Vol 17 Issue 3

VOLUME 17 ISSUE 3 MARCH 2012

C O R N E A

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ESCRS

EUROTIMES

march 2012 Volume 17 | Issue 3 This month...

Special Focus: Cornea 4

Cover Story: New treatment options discussed for ocular surface diseases

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Newsmaker interview with EuCornea Board member Friedrich Kruse

10 Correcting astigmatism and anisometropia following keratoplasty

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Imaging techniques open up new era in ophthalmic surgery, says expert

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New technique could provide best of both worlds

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Importance of detecting and treating ocular surface disease stressed

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New collagen preparation for epithelium repair

Cataract & Refractive 16

LAL and presbyopic correction

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Emphasis on managing patient expectations in monovision procedures

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Researchers report positive results with three new multifocal IOLs

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Optic membranes may solve PCO problems

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New motorised IOL injector may stretch corneal incisions less than manual devices

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Studies show safety and efficacy with new IOL designs

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Diagnosing cause of problems can result in happy patient

Glaucoma 23 IOLs for glaucoma patients 24 24-hour IOP measurement could be close to reality

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ESCRS Meeting Report 26 Coverage from the 16th ESCRS Winter Meeting in Prague

Retina 27 Diabetic macular oedema classification may need update 28 Can you eat away your genetic risk for AMD?

Global Ophthalmology 30 Cataract surgery in Sudan

News 32 Eye Facts looks at endophthalmitis dosing regimen 33 Call for entries for EURETINA Innovation Award 2012 34 Preview of the four congresses to take place in September in Milan

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39 editorial staff

ESCRS

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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 36 Practice Development

43 Industry News

38 Book Review

44 JCRS Highlights

39 Eye on Travel

46 Ophthalmologica Highlights

42 EU Matters

48 Calendar

Assistant Designer Janice Robb

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

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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: escrs@escrs.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.

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GUEST EDITORIAL

Medical Editors

Volume 17 | Issue 3

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

EUCORNEA IS GROWING

Strength of society lies in large number of young delegates submitting clinical and scientific research

by Harminder S Dua

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY

T

he second EuCornea congress in Vienna saw close to 700 delegates registering for the meeting. We also had packed lecture rooms for all of the sessions. We had 99 free papers and over 100 posters at the meeting. Delegates came not only from Europe, but from all over the world. We expect to match or exceed this at the third EuCornea congress in Milan, Italy, in September.

A fair proportion of the success of the society can be attributed to the collaboration with ESCRS and we hope that the collaboration will continue to be fruitful for the foreseeable future. As a new society we still face the usual challenges. Delegates’ and speakers’ time and money is a limited resource. They choose to spend their time and money wisely and select meetings that are special and meet their needs from amongst the numerous events organised the world over.

Our biggest challenge is to sustain our attraction by inviting renowned opinion leaders to deliver keynote lectures and putting up a scientific programme that serves the needs of general ophthalmologists and cornea and ocular surface disease specialists of all ages and experience.

Our strength is in our large number of young delegates who submit their clinical and scientific research to our meeting and we will continue to encourage young ophthalmologists to join our society and attend our meetings.

Our second congress took place in Vienna, Austria in September 2011 and work is already well advanced on the programme for our third congress in Milan, Italy in 2012. The latest in anterior lamellar and endothelial transplantation, new developments and applications of lasers in corneal surgery, a showcase symposium on new scientific research in cornea and ocular surface, collagen cross linking,

EUROTIMES | Volume 17 | Issue 3

Hiroko Bissen-Miyajima JAPAN keratoprosthesis and artificial cornea are among the hot topics that will be discussed. In addition, a highlight will be the 3rd EuCornea Medal Lecture.

The 3rd EuCornea Congress will coincide with the XXX ESCRS Congress. Although the corneal, cataract and refractive surgeons distinguish themselves in relation to the primary area of their specialisation, the ‘cornea’ ‘lens’ and the eye do not.

In real terms, these tissues relate to each other in their physiology (transparency) and function (refraction and transmission of light).

Each impacts on the other and several pathologies are inter-related.

Hence there is considerable scope for all of us to share our expertise and learn from each other’s knowledge and experience. In 2012 we have a special joint symposium with ESCRS, which I expect as before, will be a big attraction.

My special thanks to the council of ESCRS, the Board of EuCornea and the staff of Agenda for bringing EuCornea to its present global status. I look forward to seeing you all in Milan in September and in the meantime, I would encourage you to visit our website at: www.eucornea.org.

John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY

* Harminder S Dua is president of EuCornea.

Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Cover Story

cornea

ocular regeneration

Ocular surface diseases and disorders including chemical or burn injuries, Stevens-Johnson syndrome and neurotrophic keratopathy continue to be major challenges

by Sean Henahan

“

Now we have seen much progress and have a better understanding of the pathogenesis of corneal disorders, which is leading to some sophisticated therapeutic modalities

Shigeru Kinoshita MD, PhD

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Patients receiving E-PRP for chronic epithelial defects and for corneal ulcers did exceedingly well Jorge Alio MD, PhD

EUROTIMES | Volume 17 | Issue 3

W

ith several new stem cell strategies and tissue engineering techniques now close to clinical utility, and numerous innovative biotech approaches in the pipeline, research groups around the world report being tantalisingly close to the goal of producing effective new treatment options while solving the limitations of current approaches.

“When I began residency some 36 years ago we had very little knowledge of the pathogenesis of devastating ocular surface disorder such as Mooren’s ulcer, StevensJohnson syndrome, and meibomitis-related severe keratoconjunctivitis. Now we have seen much progress and have a better understanding of the pathogenesis of corneal disorders, which is leading to some sophisticated therapeutic modalities,” said Shigeru Kinoshita MD, PhD, professor and chair, Department of Ophthalmology, Kyoto Prefectural University of Medicine, Japan, in a keynote lecture at the 2nd Asia Cornea Society conference in Kyoto.

Ocular surface reconstruction using regenerative medical approaches and tissue engineering aims to restore the anatomic and physiologic ocular surface, and ultimately to prevent recurrence of the ocular surface pathology.

Japanese corneal specialists pioneered some of the key approaches in the treatment of ocular surface disease, such as cultivated mucosal epithelial cell transplantation. Dr Kinoshita, a leader in the field, continues to be involved in some of the most leadingedge research.

Dr Kinoshita and colleagues are also interested in producing human corneal endothelial cell regeneration through implantation of cultivated corneal endothelial cells. His lab is currently looking at three types of therapies to treat corneal endothelial disease: cultivated corneal endothelial cell sheet transplantation, cultivated corneal endothelial cell injection therapy, and eye drops for promoting

corneal endothelial cell proliferation and migration.

He has reported promising results in animal experiments with transplantation of corneal endothelial cell sheet on type 1 collagen. This produced high endothelial cell density with long-lasting clear corneas.

“This research showed that the cells could easily migrate out of the transplanted cultivated cell sheet and proliferate. They migrated to peripheral cornea, eventually creating endothelial cells on the entire cornea,” he told a session of the XXIX Congress of the ESCRS. Problems with sloughing of the cell sheet led to the search for an alternative way to deliver the cells. Animal experiments using human DSAEK flaps demonstrated that it was possible to transfer cultivated cells into the anterior chamber in this manner, with transparent corneas as far out as eight months.

Dr Kinoshita and colleagues are also evaluating direct injection of cultivated corneal endothelial cells. He believes this would ultimately prove a better approach than transplanting cultivated cornea endothelial cell sheets. Several researcher groups are now working on this.

While doing this research Dr Kinoshita and colleagues, notably Drs Naoki Okamura, Noriko Koizumi and Morio Ueno, discovered an interesting molecule, ROCK (rho kinase) inhibitor (Y027632).

This molecule enhances corneal endothelial cell survival, promotes cellular attachment and proliferation, and inhibits apoptosis.

Ocular regeneration with an eye drop The combination of direct cell

injection with ROCK inhibitor offers an intriguing potential treatment of ocular surface disease. In a recent landmark publication (N Okamura et al., Br J

Courtesy of Shigeru Kinoshita MD, PhD

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Courtesy of Bruce Jackson MD

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A slit lamp photo and OCT image of the corneal lamellar graft at 24 months in a patient treated with keratoconus by Dr Per Fagerholm

Ophthalmol doi:10.1136/bjo.2010.194571), Dr Kinoshita and colleagues report research demonstrating that ROCK inhibitor promoted and enhanced corneal endothelial wound healing both in vitro and in vivo. This was accomplished not with cultivated cell sheet transplantation, but rather through the use of an eye drop. This suggests that in the not too distant future it may be possible to regenerate the corneal endothelial surface in some conditions with a simple eye drop administration.

“We are quite confident about this kind of procedure. Cell injection combined with ROCK inhibitor, which we are calling ‘advanced cell therapy’, offers a distinct advantage over other approaches, as it enables cultivated corneal endothelial cell transplantation by a minimally invasive surgery,” said Dr Kinoshita.

Dr Kinoshita said he is preparing a clinical study protocol to test this approach in humans. It may take some years to gain approval according to Japanese government guidelines for clinical research using somatic stem cells, he noted.

Practical application of a new emerging therapy Stevens-Johnson

syndrome, persistent epithelial defects, dormant corneal ulcers, and chronic severe dry eye are some of the most common, and most challenging ocular surface disorders.

Jorge Alio MD, PhD, chair, Department of Ophthalmology, Alicante Ophthalmology Institute, believes that biological activation of the ocular surface by platelet rich plasma (E-PRP) could prove a useful new way to approach these problems.

Blood-derived products have been used for a long time in ophthalmology. Blood derived products have demonstrated their capacity to enhance healing and stimulate the regeneration of different tissues. This healing effect is attributed to the growth factors and bioactive proteins in the blood.

“Autologous platelet rich plasma (E-PRP) is easy to prepare. It is an amber coloured and slightly turbid blood fraction obtained after centrifugation of uncoagulated total blood with sodium citrate. It is very rich in platelets, growth factors and clotting proteins.

It is different from autologous serum because in that case the blood has previously been coagulated, so platelets are not present in the fraction. Platelets contain great reservoirs of growth factors that enhance proliferation and EUROTIMES | Volume 17 | Issue 3

wound healing. In particular, growth factors enhance ocular surface healing, and induce mesenchymal and epithelial cells to migrate and proliferate, restoring the ocular surface,” he told the XXIX ESCRS Congress.

Dr Alio reported treating more than 1000 patients in the last five years with autologous platelet rich plasma (E-PRP). Depending on the situation, he uses either a topical eye drop or a solid form of the blood product.

He has used the drops for medical treatment of ocular surface disorders including persistent epithelial defects, dormant corneal ulcers, corneal trauma, immunological disorders, chronic severe dry eye and post-LASIK ocular surface syndrome.

A review of cases showed for example that 77 per cent of epithelial defect patients got good or excellent results following treatment with E-PRP drops. The eye drops also benefited patients with dormant corneal ulcers not responsive to conventional therapy, with 50 per cent healing completely and 42 per cent showing improvement.

“Patients receiving E-PRP for chronic epithelial defects and for corneal ulcers did exceedingly well. The drops promoted healing, improved the anatomy and symptoms, closing the wound, and restoring visual function in most cases. This appears to be a very promising and practical approach,” he said.

The drop regimen also improved the conjunctival and corneal surface in cases of micropunctate keratitis, decreasing inflammation, and promoting wound healing, lubricate. A study of patients with severe dry eye showed that at three months 89 per cent had improvement in subjective symptoms, and 86 per cent had significant decreases in hyperaemia, he reported.

Ocular surface syndrome post-LASIK can be very distressful for patients and refractive surgeons, he noted. It is characterised by symptoms of dry eye, micropunctate keratitis, decreased and unstable tear film and decreased visual acuity. Of neurotrophic aetiology, it is a long-lasting problem that is difficult to treat, he commented.

Treatment with platelet rich plasmin shows promise in the treatment of that condition as well. In a study of 32 eyes treated for four to six weeks, half of the patients had significant or very significant improvement in symptoms. Most had improvements in vision. Staining showed

that the underlying neurotrophic problems improved, Dr Alio said.

He reserves a solid form of E-PRP as an adjuvant in surgical procedures for corneal and ocular surface reconstruction. It can be used with amniotic or autologous fibrin membrane transplantation in perforated eyes, or in those at high risk for perforation.

“In our hands E-PRP is a reliable and an effective therapeutic tool to enhance epithelial wound healing in ocular surface disease. Platelet rich plasmin provides a high concentration of essential growth factors and cell adhesion molecules by concentrating platelets in a small volume of plasma. It has a major role in wound healing and enhances physiological processes at the site of injury or surgery,” he said.

The E-PRP is made from patients blood an hour before the procedure. Nothing needs to be added, and it requires no special preparation. This means it can easily be used in any practice, he added.

Improving limbal cell transplantation One goal of

ocular surface reconstruction strategies is repairing limbal epithelial stem cell deficiency, a problem common to many disorders including thermal or chemical injury, Stevens-Johnson Syndrome, microbial keratitis, and contact lens keratopathy. Symptoms of limbal epithelial stem cell deficiency include epithelial haze, sub-epithelial vascularisation and epithelial defects.

Limbal epithelial deficiency can be treated with limbal epithelial cell culture for transplantation, derived from human donor corneas. This can be accomplished with autologous grafting in unilateral disease. Bilateral disease is currently treated with allogeneic grafting, although other approaches are in the early stages.

Alternative approaches for unilateral disease now under investigation involve culturing autologous tissue from oral mucosa, nasal mucosa, and other sites. This research field is very active, motivated by the need to overcome inherent immunogenic problems associated with allogeneic grafting.

Amniotic membrane, a useful treatment in its own right in ocular surgery, is currently the primary substrate for limbal epithelial cell transplantation, but several alternatives now in the pipeline may help overcome some of the limitations of amniotic membrane.

“In our hands E-PRP is a reliable and an effective therapeutic tool to enhance epithelial wound healing in ocular surface disease” Jorge Alio MD, PhD

“

The ultimate goal is a biosynthetic mimic that restores refractive function with optical clarity, and resists enzymatic degradation Bruce Jackson MD

contacts

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Cover Story

cornea

Long-Term Results of Allogeneic Cultivated Corneal Epithelial Transplantation

Shigeru Kinoshita – shigeruk@koto.kpu-m.ac.jp Jorge Alió – jlalio@vissum.com Bruce Jackson – bjackson@ohri.ca Akira Murakami – amurak@juntendo.ac.jp

“There are still a lot of problems to solve. But we have transfected a gene using this approach, which is an important first step”

Courtesy of Shigeru Kinoshita MD, PhD

Akira Murakami MD

Autologous Cultivated Oral Mucosal Epithelial Transplantation

19y Male SJS

61y Female SJS

Nakamura T, Takeda K Am J Ophth, in press

Future View of Corneal Endothelial Tissue Engineering

Don’t miss Eye on Travel, see page 39 EUROTIMES | Volume 17 | Issue 3

Amniotic membrane has a number of positive characteristics as a substrate, particularly its anti-inflammatory and anti-angiogenic properties. However, disadvantages include the biological variability between donors and even within donors. Moreover, it lacks the transparency of an ideal substrate.

The next step will be to strengthen these implants and make them more resistant to enzymes. The researchers are now investigating additional applications including imbedding the transplants with nanoparticles for the delivery of drugs, and creating collagen implants suitable for refractive correction.

Biosynthetic corneal substitute

Gene therapy with a contact lens Looking farther ahead, the future of

Speaking at the same meeting, Bruce Jackson MD, University of Ottawa Eye Institute, Ottawa, Canada, described a promising research approach that could allow the use of recombinant collagen for corneal substitution.

In addition to helping cope with the chronic shortage of human corneal donors, a safe source of synthetic implant material could reduce concerns about disease transmission and might be useful when donor grafting is not appropriate, such as in cases of previously failed grafts, autoimmune diseases, and alkali burns, he noted.

“The ultimate goal is a biosynthetic mimic that restores refractive function with optical clarity, and resists enzymatic degradation. It could be sutured, would be biocompatible, would allow regeneration of host tissue, be non-toxic, with no inflammation or immunogenic problems,” he said.

Recombinant type 3 human collagen might prove an ideal scaffold to recreate the natural corneal microenvironment, allowing for the colonisation of the central cornea by keratocytes. Type III human collagen, which is found in the skin, rather than type II collagen, which is found in the cornea, appears to be a better choice because of its superior mechanical properties and lower cost.

Dr Jackson’s institution is involved in collaborative research with Per Fagerholm MD, University Hospital, Linköping, Sweden, to evaluate the clinical potential of this approach. He cited a recent clinical study in which 10 patients, nine with keratoconus and one with a deep corneal scar, underwent anterior lamellar keratoplasty and implantation of the biosynthetic cornea. At 24 months, the biosynthetic implants remained stably integrated and avascular, with evidence of nerve ingrowth. The epithelial surface barrier was re-established and remained stable.

corneal disease treatment is likely to include gene therapy. The successful treatment of humans with a rare form of retinal disease, Leber’s congenital amaurosis, with gene therapy, suggests that treatment of corneal disease may not be that far in the future.

Leber’s congenital amaurosis was a particularly good candidate for gene therapy because its pathogenesis was associated with a very small number of genes, and the gene defect was well understood.

Akira Murakami MD, professor of ophthalmology, Juntendo University School of Medicine, Tokyo, Japan, has identified a potential candidate corneal disease for gene therapy, and a potential treatment.

Gelatinous drop-like corneal degeneration (GDLD) is a rare refractory corneal disease that generates sub-epithelial deposition of amyloid. Mutations in the TACSTD2 gene have been identified in Japanese families with GDLD, leading researchers to believe it may be amenable to gene therapy.

Presenting at the 2nd Asia Cornea Society conference in Kyoto, Dr Murakami noted that he and his team wanted to use a non viral vector approach to deliver the corrected gene. He reported the transfer of the TACSTD2 gene into the corneal epithelial cells encapsulated in a hydrogel contact lens. In animal studies the team reported being able to successfully introduce the gene into epithelial cells, and to record expression of the relevant protein.

“There are still a lot of problems to solve. But we have transfected a gene using this approach, which is an important first step. We believe that some day the use of phosphate groups containing hydrogel as a gene transfer device could be applied to non-invasive novel therapeutic method for GDLD,” said Dr Murakami.

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Newsmaker Interview

eucornea

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

AN EXCITING TIME FOR CORNEA

EuCornea Board member Friedrich Kruse discusses EuCornea’s progress to date and outlines possible future directions for the organisation

T

he European Society of Cornea and Ocular Surface Disease Specialists (EuCornea) is still a very young organisation but overall we are very happy with the way things have been evolving. We are satisfied to have created a platform for people in Europe interested in cornea. There was a definite need for such a body and the two successful EuCornea meetings in Venice in 2010 and Vienna in 2011 reflected that there was indeed a real demand for exchange and education among corneal specialists in this part of the world. I am also involved in the Cornea Society in the United States and the perception over there is that Europe now has its own functioning cornea organisation which is making progress from year to year. They have been very supportive in our endeavours and were quick to see the potential for creating synergies between our organisations rather than considering us as direct competitors. We are grateful to them for their support and look forward to continued collaboration in the future.

Our plans are progressing nicely for the 3rd EuCornea Congress in Milan in September 2012. There were fears voiced in some quarters that aligning our meeting along with those of the ESCRS, EURETINA and the 2nd World Congress of Paediatric Ophthalmology and Strabismus might dilute our identity and overshadow our efforts to create a vibrant corneal society.

The EuCornea view, however, is that the joint meetings are a positive development.

Ophthalmologists have so many demands on their time and there is a perception that there are now too many meetings and congresses. Allowing delegates to attend a

field a decade ago, that has changed in recent years with an explosion of new techniques in lamellar corneal transplantation. This development has sparked a lot of interest in cornea and new techniques. The result is that surgical cornea has now become one of the fastest moving fields in ophthalmology. This is where EuCornea can play a fundamental role because there is a great need for education to accompany this surge in interest. There is a thirst for knowledge and a desire to learn as much as possible about new techniques, outcomes and concepts.

