL position if the nucleus rotates while reducing the risk of IOL drop,” noted Prof Agarwal. Once the IOL scaffold is established, the surgeon can proceed to remove the nuclear fragments using the phaco probe with low flow and vacuum settings. Any residual cortex is then removed using the vitrectomy probe in suction mode with low aspiration. The IOL is then manoeuvred over the capsular remnants in the ciliary sulcus. If capsular support is inadequate, a glued IOL procedure is performed. The infusion cannula/anterior chamber maintainer is removed, and the wound hydrated. Postoperative treatment includes fluoroquinolone and corticosteroid drops four times daily for two weeks with a shortacting mydriatic drop twice daily for three days. Dr Soosan Jacob, senior consultant, Dr Agarwal's Group of Eye Hospitals, was also involved in carrying out the research mentioned in this article.
IOL scaffold technique with 23 G trocar infusion and moderately soft nucleus. Posterior capsular rupture during nucleus removal
Three-piece foldable IOL injected through the clear corneal wound
Nucleus removed with phaco probe above the IOL optic
Nucleus completely emulsified
IOL pushed into the ciliary sulcus
IOL well centred at the end of surgery
Courtesy of Amar Agarwal MD
he IOL scaffold is a useful new technique for preventing further complications and achieving a successful visual outcome after posterior capsular rupture (PCR), said Amar Agarwal MD, at the XXIX Congress of the ESCRS. The procedure is intended for use in cases where PCR occurs with a non-emulsified, moderate to soft nucleus. It uses a threepiece foldable IOL as a scaffold or barrier to compartmentalise the anterior and posterior chambers, thereby preventing vitreous prolapse, vitreous hydration, and nucleus drop. Because the IOL is inserted through the existing corneal incision, the IOL scaffold technique has advantages for maintaining anterior chamber stability and IOP while also preserving the astigmatic benefit of sutureless, small incision surgery, said Prof Agarwal, chairman and managing director, Dr Agarwal’s Group of Eye Hospitals, Chennai, India. “The word scaffold comes from the medieval Latin word scaffaldus that means temporary platform. In the IOL scaffold technique, the three-piece IOL is acting as a temporary platform or artificial posterior capsule, preventing nuclear fragments from falling into the vitreous cavity,” he explained. “There are several other methods that surgeons can use to prevent nucleus drop after PCR, including the phaco sandwich, posterior assisted levitation using a Sheet’s glide, or Keiki Mehta's HEMA life boat. However, the IOL scaffold is unique in that
IMPROVED DALK TECHNIQUES
DALK can work well but there is a steep learning curve before surgeons feel fully at ease with procedures by Dermot McGrath in Vienna
mprovements in deep anterior lamellar keratoplasty (DALK) techniques, as well as greater surgical familiarity with that particular approach, are resulting in a greatly reduced conversion rate to penetrating keratoplasty (PKP) procedures, according to Vincenzo Sarnicola MD. “As our techniques have improved and we have become more familiar with this type of surgery, we no longer have to automatically convert to PKP when certain complications such as ruptures or perforations of Descemet’s membrane occur. It has been over eight years now since I have had to convert to PKP to rescue a failed DALK procedure,” Dr Sarnicola told delegates attending the 2nd EuCornea Congress. Dr Sarnicola noted that DALK, which involves the removal of central corneal stroma while leaving host corneal
endothelium and Descemet’s membrane (DM) intact, is currently the best procedure to restore corneal function in pathologies of shape and transparency of the corneal stroma in cases where the underlying endothelium remains healthy. He acknowledged, however, that there is quite a steep learning curve to be negotiated before surgeons feel fully at ease with DALK procedures. Dr Sarnicola, Misericordia Hospital of Grosseto, Italy, said that DALK offers the best features of both lamellar and penetrating keratoplasty techniques by significantly reducing the risk of immune rejection and making any rejection more easily treatable. He noted that there are also fewer intraoperative and postoperative complications with DALK compared to penetrating keratoplasty. Nevertheless, complications can and do occur in any surgery as intricate and
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EUROTIMES | Volume 17 | Issue 2
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complex as DALK, said Dr Sarnicola, who presented a review of his own complication rate in 456 DALK procedures carried out between 2000 and 2010. The data gathered by Dr Sarnicola included DALK procedures carried out using a variety of techniques such as dry dissection, hydrodissection, ‘big bubble’, air needle and, more recently, cannula DALK. “This refined technique has worked very well for us and we are now achieving deep DALK by reaching Descemet’s membrane in 93 per cent of our cases,” he said. The most common complications associated with DALK included perforation or rupture of Descemet’s membrane, microperforations and double anterior chamber, said Dr Sarnicola. Using early DALK techniques such as dry air or hydrodissection, Dr Sarnicola recorded a complication rate for microperforations of 26 per cent in 19 cases and seven per cent in 41 cases respectively. This has been reduced to 2.5 per cent using the cannula DALK approach, which equates to three cases out of 118 procedures. While only a few years ago a rupture of Descemet’s membrane invariably meant converting to penetrating keratoplasty, that no longer holds true if the surgeon follows some ground rules to rescue the situation, said Dr Sarnicola. “First, it is important to complete the stromectomy and to avoid putting air into the anterior chamber without first suturing the donor. Once that has been done, the surgeon can then put air into the anterior chamber and can then move the eye in order to remove interface fluids between the stroma and Descemet’s membrane. If the surgeon follows these simple steps he should be able to retrieve the situation and avoid the need to convert to PKP,” he said. Similarly, cases of excessive trephination leading to perforation of Descemet’s membrane can be rescued using DALK, said Dr Sarnicola. “I am sure that most surgeons would convert in this type of scenario to PKP but you can actually deal with this complication and stick with a DALK approach. First we need to suture the zone of perforation and then carry out a layer-by-layer dry delamination to remove all the stroma. We can then suture the donor in place before delaminating the zone of perforation. All
Vincenzo Sarnicola - email@example.com
that remains then is to put some air in the anterior chamber and move the eye in order to remove the interface fluids,” he said. Double anterior chamber is another complication that can arise during DALK procedures. In Dr Sarnicola’s series the incidence was 1.9 per cent for all 456 DALK procedures carried out between 2000 and 2010. Contrary to common belief, Dr Sarnicola noted that double anterior chamber is not always associated with a rupture of Descemet’s membrane. “In fact you can also have double chamber without any rupture of Descemet’s, especially if the surgeon has used some viscoelastic to separate the Descemet’s from the stroma and some viscoelastic has been left between the membrane and the stroma. Fortunately, it is quite easy to deal with this problem by putting air into the anterior chamber,” he said. In cases involving massive destruction of the stroma, the rule is to use DALK and only DALK, performing a large stromectomy and a layer-by-layer delamination, advised Dr Sarnicola. Looking at the incidence of rejection, which was 26 out of 660 cases (four per cent), Dr Sarnicola noted that it was caused by epithelial rejection in two cases and subepithelial rejection in the other 24 patients. To illustrate the utility of DALK in even the most severe cases, Dr Sarnicola presented a case study of a patient who presented to his clinic with severe infection and corneal melting 30 days after a big bubble DALK procedure. The patient was given another larger graft the following day with an enlarged stromectomy, disinfection of the recipient bed and tissue culture for fungus and bacteria. Two days later, however, the infection returned and the tissue culture was negative for bacteria and fungal infection. The same pattern emerged after a third graft was attempted, with the infection returning after eight days. After a fourth DALK procedure, a polymer chain reaction (PCR) test for viral DNA revealed that the patient had ocular herpes. Subsequent treatment with acyclovir cleared the infection and three years later the patient has suffered no recurrence. “The endothelial cell count is 1,200 cells/mm2 after three years but remains stable. I think we can ask what would have happened in this case if we had not performed DALK but PKP. Everyone knows the survival rate of multiple PKP procedures is not good, so persisting with the DALK approach paid off in this particular instance,” he said.
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espite hundreds of controlled studies of dozens of treatments over four decades, conjunctival autografting remains the best surgical procedure for treating both primary and recurrent pterygium today, Donald Tan FRCSG, FRCSE, FRCOphth, FAMS of the National University of Singapore and the Singapore National Eye Centre, told the Second EuCornea Congress. Recent adjuncts, including fibrin glue and, in some cases, mitomycin-C, can improve outcomes. But recurrence rates and cosmetic results are largely dependent on good surgical technique, he stressed. Dr Tan pointed out that more patients, especially younger patients, are presenting before pterygia cause clinical symptoms. “Modern pterygium surgery is not just safe surgery with a low rate of recurrence, it is also aesthetic surgery. A good cosmetic outcome is crucial.”
Sorting out the evidence With 563 articles published from 1968 through March 2010, pterygium is one of the most studied ocular conditions. That’s one a month for 42 years, Dr Tan pointed out. Dr Tan identified 79 randomised clinical trials, but comparing results was difficult due to inconsistent methodology. For example, there was no consensus on what constituted recurrence, sample sizes were as small as eight subjects, and follow-up ranged from one to 58 months. Treatment was masked in just 34 per cent of cases. Nonetheless, A1 level evidence, meaning reliable randomised clinical studies, exists for several major techniques. In five of seven trials, conjunctival autografts produced significantly lower recurrence rates than bare sclera excision, with conjunctival recurrence ranging from zero to 39 per cent. “I do not
I do not think it is ethical to perform bare sclera surgery. The recurrence will be worse than the primary
Donald Tan FRCSG, FRCSE, FRCOphth, FAMS EUROTIMES | Volume 17 | Issue 2
Pterygium surgery: good cosmetic result with a conjunctival autograft
think it is ethical to perform bare sclera surgery. The recurrence will be worse than the primary,” Dr Tan said. In 11 trials comparing conjunctival autografts with mitomycin-C, only two showed significant differences in recurrence rates. Dr Tan suggested that MMC is useful in cases of multiple recurrences to control scarring, but suggested using it at the edge of fibrovascular tissue and not on the scleral bed to avoid possible melting. The literature, including a study by Dr Tan (Tan D et al. Archives of Ophthalmol 1997; 115:1235-40), also show that thicker, less translucent, pterygia are associated with higher recurrence rates. “It is the fleshiness of the pterygium that is the major risk factor, so you need to remove all the fibrovascular material.” Dr Tan’s study also found that surgeon experience matters. Surgeons who had done 10 or more procedures had a five per cent recurrence rate compared with up to 83 per cent for surgeons with no previous procedures. Essential factors for successful conjunctival grafts include a large graft measuring 8.0mm by 8.0mm, adequate removal of fibrovascular tissue surrounding the pterygium, a thin Tenon’s-free graft obtained with a superficial dissection, Dr Tan said. A stable graft anchored by sutures to the episclera at the limbus above and below, or with fibrin glue, is also critical to graft survival. Fibrin glue also has been shown to cause less pain and reduce healing time, though it has not been conclusively shown to improve graft survival, he added.
Donald Tan - firstname.lastname@example.org
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*Technolas Perfect Vision data on file Some of the products and/or specific features as well as the procedures featured in this document may not be approved in your country and thus may not be available there. Design and specifications are subject to change without prior notice as a result of ongoing technical development. SUPRACOR is NOT approved for use in the US. SUPRACOR is not approved in all countries. Please contact our regional representative regarding individual availability in your respective market. The trademarks (™ and ®) and logos used in this document are the property of Technolas Perfect Vision GmbH or the respective owner. Design by kbcomunicacion. Ref. TPV-068/09-2011 ©2011 Technolas Perfect Vision GmbH. All rights reserved.
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OCULAR SURFACE TRANSPLANT
New immunosuppression and surgical options improve safety and outcomes by Howard Larkin in Vienna
dvances in immunosuppression and surgical techniques improve safety and outcomes for patients with severe ocular surface disease and limbal stem cell deficiency, while careful evaluation helps match the broadening range of options with specific patient needs, Edward J Holland MD, University of Cincinnati, Ohio, US, told the XXIX Congress of the ESCRS. “New immunosuppression protocols give better results, and new data support the safety of immunosuppression. New surgical techniques with keratoprostheses along with ocular surface transplants and ex-vivo techniques are certainly exciting news for our patients,” Dr Holland said.
Reducing immunosuppression risk Dr Holland noted that ocular surface
disease and even blindness are not life threatening, while immunosuppression may expose patients to significant health risks. So is the risk of immunosuppression in ocular surface transplantation worth the benefit of improving vision? Dr Holland believes it is for several reasons. First, ocular transplant patients generally are younger and healthier than organ transplant candidates, so they are less susceptible to immunosuppression complications. Second, ocular surface transplant patients need lower doses, and many can be weaned off oral immunosuppressants over time. Third, newer immunosuppressant agents reduce or eliminate the need for prednisone. “The biggest complaints patients have are from systemic steroids, so we use low doses or no corticosteroids orally, and all patients are off them by three months,” Dr Holland said.