Friedrich Kruse

combined meeting is a more constructive use of their time and offers delegates the widest range of information in areas of overlapping interest. In this context, the 3rd EuCornea Congress in Milan is an opportunity to be seized and we look forward to building on the momentum that we have established in a few short years, thanks in part to the efforts of individuals such as our past president Vincenzo Sarnicola, our current president Harminder Dua, and not forgetting our president elect/vice-president Jose Guell who was instrumental in forging closer links with the ESCRS. The timing for setting up EuCornea could not have been better. While traditional cornea was perhaps not the most dynamic

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We are now seeing much more interest in the pathophysiology of the endothelium.

Endothelium used to be very much a niche speciality with only a handful of people working in this area. Now it is very much in the mainstream because of the new developments in endothelial grafting. There are a lot of really exciting developments taking place in the field of cornea at the moment and EuCornea is ideally placed to take the lead in bridging the gap between basic science and surgery. I think the high attendance at the meetings in Vienna and Venice and the feedback from our delegates confirms that we are fulfilling this real need.

There are other potential roles for EuCornea in the years ahead. We could certainly play a more active part in regulatory issues and helping to ensure greater harmonisation of regulations and standards across different European countries.

We could also be more instrumental in instigating and supporting clinical trials in the field of cornea, because there is a definite need for more evidence-based medicine. We could also take inspiration from landmark

trials such as that instigated by the ESCRS concerning antibiotic prophylaxis of endophthalmitis in cataract surgery and see what could be done along similar lines for the field of cornea. There are also gaps in terms of nomenclature, surgical protocols, treatment guidelines and so forth, so these would be areas where EuCornea could definitely serve as a knowledge base for our members. However, while it is all well and good to be ambitious we must also be realistic and acknowledge that resources are limited at this point. That is why our goal for the moment is to focus on the meetings, and in particular our annual congress, and to use that platform to build a solid base for the organisation that will enable it to grow sustainably in the years ahead.

From a personal research perspective, one of the most exciting developments in corneal medicine over the past few years has been the evolution in Descemet’s membrane endothelial keratoplasty (DMEK) for the treatment of Fuch’s dystrophy and other endothelial diseases.

Since it was first described by Gerrit Melles, we have seen enormous improvement in the standardisation and application of DMEK techniques. This constitutes about 40 per cent of our graft indications and we have now successfully performed about 300 of these procedures. The rejection rates in our series are practically zero and other centres have also been reporting very promising results indeed with minimal complications. Progress is also being made in so many other areas of corneal disease, so it is a genuine privilege to be involved in such a rapidly evolving field at this moment in time.

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Special Focus

cornea

POST-GRAFT ASTIGMATISM

Many options available for optimising vision after keratoplasty procedures

by Roibeard O’hEineachain in Vienna

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efractive surgeons have an ever increasing array of strategies at their disposal for the correction of astigmatism and anisometropia following keratoplasty procedures, said Rudy M M A Nuijts MD, PhD, Oogziekenhuis Maastricht UMC, Maastricht, The Netherlands, at the XXIX Congress of the ESCRS. Penetrating keratoplasty (PKP) is in general a very successful procedure in terms of transplant survival although post-keratoplasty anisometropia and high astigmatism remains a big problem, Dr Nuijts noted.

In patients with endothelial disease, surgeons can avoid the refractive problems by opting for endothelial keratoplasty procedures, but around 30 per cent of patients undergoing PKP or deep anterior lamellar penetrating will have more than five dioptres of astigmatism and anisometropia.

In 20 to 40 per cent of penetrating and deep anterior lamellar keratoplasty (DALK) cases the anisometropia and astigmatism

are severe enough as to require contact lenses. However, 30 to 40 per cent of such patients cannot tolerate contact lenses.

The surgical options in such cases include relaxing incisions, wedge resections, excimer laser treatments, or lenticular options such as phakic and pseudophakic toric IOLs, he said.

Incisional approaches unpredictable Incisional approaches

such as relaxing incisions, can correct an average of four to five dioptres of postkeratoplasty astigmatism, and their antiastigmatic effect is proportional to the preoperative cylinder. Published studies show that arcuate keratotomy can correct 45 per cent to 72 per cent of the astigmatic refractive error. However, the technique can have unpredictable results and it has minimal effect on spherical equivalent.

Furthermore, in some cases the incisions can lead to perforations and graft rejections.

Dr Nuijts noted that in theory femtosecond lasers offer greater precision and predictability in the creation of relaxing

“

Toric IOLs are useful in eyes with cataract with post-keratoplasty astigmatism, although repeat keratoplasty at a later date can negate some of their benefit

Rudy M M A Nuijts MD, PhD incisions. However, in practice the results of arcuate keratotomy with the femtosecond laser have been similar to those achieved with manually created incisions.

Wedge resections are another alternative for correcting post-keratoplasty astigmatism, although they have been somewhat less popular due to their difficulty and lack of precision. Femtosecond lasers may bring the technique into greater favour since they may make it both safer and more effective, given the ease-of-use and precision they afford.

Courtesy of Rudy M M A Nuijts MD, PhD

Surface ablations less risky than LASIK Like wedge resections, surface

The effect of toric artisan implantation to correct post-DALK astigmatism

Don’t miss Eye Facts, see page 32 EUROTIMES | Volume 17 | Issue 3

ablations have also had their safety issues but have become safer with the use of improved technology and pharmaceutical interventions. In some early reported case series, PRK reduced post-keratoplasty astigmatism by 38 per cent to 57 per cent.

However, it also resulted in moderate to severe haze accounting for loss of more than two lines of BCVA in up to 40 per cent of cases in some studies.

More recent research indicates that much better results can be achieved using lasers with customised ablation profiles and mitomycin-C. For example, in a study involving 16 eyes with post-keratoplasty astigmatism, topography-assisted wavefront-guided LASEK with a flying 0.8mm spot excimer laser (Esiris, Schwind, Germany) reduced mean astigmatism from -7.2 D to -2.7 D. In addition, among four eyes treated with mitomycin-C there was only trace

Rudy M M A Nuijts – rudy.nuijts@mumc.nl

haze in one eye and no haze in three eyes.

By contrast, among 12 eyes that did not receive mitomycin-C there were three cases of haze grade II to IV. Dr Nuijts noted that LASEK and PRK appear to be equally safe and effective in reducing astigmatism after keratoplasty.

LASIK is another alternative for postkeratoplasty astigmatism. Published studies show it can reduce cylinder by 48 to 76 per cent. However, in several series of patients there has been a high proportion of complications that necessitated repeat keratoplasty procedures. Moreover, in some series a significant number of eyes lost two lines of vision.

Toric phakic IOLs are another technology that seems to have great potential but comes with its caveats, Dr Nuijts noted. In a study he and his associates conducted involving 57 patients with post-keratoplasty astigmatism, implantation of a toric Artisan/Verisyse anterior chamber IOL (Ophtec/AMO) reduced mean sphere by 100 per cent and mean cylinder by 86 per cent, and BCVA was 20/40 or better in 84.2 per cent of eyes.

However, at four years’ follow-up there were significant reductions in endothelial cell count, with the mean value falling from 1666/mm2 preoperatively to 861/mm2. On the other hand, that rate of loss is similar to what occurs in PKP patients without the lenses in many case series.

Meanwhile, posterior chamber phakic IOLs can provide similar results and do not appear to pose any danger to the endothelium because of their position in the posterior chamber. In a study involving 15 eyes with post-keratoplasty myopia and astigmatism, implantation of the Staar ICL reduced mean sphere from -7.1 D to -0.95 and astigmatism was 1.0 D or less in all eyes, compared to mean of -3.5 D preoperatively.

Furthermore, mean UCVA was 0.51 and mean BCVA was 0.79 (Alfonso et al, J Cat Refract Surg 2009; 35:1166).

For keratoplasty patients who also have cataracts there are now a broad range of toric IOLs available composed of silicone, hydrophobic acrylic and hydrophilic materials. The Lentis Mplus (Oculentis) IOLs can correct 0.5 D to +12.0 D of cylinder. The AcrySof toric lens and the Tecnis (AMO) toric lens can correct +1.5 to 6.0 D and +1.0 D to 4.0 D of cylinder, respectively.

“Toric IOLs are useful in eyes with cataract with post-keratoplasty astigmatism, although repeat keratoplasty at a later date can negate some of their benefits. In eyes with cataract surgery and endothelial disease, it is a good idea to target the patient for -1.0 to -1.5 D to compensate for the hyperopic shift of DSAEK,” he added.

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contact

Susana Marcos – Susana@io.cfmac.csic.es

Special Focus

11

cornea

IMAGING THE EYE

Quantitative anterior segment imaging shows correlations between ocular anatomy and aberrations

by Roibeard O’hEineachain in Vienna

Three-dimensional OCT reconstruction of the cornea and iris and cross-section in a patient implanted with an intrastromal ring segment, after application of correction of fan and distortion correction algorithms, and image processing tools described by Ortiz et al. Optics Express 2010

EUROTIMES | Volume 17 | Issue 3

validated. Moreover, there are at present no commercially available instruments that provide measurement of the lens shape, tilt or decentration. Some devices for measuring posterior corneal geometry need yet further validations, she added.

New technology Prof Marcos noted that she and her associates have developed devices and techniques over the past decade that may help fill some of these gaps and provide information that is not available with currently available machines.

Among them is a Purkinje imaging system for measuring the dimensions of the crystalline lens and the tilt and decentration of both natural and artificial lenses within the eye. It works by projecting point sources of light on the eye and capturing images from the different reflective interfaces. By using either an equivalent mirror or merit function approach, it is then possible to determine the shape of the crystalline lens from the position of the Purkinje images. In the same way, it also becomes possible to determine the tilt and decentration of the crystalline lens or of an implanted IOL. Scheimpflug imaging is another technology that can provide information on the anatomy of the cornea and crystalline lens, Prof Marcos noted.

However, the geometry of the scanning system, and refraction through ocular media can cause geometric distortion of the images of intraocular structures.

Prof Marcos and her associates have therefore developed algorithms and custom routines that correct the distortion of images obtained with the Pentacam® system (Oculus). The corrected images have yielded more accurate measurements of lens tilt and decentration as well as the radius of curvature of the crystalline lens, she said.

“With Scheimpflug imaging you can derive quantitative information but you have to be sure that the correction algorithms are in place,” she emphasised.

In other research, working in collaboration with Michiel Dubbelman and Rob G L van der Heijde in the Netherlands, Prof Marcos and her associates have compared phacometry findings obtained from their Purkinje system with those obtained from the Scheimpflug system

Scheimflug (left) and Purkinje (right) images in a pseudophakic eye. Quantitative tools allow measurement of IOL tilt and decentration.

Adapted from de Castro et al. JCRS 2007

Courtesy of Susana Marcos PhD

R

ecent developments in imaging techniques for the anterior segment are opening up a new era in ophthalmic surgery in which precise customised eye models of individual patients will be available to surgeons, affording more predictable outcomes of cataract and refractive procedures as a result, said Susana Marcos PhD, Instituto de Optica, CSIC, Madrid, Spain.

“Quantitative information on the anterior segment of the eye will help create good customised eye models showing the relationships between the geometry of the eye and the optical aberrations and their clinical significance,” Prof Marcos told the XXIX congress of the ESCRS. The kind of data that are likely to be most useful in ophthalmic surgery as it relates to vision are the corneal radius and asphericity, anterior and posterior corneal shape, the distances between structures within the eye, anterior and posterior lens shape, lens tilt and decentration and the gradient refractive index distribution of the crystalline lens, she noted There are already many commercial instruments available which provide some of these kinds of data. However, different instruments give different measurements of the same parameters and the accuracy of the devices in different ranges of applications has yet to be

Three-dimensional sOCT image of porcine crystalline lens in vitro (left) and estimated Gradient Index Distribution (right). Adapted from de Castro et al. Optics Express 2010

in a group of young eyes in a relaxed accommodative state. They found that both instruments gave very similar information and also showed great variability between patients. More recently Prof Marcos’ group has shown similar geometrical changes in the crystalline lenses upon accommodation using quantitative OCT.

GRIN lens model Prof Marcos noted that OCT surpasses Scheimpflug imaging both in terms of resolution and its ability to provide dynamic images of the eye’s anatomy. That capability in turn enables imaging of the lens as it changes shape during accommodation.

Prof Marcos and her associates have developed a high-resolution spectral domain OCT device, in collaboration with researchers from Copernicus University. By applying fan and optical distortion correction algorithms to the OCT measurements they have been able to obtain accurate quantitative data about the cornea's shape and thickness as well as crystalline lens measurements. In particular, the application of image denoising and segmentation tools, along with the correction of distortions has allowed the team to obtain accurate estimates of corneal elevation from OCT. One recent achievement of Prof Marcos and her team using their OCT system has been a three-dimensional reconstruction

of the crystalline lens gradient index distribution of a porcine and human lens in-vitro. Their findings could have important implications in the understanding of the optical aberrations of the lens, as well as the mechanisms of accommodation and the loss of accommodation with age.

“This relates to structure and optics. We have seen that for the same lens geometry but with a homogenous distribution of refractive index the lens would show a positive spherical aberration. However, in the presence of the measured gradient index the spherical aberration is negative indicating that the gradient index does play a very significant role in the spherical aberration of the eye. It is likely to be playing a role in the decline of accommodative amplitude that occurs with ageing,” she said.

Furthermore, she noted that in more recent research in which they compared human eyes of different ages, their findings indicated that in addition to the changes of shape and elasticity the lens undergoes with age, it also develops a more homogenous refractive index.

“Quantitative information can contribute to an improved understanding of the eye’s accommodative mechanism. In addition, a better understanding of the lens and related intraocular structures could lead to improvements in cataract surgery outcomes and intraocular lens designs,” she concluded.

contact

Special Focus

cornea

Massimo Busin – mbusin@yahoo.com

ULTRA-THIN DSAEK

Hybrid endothelial keratoplasty technique safer than DMEK but has similar visual outcomes

by Roibeard O’hEineachain in Vienna

A

n endothelial graft consisting of the endothelium, Descemet’s membrane, and an ultra-thin layer of stroma provides nearly the same visual acuity benefits as Descemet’s membrane endothelial keratoplasty (DMEK), but involves less difficulty in terms of donor tissue preparation and manipulation, according to Massimo Busin MD, Villa Serena Hospital, Forli, Italy.

“About half of my patients undergoing this procedure have 20/20 vision at six months, which scores well against DMEK. We don’t get hyperopization because the peripheral edge is very thin, and cylinder is negligible with the three millimetre incision we use. Furthermore, we don’t have a primary graft failure, and endothelial cell loss at one year is the same as with DSAEK,” Dr Busin told the XXIX Congress of the ESCRS. Dr Busin noted that Descemet’s stripping automated endothelial keratoplasty (DSAEK) is currently the gold standard for the treatment of endothelial disease. Since it leaves the anterior corneal surface unchanged, it does not result in the types of refractive errors that occur after penetrating keratoplasty (PKP). At most it will cause a slight hyperopic shift, due to the increased curvature of the cornea’s posterior surface, and a slight amount of astigmatism, due to the incisions made during surgery.

However, DSAEK has its limitations in that although bestcorrected visual acuity of 20/40 or better occurs in up to 80 per cent of patients who have undergone the procedure, it is 20/20 or better in only around a third of patients at best. The loss of best-corrected visual acuity apparently results from the stroma-to-stroma interface.

DMEK’s disadvantages Better results have been reported for DMEK, a newer alternative procedure that uses only the donor endothelium and Descemet’s membrane for graft tissue. Notably, in a study by the procedure’s inventor, Gerrit Melles MD from the Netherlands, 45 per cent have achieved a BSCVA of 20/20.

But DMEK also has its own drawbacks, he said. In fact, preparation and manipulation of the donor material is so difficult and unpredictable that up to 16 per cent of grafts may be lost before surgery and up to 63 per cent of DMEK procedures can have detachments, with up to eight per cent primary graft failure, Dr Busin said.

“The delivering and positioning as well as the attachment are the main surgical challenges with this technique. Those who prepare the tissue routinely come down to one-totwo per cent rate of tissue waste. With DSAEK the rate is practically zero. But detachment rate remains the main postoperative problem: many patients do experience one detachment and some of them even two or three detachments before the graft finally attaches properly,” he added.

Dr Busin and others have attempted to improve on results obtained with DMEK by including a ring of stroma on the periphery to aid in the handling of the tissue. However the technique remains highly complex and is particularly unsuited to more complicated cases.

“Not only are special surgical skills required for DMEK, it is a longer procedure and more complicated. It is also not suitable for a lot of eyes which would certainly benefit from a closed system approach like DSAEK and a DMEK would be, and that is the main problem with the technique,” Dr Busin said.

New technique provides best of both worlds To develop an epithelial graft that makes the preparation and handling of the donor tissue as easy as with DSAEK while providing the same optical clarity as DMEK Dr Busin looked to the analogy of a LASIK flap. DSAEK resembles LASIK in many respects since it involves the creation and placement of a flap-like piece of donor tissue and creates a stroma to stroma interface.

However, unlike DSAEK, LASIK results in 20/20 uncorrected visual acuity in the majority of patients.

AS-OCT scan of an UT-DSAEK graft. Central Graft Thickness is <100 microns

EUROTIMES | Volume 17 | Issue 3

Courtesy of Massimo Busin MD

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Cornea with Bullous Keratopathy before (a and b) and after UT-DSAEK (c and d)

The reason may be the thinness of the flap in LASIK. In addition, research has shown that DSAEK grafts less than 130 microns in thickness result in improved visual outcomes. Dr Busin therefore developed a technique for preparing ultrathin DSAEK graft material using a doublepass microkeratome approach.

“The technique of ultra-thin DSAEK differs from ordinary DSAEK in terms of graft preparation and graft delivery.

I didn’t try to prepare the donor tissue with a single pass because if you cut with a wide slit the risk of perforation is high. The wider the slit of your microkeratome head the higher is the error. A 400 or 450 micron microkeratome head can cut 500-600 and then you perforate, so I came up with the two-pass procedure, first one cut with a 300 micron and the second cut based on the pachymetry that you find.”

Once the graft has been prepared it can be placed into a glide, which allows its insertion into the anterior chamber through a 3.0mm incision. Dr Busin noted that he uses the bimanual technique to insert the donor tissue, drawing it across the anterior chamber from the temporal side.

Furthermore, if the graft is initially decentred it can easily be manoeuvred into place through the simple expedient of externally applying pressure to the appropriate region of the cornea.

“We get significantly thinner grafts with a doublepass technique that are easy to handle as with DSAEK. Furthermore, by starting the two cuts from opposite directions, the second cut is deeper exactly where the first cut was shallower. As a result, the risk of perforation is minimised and the final shape of the graft is planar. Visual recovery after UT-DSAEK is the same as after DMEK with a similar percentage of patients reaching 20/20. In addition, cell loss is the same as with DSAEK and you can barely tell the difference between the two on OCT,” Dr Busin concluded.

Special Focus

cornea

Detecting OSD

Preoperative, intraoperative and postoperative strategies all needed to minimise impact

by Cheryl Guttman Krader in Vienna

C

ataract and refractive surgeons must be careful not to misjudge the importance of detecting and treating ocular surface disease (OSD), said Béatrice Cochener MD, PhD, at the second EuCornea Congress.

“As we aim for perfection in our surgical outcomes, we are coming close to achieving super vision with excimer laser vision correction as well as with our intraocular procedures. However, OSD continues to be a source of postoperative frustration for patients and surgeons,” said Prof Cochener, chair, Department of Ophthalmology, University of Brest, France.

“Preoperative identification of OSD is necessary not because its presence contraindicates surgery, but because it can guide appropriate strategies. Optimising outcomes and patient satisfaction after surgery depends on preparing the ocular surface for the procedure, protecting it with appropriate intraoperative techniques, and rehabilitation of the ocular surface after the procedure with awareness that long-term care may be needed to maintain ocular surface integrity.”

Data on the prevalence of OSD and its adverse sequelae in patients undergoing laser and cataract refractive surgery underscore the importance of undertaking a careful evaluation to identify a pre-existing condition or risk factors for dry eye after surgery. OSD resulting from dry eye disease associated with blepharitis, ocular allergy, or other etiologies is estimated to be a significant comorbidity in up to 30 per cent of LASIK candidates and in up to 50 per cent of the older cataract surgery population, said Prof Cochener.