Dr Holland tailors immunosuppressant regimen to each individual patient based on factors such as HLA match, panel reactive antibodies and blood type. Transplants from living related donors with high HLA match are lower risk for rejection than cadaveric donors, and primary grafts are lower risk than repeat grafts. For high-risk patients, Dr Holland induces immunosuppression intravenously with the powerful new agent basiliximab on the day of surgery and in the early postop period. His basic protocol combines tacrolimus, microphenolate and a low dose of oral prednisone. The prednisone is rapidly tapered off at three months. He tapers low-risk patients off tacrolimus at six to 12 months, and high-risk patients at 24 months. He tapers microphenolate at 12 to 24 months, and aims for low-risk patients completely off oral suppressants at 24 months, based on labs and assessment of side effects. Dr Holland reported good success with this approach. He followed 225 eyes in 136 patients for a mean 4.5 +/-2.7 years. At presentation, 56 per cent of patients had no systemic co-morbidities. Mean duration of immunosuppression was 3.5 years, and 105 patients, or 77 per cent, had stable ocular surface at the last follow-up. Thirty-seven patients, or 35 per cent, were successfully tapered off immunosuppression. The majority of remaining patients were on monotherapy, mostly microphenolate. There were no deaths or secondary tumours. Three severe events including a myocardial infarction and a pulmonary embolism occurred in two patients with pre-existing risk factors. Nineteen minor events including transient hypertension,
Visit: www.eurotimesrussian.org EUROTIMES | Volume 17 | Issue 2
increased blood sugar and liver enzymes, and pneumonia occurred in 19 patients (Holland et al. Cornea in press). Although a legitimate concern, Dr Holland believes that fears of systemic immunosuppression side effects are overblown. “The bigger problem in the patients I inherit is not enough suppression. Once allograft rejection is under way, the immune system is sensitised to corneal and conjunctival antigens and we have a much higher risk for future procedures.” In surgery, Dr Holland now uses tissue glue to secure the ocular surface transplanted tissue instead of multiple sutures. “It significantly shortens the duration of surgery, which is good for the patient and the surgeon, and we see a lot less inflammation.” For patients with severe conjunctival and limbal disease, often in conjunction with Stevens-Johnson syndrome, Dr Holland recommended the “Cincinnati Procedure,” which combines living-related conjunctival limbal allograft (LR-CLAL) tissue transplant combined with cadaveric cornea tissue transplant, keratolimbal allograft (KLAL). “If we did the LR-CLAL only, we would not have enough tissue to surround the diseased limbus and we had failure at three and nine o’clock. If we just did cadaveric cornea, we have enough tissue to cover the limbus, but no conjunctival tissue which is vital for the rehabilitation of the ocular surface in these patients,” he explained. Augmenting the conjunctival and limbal cells from the LR-CLAL with cadaveric limbal tissue from the KLAL tissue completely surrounds the recipient
Edward J Holland - email@example.com
limbus and provides more stem cells. This increases goblet cell and mucin production, increasing ocular surface stability and improving the environment for keratoplasty, Dr Holland said. Success with the “Cincinnati Procedure” has been high. In a study of 24 eyes in 19 patients with severe ocular surface failure, almost all with Steven-Johnson syndrome, 79 per cent underwent staged keratoplasty and 75 per cent had stable corneal surface at a mean follow up of 43 months. Mean best corrected visual acuity before surgery was 20/400 or worse in 87.5 per cent of eyes, improving to 20/125 or better in 71 per cent of eyes after surgery (Biber et al. Cornea 2011; 30(7):765-771). Keratoprostheses may also give good results in patients with severe ocular surface disease, with some reports showing onequarter of patients achieving 20/40 vision and most 20/200 or better, Dr Holland noted. But while keratoprostheses are technically similar to PK, and rejection and immunosuppression are not an issue, corneal melt, infectious keratitis and endophthalmitis are risks. Risks are much higher in patients with severe dry eye or with conjunctival deficiency. Older patient in poor health and thus not ideal candidates for ocular surface transplantation and immunosuppression are good keratoprosthesis candidates. “Both techniques of ocular surface transplant and keratoprosthesis are very appropriate based on the patient’s presenting symptoms. Corneal surgeons should become accomplished in both techniques and their complication management,” Dr Holland said. Ex-vivo cultures of corneal cells also show great promise. A recent review found no difference in success rates for corneal cells cultured from a limbal biopsy on an amniotic membrane or a suspension culture of epithelial cells on amniotic membrane or plastic. A total success rate of 76 per cent was achieved for 194 eyes using cultured limbal tissue and 27 receiving culture oral mucosal cells with 70.6 per cent autografts (Short et al, Surv Ophthal 2007; 52(5):483502).“I think ex-vivo will be more popular in the future,” Dr Holland said.
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for toric IOLs
Vital to ensure that identified risk factors are not completely explained by co-related factors or inappropriate comparisons
Mark the patient
by Dermot McGrath in Paris
Courtesy of Paul Healey MD, PhD
Using this marker the surgeon impresses three dot-shaped landmarks at the 3, 6, & 9 o’clock positions. The tips of the prongs are flattened to prevent damage to the epithelium even if the patient inadvertently moves. K3-7908 Henderson Alignment Marker
Orient the gauge to the marks
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To correctly position the gauge, the surgeon simply aligns the notches on the inside edge of this instrument with the dots produced by the Henderson Alignment Marker. K3-7904 Henderson Degree Gauge
Mark the axis of astigmatism
Once the gauge is oriented, the surgeon simply aligns the marks of this instrument with the desired degree lines on the gauge. This produces two thin lines along the axis of astigmatism which can be used to correctly align the toric IOL. K3-7912 Henderson Toric IOL Marker
Instruments designed by Bonnie Henderson, MD of Boston, Massachusetts
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EUROTIMES | Volume 17 | Issue 2
reater understanding of the nature and role of risk factors for the onset and progress of glaucoma is a complex task that requires the collaboration of epidemiology, basic sciences and clinical trials, according to a study presented at the 2011 World Glaucoma Congress. “The risk estimates for glaucoma depend on disease definition and are sample specific,” said Paul Healey MD, PhD, clinical associate professor at the University of Sydney, Australia. “One of the problems many ophthalmologists have is that there are so many different studies out there showing so many different risk factors and it is rather hard to decipher what is important and what is not, as the impact of a risk factor may vary across different populations and disease states,” he added. Defining a risk factor as a factor associated with an increased occurrence of a disease, Dr Healey said it is vital to ensure that the identified risk factor is not completely explained by a co-related factor (confounding) or an inappropriate comparison (bias). “Those two aspects separate many purported risk factors in many studies from what are probably true risk factors. Hence, the most important thing to do when reviewing a paper purporting to show a risk factor for glaucoma is to question whether there could be a correlated factor or an inappropriate comparison that explains it,” he said. The next step is to establish whether the identified risk factor is a causal risk factor that leads directly to the disease. If the risk factor is causal, then removing that risk factor should reduce or remove the disease itself, said Dr Healey. “Risk factors are not always causal, however. They may be surrogates for true causal risk factors that we have not been able to discover or do not have the technology to discover, or they could be epi-phenomena on the causal pathway. These are reliable features that are strongly associated with the glaucoma, but the removal of which does not reduce the risk of disease progression” he said. Proving a causal risk factor is a complex task, with the first step being to rule out biases or possible confounders,
said Dr Healey. This needs robust study design and standardised statistical methodology. “It really requires a number of high-quality studies that are well conducted and independent from each other that show similar risk factors and a similar magnitude of risk. A good example is IOP, which has been very well described and its association with glaucoma by many independent studies,” he said. The next step is to identify a plausible biological link between the risk factor and the disease, said Dr Healey. “This is the role of much of the basic laboratory science, to describe how what we find in a clinical or epidemiological study is linked to the disease, and it usually entails understanding the cellular mechanisms involved. We also need to show a reduction in disease progression in people not exposed to the risk factor and that of course requires randomised controlled interventional trials or sometimes cohort studies,” he said. Other factors which need to be borne in mind when identifying risk factors are the varying definitions of glaucoma across different studies, taking account of whether the study was looking at early onset or more advanced disease, and whether patient groups had diagnosed or undiagnosed glaucoma, said Dr Healey. While multivariate modelling can help in adjusting the correlation to risk factors, some interactions may still persist, said Dr Healey. “A perfect example of that are vascular risk factors. There are so many different measurements that can be made relating to vascular risk, heart attack, stroke status, systolic blood pressure, perfusion pressure, mean blood pressure and so forth, that it is very hard to tease out which one or group of these is actually more important,” he said.
contact Paul Healey - firstname.lastname@example.org
Glaucoma NON PENETRATING APPROACH
Glaucoma implant offers minimally invasive treatment
NATURAL RESTORE OF IOP
by Dermot McGrath in Vienna
arly results from trials of a novel intracanalicular implant (Hydrus I, Ivantis Inc) show that the device is effective at lowering intraocular pressure and reduces the need for medications in patients with primary open angle glaucoma (POAG), according to a study presented at the XXIX Congress of the ESCRS. “These early clinical results with the Hydrus are very promising and the device may provide an interesting minimally invasive alternative to other surgical modalities intended to lower intraocular pressure,” said Manfred Tetz MD, scientific director of the Berlin Eye Research Institute, who was the first European investigator to implant the device. Prof Tetz noted that the new device fits in with the current trend towards exploring possible surgical solutions to POAG focusing on the trabecular meshwork and Schlemm’s canal. Made from nitinol, a flexible nickeltitanium alloy used for vascular stents, the crescent-shaped, non-luminal 8.0mm long Hydrus implant is a scaffold design intended to re-establish the patient’s conventional outflow pathway through a minimally invasive, microsurgical procedure, said Prof Tetz. “The Hydrus comes preloaded in a disposable injector system and it is implanted using an ab-interno approach through a 1.0mm to 1.5mm incision into Schlemm’s canal, which minimises trauma to the surrounding tissue,” he said. Since glaucoma patients often have both a blockage and a collapse of the natural outflow pathway, the Hydrus device relies on a twofold mechanism of action to tackle both aspects of the problem, first creating a relatively large opening through the trabecular meshwork, and then dilating and scaffolding Schlemm’s canal to maintain a clear outflow pathway over time. Prof Tetz’s study was carried out at six European centres on 69 patients with mildto-moderate glaucoma, and was intended to assess the safety and efficacy of the Hydrus implant in two distinctly different surgical settings. Twenty-nine patients received the Hydrus device in conjunction with cataract surgery, while 40 patients received the device alone. Six-month follow-up included
EUROTIMES | Volume 17 | Issue 2
These early clinical results with the Hydrus are very promising and the device may provide an interesting minimally invasive alternative to other surgical modalities intended to lower intraocular pressure
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Manfred Tetz MD measurements of the change in IOP and change in glaucoma medication required by the patient. In the combination surgery group, the patients’ average IOP decreased from 21.1 mmHg before surgery to 15.6 mmHg at the six-month-follow up point. The patient’s use of glaucoma medication was reduced from an average of 2.1 to 0.4 ophthalmic eye drops per patient. In the device-only surgery group, the average IOP decreased from 21.6 mmHg before surgery to 16.9 mmHg at follow-up, and the average medication use was reduced from 1.7 to 0.6 glaucoma eye drops per patient. Furthermore, 85 per cent of patients in the combination surgery group and 70 per cent of device-only surgery patients were free of glaucoma medication at followup, said Prof Tetz. “The encouraging thing is that this effect seems to be maintained over time. We now have 25 per cent of patients at the one-year follow-up mark and this relationship has not changed,” he said. In terms of adverse events, Prof Tetz cited some issues with minor hyphaema and anterior synechiae, primarily at the port of entry of the implant, but said that there had been no problems of device migration, hypotony or corneal oedema. Summing up, Prof Tetz said that the Hydrus implant had shown its effectiveness at lowering IOP while also reducing the patient’s medication burden. He added that further results and studies were needed to confirm the effects of the procedure with and without combination cataract surgery over a longer follow-up.
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The Glaucolight is a lightfiber based device with an integrated (battery powered) LED source and an atraumatic tip-design for a smooth transfer through the Schlemm’s canal. The bright LED illuminated fiber tip helps visualize the position of the fiber during the 360 degree Schlemm’s canal passage.
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Implantation of EX-PRESS device under scleral flap appears clinically safe
Up to two times faster The more efﬁcient measurement procedure of the latest EyeSuite release allows signiﬁcant time savings.
by Roibeard O’hEineachain in Vienna
lacement of the EX-PRESS™ glaucoma drainage implant (Alcon) beneath a scleral flap can provide an IOP reduction equivalent to that of trabeculectomy, possibly with a lower rate of complications, said Carlo Traverso MD, University of Genoa, Genoa, Italy. “Results coming from numerous centres show that the implantation of the EX-PRESS device under a scleral flap is clinically safe and effective in maintaining a durable and large reduction in IOP,” Prof Traverso told the attendees of the EGS-sponsored Glaucoma Day at the XXIX Congress of the ESCRS. The EX-PRESS implant is a stainless steel device consisting of a 27-gauge shaft with an outer diameter of 0.4mm with either a 50 micron or 200 micron axial lumen and a bevelled tip to allow easy insertion. The shaft terminates in a faceplate that fits under the scleral flap. “During trabeculectomy there is one part which is a little bit cumbersome in my hands, and that is the ‘ectomies,’ that is, the sclerectomy or corneosclerectomy and the iridectomy. The idea of this implant was that it would allow to perform filtration surgery with still a lot of flow but without the ‘ectomies’,” he said. Prof Traverso noted that the implant was originally designed to drain from the anterior chamber directly to the subconjunctival space with just a conjunctival flap modulating the flow of aqueous. The technique initially appeared to be very successful. In a study involving patients undergoing combined phacoemulsification and filtration procedures, the mean IOP remained below 20 mmHg for four years (Traverso et al. Br J Ophthalmol 2005). However, it became clear that when implanted in this way the filtration device would rotate slightly in some cases, resulting in extrusions, Prof Traverso noted. Elie Dahan MD, from South Africa therefore proposed implanting the device under a scleral flap. The technique is more complicated than the original procedure but is less traumatic to the eye than trabeculectomy in that it does not require an iridectomy or removal of scleral tissue, Prof Traverso said.
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Lenstar_Eurotimes_WinterESCRS+WOC'12.indd EUROTIMES | Volume 17 | Issue 2
Results coming from numerous centres show that the implantation of the EX-PRESS device under a scleral flap is clinically safe and effective in maintaining a durable and large reduction in IOP Carlo Traverso MD
In a study involving 37 eyes of 35 primary open angle glaucoma patients, implantation of the device under a scleral flap reduced mean IOP from a preoperative value of 27.2 mmHg to 12.4 mmHg at one year’s follow-up. Nearly 80 per cent of eyes had an IOP below 18.0 mmHg, he noted. Moreover, IOP remained stable throughout follow-up, which reached two years in some patients (De Feo et al, Can J Ophthalmol, 2009; 44:457-462). Several other studies have yielded similar results, including a prospective randomised study in which primary open-angle patients underwent implantation of the EX-PRESS shunt or trabeculectomy. The study showed that there was no significant difference between the success rates of the two groups (P = 0.594). However, early postoperative hypotony and choroidal effusion were significantly more frequent in the trabeculectomy group (P < 0.001) (Maris PJG, et al. J Glaucoma. 2007; 16:14-19). “There are still some unresolved issues, for example, we need to see some longterm comparison studies with other devices, and a cost benefit analysis; moreover we need to determine whether it’s better to use the model with the 50 micron diameter lumen or the 200 diameter lumen,” Prof Traverso said.
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James C Tsai – firstname.lastname@example.org
GLAUCOMA AND LIFESTYLE
Growing demand from patients to know more about possible role of lifestyle factors in glaucoma by Dermot McGrath in Paris
hile the main emphasis in current glaucoma research is focused on finding more efficacious and safer treatments for the disease, lifestyle-related risk factors should not be overlooked in helping to combat glaucoma onset and progression, according to a presentation at the 2011 World Glaucoma Congress. James C Tsai MD, chairman and Robert R Young, professor of ophthalmology and visual science at Yale University School of Medicine in New Haven, Connecticut, US, said that while a lot more research was needed to understand this complex disease, there is growing evidence that certain lifestyle modifications might be beneficial for glaucoma. “Aerobic exercise does seem to be helpful in reducing intraocular pressure. I also tell my patients to limit their cigarette smoking since this action will improve their general health as well as perhaps enhance their ocular perfusion pressure. A diet rich in antioxidants and low in fat content may also be beneficial. In addition, there is some evidence that limiting caffeine intake, avoiding head-down positions and drinking red wine may help in preventing or slowing down glaucoma,” he said. Dr Tsai said that he has personally noticed a growing demand from his patients to learn more about the possible role and effects of lifestyle factors in glaucoma. “There is increasing interest in exploring complementary and alternative treatments, and patients are viewing these nontraditional therapies as possible supplements to their conventional medical and/or surgical therapy. More importantly, patients want greater control over their disease and they are constantly asking what they can do to alter their lifestyle habits for a positive/beneficial effect on their disease,” he said. Moreover, shedding light on the link between lifestyle and glaucoma may have important implications for public health strategies and possibly provide insights into the causes of the disease, said Dr Tsai. Reviewing the scientific literature on lifestyle and glaucoma, Dr Tsai stated that some studies had pointed out the negative effects of yoga and head-down activities on IOP levels. Similarly, wearing tight neckties and playing high resistance wind instruments have been implicated in raising IOP, as have caffeine consumption and stress. By EUROTIMES | Volume 17 | Issue 2
“Aerobic exercise does seem to be helpful in reducing intraocular pressure” contrast, several studies have noted that aerobic exercise has been shown to reduce IOP. Alcohol consumption, while not having a proven effect on the risk of open angle glaucoma, has been shown to lower IOP levels, said Dr Tsai. He noted that in discussing the potential benefits of exercise for glaucoma, most of the studies in the literature have been carried out in patients without glaucoma. “In non-smoking and healthy volunteers, exercise increases heart rate, systolic blood pressure and ocular perfusion pressure but it also decreases IOP and diastolic blood pressure. In physically active college-aged students, dynamic resistance exercises lowers IOP as well. There have also been papers looking at healthy subjects where there was a link shown between beta 2 receptor polymorphism and IOP lowering with dynamic exercise. And just this year, there was a paper published in a population of myopic and emmetropic young adults that showed that dynamic exercise does in fact reduce IOP,” he said. Cigarette smoking has also been targeted for its potentially deleterious impact on ocular health, said Dr Tsai. “We know that cigarette smoking seems to have broad deleterious effects across the entire health spectrum. There are over 4,000 bioactive substances in cigarettes so it is difficult to isolate out the effects of every one of these bioactive substances. But we know that there appears to be both acute and chronic IOP elevation with smoking,” he said. Dr Tsai added that there have been some reports linking smoking with increased blood flow to the brain. “There is a possible reduction in the levels of apoptosis; however, smoking has been linked to macular degeneration and cataracts. It is important to stress that when adjusted for IOP level, there does not appear to be an increased risk of glaucoma linked with cigarette smoking at this time,” he said.
The relationship between diet and glaucoma is quite complex, said Dr Tsai, although at least one published paper has suggested that the ratio of omega-3 fats to omega-6 polyunsaturated fats might be important. This study reported that a diet favouring omega-6 fats, which include corn, sunflower and safflower oils, relative to omega-3 fats in flaxseed, canola and soy oils was associated with a reduced risk of primary open angle glaucoma. There is also some evidence to support the idea of dietary approaches influencing vascular regulation and blood flow to the eye, said Dr Tsai. “Antioxidants such as those found in ginkgo biloba, and polyphenolic flavenoids found in tea, coffee and red wine may reduce the extent of mitochondrial oxidative stress. In terms of supplements, ginkgo biloba in particular has been studied as a potential neuroprotective
agent with possible blood flow effects. One study showed a short-term visual field improvement in patients with normal tension glaucoma taking ginkgo. For other antioxidants, there does not appear to be any effect on the risk of open angle glaucoma,” he said. Dr Tsai also stressed the role of the cardiovascular system, which is heavily lifestyle influenced, in glaucoma development and progression. “We know that there may be potential vascular risk factors in glaucoma and one of the proposed ideas is that influencing ocular circulation may be beneficial for the disease process. In certain patients there appears to be abnormal auto-regulatory responses to changes in ocular perfusion pressure in play,” he said. Studies such as the Barbados Eye Study have reported that lower systolic blood pressure and lower ocular systolic, diastolic and mean perfusion pressures were all associated with an increased risk of developing glaucoma, said Dr Tsai. Another landmark study, the Early Manifest Glaucoma Trial, showed that lower ocular systolic perfusion pressure and cardiovascular history in patients with higher baseline IOPs, as well as lower systolic blood pressure in patients with lower baseline IOPs, were associated with increased progression of glaucoma.
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Encapsulated cell therapy delivers nerve growth factors
Credit: UCSD School of Medicine
by Sean Henahan in La Jolla
atients with advanced geographic atrophy associated with nonneovascular age-related macular degeneration (AMD) showed promising visual improvements when treated with an innovative approach known as encapsulated cell therapy that delivers neurotrophic factors to the back of the eye. In a recent multicentre phase II clinical trial patients were implanted with a small capsule designed to release a steady stream of ciliary neurotrophic factor for at least one year. The design of the device, known as NT-501, is such that the implant can do its work without antibodies and immune cells attacking it, Kang Zhang MD, PhD, professor of ophthalmology and human genetics at the UCSD School of Medicine, and director of UCSD’s Institute of Genomic Medicine, told EuroTimes. “The study findings are very promising since both structural and functional improvements were demonstrated in a disease that is currently untreatable. These results support the initiation of larger confirmatory studies of NT-501 in patients with geographic atrophy,” noted Dr Zhang, lead author of the study. The intraocular implant device used in the study consists of human cells genetically modified to secrete ciliary neurotrophic factor (CNTF), a nerve growth factor capable of rescuing and protecting dying photoreceptors. It is a relatively simple surgical procedure, implanting the device via pars plana vitrectomy to position in the pars plana, and securing it with a single suture. It is placed outside of the main visual axis, he explained. The 51 study participants were divided into three groups. One group received a high dose CNTF implant, another group received a low dose, and the third underwent sham surgery with no active drug. The study results, reported recently in the Proceedings of the National Academy of Science (PNAS), showed a dose-dependent increase in retinal thickness suggesting increased photoreceptor metabolic activity. This increase was followed by visual acuity stabilisation (loss of fewer than three lines of vision, or 15 letters) of 96.3 per cent in the high-dose group compared to 83.3 per cent in the low-dose group and 75.0 per cent in the sham group.
EUROTIMES | Volume 17 | Issue 2
“It’s a big step forward. It means we can generate stable, renewable neural stem cells or downstream products quickly, in great quantities and in a clinical grade – millions in less than a week – that can be used for clinical trials and, eventually, for clinical treatments”
Stained mature neurons, derived from precursor cells, expressing the neurotransmitter dopamine Credit: UCSD School of Medicine
Researchers measured retinal thickening using time domain optical coherence tomography. They measured lesion size using fundus photography. Patients in the high-dose group showed retinal thickening as early as four months after receiving the implant. A sub-group analysis indicated that patients who began the trial with visual acuity of 20/63 or better tended to have better visual outcomes. All of the patients in the high-dose group maintained visual acuity stabilisation at one year, compared to 55.6 per cent of those in the combined lowand sham-treated groups. Patients receiving the high-dose had a 0.8 mean letter gain compared to a 9.7 mean letter loss in the combined low- and sham-treated groups.
“This makes sense, because if all the cells are gone there is no way for you to actually protect the cells. This approach will have more success with the cells that are near dying where you are able to keep them alive, and ultimately provide better vision,” he told EuroTimes. Additional data was presented at the recent ARVO meeting by Glenn Jaffe MD and colleagues, Duke University Eye Centre, Durham North Carolina, US. Eighteen-month data from the multicentre trial showed very similar results to those reported by Dr Zhang and colleagues, with lasting retinal thickening and stabilisation of vision in the high-dose patient group. The device appeared to be safe and well tolerated with no reports of serious adverse
Image showing geographic atrophy (GA)
events associated with the implant or implantation procedure. A few patients required explantation of the device. This gave the investigators a chance to check the patency of NT-501 device. These evaluations confirmed that the devices continued to show healthy cells and stable CNTF output for up to 12 months. In another recent study (Investigative Ophthalmology & Visual Science April, 2011, Vol. 52), researchers reported promising findings with NT-501 in patients with retinitis pigmentosa. The implant provided statistically significant cone photoreceptor preservation in two patients with retinitis pigmentosa and one patient with Usher syndrome. That study used adaptive optics scanning laser ophthalmoscopy to image and measure the rate of the progressive degeneration of cone photoreceptors.
Stem cell breakthrough Dr Zhang noted that he was also very excited about recent work in his lab on the creation of long-term, self-renewing, primitive neural precursor cells from human embryonic stem cells. In another study published recently in the Proceedings of the National Academy of Sciences, Dr Zhang and colleagues reported they had developed a relatively straightforward way to create these stem cells without any increased risk of tumour formation. “It’s a big step forward. It means we can generate stable, renewable neural stem cells or downstream products quickly, in great quantities and in a clinical grade – millions in less than a week – that can be used for clinical trials and, eventually, for clinical treatments. Until now, that has not been possible,” Dr Zhang emphasised. He told EuroTimes that research is already under way in his lab to develop an array of neural cells. On the ophthalmic front, this could lead to new approaches to the treatment of AMD, retinitis pigmentosa and glaucoma. Developing lines of motor neuron cells would open the way to new treatments for a host of neurological disease including Lou Gehrig’s disease (ALS), and Parkinson’s disease, he said.
Impressive visual acuity gains and prevention of moderate vision loss with ranibizumab by Cheryl Guttman Krader in Fort Lauderdale
nti-VEGF treatment for clinically significant diabetic macular oedema with intravitreal ranibizumab (Lucentis, Genentech) provides a rapid and robust increase in visual acuity that is sustained for 24 months with monthly injections, reported David M Brown MD (The Methodist Hospital, Houston, Texas), at the annual meeting of the Association for Research in Vision and Ophthalmology. Dr Brown reviewed the results from the RISE and RIDE trials that randomised 377 and 382 patients, respectively, to monthly intravitreal injections with ranibizumab 0.3mg, 0.5mg, or sham. Ranibizumab treatment at both doses produced statistically significant increases of three or more lines of BCVA at month 24 in both studies. Ranibizumab’s benefit for improving visual acuity was already seen at the first followup visit at one week when patients in all ranibizumab groups achieved a mean BCVA gain of more than one line. A statistically significant difference compared with sham persisted at all monthly evaluations. Ranibizumab treatment also reduced the rate of significant BCVA loss (≥3 lines) to less than five per cent in all arms. The functional benefits corresponded with anatomic improvements in macular thickness and resolution of fluorescein leakage. The ocular safety of intravitreal ranibizumab was consistent with prior Phase III studies for treatment of exudative agerelated macular degeneration (AMD) and retinal vein occlusion. There were no new significant systemic safety findings, although there were a few more strokes among patients treated with ranibizumab 0.5mg, and a few more deaths in the pooled ranibizumab groups compared with controls. “Since the results of the Early Treatment Diabetic Retinopathy Study (ETDRS) were published in 1985, photocoagulation has been the standard of care for DME, and photocoagulation became the standard because it significantly reduced the risk of loss of three or more lines of BCVA and not because of its improved visual acuity. This type of functional loss is what causes patients to stop working, and photocoagulation reduced its incidence by more than half to just 10 per cent,” commented Dr Brown, who was a Phase III study investigator and is a vitreoretinal specialist in private practice. EUROTIMES | Volume 17 | Issue 2
“With ranibizumab treatment, we are seeing a further significant reduction in the rate of moderate vision loss in eyes with clinically significant DME for the first time since 1985.” Dr Brown said the pivotal studies are not powered to detect significant differences between groups in systemic adverse events potentially related to VEGF. “However, it is important to look carefully at this issue because patients being treated for diabetic retinopathy are relatively sick. Rates of serious adverse events were low in all groups, and we hope that the small increase in cases of stroke and death among ranibizumabtreated patients are related to chance.” The RISE and RIDE trials enrolled patients with central subfield thickness ≥275 microns and ETDRS BCVA between 20/40 and 20/320 in the study eye. The treatment groups in the two studies were well matched at baseline. Patients averaged 60 years of age and had diabetes for about 15 years. Baseline VA averaged around 20/80 and mean centre point thickness was about 440 to 480 microns across the groups. About two-thirds of patients had prior focal/grid laser treatment and in the two studies, about one-fourth to one-third received intraocular steroid. At 24 months, mean BCVA improvement exceeded two lines in all ranibizumab groups compared with less than three letters in the control groups. Rates of BCVA loss of three lines or more were 2.4 per cent for both ranibizumab arms and 10 per cent for the controls in RISE, and 1.6 per cent, 3.9 per cent, and 8.5 per cent, respectively, for the ranibizumab 0.3mg, 0.5mg and sham groups in RIDE. The benefit of ranibizumab treatment corresponded with anatomic improvement and was achieved with much lower rates of laser treatment. Centre point thickness decreased rapidly and immediately in the ranibizumab arms and only gradually decreased over time in the control group. Overall, the ranibizumab-treated eyes achieved about a 250 micron reduction in centre point thickness at 24 months versus 133 microns in the control group. All patients were eligible for focal laser treatment beginning at month three if centre point thickness was greater than 250 microns and the investigator thought the treatment could be beneficial.