In addition, corneal surgery can induce or exacerbate OSD through multiple pathways mediated by inflammation or involving alterations in various components of the ocular surface system or its secretions. The result may be bothersome, irritation-related symptoms after surgery causing patient dissatisfaction. However, there may also be fluctuating vision, refractive regression, deterioration in visual quality, decrease in visual acuity, as well as glare and night symptoms.

Furthermore, OSD and its underlying etiologies, including blepharitis and ocular allergy, are risk factors for true complications after laser vision correction, including infection, increased inflammation, delayed EUROTIMES | Volume 17 | Issue 3

healing, and corneal opacity, while preexisting OSD in patients undergoing cataract surgery can affect the accuracy of IOL power and astigmatic axis calculations because of its impact on topographic and keratometric measurements.

Being proactive Unfortunately, OSD often emerges as a postoperative surprise because unless the patient spontaneously volunteers complaints preoperatively, a careful evaluation for OSD may not be undertaken. To avoid this situation, all refractive and cataract surgery candidates should have a thorough history and evaluation focusing on detecting dry eye and predisposing factors. The workup should include questions about visionrelated quality of life, a systemic and ocular history, medication history, and slit-lamp examination of the ocular surface and lids.

Standard clinical tests, including staining for ocular surface damage, measurement of tear breakup time, and a Schirmer's test, help to detect frank OSD, but may not identify patients with subclinical disease that can be worsened postoperatively, said Prof Cochener.

Increasing appreciation for the prevalence and clinical importance of OSD has prompted industry to develop new diagnostic tools. A device for non-invasive measurement of tear osmolarity (TearLab) in the office is now commercially available.

However, Prof Cochener stated that considering its cost, she believes it is best reserved for use in clinical research studies in academic settings.

Another new commercially available device (InflammaDry Detector, RDS) evaluates the tears for an elevated level of matrix metalloproteinase-9 (MMP-9), a nonspecific marker of inflammation that has been shown to be consistently elevated in dry eye. When present at high levels, MMP-9 can cause functional alteration of the epithelial barrier, corneal desquamation, and surface irregularity, Prof Cochener explained.

The Optical Quality Analysis System (OQAS, Visiometrics) provides an optical assessment of tear film quality dynamics based on a double-pass technique, and Prof Cochener said she has found it very useful for the detection and follow-up of tear film abnormalities in surgical patients pre- and postoperatively.

Another manufacturer, TearScience, has introduced three devices for detecting and treating abnormalities due to meibomian gland dysfunction. One device (LipiView) is an ocular surface interferometer that provides a quantitative analysis of the lipid layer of the tear film. Another instrument (Meibomian Gland Evaluator) is designed to enable detection of meibomian gland obstruction at the slitlamp, and a third technology (LipiFlow) works with thermal pulsation to open obstructed meibomian glands.

“

Postoperative care

Béatrice Cochener MD, PhD

Dryness after LASIK results in part from changes in corneal shape that affect tear film distribution, but flap creation also plays an important role because transection of afferent sensory nerves results in decreases in the neurotrophic influence on epithelial cells, blink rate and reflex and basal tear production. Making a thinner flap with a larger hinge and smaller diameter can help to minimise the impact of flap creation on postoperative dryness. Use of the femtosecond laser to create a flap with inverted edge geometry may also be helpful, although lower energy settings are also important.

Prof Cochener said that all patients should be educated about the risk of dryness after corneal surgery and routinely treated with non-preserved artificial tears postoperatively

Preoperative identification of OSD is necessary not because its presence contraindicates surgery, but because it can guide appropriate strategies

for at least one to three months with ongoing use maintained as needed based on patient comfort. For patients with more severe dry eye, topical cyclosporine 0.05 per cent emulsion (Restasis, Allergan) started preoperatively and continued after surgery is an option in the US. Treatment of blepharitis should be continued after surgery, application of a bandage soft contact lens is helpful after PRK, and some surgeons recommend nutritional supplementation with omega-3 fatty acids to improve the tears, although its benefit is controversial. Punctal plugs can help to maintain the tear film on the ocular surface, and a multicentre study is currently under way in Europe investigating this strategy using the Painless Plug (FCI).

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14

Special Focus

cornea

EPITHELIUM REPAIR

New collagen substrate enables growth of differentiated epithelial tissue in cell culture

by Roibeard O’hEineachain in Vienna

“In our hands, 40 per cent of those amniotic grafts with epithelial stem cells failed before they even got to the patients, so it’s not really an ideal carrier for these epithelial carrier cells in this context.

Some of the alternatives that have been investigated include cross-linked collagen, electrospun collagen, collagen vitrigels, silk fibroin scaffolds and fibrin gels.

They all have advantages but also many disadvantages, so we are trying to find a suitable alternative substrate.’

New substrate based on ideal criteria Dr Levis said that the new

Courtesy of Hannah Levis PhD

Figure 1. A schematic diagram showing the plastic compression process with fluid being expelled from the hydrogel in an unconfined manner (blue arrows)

Figure 2. Light micrographs of haematoxylin and eosin stained histological cross sections of (A) human corneal epithelium and (B) human limbal epithelial cells on collagen constructs. (CC collagen construct, CS corneal stroma, CE, corneal epithelium CF corneal fibroblast, LF Limbal fibroblast. Scale bar 50mm)

A

new, easily prepared and highly reproducible collagen preparation could serve as an alternative to amniotic membrane as a substrate for the production of epithelial tissue for use in the treatment of limbal stem cell deficiency, said Hannah Levis PhD, UCL Institute of Ophthalmology, London UK. The new substrate material consists of highly concentrated collagen imbedded with human limbal fibroblast cells.

Laboratory studies conducted to date indicate that it provides a scaffold on which limbal epithelial stem cells can generate layered epithelial tissue that is similar in morphology and biochemical profile to that of the natural healthy corneal epithelium, Dr Levis said.

Dr Levis noted that limbal stem cell deficiency – whether arising from burns, chemical injury or disease, such as contact lens keratopathy or StevensJohnson syndrome – undermines the ability of the epithelium to maintain the integrity of the cornea. The current conventional treatment of the condition consists of the cell culture of autologous or allogeneic stem cells on an amniotic membrane substrate, and placing that on the eye, she noted.

She pointed out although amniotic membrane has many advantages as a substrate for limbal stem cell culture, including its anti-inflammatory and antiangiogenic properties, it also has a lot of disadvantages including its semi-opacity, supply problems and biological variability between donors.

Don’t miss Practice Development, see page 36 EUROTIMES | Volume 17 | Issue 3

substrate is designed to have all properties that an ideal material would need in order to generate functional epithelial tissue for transplantation to patients’ diseased or traumatised corneas. Those properties include reproducibility, ease of preparation under aseptic conditions, transparency and the ability to allow the formation and maintenance of a multilayered epithelium with a basement membrane and a mixed population of differentiated and undifferentiated cells. The cells also need to form cell-to-cell junctions so that the resulting tissue will act as a protective membrane.

Dr Levis and her associates prepare the collagen-based substrate through a process called plastic compression, wherein they compress the rat-tail derived collagen hydrogel between two nylon meshes, with a glass plate pressed down with a weight on top of it. The process reduces the thickness of the hyperhydrated collagen from around 6.0mm to about 100 microns thick. The result is a membrane that is strong and easily manipulated, unlike collagen hydrogels that have not been processed in this way.

“It’s a simple process, but the advantage of this plastic compressed collagen gel is that it is a highly reproducible substrate, because it’s just collagen and cells and the cells are seeded directly into the hydrogel before compression unlike other scaffolds, which usually require a lengthy wait for the cells to populate the scaffold. The process can be repeated every time; there is no variation as seen with amniotic membrane. This construct also has many tuneable properties, you can change the thickness, the collagen density, form it into any shape you like and you can also modulate the surface topography,” she noted.

Prior to performing the compression, Dr Levis and her team populate the collagen gel with human limbal fibroblasts. The fibroblasts appear to play an integral role in the development of the differentiated epithelial layers. The cells survive the compression process and continue to divide afterwards. Once the substrate is prepared, a single cell suspension of cultured limbal

Hannah Levis – h.levis@ucl.ac.uk

“

In our hands, 40 per cent of those amniotic grafts with epithelial stem cells failed before they even got to the patients...

Hannah Levis PhD

cells is placed on its surface, which stays submerged for three weeks after which it is brought to the surface and exposed to air.

“The resulting constructs are relatively transparent and they have enough mechanical strength to withstand being sutured to the surface of an eye and maintained even under quite harsh mechanical treatment,” Dr Levis noted.

Natural appearing epithelial layers Experiments conducted thus far

have demonstrated that the epithelial stem cells grown on the compressed, fibroblastenriched collagen construct develop the same types of cells and cell layer arrangement as is the case in the natural corneal epithelium.

That is, transmission electron microscopy and scanning electron microscopy confirmed that there were more cuboidal-like cells on the basal layer and more squamous-like cells on the surface. “The cells are highly interdigitated, and desmosome junctions form between the cells, which is an indication of a mature epithelium that will act as a barrier. The scanning electron microscopy images show that there are smooth polygonal cells on the surface with many microvilli, indicative of a healthy epithelium.”

She noted that the cells’ immunohistochemistry mirrored their morphology. For example, cytokeratin 3, a differentiated corneal epithelial marker, was highly expressed in the squamous-like cells on the surface layer but was not expressed in the cells in basal layer. Similarly, p63alpha, a putative stem cell marker was highly expressed in the cells of the basal layer but not in the surface squamous-like cells.

“We conclude that this plastic compressed collagen is a suitable substrate for limbal epithelial stem cell culture for transplantation and this could be a possible replacement for amniotic membrane and could also form the basis for a corneal epithelial model which would be very useful for studying the interactions between cell types.” nThis study was undertaken in collaboration with TAP Biosystems, funded by the Technology Strategy Board.

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

For more information, visit: www.SymptomaticVMA.com 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.

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ThromboGenics NV | Gaston Geenslaan 1, B-3001 Leuven, Belgium | Tel: +32 (0) 16 75 13 10 | Fax: +32 (0) 16 75 13 11

OCRVMA004 R1

Update

cataract & refractive

Promising results

Secondary spherical aberration adjustment basis for advanced aspheric monovision technique

by Cheryl Guttman Krader in Vienna

contact

16

Pablo Artal – pablo@um.es

“

All of our patients were very happy with their outcomes.

However, dissatisfaction can occur if the refractive or SA target is not properly achieved

Courtesy of Pablo Artal PhD

Pablo Artal PhD

“ Combining the procedure with pre-treatment evaluation using the Adaptive optics visual analyzer developed by Voptica SL to fully customise the induced SA would be an amazing next step”

S

econdary aspheric treatment of the Light Adjustable Lens (LAL, Calhoun Vision) to create an optimised form of monovision provides patients with excellent visual acuity for most distances and allows for spectacle independence, reported Pablo Artal PhD, at the XXIX Congress of the ESCRS. The procedure has been dubbed “advanced aspheric monovision” to distinguish it from standard monovision, which is based on inter-eye differences in refraction. It involves bilateral implantation of the LAL. The dominant eye is treated for near emmetropia and zero spherical aberration (SA) to optimise distance vision. The nondominant eye is made to be slightly myopic and to have some negative SA that results in increased depth of focus and enables good uncorrected near vision.

Dr Artal presented results from the first 14 patients treated with advanced aspheric monovision. All of the surgeries and light treatments were done by Jose Maria Marín MD, Department of Ophthalmology, Hospital Virgen de la Arrixaca, Murcia, Spain.

Measurement of refraction and spherical aberration to guide the light adjustment procedures was performed using a Hartmann-Shack wavefront sensor. Post-adjustment, SA measured with a 4.0mm pupil in the aspheric eyes ranged from -0.05 to -0.2 microns, and the results also showed good precision (±0.05 microns) in achieving the SA target.

UCVA testing was performed using a computer-assisted procedure with letters projected on a microdisplay placed at 10m, 60cm, 40cm, and 30cm. The monocular data

EUROTIMES | Volume 17 | Issue 3

showed good vision for distance in the dominant eyes as well as across the near and intermediate range for the non-dominant eyes, and the binocular results showed a summation effect such that binocular UCVA for all distances was equal to or slightly better than that of the better monocular result.

Spectacle independence Considering a subgroup of four patients with -0.1 to -0.2 microns of SA in the aspheric eye, 100 per cent had simultaneous UCVA better than 20/20 at 10m, J1 or better at 60 and 40cm, and J2 or better at 30cm, reported Dr Artal, professor of physics and founder and director of the Optics Laboratory, University of Murcia, Spain.

“Achieving perfect refractive outcomes was the primary goal for creating the LAL. However, the LAL technology also allows options for manipulating the optics so that it can provide good quality near vision for spectacle independence. In fact, many of the patients in this early series became spectacle independent, and we think these are very promising results,” he said.

However, even better outcomes may be achieved in the future by taking advantage of the customisation feature of the procedure, Dr Artal told EuroTimes.

“In this study, patients were treated to achieve a specific amount of negative SA in each eye based on a target range we determined in a previous study using adaptive optics.

However, this earlier research was done in normal subjects and not in patients,” he explained.

“In the near future, the target could be fully customised for each patient based on pre-treatment evaluation with an adaptive optics visual analyzer. Inducing SA specific to each patient would surely be an extremely powerful approach for providing the best quality vision and achieving optimum satisfaction.”

In performing advanced aspheric monovision, the LAL is implanted in the conventional manner with about a two-week waiting period before performing the refractive adjustments and inducing SA. Based on findings from in vitro and animal studies, two lock-in treatments are performed one or two days apart to assure that the lens is completely stable and not subject to change from environmental UV exposure.

Discussing the UCVA results in more detail, Dr Artal reported that for eyes set for distance, mean monocular UCVA was 1.2 (better than 20/20). However, not surprisingly for this monofocal lens, UCVA was worse for closer distances, decreasing to about 0.40 at 30cm. For the 14 aspheric-treated eyes, mean UCVA was still 0.9 for distance, was nearly 1.0 at 60cm, and remained better than 0.5 (20/40) at 30cm.

The power of being able to customise the amount of induced SA was demonstrated by comparing results with the patients divided into subgroups based on SA in the aspheric eye. Eyes with minimal SA (<-0.1 microns) maintained excellent UCVA for far (mean 0.96) and at 60cm (mean 1.0) and had reasonably good vision at 30cm (mean 0.50) and 40cm (mean 0.75). In the subgroup of patients with more induced SA, there was some compromise in distance vision for the aspheric-treated eye, which was reduced to about 0.8. However, mean UCVA was about 0.95 at both 60 and 40cm and 0.8 at 30cm. In binocular testing, mean UCVA was 1.0 or better at 10m, 60cm and 40cm, and about 0.8 at 30cm.

Dr Artal observed that compared with other methods of presbyopia correction, advanced aspheric monovision has several advantages. The results are much better than with standard monovision because there is less retinal disparity between eyes. In addition, the technique avoids the photic phenomenon associated with multifocal diffractive optics.

“All of our patients were very happy with their outcomes. However, dissatisfaction can occur if the refractive or SA target is not properly achieved. Therefore, obtaining accurate measurements before and during the light adjustment procedure is critical to ensure satisfactory outcomes.”

Dr Artal told EuroTimes that refinement of the algorithms for the light treatments for advanced aspheric monovision is nearly done.

“Combining the procedure with pre-treatment evaluation using the Adaptive optics visual analyzer developed by Voptica SL to fully customise the induced SA would be an amazing next step,” he concluded.

17

Update

cataract & refractive

MONOVISION

Managing patient expectations key to successful outcomes

by Dermot McGrath in Vienna

W

hile surgeons now have an array of potential solutions for presbyopia such as PresbyLASIK, multifocal IOLs and intracorneal inlays, the triedand-trusted approach of refractive laser monovision correction remains an effective technique in the longer term, Tasneem Khatib MD reminded delegates attending the XXIX Congress of the ESCRS. “Monovision works well, but rigorous patient selection criteria need to be adhered to in order to obtain optimal outcomes. While there does not appear to be any single factor that contributes to patient dissatisfaction, patients do need to be carefully counselled preoperatively and be willing to accept and adapt to visual compromises such as reduced visual acuity, loss of stereopsis and the potential need for top-up glasses for driving,” she said.

Her retrospective study included 170 patients, 137 women and 33 men with a mean age of 51.7 who underwent LASIK or LASEK procedures between 2002 and 2010 at the MDA Clinic in Cardiff, Wales. The mean follow-up time was 52 months and one surgeon performed all procedures.

“Monovision works well, but rigorous patient selection criteria need to be adhered to in order to obtain optimal outcomes” Dr Khatib emphasised that all patients were carefully counselled prior to selection. Those that had professions where binocular vision was required, for instance night-time lorry drivers, crane operators, professional tennis players and so forth, were not selected. Patients were sent questionnaires postoperatively and asked to comment on a variety of factors, including whether they required glasses for tasks such as driving, reading, television and general routine activity.

Among eyes that were targeted for near vision 88 per cent achieved N5 or EUROTIMES | Volume 17 | Issue 3

better unaided vision. In eyes targeted for distance correction, 99 per cent achieved 6/12 or better uncorrected visual acuity, which is the legal requirement for driving in the UK. Five patients (2.9 per cent) required enhancement and three (1.75 per cent) required reversal of monovision. Of the 170 patients who underwent surgery, 101 responded to the patient satisfaction questionnaire. Of these, 74 patients reported their vision to be as they expected or better than expected, while 27 patients reported their vision to be less than they expected.

Looking at these groups in greater detail, Dr Khatib noted that the number of myopes and hyperopes were similar across both groups as was the age profile and male-female ratio. There did not appear to be any single activity either for distance or near work from those measured that was significantly affected in the patients reporting less than expected vision compared to those who were satisfied with their postoperative vision.

In terms of time needed to adapt to monovision, the majority of patients adapted to monovision within three months of having had the surgery. One per cent of patients in both satisfied and non-satisfied groups required glasses for routine activities, while 12 per cent of the less satisfied group required glasses for driving compared to nine per cent in the satisfied group.

Summing up, Dr Khatib emphasised that managing patient expectations holds the key to successful outcomes in monovision procedures.

“While there did not seem to be any one factor in particular which contributed to patient dissatisfaction, out of the ones we measured we think that patient expectations need to be carefully considered, and they need to be carefully counselled and selected preoperatively and be prepared to accept certain compromises in their vision such as loss of stereopsis or the potential need for top-up glasses until better techniques become more widely available,” she concluded.

contact Tasneem Khatib – tasneem.khatib@lmh.ox.ac.uk

Update

cataract & refractive

MULTIFOCAL IOLS

Data from short follow-up in small patient series show favourable functional outcomes

by Cheryl Guttman Krader in Vienna

contacts

18

Matteo Piovella – piovella@piovella.com Georgina Rosca – roscageo@yahoo.com Alfredo Vega-Estrada – alfredovega@vissum.com

“

These data suggest posterior capsule opacification (PCO) development may be minimised with the SeeLens.

However, longer follow-up is needed to assess PCO

Courtesy of Georgina Rosca MD

Alfredo Vega-Estrada MD

T

hree new multifocal IOLs with novel optic designs may come closer to delivering spectacle independence, with fewer problems typically associated with current lenses in this category, reported researchers at the XXIX Congress of the ESCRS. Georgina Rosca MD, Nantes, France, reported outcomes with the OptiVis MFIOL (Aaren Scientific). The multifocal surface of this lens lies on the posterior aspect and comprises three zones, a 1.5mm central zone of progressive refractive powers, an apodised diffractive zone between 1.5 and 3.8mm with a 2.5 D effective add for near, and a peripheral refractive zone shaped for bi-sign aspherization.

The optic’s design aims to provide far, intermediate and near foci, minimise light loss at all pupil sizes to improve contrast sensitivity and reduce night vision disturbances, and allow optimal image quality even if the lens is tilted or decentred.

Dr Rosca reported results from 20 patients bilaterally implanted with the OptiVis MFIOL. Six-month followup was available for 16 eyes. Uncorrected distance visual acuity (UCDVA) was 20/20 or better in nearly half of eyes at one week and in 95 per cent of eyes at six months. Bestcorrected distance visual acuity (BCDVA) was 20/25 in 91 per cent of eyes at one month and 20/20 or better in 81 per cent of eyes at six months. By one month, near UCVA was

“

With all diffractive multifocal IOLs we are facing penalisation related to contrast sensitivity up to 30 per cent, and so it is important to achieve a plano result Matteo Piovella MD

EUROTIMES | Volume 17 | Issue 3

20/25 or better in 90 per cent of eyes while 56 per cent of eyes had uncorrected near visual acuity of 20/20 or better at six months. Intermediate UCVA was 20/25 or better in 80 per cent of eyes at one month and 20/25 or better in all eyes seen at six months.