David Brown – email@example.com
Vitrectomy in diabetic eyes with advanced retinopathy is difficult but possible
by Roibeard O’hEineachain in London
2nd world congress of paediatric ophthalmology and strabismus 7-9 september 2012 www.wcpos.org CALL FOR PAPERS DEADLINE: 29 FEBRUARY 2012
EUROTIMES | Volume 17 | Issue 2
here are numerous conditions that can make diabetic vitrectomy a nightmare, but modern vitreoretinal surgery offers approaches that can overcome many of the difficulties those situations present, according to Philip J Ferrone MD, Great Neck, New York, US. Vitrectomy in the case of a simple diabetic vitreous haemorrhage is generally fairly straightforward, he noted. However, some eyes will have co-morbidities and anatomical characteristics that can necessitate a more complex procedure, Dr Ferrone said. The problematic conditions occur in the anterior and posterior segment. The main problem they create is in the visualisation of the retina and vitreous. Problems in the anterior segment include neovascularisation of the iris, with or without blood in the anterior chamber, small pupils, dense cataracts and dense retrolenticular blood, Dr Ferrone said. In the posterior segment the nightmare conditions include dense organised old vitreous haemorrhage, high traction retinal detachments, dense pre-retinal plaques, thin, avascular atrophic retina, and, worst of all, combined rhegmatogenous/tractional retinal detachment, he noted. In cases where there is blood in the anterior chamber, a two-needle washout technique is generally sufficient. However, if the lens is not clear, cataract extraction may also be necessary, he noted. In mild-to-moderate diabetic retinopathy, phacoemulsification and implantation of a posterior chamber IOL will generally produce satisfactory results. However, in the worst cases, it is necessary to clean out all vitreous gel to prevent the risk of anterior hyaloidal proliferation, he explained. “Wide-field viewing optimises visualisation for moderately bad lens opacities and makes intraoperative combined cataract removal less common,” Dr Ferrone said. Regarding retrolenticular haemorrhages, Dr Ferrone noted that it is generally possible to remove them when shaving the vitreous base. The vitreous base gel stabilises the haemorrhage. He added that dense vitreous haemorrhages are not the challenge they once were, thanks to the advent of high-speed vitreous cutters available today, including 25-gauge devices. There are several strategies for preventing intraoperative bleeding in eyes with active
proliferative diabetic retinopathy. First of all, patients should ideally be taken off any anticoagulation or antiplatelet drugs if possible. Where that is impossible, because of the risk of cardiovascular or cerebrovascular events, raising the IOP can reduce the bleeding to some degree, he noted. Valved cannulas are helpful in this instance, Dr Ferrone said. In addition, the surgeon can perform intraocular cautery with either a single function or multiple function instruments. There is also the more modern approach of injecting the anti-VEGF agent bevacizumab (Avastin, Genentech/Roche) three to 10 days prior to surgery. “Avastin is our best weapon against intraoperative bleeding,” he said. Another set of situations that can create serious difficulties for the vitreoretinal surgeon are posterior cortical vitreous adhesions. Their location can vary and they may be present around the fovea, along the vascular arcades, in the peripapillary area, and in the mid-peripheral area. Dr Ferrone noted that eyes with broadly adhered and diffuse adhesions typically have atrophic retinas and most only require treatment with a high-speed mechanical vitrector with suction with no need for scissors. The surgeon can use a bimanual technique. A bimanual technique is also an option when performing vitrectomy in eyes with broadly adhered posterior cortical vitreous with multiple, focal cellular pegs. For the focal adhesions with broad fibrin and cellular plaques, a high-speed vitrector can isolate the plaques, but a pair of curved scissors may be necessary to gently separate the plaques from the retina, he said. In eyes with combined tractional/ rhegmatogenous retinal detachments arising from proliferative diabetic retinopathy, valved cannulas are particularly helpful, as is triamcinolone for visualising the vitreous. In addition, using perfluorocarbon liquid as a third hand can make some of the more difficult manoeuvres easier. Scleral buckling is helpful if there are peripheral breaks, and silicone oil can be used as well in worst cases, Dr Ferrone continued. He concluded his presentation by stressing that the best way to mange nightmare diabetic situations is prevention.
Philip J Ferrone – firstname.lastname@example.org
Lyndsey Rice – email@example.com Allan Thompson – firstname.lastname@example.org
ORBIS AND OXFAM
Society raises €33,500 and pledges support for further two years
Oxfam in Uganda The donation to Oxfam is supporting a public health project in the Kitgum and Lamwo Districts of Uganda which will provide safe water and sanitation, and so contribute to improved health and education in both communities. “Oxfam has continued to strengthen the services provided by local government and build the self-reliance of households who returned to their villages after the two-decade conflict ended. There is still a significant amount of work to do, but the region feels to be truly in a development, rather than a humanitarian or recovery, context,” said Lyndsey Rice of Oxfam. She
ORBIS/Oxfam support-team at ESCRS Vienna
EUROTIMES | Volume 17 | Issue 2
“Charitable initiatives are very important for the society and our support of Oxfam and ORBIS has been very rewarding” also thanked ESCRS members and the ESCRS Board for their continuing support of the programme. The money raised by ESCRS will help Oxfam support district water officers who will assess, train and certify a cadre of 150 hand pump mechanics. This will help ensure communities have access to prompt, reliable and affordable maintenance and repair services. A District Water Quality Laboratory, including a motorcycle, will also be provided so that samples can be taken and analysed from water sources throughout Kitgum and Lamwo.
Courtesy of ORBIS
Peter Barry, president of the ESCRS
ORBIS: Dr Mulusew Asferaw (who is the ophthalmologist who will be trained on paediatric ophthalmology with the money raised through the ESCRS partnership) doing some initial paediatric examinations at the new hospital
ORBIS in Gondar The money raised for ORBIS is assisting the organisation to provide specialist training in paediatric ophthalmology for Dr Mulusew Asferaw at the Paediatric Ophthalmology Department at the Gondar Referral Hospital in Ethiopia. Additionally Dr Fisseha Admassu has been selected for Glaucoma training. ORBIS has committed to work with Gondar University Hospital to establish a Child Eye Health Tertiary Facility (CEHTF) for North West Ethiopia. “This will provide children with access to high-quality eye care, which in turn will contribute to a decrease in childhood blindness and low vision in North West Ethiopia,” Allan Thompson of ORBIS told EuroTimes. “The money raised by ESCRS has helped us to recruit and train doctors from the region to work on the project, so thank you so much to all ESCRS members for making this possible” said Mr Thompson, “and we are delighted to announce the commencement of the training programme with Dr Asferaw and Dr Admassu.” n
For further information visit: www.escrs.org/Charitable-Donations/
Courtesy of Oxfam
he president of the ESCRS, Peter Barry, has pledged to continue the society’s support for the fundraising projects organised by ORBIS and Oxfam. “Charitable initiatives are very important for the society and our support of Oxfam and ORBIS has been very rewarding,” said Dr Barry. “I am delighted to announce our continuing support for the ORBIS and Oxfam projects for a further two years. A total of €33,500 was donated to the two charities in 2011. Funds were initially raised from delegates when registering for the 15th ESCRS Winter Meeting in Istanbul, Turkey and the XXIX ESCRS Congress in Vienna, Austria. Additional funds were raised from a raffle at the Vienna congress. The ESCRS Board also pledged to donate an additional €25,000 from the society’s funds. The amount donated to each charity in 2011 was €16,750 and new activities are already being planned for 2012.
Oxfam: Water being collected from a water kiosk – part of the motorised water system in Padibe East Sub-County
Eye on technology
GLUED ENDOCAPSULAR HEMI-RING
New intraocular device for fibrin glue-assisted sutureless fixation of the capsular bag to the scleral wall by Soosan Jacob MD
Courtesy of Soosan Jacob MD
Figure 1: The Glued Endocapsular hemi-ring (Glued ECHR) segment is seen. It is made of polyvinylidenefluoride and has two arms, a double scroll locking mechanism and a haptic
Figure 2: Glued ECHR segment implantation in an intraoperative subluxation: 2A: An intraoperative subluxation is seen. The capsular bag fornix is seen prolapsed into the anterior chamber (see arrows); 2B: A partial thickness scleral flap is made in the zone of dialysis and a sclerotomy is made with a 20-gauge needle; 2C: The tip of the haptic of the glued ECHR segment is grabbed with an MST forceps and exteriorised through the sclerotomy while the rest of it is flexed in using a fishtailing technique;
2D: The arms of the segment are inserted under the rhexis while the double scroll mechanism engages the capsulorhexis rim
large amount of effort has gone into the development of devices and techniques with which to manage subluxated cataracts and IOLs. Before any discussion on this topic, it is necessary to acknowledge the work of those innovators who have contributed so much. The endocapsular ring, introduced by Drs Hara and Nagamoto & Bissen-Miyajima, and further popularised by Leglen, revolutionised subluxated cataract surgery by EUROTIMES | Volume 17 | Issue 2
providing a mechanism for achieving capsular forniceal expansion. This was further modified by Drs Henderson, Nishi & Menapace and Burkhardt Dick. Subsequently, suture fixation of the capsular tension ring was described by Drs Cionni and Osher and made possible scleral anchorage of the capsular bag in larger subluxations. Scleral sutured segments were described by Drs Ike, Assia, Yaguchi. For larger as well as progressive subluxations, the glued IOL technique was described by Prof Agarwal.
New device I would now like to describe a new intraocular device â€“ the glued endocapsular hemi-ring (ECHR) segment for fibrin glue-assisted sutureless fixation of the capsular bag to the scleral wall. This is a new device to stabilise the capsular bag intraand postoperatively (Figure 1). It is made of polyvinylidene fluoride (PVDF) which is a popular material used for manufacturing IOL haptics and hence is known to be biocompatible within the eye. We also chose PVDF over other materials because of its superior memory and better shape retaining abilities. It is designed to have two arms that sit in the capsular fornix and expand the fornix, a double scroll locking mechanism for engaging the rim of the rhexis and a haptic that is exteriorised out through a sclerotomy (made under a lamellar scleral flap in the zone of subluxation) and tucked into a scleral tunnel. The arms of the segment extend about two quadrants in arc length and hence, despite being a segment and not a full ring, it provides equatorial expansion of the capsule as well. The double scroll mechanism anchors the capsule via the haptic to the scleral wall without the use of any sutures. Surgery involves creating a lamellar scleral flap in the area of subluxation. A sclerotomy is made under the flap with a 20-gauge needle, taking care not to damage the lens capsule (Figure 2A, B). This can be easily done by creating space between the iris and the anterior capsule with a cohesive viscoelastic. Capsulorhexis, hydro-dissection and hydro-delineation are then performed. An end gripping forceps introduced through the sclerotomy then grasps the haptic tip using the handshake technique. The device is then single-handedly inserted using Little's fishtailing technique into the anterior chamber while simultaneously exteriorising the haptic through the sclerotomy (Figure 2C). The arms are inserted under the rhexis margin using
12th EURETINA Congress
Figure 3: Glued ECHR segment implantation in an intraoperative subluxation 3A: The haptic is cut to the desired length and tucked into a scleral tunnel made with a 26-gauge needle at the edge of the scleral flap for adequate centration and support of the bag; 3B: Phacoemulsification and cortex aspiration are carried out as usual; 3C: Post-implantation, the good centration of the IOL can be appreciated; 3D: Fibrin glue is used to seal the flap and the conjunctiva
the microforceps and the double scrolls are made to engage the rhexis rim (Figure 2D). At this point, pulling on the haptic centres the entire capsular bag complex. After cutting the haptic to the desired length in order to get an adequate tuck, it is tucked into a 26-gauge tunnel made at the edge of the scleral flap (Figure 3A). The rest of the phacoemulsification is then performed as usual followed by IOL implantation (Figure 3B, C). The degree of centration of the bagIOL complex is once again verified and if not satisfactory is readjusted by adjusting the tuck of the haptic until good centration is achieved. The scleral flap is then glued down using fibrin glue (Figure 3D), which creates a hermetic seal around the haptic. The same technique can also be similarly used for subluxated IOLs after opening up the bag by injecting viscoelastic.
Double scroll mechanism The double scroll mechanism used in the device is similar to the single scroll pupil engaging mechanism used in the Malyugin ring which is made of prolene. Tucking of the haptic of the device is similar to the intra-scleral tuck of haptic that is used in the glued IOL technique and the Scharioth intrascleral haptic tuck. Experience with both these techniques has shown absence of any significant long-term complications of an intra-sclerally tucked haptic. The scleral flap and fibrin glue closure has also been used since 2007 for the glued IOL technique with no significant postoperative complications. The advantages of the glued ECHR segment includes ease and rapidity of surgery. It does away with the use of sutures and difficult-to-manoeuvre long and thin needles that are used for sutured scleral fixation of endocapsular rings. At the same time, it gets rid of all suture related complications such as suture erosion, degradation, knot loosening or slippage EUROTIMES | Volume 17 | Issue 2
etc. There has been a shift to the use of 9-0 prolene or Gortex for the use of sclerally sutured IOLs and endocapsular rings with the assumption that 9-0 sutures are less likely to degrade over time than 10-0. The glued endocapsular hemi-ring segment being of the same gauge as IOL haptics provides sturdier and more robust fixation to the scleral wall. The device is flexible and is therefore easy to insert. It also has good memory and so re-expands within the anterior chamber. In our experience, implantation of these segments was more surgeon friendly than suturing a ring to the sclera. Intra-operative adjustability is easy and simply involves adjusting the degree of tuck of the haptic into the scleral tunnel. As the haptic of the device is exteriorised out from the sclerotomy at the very beginning of surgery, there are less chances of dropping the device accidentally into the vitreous. It provides adequate fixation of the bag complex to the scleral wall and hence initial stabilisation of the bag with capsular hooks for the sake of stability is not required. We also felt that there was less pseudophakodonesis as compared to suture fixation of capsular bag, as it is a part of the device per se that carries outwards through the sclerotomy to get anchored to the sclera unlike in suture fixation where it is the suture that suspends the capsular bag complex to the scleral wall. This device not only provides centrifugal expansion of the capsular equator but also anchors the bag to the scleral wall giving vertical and horizontal stability intra-operatively as well as postoperatively. This device was designed by Dr Soosan Jacob (senior consultant, Dr Agarwal's Group of Eye Hospitals, Chennai, India) and is manufactured by Mateen Amin (Epsilon, USA).
6-9 September 2012
for further information visit: www.euretina.org
Abstract Submission Deadline:
15 February 2012
ESCRS FUNDS CME STUDY
Study at University Eye Clinic Maastricht, the Netherlands, will seek to answer critical questions relating to cystoid macular edema by Dermot McGrath in Paris
potentially groundbreaking European multicentre, randomised study to be funded by the ESCRS could help to transform the current clinical management of cystoid macular edema (CME). The PREvention of Macular Edema after cataract surgery (PREMED) study, a proposal by the University Eye Clinic Maastricht, the Netherlands, under the supervision of Rudy Nuijts MD, PhD, has been approved for a substantial grant by the ESCRS. “It is an exciting development and we are very proud that our proposal was selected by the External Review Committee and the Research Committee of the ESCRS as one of the studies that has the potential to be of real benefit to our patients,” said Dr Nuijts, co-author of the study proposal together with clinical epidemiologist and medical retina specialist Dr Jan S A G Schouten and health economist Dr Frank J H M van den Biggelaar. Dr Nuijts said that the study will seek to answer some critical questions relating to CME. “Cystoid macular edema remains a significant problem in cataract patients and especially in the diabetic population where the incidence in cataract surgery can be as high as 31per cent. So the hope is that this study will give us more definite
evidence-based recommendations for clinical guidelines to prevent the occurrence of CME after cataract surgery in patients with and without diabetes,” he said. Dr Nuijts said that funding such a landmark study would also serve to reinforce the ESCRS’s core mission to serve the interests of its members and ophthalmology in general. “We know from the excellent work accomplished by Peter Barry with the Endophthalmitis Study some years back of the importance of being able to conduct large-scale, randomised trials that study different treatment regimes and can give answers to the questions that concern us all in our day-to-day clinical practice. So it is important for us as researchers that we receive funding and that we have the confidence of the ESCRS, but it is also important for the ESCRS to perform another landmark study and to show the world that the resources of the ESCRS are being used for primary research for the benefit of all of its members in Europe and around the world,” he said. Dr Nuijts noted that while CME is a common cause of vision loss after cataract surgery, there has to date been no randomised controlled clinical trial comparing all the currently existing interventions and to investigate whether combining treatments may have an additional effect.
It is an exciting development and we are very proud that our proposal was selected... Rudy Nuijts MD, PhD
The aim, said Dr Nuijts, would be to enrol around 2,400 patients without diabetes mellitus and 650 patients with diabetes mellitus who require cataract surgery in at least one eye. In all groups of the non-diabetic and diabetic population phacoemulsification will be performed with an intracameral cefuroxime injection and postoperative administration of topical betamethason for four weeks and topical levofloxacin for six days. Two preventive strategies in the nondiabetic population will be studied, said Dr Nuits. Firstly, a subtenon triamcinolone injection, followed by a postoperative course of topical corticosteroids and antibiotics. The second group of patients will receive a subtenon triamcinolone injection, with no topical corticosteroids or antibiotics administered postoperatively.
Rudy Nuijts – email@example.com
In the diabetic population the control group will receive postoperative administration of topical NSAID and corticosteroid and four preventive strategies will be evaluated: Firstly, subtenon triamcinolone injection, followed by postoperative topical corticosteroids and antibiotics; secondly, intravitreal bevacizumab injection with postoperative topical corticosteroids and antibiotics. The third group will include patients treated with a subtenon triamcinolone injection and an intravitreal bevacizumab injection, followed by postoperative topical corticosteroids and antibiotics. The final group will be treated with an intravitreal triamcinolone injection and an intravitreal bevacizumab injection, followed by postoperative topical corticosteroids and antibiotics. The duration of the study will be 36 months, said Dr Nuijts, at the end of which the researchers hope to have a much clearer picture as to the optimum treatment regimen for cataract patients with and without diabetes mellitus. “Most surgeons in Europe are still using a combinations of non-steroidal antiinflammatory drugs (NSAIDS) together with topical steroids. The question is, of course, for how long and how often we can administer these treatments and to determine if we could be successful giving only one subconjunctival injection of triamcinolone ideally at the time of the surgery and thereby decreasing the problem of compliance. We know this is a significant problem in the older patient population because they have to use the drops every day, mostly for three to four weeks in most cases. So if we could bring that back to a single injection at the time of surgery, this would have a great advantage and could prove very costeffective as well,” he said.
Journal Watch Test distinguishes NMO from MS Research immunologists have developed an antibody test that will allow clinicians to distinguish between neuromyelitis optica (NMO) and multiple sclerosis, a disease with which it is often confused. A group of researchers from the Mayo Clinic in the US and the University of Tübingen in Germany built on earlier research on the role of aquaporin-4 water channel, an essential component of the central nervous system. They determined that an antibody associated with NMO affects two forms of the aquaporin-4 water channel: M1 and M23. The M1 channel more readily escapes from antibodies, but antibody binding to M23 causes aggregation of M23 on the astrocyte surface, which amplifies cell damage. The investigators determined that the NMO antibody targets astrocytes, which are 10 times more numerous in the brain and spinal cord than neurons. In addition to providing nutrients to neurons and supporting the repair and scarring process, other critical functions of astrocytes include regulation of tissue water and electrical activities of neurons, and the stabilising myelin. By attacking the water channels on astrocytes, the antibody disrupts all related dynamic functions of the astrocyte and in acute attacks kills many astrocytes. When the antibody interferes with the transfer of water in the brain, water accumulates in the myelin sheath, preventing rapid transmission of nerve messages, causing breakdown of myelin, a traditional hallmark of multiple sclerosis, thus contributing to the diagnostic confusion. NMO is an inflammatory autoimmune disease of the central nervous system that damages the optic nerves and spinal cord. It has similar symptoms to multiple sclerosis including vision loss, weakness, numbness, arm and leg paralysis and loss of bowel and bladder control. The antibody test has made it clear that NMO is more common than previously thought. The researchers hope the research will point the way to effective therapies. n SR Hinson et al., Proceedings of the National Academy of Sciences, “Molecular outcomes of neuromyelitis optica (NMO)-IgG binding to aquaporin-4 in astrocytes”, published online ahead of print, doi:10.1073/pnas.1109980108. EUROTIMES | Volume 17 | Issue 2
EXCITING TIMES School launches new website and has very busy programme planned for 2012 by Dr Giuseppe Guarnaccia
his will be a very exciting year for ESASO and I would like to take this opportunity to outline some of the ambitious projects we have planned for 2012. The very good news for faculty and students at the school is that we have redeveloped our website to make it more attractive to visitors and also easier to navigate. Everything you want to know about ESASO is at: www.esaso.org, so make sure to keep up to date by visiting the site on a regular basis.
By the time you read this article students will have had the privilege of attending our first module in Plastic Surgery which was held from 30 January to 3 February 2012, in Valetta, Malta, under the guidance of Dr Ramon Medel. This module gave students the opportunity of learning the basic theoretical knowledge in eyelid, orbital and lacrimal surgery, together with practical work on cadaver dissection and we look forward to organising more courses in this exciting area in the future. Our second module in Cornea and Corneal Refractive Surgery takes place from 6 February to 10 February 2012, in Lugano, Switzerland where students will get the chance to study important topics such as femtosecond and excimer laser for corneal refractive surgery, corneal evaluation techniques: topography, biomechanics and IOL power calculation in difficult cases. Module Three is in Medical Retina and this will be held in Lugano from 4 to 8 June. We have a very exciting programme with topics including OCT Imaging CNV, current protocols of treatment for wet AMD and Retinal Vein Occlusion before treatment. Our fourth module is in Surgical Retina and takes place from 11 to 15 June in Lugano. This module includes courses on indications for vitreous surgery, intraocular tamponades and surgical management of retinal tractional detachment in DR. The fifth module will be held on Cataract and Intraocular Refractive Surgery in early September 2012. More information to follow soon. n
For more information on all of these modules visit: http://www.esaso.org/ programme-2012.
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By the time you read this article students will have had the privilege of attending our first module in Plastic Surgery... Giuseppe Guarnaccia
Fellowships It is also important to note that ophthalmologists who complete five ESASO modules receive the Diploma of Specialist Superior in Ophthalmology (DiSSO) and the opportunity to reach a higher level of specialisation. The ESASO Fellowship is a full year advanced specialist training programme in which the recipient can acquire a thorough, in-depth understanding of the specific subject and, accordingly, proficiency in the exercise of the clinical-surgical profession in renowned clinics with leaders in ophthalmology. Information on the Fellowship Programme is available at: http://www.esaso.org/esaso-fellowships. Meetings I would also like to draw your attention to two major meetings which we will hold later this year. On 5-6 October we will be holding a live surgery symposium on “New Trends in Anterior Segment Surgery” in Lugano. We will be showing 8-10 surgeries and discussing new surgical strategies in the management of keratoconus, as well as new phakic and pseudophakic IOLs. Secondly, we will look forward to the 12th International AMD and Retina Congress which will be held in Prague, Czech Republic from 2-3 November. As you can see we have a very busy schedule so make sure to keep informed by visiting www.esaso.org and also through our electronic newsletter eFOCUS which we will be sending out bi-monthly. You can register for it through the ESASO website. n Dr
Giuseppe Guarnaccia is global executive director of the ESASO.
contact Gabriella Skala – firstname.lastname@example.org ES_19-11 ESASO_Anz_120x300_Career_RZ.indd 1
7.12.2011 12:24:51 Uhr
Bearing the responsibility on call in the early hours by Leigh Spielberg
t’s my first night on call alone in the emergency room of the country’s largest eye hospital. There is no one to help out. No in-house supervisors, no senior residents and no “yonkies” – Dutch for “young ones,” in this case other first-year residents – with whom to discuss difficult cases. Behind me in the night ER sits a veteran secretary who registers patients and helps with triage. Upstairs on the ward are a few nurses who are ready to rinse the eyes of caustic trauma patients but are otherwise busy taking care of inpatients. The senior staff members are a phone call away, but at this point I still consider calling as a lastresort option. It’s barely 5pm, I’ve just started and the waiting room is already half full. I’m a little nervous and I haven’t yet slipped into the comfortable, repetitive rhythm that I’m able to develop during normal clinic hours: “Hi, hello, I’m Dr Spielberg – please come in – take a seat – how can I help you? Red eyes – pain – decreased vision – since when? Flashes & floaters? Right. Can you read those letters on the wall? Good, now let’s take a look at your eyes. Here’s an anaesthetic drop – it might sting a bit – look at the blue light – you
won’t feel a thing. OK, pressure’s good. Here comes a dilating drop – you might see a bit blurry – yep, lasts a few hours – see you in 20 minutes. Next!” Nope, right now I can’t even seem to figure out how to use the equipment, which is for whatever reason not the same as the units we use in the daytime clinic. The buttons are all in different places and the patient’s chair goes up instead of down, the lights dim inappropriately and the table jerkily locks at a weird angle. The patient looks at me and probably wonders whether I’m just a random guy who wandered in off the street, pulled on a white coat and started playing jokes on patients. Hidden camera, maybe? But forget about the equipment. That’ll work itself out just fine. What I’m really trying to get used to is the unprecedented feeling of responsibility that I’m now experiencing. Tonight is the first time in my medical career that my own decisions will have actual consequences. The patients in the waiting room have likely heard that our eye hospital is highly specialised in eye disease. Their family members come here for checkups and their friends have been operated here. They have read about the hospital
in the local paper or have seen the recent Rotterdam Eye Hospital documentary in the movie theatre. The name says it all. What they don’t know is that the primary decision-maker for the next 16 hours is a first-year resident. Sure, he has studied a big book on the topic, passed a few tests and has managed what must be several thousand patients by now, under the close supervision of the attendings. But to sit there before a patient and say, “Sir, something has blocked the main artery leading into your right eye. The visual prognosis is not good,” is not easy. People are coming to me for their eye problems, but who am I to say this to someone? Am I really qualified for this?
The conversation goes well enough and the patient seems to understand what has happened. He also seems to understand the limited treatment options: yes, I’m sure it’s not cataract; no, sorry, but laser surgery is not useful for arterial occlusions; no, there are no eye drops for this condition; no, glasses won’t help – as well as the follow-up protocol he has been advised to follow. We will see the patient a few more times and during that time he will gradually get used to the dramatic loss of visual acuity. I hope that I have done everything possible to get him psychologically ready for this process. The onset of blindness, even if only unilaterally, is a difficult thing to accept, and I keep in mind what the poet John Milton said: “To be blind is not miserable; not to be able to bear blindness, that is miserable.” Fortunately, this patient is not bilaterally blind, and I would like to keep it that way while allowing him to be able to bear the unilateral near-blindness he has developed. The next several patients present with simple pathologies before someone with what looks like post-op endophthalmitis sits down in my examining chair. After just one night on call, I feel as though I’ve somehow been initiated into a new order. I have developed a totally different perspective on my role as a physician. No longer am I just an evaluator, an observer, a preliminary examiner waiting for the supervisor to help make a final decision. I am now the one who is making the decisions and actively managing patients – at least within the bounds of my abilities. n Leigh Spielberg is an ophthalmology resident at the Rotterdam Eye Hospital in the Netherlands.
Big Challenge Making the diagnosis of a central retinal artery occlusion in a patient with sudden, painless loss of vision, a pale fundus, a cherry-red fovea and significant cardiovascular risk factors is not a big challenge. Telling someone you’ve just met that they will likely no longer have functional use of one eye, that is another thing entirely. Most people would be startled by these words alone, not to mention the further discussion regarding the necessity of further cardiovascular screening, the sweeping lifestyle changes and the possibility of daily anticoagulant therapy to avoid even more devastating occlusive events. Wow! And all this news coming from someone who has seen maybe three CRAOs in real life before. It is often said that the transformation from “student” to “doctor” via “resident” is a mostly gradual evolution. If that’s true, then this must be the big moment when the asteroid hits the Earth and changes everything.
SIR ERIC ARNOTT 1929-2011
Emanuel Rosen pays tribute to the late Eric Arnott, a ‘generous and inspiring colleague’
rof Eric Arnott died peacefully at his home in Hampshire, UK, on December 1, 2011. He is credited with bringing modern cataract surgery to Europe and trained under most of the famous British ophthalmologists of his day, including Sir Harold Ridley and Sir Stewart Duke-Elder. In 1971, he became the first physician outside the US to take the phaco course offered by Charles Kelman MD, in New York. That year he also bought a phaco machine and brought it to London. Later that year he performed the first phaco procedure outside of the US at Charing Cross Hospital.