At three months, no patients suffered severe haloes or night glare. Haloes and glare were absent in about two-thirds of patients, while only four per cent reported moderate haloes and 5.6 per cent reported moderate night glare.

Mesopic and photopic contrast sensitivity testing was done in six patients, and the results were good, except photopic contrast sensitivity at high spatial frequencies was reduced in patients aged 70 and older.

Promising results Questionnaire results showed 98 per cent of patients reported never wearing glasses, 96 per cent were mostly or completely satisfied with their vision without glasses during the day, and 87 per cent were mostly or completely satisfied without glasses at night.

“These are promising results, and the intermediate vision outcome is particularly impressive. Now we are waiting for the hydrophobic acrylic version of this lens,” said Dr Rosca.

Matteo Piovella MD, Monza, Italy, reported “promising” results from a series of 12 eyes of 12 patients implanted with the FIL 611 PV MFIOL (Review, Soleko). It is an aspheric plate lens with a near add of +3.75 D concentrated in the central 1.48mm of the optic, the optic periphery (from 2.48 to 6.0mm) is dedicated to distance vision, and the two areas are linked by an aspherically curved midzone dedicated to intermediate vision.

For the 12 eyes, mean SE was -0.45 D preoperatively and 0.06 D at three months. At three months, mean UCDVA was 0.92, mean UCNVA was J2.08, and mean CDNVA was J1.17 with +1 D sphere.

Dr Piovella mentioned there is also a multifocal toric version of the Review IOL (FIL 611 PVT) with a cylinder range from +1.00 to +6.00 D in 0.5 D steps. The lens is

“customised” at the time of manufacture as the cylinder axis is set during production and shown in a technical drawing packaged with the IOL. Due to this technology the lens is implanted always at 0/180 degree (temporal corneal incision) and does not require any rotation to get the proper astigmatic axis. “With all diffractive multifocal IOLs we are facing penalisation related to contrast sensitivity up to 30 per cent, and so it is important to achieve a plano result. Experience shows that a small amount of residual sphere and or astigmatism is responsible for patient complaints,” noted Dr Piovella. “A residual refractive error equal or over 0,75 spherical equivalent result, causes one line of visual acuity loss”.

Alfredo Vega-Estrada MD, Alicante, Spain, reported positive results from a series of 24 patients implanted bilaterally with the SeeLens MFIOL (Hanita), a hydrophilic aspheric apodised diffractive IOL with a +3 D add that can be implanted through a 1.8mm incision. Preoperatively all eyes had less than one dioptre of corneal astigmatism.

Mean post-op sphere was -0.07 D and mean cylinder was -0.38 D. At three months, mean logMAR UCDVA was 0.21, mean logMAR BCDVA was 0.05, mean binocular logMAR UCNVA was 0.10, and mean binocular logMAR DCNVA was 0.06. All of the values represented significant improvements from baseline. Nearly 80 per cent of patients achieved logMAR UCNVA of 0.2 (J2) and about 70 per cent achieved this level for UCIVA. Defocus curve testing similarly showed patients had excellent vision across the full distance range with just a slight decrease in intermediate vision. Photopic contrast sensitivity was close to normal and scotopic contrast sensitivity was only slightly decreased.

Compared with results published by Dr Vega-Estrada’s colleagues for two other diffractive multifocal IOLs (AcriLisa 366 D, Carl Zeiss Meditec and AcrySof ReSTOR SN6AD3, Alcon) [J Refract Surg 2011;27:570-81], the SeeLens had similar mesopic contrast sensitivity performance but superior results under photopic conditions at spatial frequencies of six, 12 and 18 cpd. There were no statistically significant differences between the three diffractive multifocal IOLs in their defocus curves, although the SeeLens had slightly better results in the intermediate range and was slightly worse for near vision.

Dr Vega-Estrada also highlighted the unique 360-degree double square edge optic of the SeeLens.

Based on a method described by Werner et al. to evaluate IOL microedge structure [J Cataract Refract Surg 2009;35:556-66], the SeeLens was closer to a perfect square configuration than the IOL with the best edge profile in the published study.

“These data suggest posterior capsule opacification (PCO) development may be minimised with the SeeLens.

However, longer follow-up is needed to assess PCO,” Dr Vega-Estrada said.

19

Update

cataract & refractive ‘FOR ADVANCED DMEK SURGERY

new approach

Optic membranes may solve leakage and PCO problems

I FOCUS ON D.O.R.C. INSTRUMENTS’ STANDARDIZED ‘NO TOUCH’ DESCEMET MEMbRANE ENDOTHElIAl KERATOplASTY TECHNIQUE

by Roibeard O’hEineachain in Vienna

A

new approach to capsule refilling which involves the use of a pair of accommodating membranes to cover and seal an anterior and posterior capsulorhexis has produced encouraging results in animal studies. The method appears to provide around 2.5 D of accommodation while leaving the optical axis clear, said Okihiro Nishi MD, Nishi Eye Hospital Osaka, Osaka, Japan.

“Some useful accommodation can be obtained by this refilling technique in young monkeys. This procedure solved two of the persisting problems in lens refilling, leakage of the injectable silicone and capsular opacification,” Dr Nishi told the XXIX Congress of the ESCRS. The basic concept behind capsule refilling is that the non-accommodating stiffened lens material of a presbyopic patient is replaced by a silicone liquid polymer in an empty but intact capsule.

The silicone polymerises and the elasticity of the retained capsule will then alter its shape in response to the natural physiological mechanisms of accommodation. That is, the relaxation of the zonule will cause the capsule and its contents to assume a more spherical shape.

Dr Nishi noted that early research conducted in the 1980s proved the validity of the concept in animal studies, which showed that the eye would alter its shape in response to pilocarpine injections to an amount of around 6 D. However, problems with leakage and capsule opacification have prevented the clinical application of the capsule-refilling approach.

More recently, Dr Nishi has developed a new approach to preventing leakage and capsule opacification that involves the removal of the visually important parts of the capsule and replacing them with foldable silicone membranes.

In a study involving 18 macaque monkeys, refilling the lens in this way resulted in accommodative amplitude of 2.0 D to 3.0 D, regardless of whether the capsule was filled to 80 per cent, 100 per cent or 125 per cent of its capacity. Mean refraction on the other hand was closest to

“

This procedure solved two of the persisting problems in lens refilling, leakage of the injectable silicone and capsular opacification Okihiro Nishi MD

emmetropia in eyes in which the capsule was filled to 80 per cent, with a spherical equivalent of -0.5 D, compared to -6.1 D with 100 per cent refilling and -8.8 D with 125 per cent refilling. The same held true for astigmatism, which was -1.0 D in the 80 per cent refill group, -3.7 D in the 100 per cent refill group and -6.9 in the 125 per cent refill group.

Furthermore, in a series in which rabbit eyes underwent capsule refilling with anterior and posterior accommodating membranes and anterior and posterior capsulorhexis, there was no capsule opacificationat least in the visual axis five to eight weeks after surgery, he noted.

Some of the remaining problems with the capsule-refilling approach include the improvement of the refractive predictability of the procedure. Also requiring elucidation is the impact of capsule opacification outside the optical axis on accommodation, he noted.

“The next step may be applying the procedure for a blind eye of volunteer patients and conducting postoperative examinations such as refraction, accommodation, topography, OCT, UBM, wavefront analysis, optical quality and clinical safety. Precise, exact and thorough examinations for all these parameters are not possible in monkeys but only in humans,” Dr Nishi said.

NO TOUCH DMEK FOR: Contact us to learn more or to arrange for a surgical demonstration.

D.O.R.C. International B.V. Scheijdelveweg 2 3214 VN Zuidland The Netherlands Phone: +31 181 45 80 80 Fax: +31 181 45 80 90

• FAST AND FULL VISUAL REHABILITATION • EFFICIENT USE OF DONOR TISSUE • REFRACTIVE NEUTRAL • ANATOMICAL RESTORATION OF THE CORNEA • DESIGNED AND DEVELOPED IN CLOSE COLLABORATION WITH DR. MELLES (NIIOS ROTTERDAM)

contact Okihiro Nishi – okihiro@nishi-ganka.or.jp

Don’t miss Milan Congress preview, see page 34 EUROTIMES | Volume 17 | Issue 3

109-647_ADV_DMEK_nic.indd 1

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cataract & refractive

contacts

Update

AUTOMATED IOL INJECTION

David Allen – allen401@btinternet.com Christer Johansson – christer.ptab@telia.com

“This is a valuable tool for future cataract surgery through ultra-small incisions”

Motorised injectors may stretch small incisions less than manual devices

by Howard Larkin in Vienna

Christer Johansson MD

W

hen operated at higher injection speeds, a new motorised IOL injector stretched small corneal incisions about half as much as a popular manual injector, David Allen FRCOphth, Sunderland, England, UK, told the XXIX Congress of the ESCRS. The motorised AutoSert (Alcon) device enables one-handed injection, freeing the other hand to stabilise the globe. It also eliminates the sudden drop in plunger resistance that can result in overshooting with a manual injector, Dr Allen noted.

“The device is easy to use, it allows a much greater degree of control than the Alcon Monarch III manual injector, and when used at this fast setting we find it has statistically significantly less incision stretch,” Dr Allen said.

However, more research is needed to determine if decreasing incision stretch correlates with better wound integrity and less postoperative leakage or reduced surgically induced astigmatism, he added.

As cataract surgical incisions get smaller IOL insertion challenges are growing, Dr Allen said. The AcrySof D cartridge is designed for the AcrySof IQ IOL, and is specified for incisions down to 2.4mm, or 2.2mm with incision assist. But many surgeons go lower, to 2.0mm or even 1.8mm incisions, he noted.

However, these small incisions require holding the injector tip steady against the moving wound throughout the injection, Dr Allen said.

“This can result in a rather less-thanaesthetic procedure – it is as if you are trying to push the eye through the nose into the other socket to maintain apposition so the injection doesn’t fail.”

Inserting an instrument in a sideport helps stabilise the globe. But it also requires a single-handed injector, Dr Allen said.

“The problem with a single-handed injector is that significant injection force is required to compress the lens through the small cartridge. You have to increase the pressure on the plunger, but once the lens leaves the cartridge, the force required rapidly drops off and there is a danger of overshoot.”

Studies show that up to 15 Newtons are required to push the widest part of the lens through the smallest cartridges, he added.

EUROTIMES | Volume 17 | Issue 3

Conversely, the fast auto had the lowest incidence of stretching an incision by more than 0.1mm, with four overall compared with 26 for manual and 18 for slow auto insert. For 1.9mm pre-insertion incisions, only three fast auto incisions stretched 0.1mm or more compared with seven and nine for manual and slow auto incision.

No incision 2.1mm or larger was stretched more than 0.1mm by the fast auto insertion.

Credit: Reprinted with permission from Journal of Cataract & Refractive Surgery (2012; 38:249–255).

20

IOL implantation through a 1.9mm incision. Above: Monarch injection. Considerable pressure applied to keep the tip of the cartridge in contact with the nasally rotated globe. Below: AutoSert injection. Less pressure applied because the eye can be stabilised with second instrument

The AutoSert injector was designed to apply a steady force, enabling insertion with one hand and stabilisation with the other.

Over nine months prior to its commercial release in late 2011, Dr Allen and his colleagues tested it against the manual Monarch III to determine if it stretched incisions less.

The study involved 256 patients and three injection sizes, 1.8mm, 2.0mm and 2.2mm. Eyes were injected manually, or using the automated injector at a slow speed of 1.5mm/second or a fast speed of 4.4mm/ second. To estimate incision stretch during surgery, wounds were measured at the end of irrigation and aspiration, and again after the lenses were inserted.

For pre-injection incisions of 1.9mm, the mean enlargement with manual injection was 0.17mm, with slow auto injection 0.14mm and fast auto injection 0.10mm.

The difference between the manual and fast auto result was statistically significant, Dr Allen reported. Similar results were observed with larger incisions, with a 2.2mm pre-injection wound stretching a mean of 0.11mm manually and 0.04mm with fast auto.

Overall, 42 fast auto insertions resulted in no incision enlargement, compared with 15 for slow auto and eight for manual. Even through the smallest 1.9mm incisions, the fast auto sometimes created no enlargement while the slow auto and manual always did.

Added seconds Studies presented by Christer Johansson MD, Kalmar, Sweden, largely confirmed Dr Allen’s findings. In a study of 30 eyes with IOLs inserted with a manual Monarch III and 30 eyes with the AutoSert at 2.5mm/second, all with 2.0mm incisions, the automated eyes had less mean wound stretch after insertion, about 0.05mm vs. 0.11mm. Mean incisions size and wound stretch differences were statistically significant at p<0.001, Dr Johansson said.

However, automated insertion at 2.5mm/ second took longer than manual by about 14 seconds, with a mean of 38.7 seconds compared with 25.1 seconds, he noted.

In a second study, Dr Johansson also found that speeding up auto insertion to 4.4mm/second reduced wound stretch.

In two groups of 30 patients each, lenses inserted at 4.4mm/second had a mean wound stretch of 0.020mm compared with 0.056mm for those inserted at 2.5mm/ second, a statistically significant difference at p<0.01.

Dr Johansson also examined the impact of pause time – the time the automated injector pauses between loading the lens in the cartridge and injecting it into the eye.

At an injection speed of 2.5mm/second, he found no significant difference in wound stretch between a 1.0 second pause and a 3.0 second pause, though mean wound size and stretch were slightly larger in the 3.0 second group.

Dr Johansson noted that the automated injector is controlled by a foot pedal, leaving both hands free to stabilise the globe. The learning curve is short and it simplifies lens insertion. “This is a valuable tool for future cataract surgery through ultra-small incisions.” He echoed Dr Allen in calling for further study on how injection techniques affect wound integrity, appropriate wound architecture and the impact on surgically induced astigmatism.

Update

21

th ne, 2012 Friday 15 Ju nce Optical Cohere CT) Tomography (O

cataract & refractive

Saturday 16th

June, 2012 UBM & Ultrasound Im aging

SUPPLEMENTARY IOLS

Instructional Courses from Theory to Practice

New IOL designs herald renaissance of add-on lenses

by Roibeard O’hEineachain in Vienna

T

wo types of IOL designed specifically for supplementary implantation into the sulcus, the Rayner Sulcoflex® and the Humanoptics MS714, appear to provide a safe and effective alternative in the treatment of refractive surprises after cataract surgery, and can also provide a more easily reversible form of multifocal pseudophakia, said Michael Amon MD, Academic Teaching Hospital of St John, Vienna, Austria.

“Peer-reviewed studies show that both lenses are very biocompatible. They show that there is 100 per cent clearance of the IOL between the lens and the uveal tissue.

There was also excellent rotational stability and excellent visual results and there were no serious intraoperative or postoperative complications,” Dr Amon said at the XXIX Congress of the ESCRS. Dr Amon noted that the lenses offer a greater level of safety and predictability compared with standard IOLs implanted as add-on lenses in the capsular bag or sulcus. For example, there is no danger of interlenticular opacification because of their position in the sulcus, he said. Moreover, unlike biconvex conventional IOLs, their concave posterior surface does not press against the posterior chamber IOL, which can distort the shape of both lenses and cause a hyperopic defocus.

The two sulcus-fixated lenses both come in aspheric monofocal, multifocal, toric and multifocal toric versions.

The Humanoptics lens is a three-piece lens with a silicone optic and PMMA haptics. The Rayner lens is a single-piece lens composed of hydrophilic acrylic. The materials of both lenses are very well tolerated within the uveal tissue in terms of foreign body giant cell reactions. Both lenses have large optics, 6.5mm for the Rayner and 7.0mm the Humanoptics lens. They therefore cover the whole of the primary lens, he pointed out.

Furthermore, both lenses also have round edges to reduce photic phenomena. The haptics of both lens types are 14mm and have an undulating design to insure centration and rotational stability, and an angulation designed to insure uveal and iris clearance and prevent the inflammatory reactions and pigment dispersion that can occur when conventional IOLs are implanted in the sulcus.

Studies demonstrate safety and efficacy Dr Amon noted that in a study involving 92 eyes of patients with mean age of 53.4 years who underwent implantation of the Sulcoflex IOL, the mean postoperative uncorrected visual acuity was 0.92 at a mean follow-up of 42 months and all eyes were within 0.25 D of intended refraction.

Furthermore, there were no intraoperative complications and the procedure appeared to be only minimally traumatic.

Intraocular pressure at final follow-up ranged from 11.0 mmHg to 22.0 mmHg and laser flare cell metre counts ranged from 5-30 photon counts/ms, which was less than after phacoemulsification during the primary IOL procedure. In addition there was no evidence of iris trauma, pigment dispersion or interlenticular opacification.

PARIS- FRANCE

Moreover, in all cases of OCT, Scheimpflug imaging and ultrasound biomicroscopy showed positive distances between the supplementary IOL’s anterior surface and the iris and between the posterior surface of the add-on lens and the anterior surface of the IOL in the capsular bag.

Furthermore, IOL stability and rotation were also very good in the majority of cases although in three per cent of eyes there was a rotation of more than 10 degrees (J Cat Refract Surg 2010; 7:1090-1094).

Patients implanted with the diffractive multifocal version of the Humanoptics lens achieved very similar results in a study involving 73 eyes carried out by Georg Gerten MD and associates in Koln Germany, Dr Amon said. The patients in the study underwent implantation of both the primary IOL in the capsular bag and the diffractive multifocal version of the Humanoptics sulcus-fixated IOL in the same procedure.

At a follow-up of 18 months, the patients’ mean monocular uncorrected distance visual acuity was 0.10 logMAR, and their mean uncorrected near visual acuity was 0.16 logMAR. Furthermore there were no major complications, no interlenticular opacification, and no iris trauma. Some pigment dispersion occurred in five cases but it resolved in three months. ( J Cat Refract Surg 2009; 35: 2136-2143.)

Surgery easy and reversible Dr Amon said that implantation of the Sulcoflex and Humanoptics supplementary IOLs is a fairly simple procedure. Injectors are available for both lens type and they can also be implanted with forceps, he noted. He generally implants the lenses through a 2.75mm incision, although an injector for implantation through a 1.8mm incision is available for the Sulcoflex.

Furthermore, unlike IOL exchange, the ease of surgery and the quality of the results with supplementary IOLs are not affected by the changes that occur to the capsular bag during the first few months after primary IOL implantation.

In addition, unlike LASIK, the results are reversible. The sulcus-fixated design also lends itself well to use in the growing eyes of paediatric patients, since the lenses can be easily exchanged, without resorting to capsular surgery.

Moreover, the supplementary IOL approach also offers surgeons and their patients a more reversible approach to pseudophakic multifocality, Dr Amon said. Multifocal versions of the lens are available in versions with no affect on the distance focus of the primary intracapsular IOL, he noted. Therefore, if the patient is unhappy with their multifocality, only the sulcus fixated lens has to be removed and no further surgery is necessary.

“I think that these supplementary IOLs are effective for enhancement of the surgical result in pseudophakic eyes or for primary duet implantation with conventional IOLs,” Dr Amon concluded.

contact

Wetlabs with the experts for ophthalmologists and technicians

Dear Colleagues, I invite you to attend these english courses dedicated to ophthalmic imaging.

Dr Michel Puech, MD, FRCS

Program, information and registration: www.vuexplorer.fr VUEXPLORER INSTITUTE 4, rue des Grandes Terres 92500 Rueil-Malmaison (France) Tel : +33 1 40 26 30 30 contact@vuexplorer.fr

Michael Amon – amon@augenchirurg.com

EUROTIMES | Volume 17 | Issue 3 AP 80X300.indd 2

31/01/2012 16:20

Update

cataract & refractive

contact

Pascal Rozot – pascalrozot@sfr.fr

MULTIFOCAL DISSATISFACTION

Solutions are available for most causes of unsatisfactory visual outcomes

By Roibeard O’hEineachain in Vienna

M

ost patient complaints following multifocal IOL implantation are easily treated, although a small percentage need a specific and more complex management, said Pascal Rozot MD, Clinique Monticelli, Marseille, France at the XXIX Congress of the ESCRS. Poor patient satisfaction with multifocal IOLs can result from a wide range of causes, some temporary, such as eye dryness and inflammation during the early postoperative period, and some more persistent, such as residual ametropia, PCO, and intolerance of multifocality, Dr Rozot noted.