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In 1974, he developed his own phaco course. He went on to design and patent a number of intraocular lenses and surgical instruments that gained international acceptance, including the first one-piece PMMA lens with flexible haptics. Emanuel Rosen, chairman of the ESCRS Publications Committee, said he was a man who was well ahead of his time and his peers. “He was the first UK surgeon to practise Phaco surgery and held courses to train others including myself in 1977 but adoption of phaco surgery in the UK took another 25 years or more. Eric and I hosted two memorable ophthalmic congresses at the Gleneagles Hotel in 1979 and 1981,
dealing with anterior segment surgery, his forte, and I was in charge of posterior segment investigation and treatments. In 1978 we joined forces to compile, contribute to and edit the first comprehensive textbook on lens implant surgery which was released in 1984. It remains a classic historical account of the evolution of lens implantation in the eye with all the innovators at that time including, Ridley, Choyce, Fyodorov and many others. Eric was a generous and inspiring colleague and friend and leaves many sound and happy memories.” Predeceased by his wife Veronica, Eric is survived by his two sons, Stephen and Robert and daughter, Tania.
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JOHN HENAHAN AWARD
WIN E1000 BURSARY FOR MILAN CONGRESS
Young ophthalmologists are invited to enter The John Henahan Prize for 2012
he John Henahan Prize, for an original piece of writing on an ophthalmological subject, is open to ophthalmologists who are members of the ESCRS and who are 40 years of age or under before January 1, 2012. Entrants are invited to write a 900-word essay on the topic of, “The trials and tribulations of a young ophthalmologist”. The article can focus on the educational highlights of the residency, teachers, lecturers and mentors, fellow students and patients. The essays will be judged by Emanuel Rosen, chairman ESCRS Publications Committee; Jose Guell, former president ESCRS; Oliver Findl, chairman ESCRS Young Ophthalmologists’ Forum; Sean Henahan, editor EuroTimes; Paul McGinn, editor EuroTimes; and Robert Henahan, contributing editor EuroTimes. The two main criteria for consideration by the judges are the clinical content of the story and the writing style, including punctuation and grammar, which should reflect the high standard of material published in EuroTimes. The winner will receive a travel bursary worth €1,000 to attend the XXX Congress of the ESCRS in Milan, Italy and a special trophy which will be presented at the Young Ophthalmologists' Programme in Milan. Entries, which must be accompanied by an ESCRS membership number, should be sent to Colin Kerr, executive editor, EuroTimes at: email@example.com.
2011 Winner The 2011 John Henahan Prize winner was Indian ophthalmologist, Dr Soosan Jacob, for her
essay, “There Is No Beautiful Case”. Dr Jacob is a senior consultant ophthalmologist and head of the Department of Orbit & Oculoplasty and Cornea & Refractive Surgery in Dr Agarwal‘s Eye Hospital, Chennai, India. Dr Rosen, also chairman of the judging panel, said Dr Jacob's winning entry revealed insights into the learning processes of a developing ophthalmologist. “She articulates what many know but few can put into a compact word essay that behind every potential tragic case there is a person who has to cope with disease and yet keep life going,” said Dr Rosen. “There were many excellent contributions to the 2011 ESCRS Henahan essay prize for young ophthalmologists but the judges were unanimous in selecting Soosan’s essay for the prize,” he said.
Entry forms The prize is named in honour of John Henahan, who edited EuroTimes from 1996 to 2001. “John’s work has inspired a generation of young doctors and journalists, many of whom continue to work for EuroTimes. The prize will not only bring satisfaction to the winner and credit to all the contributors but may enhance all their prospects of pursuing a medical writing aspect to their future careers. We look to their further contributions to EuroTimes and the Journal of Cataract & Refractive Surgery,” said Dr Rosen. Entry forms are available from: firstname.lastname@example.org. Requests for entry forms should be marked ‘Henahan Prize 2012’. The closing date for entries is Monday 4 June, 2012. For further information see www.escrs.org.
Dr Soosan Jacob, receives her award last year from Emanuel Rosen
EUROTIMES WINS AWARD
uroTimes is the 2011 Magazines Ireland Business to Business Magazine of the Year (more than 5,000 circulation). Magazines Ireland represents 42 Irish publishers who together produce over 200 magazines, both consumer and business to business titles. The judges said that in a strong category with many worthy contenders, EuroTimes was chosen as the winner because of its excellent content and highly impactful design EuroTimes executive editor Colin Kerr said that EuroTimes had continued to go from strength to strength in 2011 with an ABC audited annual readership of 32,019. This represented a year-on-year increase of seven per cent and made EuroTimes the highest audited circulation for ophthalmic news publications in Europe.
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“A EuroTimes readership study was commissioned in April 2011 and 500 telephone surveys were conducted with EuroTimes readers,” he said.”The results of the survey show EuroTimes leads all publications in both spontaneous and total recall and that more subscribers read every issue of EuroTimes than any of its competitors.” Dr Emanuel Rosen, chairman of the ESCRS Publications Committee, EuroTimes, congratulated the EuroTimes staff and editors and said that winning the award was a major recognition for the magazine. This is the third award that EuroTimes has received from Magazines Ireland in the last five years. In 2007, the magazine won the Business to Business Specialist Magazine of the Year award and in 2010, Senior Designer Paddy Dunne won a Designer of the Year (Business Magazines) award.
EuroTimes executive editor Colin Kerr receiving the Magazines Ireland award from MI chief executive Grace Aungier
A G LO BA L V I E W O F O P H T H A L M O LO G Y AT
www.eurotimes.org easy access to...
Eurotimes.org, the website of the award-winning news magazine of the European Society of Cataract and Refractive Surgeons, provides a unique insight into the world of ophthalmology.
EuroTimes Winner of the 2011 Magazines Ireland Business to Business Magazine of the Year (more than 5,000 circulation)
Breaking News Exclusive online content on the latest developments in ophthalmology
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Online Archive Our easy to use search engine gives users access to content from past issues of EuroTimes
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outlook on industry
Ed Stevens – email@example.com
OFFERING SURGEONS CHOICE
Bausch + Lomb is adding support specialists in pharmaceutical and devices to better serve by Howard Larkin
ausch + Lomb’s entry into the femtosecond cataract surgery arena will offer surgeons the choice of doing corneal refractive surgery or cataracts with a single laser system. Based on the existing TECHNOLAS femtosecond workstation, the new VICTUS™ system can do LASIK flaps, intrastromal refractive procedures, and corneal surgery – as well as corneal incisions, including corneal arcuate incisions, anterior capsulotomy and nuclear softening for cataracts. Following clinical trials involving more than 450 cataract procedures, VICTUS earned the CE mark for both cataract and corneal refractive procedures, said Robert Grant, CEO of Bausch + Lomb's surgical division. Mr Grant believes the dual-purpose VICTUS is an economical alternative for surgeons who do both refractive and cataract work. “It allows leveraging the cost across both kinds of procedures. I think that is a significant advantage,” he said. Beyond initial purchase savings, replacing two lasers with one will also save about €40,000 annually in maintenance, he said. There is a plan to offer an upgrade path to existing TECHNOLAS femtosecond workstation customers, making it even more attractive to surgeons who want to offer premium refractive cataract procedures. Most important is performance. VICTUS provides the perfectly centred and sized capsulotomies and reduced phaco benefits of femtosecond laser-assisted cataract surgery. The system also includes
We strongly believe that this technology will fundamentally change how all cataract surgery is done, not just cataract refractive surgery Robert Grant
safety features such as real-time OCT for procedural planning and monitoring to guide the laser as it operates much deeper in the eye with larger amounts of energy for cataract procedures, a solution TECHNOLAS Perfect Vision (TPV) engineers believe is superior to snapshots offered by a competing system. The user interface is designed to make it intuitive and quick to use in surgery. Rather than installing the OCT module and modified laser on existing workstations, new lasers will be swapped out for surgeons who upgrade, Mr Grant said. VICTUS uses a disposable curved laser interface in combination with an intelligent pressure sensor system to gently dock the eye to the laser. The approach avoids applanating the cornea, which both eliminates wrinkles that can produce laser “skips” in capsulotomies and reduces the suction required to dock the laser. To date, during the clinical study conducted at Hyderabad, all patients have maintained vision throughout all cataract procedures performed, further indicating safe operations, Mr Grant said. The VICTUS system can be configured on a pivoting bed for laser corneal surgery or paired with a surgical microscope and Stellaris phaco system for cataract surgery, said Mr Grant, or it can be set up in its own space to serve both refractive and cataract patients, potentially feeding multiple operating suites. “How workflow will develop depends on how surgeons use the system,” he said. Bausch + Lomb is so confident in the potential of VICTUS to revolutionise cataract and refractive procedures that it has also entered into a definitive agreement providing it with an option to purchase all outstanding TPV shares for up to €450m. TPV was formed in 2009 when Bausch + Lomb spun off its TECHNOLAS division and merged it with 20/10 Perfect Vision. Grant said that Bausch + Lomb intends to retain the technical experts at TPV, and integrate laser platform development with other products, including new intraocular lens designs. “We are looking at a holistic product line that will be femto-optimised,” said Mr Grant.
Don’t miss Ophthalmologica Highlights, see page 42 EUROTIMES | Volume 17 | Issue 2
It allows surgeons to use everything they have learned from refractive surgery to improve vision in cataract patients Calvin W Roberts
While premium surgery is the initial market, Mr Grant believes femtosecond technology will soon become the norm. “We strongly believe that this technology will fundamentally change how all cataract surgery is done, not just cataract refractive surgery. Our goal is 20/20 uncorrected vision by 2020.”
Glistening-free hydrophobic lens
During 25 years as a cataract surgeon, Calvin W Roberts MD, Bausch + Lomb’s chief medical officer, said he was often frustrated by IOL manufacturers pushing their preferred lens regardless of patient need or surgeon preference. “If they made a hydrophobic acrylic IOL, that was the only lens you’d get. If they made a hydrophilic acrylic, that was the answer for everything.” Bausch + Lomb is taking a different tack, offering both hydrophobic and hydrophilic lenses, as well as innovative new designs such as the glistening-free enVista hydrophobic lens introduced at the XXIX Congress of the ESCRS in Vienna. This makes it possible to take advantage of the superior resistance to PCO of hydrophobic materials without having to worry about light scatter and potential degradation of vision due to infiltration of water into microvacuoles seen in many earlier hydrophobic acrylic lenses, Dr Roberts said. He also noted that enVista can be inserted through a 2.2mm incision with a wound-assisted insertion technique. “This gives surgeons an opportunity to use a hydrophobic acrylic lens with a smaller incision.”
We offer a broad portfolio of surgical, pharmaceutical and vision care that allows surgeons to choose solutions that meet their needs Charl van Zyl
For those wanting even smaller incisions, Bausch + Lomb offers the hydrophilic Akreos microincision cataract surgery lens designed for implanting through a 1.8mm incision. The lens features a 360-degree sharp edge and a design that holds the lens against the posterior capsule to prevent cell growth. The MICS system also includes handpieces and fluidics controls for the Stellaris phaco machine as well as specialised instruments and viscoelastics. Dr Roberts believes that the MICS system combined with the refractive capabilities of the VICTUS laser will elevate refractive cataract surgery to a new level. “It allows surgeons to use everything they have learned from refractive surgery to improve vision in cataract patients. Our goal is 20/20 uncorrected.” Demand for the new cataract and refractive products, as well as Bausch + Lomb’s broad range of pharmaceutical and eye care products, is strong, said Charl van Zyl, corporate vice-president and commercial leader for Europe, Middle East and Africa. Bausch + Lomb is pursuing a two-pronged strategy of expanding into emerging markets in Russia, eastern Europe and the Middle East and Africa, while deepening its advanced technology product lines in more established markets. Bausch + Lomb is adding support specialists in pharmaceutical and devices to better serve surgeons, Mr van Zyl said. “We offer a broad portfolio of surgical, pharmaceutical and vision care that allows surgeons to choose solutions that meet their needs. We want to make Bausch + Lomb the preferred partner for surgeons for the future.”
How to diagnose eye disease
Ophthalmology atlases abound. It seems that not a month goes by without a new retinal or corneal atlas being published and packaged as the definitive one for practitioners. They are, of course, generally quite good, packed with extremely high-quality photographs and painstakingly organised according to ocular sub-specialty, etiology or clinical symptomatology. However, they often assume a high level of knowledge and insight into the topic covered. Such an assumption often means that the atlas immediately delves into great detail and sometimes impractical complexity involving hand-wringing and hair-splitting. This is not the case in a new book by Apjit Kaur Chhabra, professor of orbital disease and oculoplasty at the Chhatapati Shahuji Maharaj Medical University in Lucknow in northern India, a book that apparently seeks to reverse this trend. Assuming that the reader has little more than a medical degree and an interest in diagnosing patients’ orbital disease, Prof Chhabra has written the Clinico-Radiological Atlas of Orbital
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Disorders with a different idea in mind. Starting with a very short, basic introduction to orbital anatomy and its appearance on CT scan, she quickly jumps straight into the heart of pathology. The book’s design is extremely practical. Each page covers a single pathological entity with one clinical photograph and between one and three radiological images from the same patient. Expensive or exotic diagnostic modalities such as positron emission tomography or genetic studies are not considered. The text is concise. Accompanying every photograph are several short sentences describing the patient’s initial presentation, the duration of symptoms, a succinct differential diagnosis and prior treatment if applicable. The CT scan images’ text provides the requisite information and whether a biopsy was needed to make or confirm the diagnosis. This last bit of information is crucial: the reader of an atlas often finds him/herself wondering, “Am I really supposed to be able to make the diagnosis based on what I see here?! Help!” The answer of course depends
on the pathology (thyrotoxic orbitopathy – yes; Ewing’s sarcoma – no), but the answer is frequently no. Biopsy is often necessary, as the dozens of intraorbital tumors and malformations strongly resemble one another clinically. Thankfully, the author spares us, the clinicians, the details of the microscopic findings, trusting that we have access to a pathologist for histopathological analysis. But she does assume that we are motivated enough to make an effort to make our own diagnostic contribution based on the radiology, keeping in mind that the average, non-specialist radiologist is often not up to the task when asked to help diagnose ophthalmic disorders. The result is a true, unintimidating clinical companion. This being a purely diagnostic text, no information is given regarding the treatment and prognosis of either the specific patients shown or the condition in general. Enthusiasts of this text will hope that Prof Chhabra will publish a similar book discussing the treatment course and outcome of these or analogous patients.
In our Western practices we rarely see such advanced pathology and it would be edifying to learn how such end-stage cases are managed.
BOOKS EDITOR Leigh Spielberg PUBLICATION CLINICO RADIOLOGICAL ATLAS OF ORBITAL DISORDERS AUTHOR APJIT KAUR CHHABRA PUBLISHED BY JAYPEE HIGHLIGHTS If you a have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland
New findings about retinal pathology show link between complement factor H (CFH) and oxidative stress by Gearoid Tuohy
n Austrian research team has achieved a major breakthrough in the understanding of how certain alleles of complement factor H (CFH) increase the risk of agerelated macular degeneration (AMD). The report on the research team’s findings, published in the journal Nature, fills in a considerable part of the CFH story originally discovered by a number of research groups in 2005. The new research identifies malondialdehyde (MDA) – a decomposition product of lipid peroxidation – as a ligand of CFH which may now explain how the original risk association operates at a molecular level. More critically, the new research shows how normal CFH may prevent MDA-mediated inflammation in RPE and macrophage cells giving rise to opportunities for therapeutic intervention. As ophthalmologists well know, AMD may be divided into a non-exudative "dry" form and an exudative "wet" form. The dry form, which accounts for 85 per cent of cases, involves fatty deposits, known as drusen, which build up over time behind the retina. The wet form, which accounts for
the remaining 15 per cent of cases, involves the growth of abnormal blood vessels (neovascularisation) and leakage of blood and other fluid from behind the retina. Many of the recent therapeutic approaches to tackle AMD have focused on a key target of the neovascularisation process – a molecule known as VEGF (vascular endothelial growth factor) which can promote new blood vessel growth. Wet macular degeneration usually begins as the dry form. Following a series of independent research papers in late 2005 suggesting a link between the body’s immune system and AMD, further investigations established the alternative complement system as a potentially critical player that may help scientists to join the dots between drusen and the symptomatic degeneration of the macula. Understanding the links between the genetic susceptibility data and the clinical symptoms should provide a framework for a deeper understanding of AMD pathogenesis and consequently contribute to identifying new therapeutic targets to slow or halt vision loss associated with the disease.
Experiments in mouse models suggest a direct causal link between oxidative stress and AMD pathology. CFH polymorphisms may alter the ability to bind MDA, a by-product of oxidative stress, representing a major advance in our understanding of AMD pathology
Don’t miss Eye on Travel, see page 46 EUROTIMES | Volume 17 | Issue 2
“The findings described here may lead to novel approaches exploiting endogenous defence mechanisms for the prevention and therapy of chronic inflammation in general” Genetic studies A series of genetic studies conducted since 2005 have shown that CFH was a clear smoking gun behind much of AMD, but how it was operating remained a mystery. One of the first CFH reports, by Dr Robert Klein, of Rockefeller University, in New York, found that individuals with a CFH variant that substitutes a tyrosine amino acid for a histidine at position 402 increased the likelihood of developing AMD 4.6-fold if present on one allele and 7.4-fold if present on both alleles. A second CFH paper, by Dr Albert Edwards, now affiliated with the Institute for Retina Research in Dallas, Texas, reported that “possession of at least one histidine at amino acid 402 (of the CFH gene) increased the risk of AMD 2.7-fold and accounts for 50 per cent of the attributable risk of AMD.” A further CFH study found that the CFH haplotype significantly increased the risk for AMD and that a common variant likely explains approximately 43 per cent of AMD in older adults. The physical link between CFH that operates within the alternative complement system and AMD can be found in the drusen or extra-cellular deposits found in patients with AMD. Several components of the complement cascade have been found in drusen deposits and have led to the hypothesis that AMD may result from dysfunctional inflammation which incorporates inappropriate complement activation.
The complement cascade is an innate part of the immune defence system, consisting of over 30 serum proteins. In general, substances on the surface of microbes can trigger the complement cascade, which activates a series of biochemical steps leading to the lysis (or bursting) of invading cells. However, certain complement proteins may also help trigger inflammation.
CFH genetic alterations This most recent Austrian research – by Mr David Weismann, Dr Christoph Binder and research colleagues at the Centre for Molecular Medicine of the Austrian Academy of Sciences – appears to explain how the CFH genetic alterations might mediate their effect. Results from animal models lacking immunoglobulins showed that over 55 per cent of peptides bound to malondialdehyde (MDA) could be attributed to CFH. Mapping of the binding site for MDA on CFH showed that it crossed the amino acid position 402, highlighted in the original genetic association studies and, most importantly, the H402 variant of CFH showed reduced MDA binding by up to 23 per cent in the plasma of heterozygotes and up to 52 per cent in homozygotes. Normal CFH then appears to protect against inflammation by inhibiting the complement pathway, however once mutated, the ability for CFH to control the inflammation associated with AMD appears to be lost. The MDAs are created through the action of oxygen radicals and are a normal decomposition product of lipid peroxidation. When the MDAs react with normal cell proteins, they form adducts that act as biomarkers of oxidative stress inducing inflammation in a variety of conditions ranging from atherosclerosis to AMD. The major finding from the study appear to suggest that functioning CFH is able to suppress this inflammatory response by mopping up the MDA adducts. A clear implication here is that targeting of the MDA adducts may now open a new therapeutic strategy for the treatment of AMD, and possibly other chronic degenerative disorders. “Undoubtedly, there are multiple defences against the ubiquitous MDA adducts,” the researchers concluded. “The described homeostatic response may be particularly limiting in the eye, as opposed to other sites where MDA adducts accumulate such as the vascular wall. The findings described here may lead to novel approaches exploiting endogenous defence mechanisms for the prevention and therapy of chronic inflammation in general.”
Tropical Breezes, Exceptional Education AND Shorter Flights, Lower Costs than other Winter Meetings! Next winter, join us for the 5th Annual ASCRS Winter Update and discover all Playa del Carmen, on Mexico’s ‘Riviera’ has to offer. Hosted at the AAA Five Diamond® Fairmont Mayakoba once again, the 2012 program will continue the tradition of excellent education in a spectacular location. Make your plans for next winter now for extra savings! Register today!
For registration, housing and program updates, visit:
www.WinterUpdate.org The meeting was great. The “casual atmosphere allowed open dis-
cussion. My family loved the resort and our day trips to Xcaret to snorkel and to Coba to see Mayan ruins.
Gary J. Foster, MD, Fort Collins, Colorado
Edward J. Holland, MD Stephen S. Lane, MD Roger F. Steinert, MD
David F. Chang, MD Eric D. Donnenfeld, MD Richard A. Lewis, MD Keith A. Warren, MD
Faculty Brock Bakewell, MD Clara C. Chan, MD Vincent P. de Luise, MD Lisa Gangi, COE Terry Kim, MD W. Barry Lee, MD Richard L. Lindstrom, MD Nancey K. McCann Tina Pinke, COT, COE
Program at a Glance Thursday, February 16 • Networking & Welcome Friday, February 17 • Complicated Cataract • Cornea • Luncheon Workshops • Evening Session: Legislative Update Saturday, February 18 • New Technology in Cataract and Lens-Related Surgery • Retina • Luncheon Workshops • Evening Session: Video Complications Seminar • Attendee Networking Dinner
E. Ann Rose Jonathan B. Rubenstein, MD Thomas W. Samuelson, MD Paul Stubenbordt R. Doyle Stulting, MD, PhD Vonda Syler, COE Jonathan H. Talamo, MD Maureen L. Waddle, MBA Liliana Werner, MD, PhD
Sunday, February 19 • Challenging Cases for the Comprehensive Clinician • Glaucoma • Luncheon Workshops • Evening Session: Medicare Update Monday, February 20 • Keratorefractive • Faculty Roundtables/Wrap-Up
in h m Wit d A
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Pr ed P r o d
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Win The John Henahan Prize 2012
a €1,000 travel bursary to the XXX ESCRS Congress
EuroTimes Writing Competition Call for Entries
The Trials and Tribulations of a Young Ophthalmologist
Müller cells and retinal disease
A better understanding of the protective and toxic reactions of glial Müller cells to pathogenic stimuli may open up new therapeutic strategies in the treatment of retinal disease, according to a review of current research. Müller cells have a range of functions which are essential to the health and functionality of the retina. In reaction to retinal trauma, Müller cells exert both protective and toxic effects on photoreceptors and neurons. Moreover, Müller cells de-differentiate into cells with properties similar to pluripotent retinal progenitor/stem cells and express neuronal and photoreceptor proteins. They therefore might be used in the future to restore retinas damaged by disease and trauma. (Bringmann et al, Ophthalmologica 2012; 227:1-19).
Vitreolenticular interface and cataract surgery
A more careful documentation of the status of the vitreous before and after cataract extraction can enable surgeons to more accurately assess the risk of subsequent retinal complications, particularly in cases where disruption of the vitreolenticular interface occurs, note Carsten Framme and Sebastian Wolf. The likelihood of complications following capsular rupture or Nd:YAG laser capsulotomy will vary according to whether the posterior vitreous remains attached or whether a posterior vitreous detachment is rhegmatogenous or non-rhegmatogenous in nature. For example, when a rhegmatogenous PVD occurs it is likely to lead to an anterior shift of the vitreous base, increasing the risk of retinal detachment.
confocal scanning laser ophthalmoscope NIR-AF demonstrated CSC in 94.7 per cent of the cases. Fluorescein angiography had the best contrast of the different approaches, however, the study’s authors noted that fluorescein angiography is associated with moderate adverse events in about 1.5 per cent of cases and serious adverse events occur in about one in 1,900 case. (E. Lindner et al. Ophthalmologica 2012; 227: 34-38).
Long-term results of ranibizumab in myopic CNV
A study into the long-term efficacy of ranibizumab in the treatment of myopic CNV indicates that the effect of the therapy can increase over time and can continue even when the injections are ceased. In the retrospective, non-randomised study, 40 eyes of 39 patients with myopic CNV received intravitreal ranibizumab for three years. The researchers found that mean visual acuity improved from 55.4 (ETDRS) letters at baseline to 59.7 letters at 12 months (p = 0.07), 61.8 letters at 24 months (p = 0.008) and 63.4 letters at 36 months (p = 0.039). The proportion gaining three lines or more was 25 per cent at 12 months, 30 per cent at 24 months and 35 per cent at 36 months. Patients received a mean of 4.1 injections in the first year, 2.4 in the second year and 1.1 in the third year and 53 per cent of the eyes required no further treatment during the third year of follow-up. (Franqueira et al, Ophthalmologica 2012;227:39-44).
(Carsten et al, Ophthalmologica 2012; 227:20-33).
Near-infrared autofluorescence imaging for CSC
See www.escrs.org for details EUROTIMES | Volume 17 | Issue 2
Near-infrared autofluorescence (NIRAF) imaging may provide a safer and less invasive way to detect central serous chorioretinopathy (CSC) than fluorescein angiography, the current gold standard. In a study involving 19 eyes of 17 patients with confirmed CSC who underwent testing with fluorescein indocyanine green angiography, blue-light autofluorescence imaging, and NIR-AF imaging using a
José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA
Cataract Surgery Will Change in a Femtosecond.
With Alcon’s LenSx® Laser, the Possibilities Have Just Begun.
Delivering the accuracy of a femtosecond laser to Refractive Cataract Surgery, the LenSx® Laser is designed to predictably perform many of the most challenging aspects of traditional cataract surgery. Creating highly reproducible capsulotomy, lens fragmentation and all corneal incisions with image-guided surgeon control, Alcon’s LenSx® Laser is Putting the Future in Motion. To learn more about LenSx® Laser technology for Laser Refractive Cataract Surgery, visit lensxlasers.com.
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Recent developments in the vision care industry
High resolution OTC
NIDEK says that the Optical Coherence Tomography RS-3000 Lite achieves the optimum balance between cost and performance with its fundus surface imaging system. “The RS-3000 Lite has been developed for screening in general eye clinics,” said a company spokesman. “The RS-3000 Lite utilises a different method – the OCT phase fundus – in place of SLO to image the surface of the fundus. The 9mm x 9mm wide area map enables analysis of [NFL+GCL+IPL] status in and around macula, around optic disc, and even in the peripheral area. The high-speed scan (Max. 53,000 A-scans/s) and high-speed averaging (Max. 50 images) achieve high-definition B-scan image. The RS-3000 Lite provides multiple analyses based on practically selected four scan patterns, macula line, macula map, macula multi, and disc map,” he said.
For cataract and other ophthalmic surgeries
Corneal hydration that lets you stay focused on the surgery
Allergan re-submits application
• In clinical trials, physicians reported significantly greater optical clarity with CORNEA PROTECT®
than with BSS (median grade 1.0 vs 2.0, p=0.03)1
Following discussions with the Scottish Medicines Consortium (SMC), Allergan will re-submit an application for OZURDEX for adult patients with macular oedema due to retinal vein occlusion (RVO) in early 2012. A company spokesman said that while Allergan was surprised and disappointed to learn of the SMC’s decision not to recommend OZURDEX for use in the National Health Service in Scotland, the company is committed to bringing the medication to Scottish patients with either form of RVO; central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). “This is particularly important for Scottish patients with BRVO who do not currently have a reimbursed pharmacological treatment option,” he said.
• Just 1 drop provides corneal hydration for up to 20 minutes • No statistically significant difference between CORNEA PROTECT® and BSS in fluorescein staining
scores 1 hour after surgery1
Median Application Frequency
Median Application Frequency of CORNEA PROTECT® vs BSS (Balanced Saline Solution) During Cataract Surgery (n=101)1 10
8 7 6 5
Carl Zeiss revenue increases 12.1%
4 3 2 1 0
Carl Zeiss Meditec has announced that it generated consolidated revenue of €758.8m in financial year 2010/2011, compared to €676.7m the previous year. This corresponds to an increase of 12.1 per cent at the close of its financial year ending 30 September 2011. “Despite the adverse general economic situation we have been able to continue our growth course and even exceed our expectations,” says Dr Ludwin Monz, president and CEO of Carl Zeiss Meditec AG. “Although we continued to invest in new products, and to establish and expand our sales and service structures, we have succeeded in increasing profitability. This is not least because we managed to further improve the manufacturing cost position,” said Dr Monz.