But so long as the physician can accurately diagnose the cause of the problem, a solution that results in a happy patient is almost always possible, he added.

Spherical error Residual ametropia is the leading cause of patient dissatisfaction with multifocal IOLs, accounting for 65 per cent of complaints. Spherical error in general results in blurred uncorrected vision and so greatly reduces patients’ spectacle independence, he noted.

Residual myopic error not only reduces uncorrected distance visual acuity but also increases the intensity of haloes, and requires patients to bring reading material closer to their eyes. Residual hyperopic error, conversely, will require patients to hold reading materials further away, although it sometimes has the benefit of improved uncorrected intermediate vision.

Making a determination of residual refractive ametropia following multifocal implantation requires a wait of two weeks postoperatively to insure that the patients’ vision has stabilised adequately. It is also better to use subjective refraction because autorefractometry sometimes induces a myopic shift.

In eyes with residual myopia, refractive errors of 0.5 D or less are best left untreated, said Dr Rozot. Corneal surgery such as PRK or LASIK remain a useful option in eyes with refractive errors ranging from -0.5 D to -1.5 D. For eyes with greater residual myopia, the main options are IOL exchange, if the multifocal IOL was implanted less than two months earlier, and piggy back IOLs, if the IOL had been implanted a longer time previously.

EUROTIMES | Volume 17 | Issue 3

“There are currently many well-performing and well-tolerated multifocal IOLs and it remains a premium surgery for all levels of procedure” Dr Rozot recommended a similar strategy in eyes with residual hyperopia, although he said hyperopia of +0.75 D should be the upper limit for withholding any further intervention in the nondominant eye. If the residual hyperopia is in the dominant eye, hyperopic PRK is again a possibility. However, in the case of three-piece multifocal IOLs another option is optic capture in the capsulorhexis. The technique brings the optic forward and thereby reduces the hyperopic error. For higher refractive errors the options are the same as in residual myopia.

Problems with astigmatism are less common since the advent of toric multifocal IOLs. However, when it does occur, PRK or LASIK is again an option for lower refractive errors in the dominant eye, and piggy back toric IOLs (Figure 1) offer a potential solution in eyes with higher amounts of cylinder.

PCO problems PCO vies with residual ametropia as a leading cause for visual complaints following multifocal IOL implantation, accounting for more than half of dissatisfied patients in some series.

Research has shown that minor amounts of PCO that would not bother most patients with monofocal IOLs can be very disturbing to patients with multifocal IOLs (Figure 2a).

Surgeons should therefore be especially scrupulous in avoiding the complication in their multifocal patients, making sure to carry out a thorough capsule polishing during surgery, Dr Rozot emphasised.

Tests for the impact of PCO can include pinhole visual acuity measurements and OQAS double-pass aberrometry (Figure 2b). When Nd-YAG capsulotomy becomes necessary it is best to use a large 5.0mm,

cross-opening, beginning at periphery, to avoid marks on the optic and to reduce photic effects.

One rare but very persistent problem that can occur in some patients is intolerance of the split-vision optics of multifocal IOLs. The complication can occur in eyes where there are no objective signs of residual refractive error, or IOL decentration or tilt. It may have a neurological basis, Dr Rozot said.

“One hypothesis is that an imperfect blurred retinal image secondary to the multifocal pattern of the IOL increases the activation in the visual association areas of the occipital cortex, Dr Rozot said.

Removing the lens and replacing it with a monofocal lens improves visual satisfaction in 80 per cent of cases, but as with IOL exchange in general, it does entail the risks of inducing macular edema and other complications, he added.

Photic effects, dysphotopsias Since their earliest days back in the late 1980s, multifocal IOLs have been associated with an increased amount of photic phenomena such as glare, haloes, and ghost images.

Careful counseling of patients before and after surgery is generally adequate to relieve patients’ anxiety since the symptoms tend to become much less noticeable over time, Dr Rozot said.

Haloes occur in 10 to 20 per cent of patients, although they have become less common and less intense with modern IOLs, he noted. In the majority of cases patients no longer notice them after the first few postoperative months. However, they can be more bothersome in patients with photopic pupils greater 3.5mm in diameter. In such cases topical brimonidine can reduce the symptom, due to its pupilconstricting affect in scotopic or mesopic conditions, he added.

Ghost images are a rarer photic phenomenon and are generally the result of decentered IOLs (Figure 3). Re-positioning the IOL or exchanging it with another multifocal IOL will generally result in a satisfactory outcome, Dr Rozot added.

“There are currently many wellperforming and well-tolerated multifocal IOLs and it remains a premium surgery for all levels of procedure. Therefore pre-, intra- and postoperative support must be as precise as possible,” he concluded.

Figure 1: Add-On Torica IOL

Figure 2a: PCO developed on an AT.LISA IOL

2b: OQAS assessment of PCO: increase of the ocular scattering index (OSI)

Courtesy of Pascal Rozot MD

22

Figure 3: decentred multifocal IOL

23

Update

The moment you see your patient’s new vision matches her youthful attitude.

This is the moment we work for.

glaucoma

lens of choice

Cataract patients with glaucoma require special consideration regarding lenses

by Roibeard O’hEineachain in Vienna

P

remium IOLs are suitable for patients with glaucomatous disease, but there are certain cases where they can cause problems and multifocal IOLs are probably to be avoided in most glaucoma patients, said Jean-Philippe Nordmann MD, Hôpital des Quinze-Vingts, Paris, France, at the XXIX Congress of the ESCRS. Advances in cataract surgery and IOL design mean that emmetropia is routinely achieved for cataract patients who are without ocular co-morbidities. Aspheric and toric IOLs can further enhance cataract patients’ vision and newer multifocals can provide complete spectacle independence in the majority of cases, he said.

However, a different situation prevails in patients with glaucoma or ocular hypertension. In cases of combined surgery phaco and trab, it is not always possible to evaluate preoperatively the post-op astigmatism. The relative loss of vision with multifocal IOLs may actually increase the perception of glaucomatous visual impairment, Dr Nordmann pointed out.

“Glaucoma involves some specific types of structural and functional impairment.

For example, glaucoma patients can have significant reduction in contrast sensitivity, correlated with visual field changes, especially in advanced cases. We know well now that when choosing a lens the contrast sensitivity achieved is very important.”

Surgical challenges Glaucomatous disease can make cataract surgery more complicated in several ways, Dr Nordmann said. For example, in some cases, especially in angle closure glaucoma, there will be poor pupillary dilatation and bad quality pupillary function. That is particularly true in patients who have received pilocarpine for an extended period and those who have undergone laser iridotomy, he noted.

In pseudoexfoliative and in traumatic glaucoma, the zonule is often fragile which necessitates special care during surgery and limits the choice of IOL, he said. In addition, anterior chamber depth and axial length may be reduced after filtration surgery or combined surgery. Those changes require consideration when calculating IOL power, especially in patients with high myopia, in young patients, and in patients with very high preoperative IOP as it is the case with EUROTIMES | Volume 17 | Issue 3

angle closure glaucoma. “The choice of the implant in such cases should probably target a slight myopia of half a dioptre to one dioptre in order to reach a normal value due to this reduction of the size of the eye after filtration surgery,” Dr Nordmann said.

Aspheric lenses are designed to improve contrast sensitivity especially under mesopic and scotopic conditions by compensating for the positive spherical aberration of the cornea. They can be of benefit to glaucoma patients who may have reduced contrast sensitivity. However, the vision enhancing effect of most aspheric lenses is dependent on good centration. Aspheric lenses are contraindicated in patients at risk of poor centration, such as eyes damaged by trauma, where they cause distortions of vision.

Multifocal lenses are a good option for some patients because they can eliminate the need for spectacles for near or distance vision. However, since they work by dividing the light between two different focal points, they reduce the contrast of both images.

In glaucoma patients they can add to any reduction in contrast sensitivity that is present or will occur in the future as the disease progresses. Multifocal IOLs can make the monitoring of patients’ glaucoma difficult because they can produce OCT artefacts.

Toric IOLs can be an option in many astigmatic glaucoma patients, but should be avoided in some patients with advanced pseudoexfoliative glaucoma because of their zonular instability. Nor should they be used in eyes undergoing a combined phacoemulsification and trabeculectomy procedure, because astigmatism following such operations is unpredictable, he said.

Taking some of the main types of glaucomatous disease individually, Dr Nordmann said that patients with very stable ocular hypertension are suitable for all the same types of IOLs available to cataract patients without co-morbidities. The same is true for patients with early glaucoma that has been stable for a long time, he added.

However, in patients with moderate or advanced glaucoma, multifocal IOLs should be avoided, he stressed. He added that a surgeon often has no way of knowing whether a patient’s glaucoma is truly stable or will progress in the future.

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27.01.2012 09:50:37

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24

Update

glaucoma

IOP CONTROL

Round-the-clock IOP monitoring devices move closer to clinical reality

by Dermot McGrath in Paris

W

hile continuous intraocular pressure monitoring is not a new idea, the rapid pace of technological change in recent years means that 24-hour IOP measurement is now a feasible goal and will likely have a major impact on clinical management of glaucoma in the near future, according to a study presented here. “Continuous IOP monitoring has been around for at least 50 years and people have been probably dreaming about it for even longer than that,” Arthur J Sit MD told delegates attending the World Glaucoma Congress. “Permanent and temporary monitoring are two different paradigms that will likely have different but complementary uses. Advances in technology are coming very rapidly with some of the first devices for 24-hour IOP monitoring already on the market and when we fully integrate these into our clinical practices I think this will have a major impact on how we treat our glaucoma patients,” he added.

Dr Sit, associate professor of ophthalmology at the Mayo Clinic in Rochester, Minnesota, said that there is now a growing body of evidence highlighting the importance of round-the-clock IOP

monitoring in glaucoma patients.

“Several studies have now shown that IOP tends to fluctuate during the day and jumps up significantly at night-time.

What is particularly interesting about this pattern is that the elevation of IOP at night-time corresponds to a decrease in systemic blood pressure at night that occurs in most individuals. It is certainly possible that exaggerated nocturnal IOP peaks combined with exaggerated systemic blood pressure dips may compromise optic nerve head perfusion in certain susceptible individuals and increase the risk of glaucoma development and progression,” he said.

Dr Sit identified several different approaches to measuring 24-hour IOP, including sleep laboratories, self-tonometry, temporary continuous IOP measurement and permanent continuous IOP measurement.

While self-tonometry is technically the easiest method of monitoring daily IOP fluctuation, enabling patients to monitor their IOP over time with devices outside the clinic, it does not allow for nocturnal IOP measurement, said Dr Sit. Focusing his talk on the latter two approaches, Dr Sit said that temporary

True COMICS

continuous IOP monitoring, which could be useful for less advanced glaucoma cases, has a long history dating back to David Maurice’s indentation tonometer in 1958.

Although a clear advance on previous efforts to developed automated recording of IOP, Maurice’s technology was not suitable for widespread clinical use, he said.

More recent evolutions in this field have proved more promising, said Dr Sit, citing the work of Leonardi et al in using soft contact lenses to detect changes in the radius of curvature of the cornea with IOP.

More studies needed Dr Sit noted that this technology has been integrated into a commercial device, the Triggerfish system (Sensimed AG), available in Europe and undergoing FDA trials in the US. The Triggerfish sensor is described as a singleuse device with passive and active strain gauges embedded in a silicone contact lens to monitor fluctuations in the radius of curvature of the cornea. The output signal is sent wirelessly to an adhesive antenna worn around the eye, which is connected to a portable recorder through a thin flexible wire.

Dr Sit said that more studies needed to be done on the calibration and validation of such systems before they could become a routine part of glaucoma management.

In terms of permanent continuous monitoring of IOP, suitable for more advanced glaucoma cases, this concept also has a long history, said Dr Sit, referring to the pioneering research of Dr Collins and his “bubble tonometer’’ in 1967.

“He developed a capacitive pressure sensor that could be implanted into the eye. The

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EUROTIMES | Volume 17 | Issue 3

Arthur J Sit – sit.arthur@mayo.edu

circuit of the sensor consisted of a pair of parallel spiral coils encased within a gasfilled plastic pill, and the idea was that the distance between the two coils would change according to pressure fluctuations. It was very cumbersome to use, however, and its use never extended beyond rabbits,” said Dr Sit. More recent technology developed by Schnakenberg and colleagues holds greater promise for continuous IOP monitoring, said Dr Sit. “The technology is basically an IOL with integrated pressure sensors that are combined with a microchip to digitally transmit IOP data. This approach should overcome a lot of the signal problems that are associated with other types of devices and there is a lot of active research going on in this particular field,” he said.

In terms of how the data derived from the latest generation of monitoring devices might improve day-to-day management of glaucoma patients, Dr Sit said it would potentially enable more targeted treatments for individual patients. “We now know that latanoprost has a significant pressure lowering effect over the entire 24-hour period while timolol has good effect in the day but not at night. Similarly, brimonidine given three times a day has good efficacy during the day but not at night. If we know that a patient is experiencing IOP peaks during the night, we can alter the therapeutic regimen to take account of that factor and hopefully reduce the risk of disease progression,” he said.

In the future, Dr Sit said that such data could also be potentially combined with active implants capable of delivering IOP lowering drugs directly into the eye over sustained periods of time.

ESCRS GLAUCOMA DAY Friday 7 September 2012 Milan, Italy

Registration: 2200

Scientific programme organised by

www.escrs.org

26

Report

16th ESCRS WINTER meeting

WINTER MEETING IS EVOLVING

T

he 16th ESCRS Winter Meeting in Prague has continued the improvements made in both the format and content of the recent meetings held in Budapest in 2010 and Istanbul in 2011.

“The first winter meetings held in the late 1990s were almost entirely dedicated to refractive surgery,” he said, “and the main autumn meeting was predominantly a cataract meeting. In recent years, the thrust of the winter meeting has evolved and I think it has evolved very much for the better,” said ESCRS president Peter Barry.

Dr Barry pointed out that the society had made a commitment to hold the winter meetings in emerging European countries that in the past might not have had the opportunity to host major international meetings. “The winter meeting now has a similar format to the main meeting

included a symposium on lens surgery in glaucoma patients, free papers and basic optics, cataract and refractive courses.

The schedule on Saturday February 4 included symposia on anterior segment complications and correction of irregular astigmatism, live surgery organised by the Czech Society and cornea, refractive and cataract courses. The meeting concluded on Sunday February 5 with free papers, a Czech Society session and a symposium on evaluation of visual performance.

in terms of symposia, free papers, instructional courses and wet labs,” he said.

“It might be somewhat more didactic than the main meeting but it also has innovative components similar to our main meeting.”

Industry Support Dr Barry said the ESCRS was also very grateful that the international industry had continued to support the winter meeting to ensure that there was a lively trade exhibition at the meeting.

“The meeting is becoming more important in its own right,” he said, “and it is providing excellent opportunities for local ophthalmologists for practising and training. We also introduced lower registration fees for delegates from the countries close to Prague so that it is more economic and convenient for them to attend the meeting.”

ESCRS president Peter Barry is welcomed to the 16th ESCRS Winter Meeting in Prague by Pavel Studeny, ESCRS Board member from the Czech Republic

An indication of the success of this initiative is the fact that more than 100 delegates from the Czech Republic attended this year's meeting in Prague, compared to seven attendees from that country in 2011.

Scientific Programme The meeting opened on Friday February 3 with the Annual Cornea Day co-hosted by ESCRS and EuCornea. Other first-day highlights

iLearn Another important initiative announced at this year’s meeting was the launch of iLearn, the new e-learning solution for ESCRS members.

“I think this new e-learning initiative underscores the commitment of the ESCRS to serve its members by offering them the means to acquire new knowledge and keep abreast of developments in a field that is constantly evolving,” said ESCRS Education chairman Paul Rosen.

“We all recognise the importance of keeping our surgical skills and knowledge up to date for the benefit of our patients. iLearn will go some way towards enabling us to do that,” he said.

DMEK AND CORNEAL TRANSPLANTATION Descemet’s membrane endothelial keratoplasty (DMEK) is emerging as the best technique for eyes requiring cornea transplantation because of endothelial dysfunction and taking a little extra care in each stage of the procedure can make it a lot easier, said Friedrich Kruse MD, University of Erlangen, Germany.

Dr Kruse, delivering the Keynote Lecture at the Annual Cornea Day, noted that endothelial keratoplasty offers the advantage of an unchanged anterior corneal surface and therefore better visual outcomes. However, results with Descemet’s membrane stripping automated endothelial keratoplasty (DSAEK) have been somewhat marred by the stroma-to-stroma interface.

Better visual results have been achieved with DMEK, in which only the Descemet’s membrane and the corneal endothelium is transplanted. However, many surgeons find the technique technically difficult. Dr Kruse told the congress that many of those difficulties can be largely overcome through the use of stepwise approach to patient selection, donor tissue preparation and implantation surgery.

The ideal patients for surgeons who are just learning the technique include those with myopia or emmetropia and those with larger than normal corneal diameters. Patients best avoided are those with shallow anterior chambers,

EUROTIMES | Volume 17 | Issue 3

Dr Friedrich Kruse delivering the Keynote Lecture at the Annual Cornea Day

significant hyperopia, thick crystalline lenses, aphakia, iris defects or vitrectomised eyes.

When selecting donor tissue older eyes with high endothelial cell counts are best, due to the tendency of younger donor endothelial buttons to roll up excessively.

Organ cultured eyes also appear to be the best source for donor tissue, he said.

Steps to facilitate preparation of donor buttons for DMEK procedure include the placement of the corneoscleral buttons onto a suction block, such as is commonly used to prepare DSAEK tissue, in conjunction with the use of a Moria DSAEK trephination system. In addition, to prevent placing donor button upside down, he suggested making three circular marks in an identifiable order at the edge of the donor disc.

As regards the insertion of the graft, Dr Kruse said that after trying various techniques, he has found that injecting the rolled tissue with an air bubble already inside it with an IOL injector of the type used for micro-incision IOLs seems to be the best approach.

He added that his results to date seem to bear out the theory behind the technique. For example, at 12 months’ follow-up visual acuity is 20/40 or better in 90 per cent of patients and 20/25 or better in 90 per cent. However, endothelial cell density is a cause for concern, in his first patients it fell to 1420 cells/mm2 at 12 months’ follow-up.

“With this technique we can tell our patients that by three months their refraction will be stable and they can be fitted for glasses. As regards the loss of endothelial cell density this represents our learning curve and I think the results we are currently achieving are much better,” he concluded.

27

Update

Corneal Transplant

retina

MACULAR DISEASE

Diabetic macular oedema classification should focus on clinically relevant features

by Roibeard O’hEineachain in London

T

he current classification system for the staging of macular oedema is vague and is also inconsistent among researchers. An update based on clinically relevant features of the disease determined with modern diagnostic technology is therefore overdue, said Neil M Bressler MD, Wilmer Eye Institute Johns Hopkins Hospital, Baltimore, Maryland, at the 11th EURETINA Congress.

“We want to make sure we are all speaking the same language when we are talking about scientific treatments for our patients with diabetic macular oedema,” he said.

In current practice many retinal specialists classify diabetic macular oedema as being either focal or diffuse, he said. They do so on the unsubstantiated belief that focal oedema responds best to laser, that the natural course diffuse oedema is worse and that diffuse oedema responds best to steroids. However, those theories tend to fall on the first hurdle, because there is actually no consensus as to what is meant by focal or diffuse, he pointed out.

A recent review by the Diabetic Retinopathy Clinical Research Network (DRCR.NET) of 30 studies in peer-reviewed journals gave 30 very different definitions for the terms focal and diffuse macular oedema.

The examinations used in published definitions of focal and diffuse DME have been based on four methods, namely fundus biomicroscopy, colour fundus photography, fluorescein angiography, and OCT, which have findings that are not completely interchangeable and are often not completely objective, he noted.