Reference: 1. Chen Y-A, Hirnschall N and Findl O. Corneal wetting with a viscous eye lubricant to maintain optical clarity during cataract surgery. Submitted to J Cataract Refract Surg under review. CORNEA PROTECT® is a registered trademark of Croma-Pharma GmbH.
CE approval for multifocal toric IOL
Rayner has received the CE Mark approval for the Sulcoflex multifocal toric IOL. “This CE Mark approval completes the product family of Sulcoflex lenses – aspheric, toric, multifocal and multifocal toric – allowing Rayner to expand its range of IOLs offered in the European Union. The company expects to release the product into the market during Q1, 2012,” said a company spokesman.
Croma-Pharma GmbH • www.croma.at
ad cornea protect EUROTIMES | 120x300 VolumeENG 17 1112v1 | Issuegpf 2 eurotimes.indd
Femtosecond laser platform gets CE approval
Bausch + Lomb and Technolas Perfect Vision have announced the commercial availability of the VICTUS femtosecond laser platform in the EU. After securing CE mark approval, the VICTUS platform is approved for LASIK flap, astigmatic keratotomy, INTRACOR, capsulotomy and lens fragmentation. “This is a significant milestone for Bausch + Lomb that will deliver breakthrough capabilities to our eye care professionals and the patients they serve,” said Brent Saunders, chief executive officer of Bausch + Lomb.
escrs on your time Symposia, free papers, videos and more from ESCRS Congresses in your home
XXIX Congress of the ESCRS, Vienna and 16th ESCRS Winter Meeting, Prague Now Online
escrs on demand Visit www.escrsondemand.org
eye on travel
FASHION NEVER SLEEPS
Milan is one of Europe’s great fashion centres but you need to take time to get the best value for your euro by Maryalicia Post
Shops in the Galleria
Fashion in Milan isn’t all about clothes
certain style seems to come naturally to the Milanese. Naturally, a visitor to Milan can acquire it, too – at a price. The forerunner of all the world's “galleria” shopping malls – Milan's Galleria Vittorio Emanuele II – opened in 1871 between the Cathedral and the Opera House. Work on the triumphal arch that frames the main entrance from the Piazza del Duomo took another 10 years to complete. Then as now, luxurious shops and some of Milan's most respected restaurants and cafes lined the indoor streets of the double arcade. The Galleria, with its magnificent central dome, wall paintings and mosaic floor, was too sophisticated to be called a “mall”; instead, it was dubbed “Milan's drawing room,” and under these vaulted glass ceilings, you may feel that time stands still. Not so in the Quadrilatero d'Oro, the “golden rectangle” formed by Via Montenapoleone, Via Andrea, Via Gesù, Via Borgospesso and Via della Spiga. On these fashionfilled streets, time never stands still for a second. Milan's
EUROTIMES | Volume 17 | Issue 2
most discerning shoppers come here expecting not only “what's new” but also what's going to be new. It's an easy walk to this area from the La Scala end of the Galleria. Just cross the park behind the statue of Leonardo da Vinci and turn right on Via Manzoni. At number 31 Via Manzoni, detour into Armani's Megastore. Opened by Armani in 2000 to celebrate his 25th year in fashion, its 750 square metres are crammed with everything you need to live the Armani lifestyle – fashion for men and women, books, home decor (the Armani “Casa” range) and a flower shop. Relax Armani style in the basement electronic play centre and recharge afterwards in the cafe or sushi bar. Open every day from 09:00 to 17:00. Continue down Via Manzoni to Via Montenapoleone, a street so “fashion forward” that it maintains its own website featuring current window displays and a gallery of ‘street mood’ photos. For details, visit www. viamontenapoleone.org. You can spend hours in this neighbourhood window-shopping the exquisite collections of jewellery, clothing, handbags and shoes. You're welcome to browse inside the shops too, particularly if you've dressed smartly for the outing. (High-end shopping is not a casual sport in Milan.) If you have time, relax in Caffe Cova at 8 Via Montenapoleone. Expect to pay €15 for coffee and cake in these luxuriously elegant surroundings. But what if time is the one luxury you can't afford? Here are two shopping shortcuts: Contact a personal shopper like Marian Harber, a British ex-pat who has lived for 30 years in Milan. She knows where to go and will take you straight there – not just in the Golden Rectangle, but also in the lesser known boutiques in the surrounding small streets. She has some good addresses for household linens and home furnishings, too. For details, visit: www.shoppingwithmarion.com. Head straight for La Rinascente department store in Piazza del Duomo. You’ll find in-store boutiques of small designers, two floors devoted to men's fashions, and a Design Supermarket in the basement featuring everything from specially selected lighting fixtures to children’s toys. La Rinascente’s food shop on the seventh floor is bursting with cooking staples that would make great gifts, including oils, wines, chocolates and sweets. A meal or just a coffee on the terrace of the rooftop restaurant, almost within touching distance of the spires of the Duomo, is a positive plus. (Bring your camera.) La Rinascente is open Monday-Thursday: 09:30- 21:00; Friday-Saturday: 09:3022:00 Sunday: 10:00 to 21:00. The four restaurants on the top floor are open until midnight. After store hours, take the pink express elevator non-stop to the seventh floor; entrance around the corner from Piazza Duomo on Via S. Raffaele. Finally, if you really want to speed things up, rent a Ferrari for a day. The people at http://europeluxurycarhire. com/supercars-car-rental will quote a price. Be sure to choose a model with room for your shopping!
Milan's Galleria - no mere shopping mall
Milanese of slender means If you like a bargain, you can find them in Milan, too. Try DMagazine at 26 Via Montenapoleone, right in the Golden Rectangle. The shop sells overstock from labels like Armani, Prada, and Fendi. It's crowded with bargains and often over-crowded with bargain hunters, too. (Open Monday to Sunday, 09:3019:45 Metro Montenapoleone.) La Salvagente – the “life saver” – has been a Milanese fixture since 1978. The shop, with three floors of designer clothes for men, women and children, is located on Via Fratelli Bronzetti, off Corso XXII Marzo, a 15 minute walk from Metro San Babila. You will find the best selection of clothing in the smaller sizes. Prices here hover around wholesale. Il Salvagente is open Monday afternoon and from 10.00-12:30 and 15:00-19:00 on Tuesday, Thursdays and Fridays. On Wednesday and Saturday it stays open straight through from 10:00 to 19:00. The shop is closed all day on Sunday and on Monday morning. No credit cards; cash only. Worth knowing : “ATM” signs in Milan refer not to cash dispensers but to the transport system: Azienda Trasporti Milanesi. An automatic teller machine is a “Bancomat.” For the more committed bargain hunter, there are Outlet Shopping Tours that will take you across the border to Switzerland and back again with time to prowl the 160 shops of the Mendrisio Foxtown Outlet (www.foxtown. ch). All the familiar brands are here at 30 per cent to 70 per cent off. The ambience is fairly up market. For tour information, check with www.zaniviaggi.it or your hotel concierge.
* The XXX ESCRS Congress will be held in Milan from 8-12 September 2012.
Journal of Cataract and Refractive Surgery
Light adjustable IOL
The light-adjustable intraocular lens (IOL) had moved from the lab to the clinic, where it is producing good visual results in longer term studies. In particular, it is receiving good marks for achieving its potential for fine-tuning refractive outcomes. A new study confirms that the innovative IOL is also safe, causing no more damage to the corneal endothelium than conventional phacoemulsification and IOL implantation cataract surgery. German researchers evaluated endothelial cell loss and corneal thickness over a one-year period in 120 eyes receiving light-adjustable IOLs and the associated UV light lock-in treatment. The mean cumulative UV light dose at the cornea was 61.47 J/cm2 ± 2.37 (SD). The mean endothelial cell loss was 6.91 per cent ± 3.66 per cent two weeks after surgery before adjustment and 6.57 per cent ± 3.81 per cent 12 months after lock-in. The mean relative change in corneal thickness from preoperatively was 6.18 per cent ± 3.97 per cent two weeks postoperatively and −0.64 per cent ± 1.88 per cent 12 months after lock-in. These results are similar to those reported in the literature after conventional phacoemulsification with IOL implantation. In particular, the UV light exposure for adjustment and lock-in procedures did not appear to add to the endothelial damage caused by the cataract surgery. n FH Henger et al., JCRS, “Evaluation of corneal endothelial cell loss and corneal thickness after cataract removal with lightadjustable intraocular lens implantation: 12-month follow-up”, Volume 37, Issue 12, 2095-2100. n T Kohnen, JCRS, “Light-adjustable intraocular lens technology”, Volume 37, Issue 12, 2091.
Sequential bilateral cataract surgery safety
Advocates of sequential bilateral cataract surgery point to improvements in economy and patient satisfaction. Opponents have voiced concerns over the safety and potential increased risks posed by this approach. A large Canadian study indicated that the sequential bilateral approach is at least as safe as the traditional approach. The researchers surveyed members of the International Society of Bilateral Cataract Surgeons (iSBCS) to determine the results of unilateral and bilateral cataract surgeries performed by experienced bilateral cataract surgeons. They also looked at recently reported frequencies of postoperative endophthalmitis with or without the use of prophylactic intracameral antibiotics (as used in the landmark ESCRS Endophthalmitis Study). Four cases of EUROTIMES | Volume 17 | Issue 2
bilateral simultaneous endophthalmitis after immediately sequential bilateral cataract surgery (ISBCS) have been reported in the past 60 years, all with breaches of aseptic protocol. No bilateral simultaneous endophthalmitis occurred in the 95,606 ISBCS cases collected. The overall rate of postoperative endophthalmitis after ISBCS was one in 5,759. Infection rates were significantly reduced with intracameral antibiotics to one in 14,352 cases. These rates are at least as low as and sometimes even lower than published rates for unilateral surgery, particularly when recommended precautions are taken. The researchers suggest that simultaneous bilateral cataract surgery is more accurately referred to as immediately sequential bilateral cataract surgery (ISBCS) to clearly differentiate it from delayed sequential bilateral cataract surgery. The approach is becoming more popular around the world. n SA Arshinoff et al., JCRS, “Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery”, Volume 37, Issue 12, 2105-2114.
JCRS Symposium CONTROVERSIES IN CATARACT AND REFRACTIVE SURGERY Monday, April 23, 2012 1:00–2:30 PM Chairs: William J. Dupps Jr, MD, PhD, Nick Mamalis, MD
Femtosecond Laser Cataract Surgery: Pros and Cons
Femtosecond laser flap creation has become a popular approach to LASIK surgery, with several platforms available to ophthalmic surgeons. Claims made in favour of femtosecond LASIK include more accurate flap creation and better safety. A new metaanalysis questions these claims. A look at seven prospective randomised controlled trials describing a total of 577 eyes with myopia showed no significant differences in the efficacy, accuracy, or safety with using femtosecond or conventional microkeratomes. However, postoperative total aberrations were significantly lower in eyes that had femtosecond LASIK. n Z Zhang et al., JCRS, “Femtosecond laser versus mechanical microkeratome laser in situ keratomileusis for myopia: Meta-analysis of randomized controlled trials “,Volume 37, Issue 12, 2151-2159.
Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and jcrs journal
Correction of Refractive Surprises Following Cataract Surgery: Lens-Based Versus Laser Correction Role of the Ectasia Risk Scoring System LASIK Enhancements: To Lift or Not to Lift? How Young Is Too Young for CXL?
During the ASCRS Symposium on Cataract, IOL and Refractive Surgery Chicago, Illinois, USA
Calendar of events
Dates for your Diary
16th ESCRS Winter Meeting 3-5 prague, czech republic www.escrs.org
World Ophthalmology Congress
26th International Congress of the HSIOIRS
5th Ljubljana refractive surgery meeting
16-20 abu dhabi, UAE
XVI National Congress of Italian Society of Corneal Transplant 23-25 rome, italy
1-4 ATHENS, GREECE
Joint Irish & UKISCRS Refractive Surgery Meeting 9 Dublin, Ireland
8-10 Ljubljana, SLOVENIA
Frankfurt Retina Meeting 10-11 Mainz, Germany www.eckardt-frankfurt.de
2nd EuroLam Macula and Retina Congress
27th APAO Congress
ASCRS Symposium AND Congress
21 belgrade, serbia
27-30 paris, france
16-17 MIAMI, USA
The 3rd World Congress on Controversies in Ophthalmology (COPHy)
13-16 busan, korea
International Symposium on Glaucoma – New Insights and Updates www.glaucoma–belgrade2012.org
118th SFO Congress
20-24 chicago,il, usa
ARVO Annual Meeting
6-10 fort lauderdale, FL, USA www.arvo.org
UKISCRS Cornea & Cataract Day 2012 14 Liverpool, UK
22-25 Istanbul, TURKEY
10th SOI International Meeting 23-26 milan, italy www.sedesoi.com
25th International Congress of German Ophthalmic Surgeons
14-17 Nurnberg, germany www.doc-nuernberg.de
10th EGS Congress
ISER 2012 XX Biennial Meeting of the International Society for Eye Research
3rd EuCornea Congress 6-8 MILAN, ITALY www.eucornea.org
17-22 Copenhagen,Denmark www.eugs.org
2nd World Congress of Paediatric Ophthalmology and Strabismus 7-9 MILAN, ITALY www.wcpos.org
12th EURETINA Congress 6-9 MILAN, ITALY www.euretina.org
XXX Congress of the ESCRS
UKISCRS – XXXVI Annual Congress 27-28 brighton, uk
AAO Annual Meeting 10-13 chicago, il, usa www.aao.org
8-12 MILAN, ITALY www.escrs.org
Advertising Directory: Alcon: Pages: 3, 43, OBC; ASCRS / Eyeworld: Page: 41; Benz Research and Development Page: IBC; Carl Zeiss Meditec Page: 7; Croma-Pharma Pages: 9, 44; D.O.R.C International BV Page: 23; ESASO Page: 33; Haag Streit International Page: 24; Katena Page: 22; Ljubljana Refractive Meeting Page: 18; Magrabi Hospitals and Centers Page: 25; Medicel AG Page: 13; Medicontur Page: 35; Moria Page: 15; Nidek Page: 27; Oertli Instruments AG: Page: IFC; Santen Page: 39; Technolas Page: 19; ThromboGenics Page: 11; Ziemer Page: 8;
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A European Outlook on the World of Ophthalmology