For example, among authors using photography-based definitions the criteria might be the area of retinal thickening, but with no definite cut-off point between focal and diffuse. Others say it is the location that is most important and that when fovea is involved it is diffuse and otherwise it is focal. Still others say it is the presence of lipid that will define the oedema as local, but even among these authors there is substantial difference about whether it is quantity, configuration, or both that is most important.

Investigators using angiography to distinguish between diabetic macular oedema subtypes base their definitions on EUROTIMES | Volume 17 | Issue 3

“

We want to make sure we are all speaking the same language when we are talking about scientific treatments for our patients with diabetic macular oedema Neil M Bressler MD

the proportion of leakage originating from microaneurysms. That is, they describe eyes with at least 2/3 of the leakage associated with microaneurysms as focal leakage, those with 1/3 to 2/3 of the leakage associated with microaneurysms as intermediate, and those with 1/3 as diffuse. However, variable leakage patterns can occur within the same eye and the assessment is very subjective As regards OCT, not only do investigators differ regarding how to interpret the scans and their relationship to the focal or diffuse nature of macular oedema, but also newer technology is likely to render any standardised interpretations obsolete, Dr Bressler said.

“Focal and diffuse DME are not very relevant because they have no uniform definition. There is no strong evidence to suggest that such classification has any impact on treatment responses with laser or anti-VEGF therapy. The DRCR. net’s proposed new classification of diabetic macular oedema would be based on OCT determinations of location and extent of oedema, vitreomacular interface abnormalities, and the presence of lipid.

This is still a work in progress and awaits tests in clinical trials and practice,” he added.

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28

Update

retina

AMD Genetics

Effects of AMD-causing genes worst in smokers and those with poor diets

by Roibeard O’hEineachain in London

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ge-related macular degeneration (AMD) has a strong genetic basis, but a healthy lifestyle including a high consumption of anti-oxidants and avoiding tobacco can cancel most of the genetic disposition for the condition, said Caroline Klaver MD PhD, Erasmus Medical Centre, Rotterdam, the Netherlands.

The principal genes associated with AMD are the CFH and ARMS2 genes. In the Rotterdam Eye Study, among patients with early AMD (stage two and three) over three fourths had at least one CFH or ARMS2 risk alleles, eight per cent had three risk alleles and one per cent were double homozygotes, Dr Klaver noted.

Among patients with late, stage 4 AMD, 93 per cent had at least one risk allele, a third had two, 22 per cent had three, and two per cent were double homozygotes, she said. Among patients aged 80 or over with no AMD, 35 per cent had no risk alleles, 46 per cent had one, 15 per cent had two, four per cent had three and none were double homozygotes, she added.

Furthermore, even in the absence of the CFH or ARMS2 risk alleles, patients still had a five per cent risk of developing late AMD by the age of 85 years, she noted.

The risk went up to 16 per cent with one risk allele, up to 32 per cent with two risk alleles, and up to 70 per cent with three or four risk alleles.

Both the CFH and the ARMS2 variants are risk factors for both dry and wet AMD, she said. However, the CFH variant has a stronger effect on dry AMD, whereas the ARMS2 variant has a stronger effect on wet AMD, she said.

The protein associated with the CFH gene is an inhibitor of the alternative pathway of the complement system, Dr Klaver said. The current theory is that the risk variant performs the inhibition less effectively, with the over-activation of complement as a result, she explained.

The pathologic mechanism behind the ARMS2 variant is less clear. The gene is located in the mitochondria, which are important for oxidation; therefore it may

“Both the CFH and the ARMS2 variants are risk factors for both dry and wet AMD, she said. However, the CFH variant has a stronger effect on dry AMD, whereas the ARMS2 variant has a stronger effect on wet AMD” be that the risk variant interferes with the normal oxidation.

The findings of the Rotterdam Eye Study show that smoking status has a modifying effect on any genetic predisposition to AMD. For example, among non-smokers who were homozygous for the CFH variant, the risk of AMD was 12.51 times higher than in patients without any CFH allele, but among smokers homozygous for the gene the risk was 34 times higher than in patients without any CFH allele.

Homozygous former smokers fell around halfway between the two with a 20-fold higher risk.

The effect of diet was even more striking. That is, among those carrying the CFH and/or ARMS2 genetic variants, but who consumed high amounts of zinc, beta carotenes, omega fatty acids or lutein, the rate of AMD was close to that of patients with no genetic risk factors.

“So it appears you can eat away your genetic risk for AMD,” Dr Klaver added.

contact Caroline Klaver - c.c.w.klaver@erasmusmc.nl

Don’t miss Industry News, see page 43

12th EURETINA Congress 6-9 September 2012

www.euretina.org

registration open

30

Update

GLOBAL OPHTHALMOLOGY

CATARACT SURGERY

Study finds expense a problem, but better than expected coverage

by Howard Larkin in Vienna

N

early two-thirds of individuals with cataract-induced visual acuity of less than 20/400 and nearly half of those with less than 20/60 in the better eye receive cataract surgery in Kassala state in Eastern Sudan, Kamal Hashim Binnawi MD of Al-Neelain University, Khartoum, Sudan, told the XXIX Congress of the ESCRS. Lack of funds to pay for surgery was the most frequently reported barrier to surgery in this very impoverished region, though the level of coverage was higher than Dr Binnawi expected, he said.

Dr Binnawi conducted the study in conjunction with colleagues in the National Program for the Prevention of Blindness – Sudan. The purpose was to determine the cataract surgical coverage and investigate the barriers to cataract surgery as reported by those with cataract-induced visual impairment in Kassala state, which shares its eastern border with Eritrea.

A cross-sectional, population-based survey of people aged 50 and older was conducted. In all, 2,146 eligible people were identified and 2,050, or 95.5 per cent, were examined. Participants with cataractinduced visual impairment, defined as visual acuity of less than 20/60 in the better eye, were also invited to respond to a verbal questionnaire about barriers to cataract surgery.

The survey found that 63.2 per cent of individuals with less than 20/400 received cataract surgery. Only 59.5 per cent of those with less than 20/200 and 46.2 per cent of those with less than 20/60 received cataract surgery. However, since many patients only had one eye treated, the rates were lower for eyes at a given cut-off, with just 39.7 per cent of 20/400; 36 per cent of 20/200 and 27.3 per cent of 20/60 eyes operated.

Cataract surgical coverage was slightly higher for males than females. At the 20/400 cut-off, 67.2 per cent of male individuals and 40.4 per cent of eyes received surgery, compared with 59.7 per cent of female individuals and 39.0 per cent of eyes. At the 20/60 cut-off, 45.3 per cent of male and 47.0 per cent of female individuals received surgery.

Inability to afford care was by far the most common reason given for not taking up cataract surgery, at 45.7 EUROTIMES | Volume 17 | Issue 3

“

Implementation of strategies to raise awareness of and access to ophthalmic services may improve the uptake of cataract surgery

Kamal Hashim Binnawi MD

per cent. “This is one of the poorest states in Sudan,” Dr Binnawi noted.

Lack of awareness of the possibility of treatment was second at 14.2 per cent. “A lot of people do not know cataract can be treated,” Dr Binnawi said.

Another 7.1 per cent were waiting for the cataract to mature. “This is an old concept from the days of extracapsular extraction,” Dr Binnawi said.

Contraindication or co-morbidity that reduced the chances of a good outcome also was cited by 7.1 per cent, and unavailability of services by 6.3 per cent.

Among bilaterally blind respondents, males were more likely to cite affordability, while females were more likely to cite unawareness of possible treatment and lack of availability of services as barriers.

“Females were slightly less likely to be affected by affordability. This may be due to the degree of financial support for mothers.”

However, among bilaterally severely visually impaired respondents, affordability and lack of service were more frequently cited by women, but lack of awareness of treatment by men.

“The cataract surgical coverage was moderately high for an especially poor state,” Dr Binnawi said. “Implementation of strategies to raise awareness of and access to ophthalmic services may improve the uptake of cataract surgery.”

contact Kamal Hashim Binnawi - kamalbinnawi@yahoo.com

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T Dr Erik Mertens

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he FineVison trifocal IOL combines two diffractive structures (+3.5 D add for near vision and +1.75 D add for intermediate vision) with variable step heights at the anterior surface of the IOL. In this way the amount of light distributed to the near, intermediate and distant foci is adjusted according to the pupil size.

With more than six months experience and more than 150 eyes implanted the results are very promising. No patient so far required glasses for any activity and no glare to affect driving has been reported.

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aving been involved in Premium lens surgery since 2002 it is a joy to have a lens that really does come so close to filling the criteria of the ideal lens!

The ideal premium lens should provide patients with full depth of focus with reliable distance, near and intermediate correction with good quality vision and no night vision disturbance. Predictable refractive outcomes and ocular stability are also vital.

I have implanted the FineVision trifocal lens for almost one year. Procedures have been combined with limbal relaxing incisions where required (keratometric cylinder of EUROTIMES | Volume 17 | Issue 3

0.75D or greater). Surgical implantation is simple and the lens is perfectly suited for microincisional cataract surgery and implantable through a 1.8mm incision. Patients are astounded with their vision postoperatively and like laser eye surgery they say “Wow”.

When questioned, patients (15%) do report halos around lights and this is described often as a nuisance but reportedly does not affect the ability to drive. Outcomes have been superb with 85% obtaining 20/25 vision monocularly and 95% 20/20 binocular vision at 3 months. At 3 months 94% have 20/25 near vision at 40cm and a similar number have intermediate vision (80cm) of 20/25 at 3 months.

As a consequence of these exceptional outcomes, no patients require spectacles for any activity ! Lens stability has been found to be good with only one patient developing lens tilt and astigmatism in one eye at 6 months. This was corrected with a YAG laser posterior capsulotomy. Laser surgery enhancement through photorefractive keratotomy has been performed in only 2 eyes so far making a laser enhancement rate less than 1%.

In providing good distance, intermediate and near vision with patients reporting of great satisfaction, the lens does come to meeting our criteria for the perfect lens.

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31

contact

32

News

eye facts

Susanne Gardner – susanne.gardner@gmail.com

“

Dosing regimen analysis

To mitigate against suggestions that study drops were withheld for one day postoperatively, or that drop dosing regimens made a difference, three time frames may be analysed

Details of the dosing regimen in the ESCRS Endophthalmitis Study may have been misunderstood by some of its critics

by Susanne Gardner

Susanne Gardner

Courtesy of Susanne Gardner

Table 2 shows statistical results for the value of the two different interventions in approximately 4,000 patients per group. Aside from these clear data, discussion in an upcoming issue will focus on why further comparisons in larger numbers of patients between regimens in Groups A vs. C, or Groups B vs. C are likely futile.

I

n cataract surgery, topical antibiotic drops are included in prophylaxis regimens at “preoperative” or “postoperative” times. Results of the ESCRS Endophthalmitis Study Group1 on prophylaxis of endophthalmitis compared drop regimens with intracameral injection in previously undescribed ways. Some critiques suggest the intensive drop dosing regimen used in the study may not be fully understood.

No studies have compared clinical outcomes after prophylactic drop regimens in a controlled setting. Yet topical antibiotics are added to preoperative antisepsis with povidone-iodine and may be added after surgery to protect against contamination for an extended period of time.

Critics suggest that the ESCRS Study failed to adequately test the value of topical antibiotic drops because postoperative drops were “withheld for one day” after surgery. However, details of the regimen used may be misunderstood.

Group C in the ESCRS study received an intensive drop regimen in two phases: two preoperative drops (one at 30 and 60 minutes before surgery); then, three additional, pulsed drops at the close of surgery (each five minutes apart).

The latter were immediate “postoperative” drops, given at comparable times to the intracameral injection, making “apples to apples” analysis possible and imposing a stiffer statistical challenge to the intracameral injection.

EUROTIMES | Volume 17 | Issue 3

To mitigate against suggestions that study drops were withheld for one day postoperatively, or that drop dosing regimens made a difference, three time frames may be analysed. First, data show that preoperative dosing more intense than the two drops given in ESCRS study groups would unlikely add significant effects over the povidoneiodine used in all study groups. Studies show prolonging or increasing preoperative antibiotic drops had little impact over prudent use of povidone-iodine alone.2,3 Therefore it is unlikely that drop differences in this time frame could dismantle ESCRS study outcomes.

Focusing on the immediate postoperative period, the notion that drops were delayed for one day after surgery is inaccurate. The three pulsed drops used in ESCRS study Group C (and Group D) are comparable to the administration of antibiotic drops immediately after surgery or in the postoperative holding area (although such practices vary widely or may be omitted altogether).

A study by Sundelin and associates4 duplicated the drop regimen of Group C, measuring aqueous humour (AH) antibiotic levels before and after surgery to anticipate what levels had likely been achieved in ESCRS study groups. Mean AH levels were higher than any previously reported for topical fluoroquinolones, no matter what regimen had been used, achieving peaks of 4.4 ug/ml levofloxacin at one hour after the last postoperative drop and remaining at 3.1 ug /ml at 90 minutes afterwards, still higher than previously reported levels (Figure 1). These AH levels imply that corneal sequestration also occurred, with antibiotic remaining on ocular surface layers and conjunctiva for a period of time after surgery.

During the extended postoperative period, all study groups received QID antibiotic drops beginning the day after surgery x six days. Is it reasonable, then, to surmise that any other immediate “postoperative” dosing regimen, during a few hours time, in Group C (or D), would nullify the statistically significant differences seen between controls and Group C, or between Group C and the intracameral injection in Group B (Table 1)?

Intracameral cefuroxime Approaches to managing risks for postoperative infection are unclear and vary widely among settings. Dr Günther Grabner of the Salzburg University Eye Clinic, who entered the most patients in the ESCRS study, has encountered no case of endophthalmitis since initiation of the study and instillation of cefuroxime at the end of surgery (with 28003500 surgeries/year and increasing). At the end of surgery, a drop of ofloxacin is given, continued the next day TID for approximately one week, then reduced weekly at the discretion of the referring ophthalmologist.

Dr Luis Cordoves of Spain describes use of immediate postoperative drops after intracameral cefuroxime (eg: chloramphenicol, ofloxacin, moxifloxacin), which patients continue hourly until bedtime, and reduce afterwards to 4x daily for 5-7 days until wound healing is complete. An eye shield at night for these first few days is also incorporated into the regimen.

Crucial to interpretation of the ESCRS study results is an understanding that early postoperative drops were initiated in two study groups in the form of the three pulsed doses given over 15 minutes immediately postoperatively.

These are anticipated to have produced higher aqueous humour fluoroquinolone levels than previously reported.

Even this, however, did not compare statistically with the overwhelming effect of the intracameral cefuroxime injection.

References 1. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons.

Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cat Refract Surg 2007; 33: 978-88.

2. He L, et al. Prospective randomized comparison of 1-day and 3-day application of topical 0.5% moxifloxacin in eliminating preoperative conjunctival bacteria. J Ocular Pharmacol Ther 2009; 25:373-8.

3. Moss JM, Sanisio SR, Ta CN. A prospective randomized evaluation of topical gatifloxacin on conjunctival flora in patients undergoing intravitreal injections.

Ophthalmology 2009; 116:1498-501.

4. Sundelin K, Seal D, Gardner S, et al. Increased anterior chamber penetration of topical levofloxacin 0.5% after pulsed dosing in cataract patients. Acta Ophthalmol.

2009;87:160-165.

* Susanne Gardner, Pharm. D, is a specialist in ocular antiinfectives and ocular pharmacokinetics, with a background in academics, research and publishing.

33

News

EURETINA

call for entries

EURETINA Innovation Award 2012 is supporting advances in retinal medicine

near

F

ollowing on from a very successful launch at the EURETINA Congress in London last year, the EURETINA Innovation Award is once again inviting applications from researchers in the field of retinal medicine.

Established with the goal of supporting and encouraging innovation in retinal medicine, the EURETINA Innovation Award will be the focus of a special symposium to be held during the 12th EURETINA Congress in Milan in September 2012.

A cheque for €20,000 will be presented to the overall winner of the EURETINA Innovation Award, with the runner-up receiving €10,000.

Reflecting on the high standard of the entries received last year for the first-ever award, Einar Stefansson MD, PhD, chairman of the judging panel, expressed confidence that this year’s crop of entries would raise the bar even higher.

“We were very happy with both the quantity and quality of entries received last year, all the more so as it was the first year and we did not quite know what to expect.

The hardest part was actually trying to select the shortlist of potential winners because the standard was so high. We are confident that this year’s entries will maintain the momentum and showcase the excellent work being carried out in retinal research in Europe at the moment,” he said.

Prof Stefansson said that it was important for EURETINA to play its part in supporting and rewarding individuals who actively consider and develop novel and innovative ideas relevant to the field of retinal medicine.

“I think this is an important role for us to facilitate and support a European entrepreneurial culture in order to deliver new market applications for the ultimate benefit of patients with retinal disorders. I think our experience last year showed that this award serves a definite need and was well received both by the innovators that submitted proposals as well as the delegates that attended the EURETINA congress. I also had many colleagues who approached me personally to voice their support for this new initiative,” he said.

While Prof Stefansson noted that there has been a definite evolution in terms of fostering innovation in retinal research in recent years, he believes that there is still plenty of scope for improvement.

EUROTIMES | Volume 17 | Issue 3

intermediate

Active-Diffractive 1.8 mm incision!!surface,

nce

dista

convi

nced

Prof Einar Stefansson, chairman of the EURETINA Innovation Award judging panel presenting the first prize to Prof Martin Rudolf at the 11th EURETINA Congress

“I think the level of interest could be and should be greater than exists at present. Over the years we have seen greater awareness of the need to move beyond research not only as a means to advance scientific knowledge, but also to take on board the practical and commercial application of that research. We have moved in that direction over time but my feeling is that this has happened more rapidly in the US, and that Europe has been following behind somewhat. I think we could certainly intensify our efforts in that respect,” he said.

With this in mind, Prof Stefansson believes that the EURETINA Innovation Award can play a part in highlighting the innovative research being carried out in European laboratories and clinics.

“One of the goals of the award is to bring forward the innovation that is taking place in Europe and to encourage industry to take an interest and support these projects,” he said.

Last year’s first prize was awarded to Prof Martin Rudolf of the University of Lübeck in Germany. He won the Innovation Award for his work on the prevention and treatment of macular degeneration by reducing pathological lipid deposition and inflammation in the eye. Second prize went to Prof Eberhart Zrenner of the University of Tübingen for his research demonstrating how subretinal electronic implants can restore basic visual function in blind retinitis pigmentosa patients.

Further information about the EURETINA Innovation Award 2012 can be found at http://www.euretina.org/Innovation/ default.asp.

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a â&#x201A;Ź1,000 travel bursary to the XXX ESCRS Congress

EuroTimes Writing

Congress Preview

MILAN 2012

four meetings

XXX ESCRS Congress to run parallel with EURETINA, EuCornea and WCPOS

by Colin Kerr

Competition Call for Entries

The Trials and Tribulations of a Young Ophthalmologist

T

See www.escrs.org for details EUROTIMES | Volume 17 | Issue 3

Aerial view from Duomo over Milan with Galleria Vittorio Emanuele II in foreground

he ESCRS will be partnering its XXX Annual Congress in Milan, Italy, with the 12th EURETINA Congress, the 3rd EuCornea Congress and the 2nd World Congress of Paediatric Ophthalmology and Strabismus (WCPOS). In addition, the ESCRS will hold its second Glaucoma Day on Friday September 7. The Glaucoma Day Scientific Programme is organised by the European Glaucoma Society.

The four meetings will run from Thursday September 6, 2012, until Wednesday September 12 to offer members of the four organisations an extended meeting facilitating increased co-operation among the different specialties.

EURETINA will be held from September 6-9, EuCornea 6-8, WCPOS 7-9 and ESCRS 8-12. More than 10,000 doctors are expected to attend the four meetings at the MiCo, Milano Congressi (formerly Fiera Milano City), making this one of the biggest gatherings of ophthalmologists to be held in Europe. A 15 per cent discount is available to doctors who register for one extra meeting in addition to their main meeting of interest.

The industry exhibition is always one of the highlights of the ESCRS Congress and this yearâ&#x20AC;&#x2122;s exhibition in Milan is heavily

booked. ESCRS and EURETINA will host a joint exhibition and EuCornea and WCPOS will hold their own separate exhibitions.

Designed in 2002 and doubled in size in 2005, the 2011 extension has placed MiCo, Milano Congressi among the largest conference facilities in Europe and worldwide, catering for up to 18,000 people in 70 or so fully appointed conference rooms. The congress centre features two plenary rooms, one with seating for 4,000 and the other for 2,000 delegates. There is also an Auditorium that seats 1,500 delegates. The exhibition halls offer 54,000 sq.m of exhibition space.

While each of the four societies will have their own dedicated scientific programme, there will be a number of joint symposia which will be publicised in EuroTimes and the society websites in the months leading up to the Milan meetings.

Further information is available at: www. escrs.org, www.euretina.org, www.eucornea. org and www.wcpos.org.

IMPORTANT NOTE: Due to the scheduling of multiple events in Milan in September 2012, it is recommended that hotel accommodation is booked as soon as possible. For hotel information visit: www.milan2012.org.

www.eucornea.org

3rd EuCORNEA CONGRESS 6-8 SEPTEMBER

www.euretina.org

12TH EURETINA Congress 6-9 SEPTEMBER

ION T A R T S REGI OPEN

www.wcpos.org

2nd WORLD CONGRESS OF PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS 7-9 SEPTEMBER

www.escrs.org

XXX Congress of the ESCRS 8-12 september

contacts

36

Feature

PRACTICE DEVELOPMENT

MANAGING CHANGE

Promise and peril in new technology

by Howard Larkin

W

ith expensive new technologies on the horizon and ageing populations already straining health services resources in many countries, European ophthalmologists will have to innovate to continue meeting patient needs, members of the ESCRS Practice Development Committee told participants at the third annual Practice Development Masterclass in Vienna last year.

“Government will no longer be able to afford to fully pay for healthcare,” said Jorge Alió MD, PhD. Of course, reduced public funding creates opportunities for private practice, but it also requires that surgeons develop their business and management skills, said Prof Alió, of the Institute Oftalmologico de Alicante, Vissum Corporation, in Spain. Surgeons must partner with business to continue improving technologies, and with government and academic institutions to continue advancing research and meeting the human needs of the population, Prof Alió said.

At Prof Alió’s VISSUM clinics, privatepaying patients are treated side-by-side with public-paying patients, with the ratio varying according to local needs. At Alicante, the ratio is about 90 per cent private to 10 per cent public; Castilla la Mancha is close to 50 per cent to 50 per cent. While VISSUM is an independent organisation owned by Prof Alió,

some of his partners, and an external investor, it is associated with the Miguel Hernandez University, Alicante, as a teaching and R&D centre.

In the UK, where the government has been privatising services for years in an attempt to improve the quality and efficiency of care, two groups of surgeons are emerging, according to Paul Rosen FRCS, FRCOphth, MBA. On the one hand are entrepreneurs, who set up their own clinics and practices; on the other are those who remain in the National Health Service, said Dr Rosen, of London. Even within the NHS there is a new emphasis on bringing surgeons into leadership. “In my hospital there has been a complete reorganisation of management,” Dr Rosen explained. “It is now a clinically led organisation and the people who are in charge are doctors.”

Budget pressure and increased demand for transparency in operations and clinical outcomes are leading to similar shifts within public and academic institutions in Austria, added Oliver Findl MD, MBA, of Hanusch Hospital in Vienna. By examining clinical processes and eliminating duplicate and unnecessary steps, his department has increased volume 35 per cent with the same staff. With healthcare costs exceeding 11 per cent of gross domestic product, Dr Findl sees innovation within the public sector as

Jorge Alió and Oliver Findl at the ESCRS Practice Development Masterclass in Vienna, 2011

essential to keep up. “Demand will increase, but budgets won’t.”

Innovation within academic practices will be essential to generate enough revenue to afford new technologies to compete with private clinics, said Thomas Kohnen MD, PhD, Goethe University, Frankfurt, Germany.

“Private clinics are gaining in Germany but they can’t treat government patients if they do not have the licence. At the same time universities are losing patients. It used to be that people were lined up to see the university surgeons, but this has shifted somewhat into the private sector.”

Managing private-public tensions

While the shift to private practice can improve productivity and make advanced technology more available, it can also create tensions and even conflicts of interest. Surgeons will be challenged to take the good from privatisation while maintaining their ethical commitment to serving all patients.

On the up side, private structures make it possible to offer advanced technologies such as femtosecond cataract surgery. Prof Alió estimates that this technology adds about €740 to cataract surgery plus hidden costs

Journal Watch Latest updates from your contact lens Your patient might someday be reminded of an appointment with you on a contact lens imbedded with a streaming information display. Researchers at the University of Washington and Aalto University, Finland report the completion of a proof of concept prototype that proved safe in living eyes. The prototype display consists of an antenna, a 500 × 500 µm2 silicon power harvesting and radio integrated circuit, metal interconnects, insulation layers and a 750 × 750 µm2 transparent sapphire chip containing a customdesigned micro-light emitting diode with peak emission at 475 nm, all integrated onto a contact lens. They tested the wirelessly powered contact lens display in a rabbit model. The display was tested on live, anaesthetised rabbits with no observed adverse effect. While the device could be remotely powered from as far as one metre away in the lab, wireless power could only be achieved in vivo at a distance of 2.0cm. The researchers later integrated micro-Fresnel lenses into the device to extend the display capabilities, which would theoretically allow the human eye to see the information presented on the contact lens by focusing the projected image onto the retina.

Contact lenses with integrated micro-Fresnel lenses were also tested on live rabbits and showed no adverse effects.

The next step will be to develop contact lenses with multiple pixels which, in their hundreds, could be used to display short emails and text messages for the wearer. The developers envision many applications. For example, the device could overlay computer-generated visual information on to the real world to facilitate navigation, or finding the nearest Starbucks. Such a device could be linked to biosensors in the user’s body to provide up-to-date information on glucose or lactate levels. And, it could still be used to improve vision. n A R Lingley et al., Journal of Micromechanics and Microengineering, “A single-pixel wireless contact lens display”, Volume 21, Number 12, doi:10.1088/0960-1317/21/12.125014.

EUROTIMES | Volume 17 | Issue 3

Jorge Alió - jlalio@oftalio.com Oliver Findl - oliver@findl.at Thomas Kohnen - Kohnen@emi.uni-frankfurt.de Paul Rosen - paul.rosen@orh.nhs.uk

associated with lost productivity. But his system is flexible enough to recoup the costs, he said. “It becomes part of the overhead.”

Countries vary in how they handle private patients. In Austria, public hospitals may treat public patients, Dr Findl said. “Hospitals like to have the private patients because it brings in extra revenue.”

But this can cause friction with publicly insured patients, who may wait longer for service. Dr Findl noted that a consumer advocacy magazine in Austria did a “secret shopper” feature in which reporters called hospitals around the country inquiring about wait times for cataract surgery. In some hospitals, staff replied that if the patient paid privately they could have it in a week, but if they were on the public system the wait would be nine months. “And this was published,” Dr Findl said. “The minister for health stood up and said, ‘This is a disaster; we cannot allow this to be.’”

Eventually, the ministry determined that private rooms and better food were okay for private patients, but different waiting times would not be allowed. “This has not been such a problem in Austria because waiting times are relatively short, but if your wait is six or nine months, it could be an issue,” Dr Findl said.

In the UK, differences in waiting times are permitted, Dr Rosen said. “You have to be open about it. Patients have a choice. If they pay themselves or are paid by an insurance company then the operation is done with the surgeon of their choice almost at the time of their choice. But if they go with the NHS, the service is free, but anyone can do the surgery.

They are buying choice; they are buying certainty about who does it.”

The UK NHS hospitals are keen to have the private business because it means extra revenues, he said. They will accommodate early scheduling of private patients at times the regular service is off, such as evenings and weekends, said Dr Rosen .

Other countries ban private practice in public facilities. In Germany, private clinics may not treat publicly financed patients, Prof Kohnen said. Norway requires that private practice be done in a separate facility.

Outside Europe, in Canada it is illegal to offer private services if they are covered under the public system. In New Zealand, a system of contracting public services to private surgeons has resulted in a handful of surgeons getting almost all the public business, but operating for a very low wage, with most surgeons left with no public business.

Dr Findl also cautioned against conflicts of interest that may arise from mixing public and private services. For example, offering premium IOLs to older patients who present for cataracts may not be appropriate. “We are seeing a lot of explants of these lenses. We have to keep in mind that the goal for these patients is to treat the cataract and they may not be able to tolerate multifocal lenses,” he said.

n a l i M

XXX Congress OF THE ESCRS 8-12 September

Registration Open

www.escrs.org

2012

Eye Chat with Oliver Findl Exclusive on www.eurotimes.org

Feature

BOOK REVIEW

Eye Chat features exclusive interviews with the major opinion leaders in ophthalmology.

The podcasts are intended to give up to date information on the latest news and innovations in the field.

They also offer instruction to young ophthalmologists on how they should deal with challenging cases.

“

Oliver Findl

Marie Jose Tassignon Scan this QR code to gain access to EuroTimes podcasts

Be Critical and Remain Critical In our new Eye Chat podcast, Marie Jose Tassignon talks to Oliver Findl about her career at the University of Antwerp, Belgium as a surgeon, teacher and presenter.

Listen to our podcasts at

www.eurotimes.org

podcast EUROTIMES

ESCRS

38

™

Podcasts are also available on iTunes

EUROTIMES | Volume 17 | Issue 3

Sharing experience This book opens with a very good question: “Why a textbook on keratoconus?”

Until recently, slit-lamp evaluation and corneoscopy were the primary diagnostic tools, while contact lenses and corneal transplantation were the only two treatment options.

Although an early mention of keratoconus was first published in 1748 and the disease was clearly described in 1854, patients would have to wait until 1888 for treatment with contact lenses and until 1936 for the first successful corneal transplantation for keratoconus.

However, over the past 25 years, there has been a veritable explosion of diagnostic modalities and treatment alternatives, leading to the condition being recognised and successfully managed by a significant proportion of practising anterior segment specialists. Further, the increased importance of refractive surgery, and increased awareness of the potential problems of post-surgical complications related to keratoconus undiagnosed preoperatively, have pushed keratoconus up the ladder of importance in corneal disease.

Adel Barbara, a corneal specialist in Israel, has gathered a large group of experts to contribute to this textbook on keratoconus.

The book is divided into three sections: 1: Epidemiology, Genetics & Pathology; 2: Diagnostics; and 3: Treatments. The book covers nearly every aspect of the disease, providing historical background, recent advances and insights and the current state of the art for each topic and technique.

Because of the incredible diversity of diagnostic options and therapeutic alternatives, keeping up with the current, evidence-based information is a daunting task for even the most motivated of practitioners. On the diagnosis side, there are a host of choices: videokeratography, wavefront analysis, Scheimpflug tomography, OCT, ultrasonic pachymetry, epithelial ultrasound and corneal hysteresis, besides the standard slit-lamp. Likewise, there are a host of choices for therapy: intracorneal rings, phakic intraocular lenses, topographic guided photorefractive keratectomy, improved lamellar transplant techniques, femtosecond laser corneal transplants and collagen corneal cross-linking, in addition to the well-known rigid contact lenses and corneal transplants.

While covering the epidemiology of keratoconus in Section 1, the author considers interesting questions such as whether the frequency of keratoconus is increasing, or whether we are simply better equipped, informed and alert to make the diagnosis. Considering the wealth of information and technology described later in the text, it seems that the latter is more likely. New research insights concerning

systemic associations, genetic factors, inflammation, eye rubbing and biomechanics are all discussed.

Section 2 starts with the clinical presentation and differential diagnostic considerations of keratoconus. It then progresses, step-by-step, from corneal topography, Orbscan and Scheimpflug imaging to wavefront analysis, the ocular response analyzer and Artemis very high frequency digital ultrasound epithelial thickness profiles.

Section 3, which takes up more than half of the book, starts with corneal collagen crosslinking and goes on to discuss more invasive treatment options: Intacs intracorneal ring segments, the Ferrara ring, the Myoring, the many different types of keratoplasty and finally intraocular lens implantation.

What makes this textbook particularly interesting is the inclusion of clinical examples, case reports and literature reviews as well as “our own experience” summaries interspersed throughout the text. The latter discusses the authors’ own evolution in clinical decision-making, including reasons for the specific choices made, as well as a sort of inside information regarding the conduct of clinical trials.

Also helpful is that descriptions of surgical techniques are highly detailed. The book also incorporates results from many clinical studies, which are conveniently cited within the descriptions.

The textbook is attractively illustrated with many large-format colour photographs of surgical techniques and instrumentation as well as clearly legible corneal topographical images that assist the reader in understanding the methods described. Dr Barbara’s new text would be an appropriate choice for ophthalmology residents with an interest in anterior segment surgery, cornea fellows, general practitioners and corneal specialists.

BOOKS EDITOR Leigh Spielberg PUBLICATION TEXTBOOK ON KERATOCONUS - NEW INSIGHTS AUTHOR Adel Barbara 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

Feature

eye on travel

BUON APPETITO

Delegates to four ophthalmology congresses can look forward to fine dining in Milan

by Maryalicia Post

Milan’s golden cuisine The term ‘golden cuisine’ may refer to the 14th century custom of sprinkling food with gold leaf or maybe it suggests the colour of the cuisine's traditional ingredients – butter, cheese, saffron and cornmeal. The term does not refer to the cost of dining out as compared to other Italian cities, but it might.

Fortunately, while the bill may be higher in Milan than it would be in Rome, you’re not likely to feel cheated. Milan diners demand the most unctuous risotto, the freshest of fish, and the most tender cuts of meat.

And they are prepared to pay for it, around €165 per person at Michelin two-star restaurants like Cracco (www. ristorantecracco.it) near the Duomo or at Trussardi alla Scala (www.trussardiallascala. com) in the 19th century Palazzo Trussardi on the Piazza alla Scala.

Diners at more modest restaurants, such as the small family-run Ristorante Papa Francesco, a very short walk away from Trussardi, at Via Marino 7, also expect value for money. The bill here may be less than €50, but there are seasonal specialities and the bread is fresh from the oven. www. papafrancesco.com.

Milan does offer one outright bargain in food. It’s called ‘Happy Hour,’ and in this city the hour stretches from 18:00 to 21:30. For the price of one drink, roughly €9, customers may help themselves to as much as they want from a buffet typically featuring pasta, risotto, meat, cheese and salads. The Navigli area is the best bet for the widest choice of buffets and the trendiest Happy Hour atmosphere. The most popular drink is the Negroni, equal parts Campari, Vermouth and gin.

Learn to 'do it yourself' If you have a few hours to spare in Milan, you can arrange a private cooking lesson at the School of Italian Cuisine. A threehour lesson concludes with a tasting of the prepared dishes accompanied by wine.

Learn to make pizza and focaccia, pasta and sauces, homemade pasta, risotto, meat dishes including the famous Milanese cutlet, or Italian sweets. The school is very flexible about meeting your requirements, either for the timing of the class or the recipes covered. For one or two students EUROTIMES | Volume 17 | Issue 3

the price is €360 per person; for three to six students, it’s €220 each. Book at least two weeks in advance by sending an outline of your requirements by email to Sabrina Notarnicola at: snotarnicola@ quadratumusa.com.

All aboard for dinner If you’re feeling adventurous, book well ahead for a meal on a vintage tramcar with a decor reminiscent of the Orient Express. Operated

by Milan's transit system, the ATM, the service is aptly named ATMosfera. The tram departs at 20:00 from a stop near the Castello and trundles along for two and a half hours including a 10-minute halt for a smoking break. The route passes by many of the key sites of the city some of which you may see, some which you may not depending on how quickly dark descends.

The atmosphere on board when I was there was very like a party, with delighted Milanese entering fully into the off-the-wall experience. A friend and I were the only tourists in our tram (there are two trams, each seating 24 people.). The difficulty of booking may account for the lack of out-of-towners. After trying in vain via email, I contacted the hotel where I would be staying in Milan, and the concierge succeeded by phone. Fixed five-course menus are served, fish-based, meat-based or vegetarian, and you must stipulate at the time of booking which you want. Payment (€65 which includes wine and water) is made on board after dinner. The meals are of a very high standard and may include delicacies like baby squid and black rice, or duck lasagne.

Reserve at least two weeks in advance, much longer for weekends and busy periods like Fashion Week. The toll-free number from Italy: 800-80.81.81 or email atmosfera@p2000.it. For a response, it is essential to include the following: your full name, choice of menu, date required, plus your mobile telephone number. For more details, visit: www.atm.it and click on “restaurant tram.”

Dining near the congress hall In light of the many congresses being held at the Fiera Milano, I asked Fabrizio Conte, the Fiera’s Marketing Manager, to share his list of recommended restaurants in the area.

Here’s his list:

Happy Hour in the Navigli quarter in Milan

Typical Happy Hour buffet Milan style

Ristorante Ribot www.ristoranteribotmilano.it Via Marco Cremosano, 41 - 20148 Milano T +39 02 33001646 Italian traditional cuisine Guerrini www.ristoranteguerrinimilano.com Via Gaetano Previati, 21 – 20149 Milano T +39 02 43416105 Refined cuisine Alfredo Gran San Bernardo www.alfredogransanbernardo.com Via G. A. Borgese, 14 (Zona Sempione) 20154 Milano T +39 02 3319000 Typical Milanese cuisine Osteria Primonovecento http://www.primonovecento.it/storia.html Via Ruggero di Lauria, 17 (Zona Sempione) - 20149 Milano T +39 02 33611643

Refined cuisine in the local early 20th century style Il Sambuco (Hotel Hermitage) www.ilsambuco.it Via Messina, 10 (Zona Paolo Sarpi) - 20154 Milano T - +39 02 33610333 Famous fish restaurant. On Monday, when the fish market is closed, the restaurant features select cuts of meat.

Bringing it home Peck is a legendary delicatessen located not far from its sister establishment, Ristorante Cracco, in the Duomo area. Choose from a treasure trove of delicacies. Peck will even ship your purchases home. Peck’s tearoom serves morning coffee, light lunch, and cocktails.

(Booking is advisable for lunch. Telephone: 02 802 3161.) Open Monday 15:30- 19:30, Tues-Sat 09:15 to 19:30. Via Spadari 9.

Website: www.peck.it.

39

ASCRS Symposium on Cataract, IOL and Refractive Surgery

April 20–24, 2012

ASOA Congress on Ophthalmic Practice Management

April 20–24, 2012

ird b y arl er e t s r i o F reg , s 12 g 0 n i 2 2, sav h c ar M y b

Register Now www.ASCRS.org

Housing Available www.ASCRS.org/gethousing

www.ASCRS.org www.ASOA.org Come Early – Friday, April 20

Cornea Day 2012

Technicians & Nurses Program

April 21–23, 2012

www.CorneaDay.org

ASCRS Glaucoma Day 2012

www.ASCRSGlaucomaDay.org

ASOA Optional Seminars

www.asoaforums.org

Saturday, April 21 ASCRS Opening General Session 10:00 AM – 12:00 PM Includes presidential speeches, the Binkhorst Lecture, Where Are We On the Road to Optical Perfection?, by Randall J. Olson, MD. Honored guests John J. Darin, MD, and Bo T. Philipson, MD, PhD, will make brief remarks. ASCRS Ophthalmology Hall of Fame inductees Jack T. Holladay, MD, MSEE, and Louis Braille (deceased) will be honored.

PROBE (Practice Revenue Optimization and Business Efficiency)

April 21-24, 2012 PROBE is a core selection of CME-designated courses that provide a comprehensive analysis of your practice to maximize revenue.

This track was designed to identify business courses of particular interest to ophthalmologists. Maximize your time at the program by learning how to improve your financial and investment strategies, productivity management, profit diversification, and business model analysis. www.ascrs.org/probe

Sunday, April 22 ASCRS Lecture on Science and Medicine 10:00 – 11:00 AM Featuring Michael T. Osterholm, PhD, MPH, an international leader on issues regarding our preparedness for an influenza pandemic. He is an expert on the effects of the use of biological agents as catastrophic weapons targeting civilian populations.

Government Relations General Session 11:00 AM – 12:00 PM Update from Washington: Fighting to Maintain American Leadership in Medical Innovation, Congressman Erik Paulsen (R-MN-3), Co-Chair of the Congressional Medical Technology Caucus

Monday, April 23 ASCRS Innovators Session 10:00 – 11:30 AM Charles D. Kelman Innovator's Lecture: Douglas D. Koch, MD Corneal Optics for IOL Selection: Cracking the Code. A better understanding of the optics of the cornea is required to optimize several aspects of intraocular lens (IOL) surgery, including the accuracy of IOL calculations, visual quality, depth of focus (pseudoaccommodation), and IOL toricity.

Tuesday, April 24 Hot Off the Press: Highlights of the 2012 ASCRS Best Papers Selected by EyeWorld Editorial Board Members 3:00 – 4:30 PM This session will be a free-flowing panel discussion by the specialty section editors of EyeWorld, who will highlight and debate the Best Papers of ASCRS 2012, as selected by EyeWorld editorial board members, as well as discuss articles in the upcoming issue of EyeWorld. Moderated by David F. Chang, MD.

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Feature

eu matters

Cross-border referrals

EU court rules that regulations requiring prior authorisation for ophthalmic care abroad are illegal

by Paul McGinn

N

o EU country can refuse to reimburse a patient for ophthalmic treatment just because the patient failed to obtain prior authorisation for the procedure, the EU’s highest court has ruled.

According to the European Court of Justice, an EU country must reimburse its own citizens for outpatient medical care they receive in another EU country unless that care requires the use of “major and costly equipment.”

In arriving at its decision, the Court of Justice struck down a Portuguese law that imposed strict rules on patients who wanted to obtain any medical care outside of the country. Unless such patients met strict requirements and received approval before leaving the country for their treatment, they would not be reimbursed for that treatment from the Portuguese health service.

Under the Portuguese law, patients could receive reimbursement of foreign medical care only if such care were “highly specialised” and not provided in Portugal.

To prove that the care was of such kind, the patient was required to obtain: 1. Detailed medical report in favour of the treatment from his or her treating doctor; 2. Approval of that report by the medical director of the local hospital service; 3. Consent to the proposed treatment by the director general for hospitals.

The decision of the Court of Justice, handed down from its headquarters in Luxembourg in late 2011, capped a five-year dispute between the Portuguese government and the European Commission. In October of 2006, the commission, which is the EU institution charged with ensuring that EU countries comply with EU law, informed the Portuguese government that the prior

Join us

Ophthalmic Women Leaders as we celebrate the 2012 OWL Visionary Woman!

OWL Visionary Woman Award Reception Monday, April 23 • 5:30 to 7 pm Hilton Chicago • Chicago, IL (USA) The OWL Visionary Woman Award honors a woman who has contributed to helping women advance in eye care. The award is given at the OWL signature Monday night reception held in conjunction with the ASCRS annual meeting in Chicago, IL (USA).

Free for OWL members and $25 for non-members.

For details and to register, visit www.owlsite.org.

Special thanks to 2012 Grand Sponsors for their support throughout the year: Abbott Medical Optics Alcon Allergan Bausch + Lomb ISTA Pharmaceuticals Santen Incorporated This Event Features: • Visionary Woman Award provided by the Lindstrom Family Foundation • OWLtinis provided by Odyssey Medical, Inc. Thank you also to ESCRS EuroTimes

EUROTIMES | Volume 17 | Issue 3

authorisation requirements violated EU law.

For its part, the Portuguese government insisted that the prior authorisation requirement was necessary and appropriate to maintain the financial stability of the Portuguese health service by limiting the amount of money it spent on citizens travelling abroad for medical treatment that was already available at home. The government also argued that the prior authorisation requirement also protected its citizens by ensuring the quality of the medical service that they received abroad.

Infringement action After four years of diplomatic and administrative wrangling about the purpose and effect of the prior authorisation requirements, the commission sued the Portuguese government in a so-called infringement action to bring the Portuguese government to the Court of Justice for a definitive ruling about the prior authorisation requirement.

In the action, the commission alleged that the Portuguese system for reimbursement of non-hospital medical care was incompatible with the right of EU doctors to provide medical services to their patients. That right is enshrined under the so-called “freedom to provide services” provision of Article 49 of the EU Treaty.

The court agreed with the commission and ruled that the Portuguese law was illegal because it infringed the freedom to provide services.

The court ruled that freedom to provide services precludes the application of any national laws that make the provision of services between EU countries more difficult than the provision of services within an EU country.

According to the court, the prospect of a possible refusal to reimburse the medical costs as a result of an unfavourable administrative decision is, in itself, clearly liable to deter the patients concerned from approaching a provider of medical services in another EU country.

The court also noted that under Portuguese law, a patient could receive reimbursement for medical costs incurred abroad only in exceptional cases, where the treatment needed by that patient was not available under the Portuguese health system. By its very nature, that condition severely limited the circumstances under

According to the European Court of Justice, an EU country must reimburse its own citizens for outpatient medical care they receive in another EU country unless that care requires the use of “major and costly equipment” which such authorisation could be obtained, the court observed.

After looking at the effect of the Portuguese law, the court then assessed whether the Portuguese government could establish any acceptable grounds for insisting on such restrictive rules. In doing so, the court was following its own previous judgments, in which it had ruled that an EU country could impose prior authorisation requirements on patients who were seeking medical care abroad that involved the use of “major and costly equipment.”

On that point, the court stated that, on the evidence, there was no indication that removal of the prior authorisation requirement for that type of care would result in patients travelling to other countries in such large numbers that the financial balance of the Portuguese social security system would be seriously upset. The court added that if insured persons go without prior authorisation to an EU country other than that in which their sickness fund is established to receive treatment there, they can claim reimbursement of the cost of the treatment given to them only within the limits of the cover provided by the health insurance scheme in the EU country in which they live.

The court also rejected the Portuguese government’s argument that the prior authorisation requirement would protect its citizens by ensuring the quality of the medical service that they received abroad.

On that basis, the court concluded that Portugal had failed to fulfil its obligations under the principle of the freedom to provide services, by unfairly inhibiting its citizens from obtaining outside of Portugal any highly specialised non-hospital treatment that did not involve the use of major and costly equipment.

For details of the judgment, see the Court of Justice website at: www.curia.eu.

Feature

industry news

Recent developments in the vision care industry

25th anniversary

Contamac Ltd has announced that it will celebrate its 25th Anniversary in 2012 with a series of special events scheduled throughout the year.

The company develops specialist polymers and provides biocompatible materials for implantable and medical applications to the ophthalmic industry. Contamac is based in Saffron Walden, Essex, UK. www.contamac.com

National Diabetic Screening Programme

Orca Surgical Epi-Clear™ device

Dynamic epikeratome

Kowa Optimed has announced that its latest innovation, the Nonmyd WX 3D, has been approved for the English National Screening Programme for Diabetic Retinopathy in the UK. With over five million people expected to have diabetes in the UK by 2025, and with diabetic retinopathy being the main cause of blindness in the 16-65 year-old age group, the National Screening Programme aims to reduce the risk of sight loss by offering annual screening to diabetic patients for prompt identification and effective treatment of sight-threatening retinopathies. www.kowa.eu/medicals

Orca Surgical introduced its patented Epi-Clear™ device and a new treatment paradigm, EBK™ (Epi Bowman’s Keratectomy) at the ESCRS winter meeting in Prague. “Fifteen years of experience in refractive surgery and over 40,000 surgeries has led us to the conclusion that when it comes to safety, surface ablation is the only choice for refractive surgery,” said Yariv Bar-On, CEO at Orca Surgical. “Market research indicates strong growth in the number of surface ablation procedures performed each year. We believe we have developed the ultimate surgical tool for this purpose.” www.orcasurgical.com

Precision laser system

The US Food and Drug Administration (FDA) 510(k) has approved market clearance of OptiMedica Corp’s Catalys Precision Laser System. OptiMedica says this is a nextgeneration laser cataract surgery system that brings unequalled precision and accuracy and a markedly streamlined workflow to the laser cataract procedure. www.optimedica.com

Coaxial mini phaco

PEP CMP Set

For smallest incisions of 2.2mm and 2.4mm Geuder has designed new “Pure Efficiency Phaco” sets. “The highlight of the sets are the high-performance Titanium PEP ultrasonic tips,” said a company spokeswoman. “Due to the special three-step design and the 40° angle the active surface for ultrasound emulsification has been maximised,” she said.

“The new tip has a smaller edge geometry so that entry to hard lens nuclei is easier and ultrasound times can be shortened. Because of the smooth transition of the sleeve to the tip the insertion is more gentle. Increased followability and efficient holdability can be realised due to improved fluidics.” www.geuder.com/PEPSets

Business expansion

D.O.R.C. international is expanding its business by opening up new branches in Austria and the UK. “With these branches we will be able to share our knowledge and offer a better service to our Austrian and British customers,” said a company spokesman.

The address for the new Austrian branch is D.O.R.C. GmbH, Mariahilfer Strasse 123, 3.Floor, 1060 Vienna. The UK branch is at D.O.R.C. Limited, Birmingham Victoria Square, One Victoria Square, Birmingham, B1 1BD, United Kingdom www.optimedica.com

Journal Watch Neuropleptic promising as cancer treatment Uveal melanoma in particular, is notoriously difficult to treat once it has metastasized and grown in a distant organ. A remarkable new study suggests a potential role for histone deacetylase (HDAC) inhibitors for reducing the rates of metastasis seen with this cancer. The drugs (Valproate et al.), normally used to treat seizures, alter the conformation of the DNA of the aggressive form of uveal melanoma, which changes the way key genes are expressed, rendering the tumour cells less aggressive. Specifically, researchers built on previous research showing that a mutation in a gene called BAP-1 helped explain why some uveal tumours develop the class 2 signature associated with high risk for metastasis. The HDAC inhibitors appear to reverse some of the effects of BAP-1 mutations on the melanoma cell.

Working in vitro, the researchers evaluated various compounds for their effects on uveal melanoma cells using morphologic evaluation, MTS viability assays, BrdU incorporation, flow cytometry, clonogenic assays, gene expression profiling, histone acetylation and ubiquitination assays. They also used an in vivo murine xenograft tumorigenicity model. The HDAC inhibitors induced morphologic differentiation, cell cycle exit, and a shift to a differentiated, melanocytic gene expression profile

EUROTIMES | Volume 17 | Issue 3

in cultured cancer cells. Valproic acid in particular inhibited the growth of uveal melanoma tumours in vivo. Because HDAC inhibitors already are on the market, the investigators believe it may be possible to begin testing the drugs in patients with aggressive forms of uveal melanoma within 12 months. Valproate and drugs in its class have relatively mild side effects that are not as severe as those seen in patients undergoing conventional chemotherapy. The most common side effect is drowsiness.

The researchers believe the likely role for HDAC inhibitors will be to slow or prevent the growth of tumour cells that have spread out of the eye but cannot yet be detected.

This might lengthen the time between the original eye treatment and the appearance of detectable cancer in the liver and elsewhere. This would allow patients with aggressive melanomas to live for many years without any detectable spread of their disease. n

S Landreville et al., Clinical Cancer Research, “Histone dacetylase inhibitors induce growth arrest and differentiation in uveal melanoma”, doi:10.1158/1078-0432.CCR11-0946.

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44

Review

JCRS HIGHLIGHTS

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

LASIK Enhancements: To Lift or Not to Lift?

Sonia H. Yoo, MD, Marcony R. Santhiago, MD, PhD Correction of Refractive Surprises Following Cataract Surgery: Lens-Based Versus Laser Correction John A. Hovanesian, MD, Nick Mamalis, MD Role of the Ectasia Risk Scoring System J. Bradley Randleman, MD, Jay S. Pepose, MD, PhD Femtosecond Laser Cataract Surgery: Pros and Cons Zoltan Z. Nagy, MD, PhD, Steven A. Arshinoff, MD, FRCSC How Young Is Too Young for CXL? Elena Albé, MD, William J. Dupps Jr, MD, PhD

During the ASCRS Symposium on Cataract, IOL and Refractive Surgery Chicago, Illinois, USA

Journal of Cataract and Refractive Surgery

All-laser LASIK after suction loss

The solid state femtosecond laser accounts for an increasing percentage of flaps created in LASIK procedures. Proponents cite predictable flap thickness and fewer complications as potential advantages over conventional mechanical microkeratomes.

However, occasionally intraoperative suction loss leads to incomplete flap creation, requiring a second pass. How well do those cases do compared to regular single pass procedures? Spanish researchers conducted a study of 42 eyes comparing visual outcomes in eyes that had undergone a LASIK flap creation with a single pass of an IntraLase femtosecond laser in one eye and a double pass in the fellow eye, followed by ablation with a Visx S2 laser. The study found that 12 months after surgery, visual acuity, refractive outcomes, and anterior corneal higher order aberrations were comparable between eyes. The authors note a need for further long-term studies using wavefront-guided excimer laser ablations and larger patient populations are desirable to evaluate possible differences, including corneal biomechanical changes and newergeneration femtosecond laser-created flaps. n

G Muñoz et al., JCRS, “Single versus double femtosecond laser pass for incomplete laser in situ keratomileusis flap in contralateral eyes: Visual and optical outcomes”, Volume 38, Issue 1, pages 8-15.

Optical ray tracing – beyond wavefront

Customised excimer LASIK ablations currently rely on corneal topography or whole-eye wavefront technology. However, critics note that these fail to consider the multiple lens structure of the eye and fail to address all optical errors of the eye, resulting in a clinical outcome that may be poorer than expected. A new study suggests that optical ray tracing may be the next step in custom ablation. Researchers conducted a multicentre study of 127 eyes with moderate to high myopic astigmatism that underwent custom LASIK ablation based on a new optical ray-tracing algorithm.

Approximately 84 per cent of 111 eyes available for follow-up at three months postoperatively had uncorrected distance acuity of at least 20/20. All were within 1 D of the intended correction, with 96 per cent within 0.5 D. Uncorrected distance visual acuity in eyes treated for high myopic astigmatism was better than in those

Don’t miss Calendar, see page 48 EUROTIMES | Volume 17 | Issue 3

undergoing wavefront-guided LASIK. The researchers conclude that the new system, which does not require a nomogram, is safe, efficacious and predictable. n

S Schumacher, JCRS, “Optical ray tracingguided laser in situ keratomileusis for moderate to high myopic astigmatism”, Volume 38, Issue 1, pages 28-34.

Long-term outcomes with Kamra inlay

The Kamra (AcuFocus) corneal inlay is under investigation as a potential solution for presbyopia. This corneal inlay is designed to increase the depth of field using the principle of small-aperture optics to restore near and intermediate visual acuity without significantly affecting distance vision in emmetropic hyperopes. Austrian researchers who did some of the first clinical studies with the inlay now report three-year postoperative follow-up data. A prospective study enrolled 32 patients. Mean uncorrected near visual acuity improved from Jaeger 6 preoperatively to J1 at three years. Mean uncorrected intermediate vision improved from 20/40 to 20/25. Mean uncorrected distance acuity was 20/20.

However, nine eyes (28.3 per cent) lost one line of corrected distance acuity and one eye lost more than two lines. Moreover, 15.6 per cent of patients reported severe nightvision problems, and 6.3 per cent (versus 87.5 per cent preoperatively) reported being dependent on reading glasses. The design of the inlay has continued to evolve along with the implantation technique, the researchers note. n

O. Seyeddain et al., JCRS, “Small-aperture corneal inlay for the correction of presbyopia: 3-year follow-up”, Volume 38, Issue 1, pages 35-45.

Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and jcrs journal

CHICAGO 2012 Save the Date

Thursday, April 19 – Monday, April 23, 2012

Among the topics to be covered in these AMA PRA Category 1 CreditsTM designated sessions are: • A discussion on recent developments in anti-infective and anti-inflammatory therapeutic treatments • Updates on diagnosing and treating the ocular surface, including dry eye disease • New developments in allergy therapeutics

Make the most of your time at the ASCRS/ASOA Annual Meeting and attend our EyeWorld programs for additional CME and an opportunity to network with your colleagues.

To register visit, www.EyeWorld.org These non-CME, ASCRS-authorized educational programs will provide timely and important information on: • Options and considerations in the use of premium IOLs • An open forum on excimer and femtosecond laser applications in ophthalmic surgery

EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products, procedures, and applications of existing products. Included among the topics discussed in these sessions are: • Live surgery • New developments in surgical instrumentation • Surgical options for the treatment of dry eye • Growing the overall size of the premium IOL lens market • Considerations in the selection of a premium IOL • New developments in laser vision correction • Advanced IOL technology • Discussion of technological advances and breakthroughs in cataract surgery

46

Review

OPHTHALMOLOGICA

Good refractive results from implants in eyes with short-term aphakia

2nd world congress of paediatric ophthalmology and strabismus 7-9 september 2012 www.wcpos.org

registration open

IOL implantation can be safely delayed for several months in eyes undergoing cataract removal for improved visualisation during vitreoretinal surgery, a new study shows. The study involved a consecutive case of 21 eyes implanted with IOLs 1.5 months to 19 months after undergoing phacoemulsification. All but one case underwent phacoemulsification to facilitate a vitreoretinal procedure and all were free of severe capsular fibrosis. At one month’s follow-up, the refractive mean error was +0.06 D and the mean absolute error was +0.24 D. The authors noted that the postoperative refractive results were comparable with those of routine cataract surgery. They added that delaying surgery could reduce the amount of biometric errors such as can occur in eyes with a detached retina (Chen et al, Ophthalmologica 2012; 227: 80–84).

All PDE5 inhibitors may pose a small risk for central serous chorioretinopathy

Not only sildenafil citrate (Viagra) but all of the other currently available phosphodiesterase 5 inhibitors used for erectile dysfunction may increase the risk of central serous chorioretinopathy (CSC). Two case studies of patients who developed taking PDE5 inhibitors (vardenafil and tadalafil) for erectile dysfunction showed that the condition resolved once they discontinued use of the agents but reappeared when they resumed using it and once again resolved when they stopped using it the second time. The authors of the study note that there have been previous reports of CSC in patients taking sildenafil citrate. Previous studies have also indicated a link between the use of PDE5 inhibitors and other ocular side effects, including lid oedema, hyposphagma, photophobia, mydriasis, dyschromatopsia, and nonarteritic anterior ischemic optic neuropathy. The evidence suggests CSC may be another rare PDE5 inhibitor classspecific side effect, the study’s authors said

Intravitreal agents may have only short-term advantage over grid laser Intravitreal triamcinolone acetonide or bevacizumab produce better short-term results than grid laser in the treatment of diffuse macular oedema but all three treatments produce similar results at one year, a comparative study suggests. The study, which involved 126 eyes, showed that eyes receiving intravitreal bevacizumab or triamcinolone had higher rates of anatomical and functional success at six months than did eyes that underwent grid laser treatment (p < 0.05 for both).

However, by one year there was no significant difference between the groups in terms of visual stabilisation (Sobaci et al, Ophthalmologica 2012; 227: 95-99).

Triamcinolone provides best short-term results A randomised study involving 111 eyes of 105 patients with diabetic macular oedema showed that, compared with baseline values, visual acuity improved significantly more at three and six months among patients receiving triamcinolone alone or in combination with bevacizumab than in eyes receiving bevacizumab alone. All three treatments produce significant reductions in central macular thickness throughout follow-up, with greater reductions during the first months of therapy in the triamcinolone groups. However, by 12 months the groups had statistically similar results in terms of both macular thickness and visual acuity (Lim et al, Ophthalmologica 2012; 227: 00-106).

(Aliferis et al, Ophthalmogica 2012; 227:85-89).

José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA EUROTIMES | Volume 17 | Issue 3

YOUR ADVERTISEMENT COULD BE HERE REACHING 32,019* READERS

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EUROTIMES

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The highest audited circulation for any ophthalmic news magazine in Europe Thank you to our readers and advertisers for making us Number One

* Average net circulation for audit period 1 January 2010 to 31 December 2010. See www.abc.org.uk

48

Reference

CaLENDaR Of EVENtS

Dates for your Diary

March

March

March

April

26th International Congress of the HSIOIRS

5th Ljubljana Refractive Surgery Meeting

2nd EuroLam Macula and Retina Congress

27th APAO Congress

www.lj-refractive.com

www.euro-lam.org

ASCRS•ASAO Symposium and Congress

2012

2012

1-4 ATHENS, GREECE www.hsioirs.org

Joint Irish & UKISCRS Refractive Surgery Meeting 9 DUBLIN, IRELAND

2012

8-10 LJUBLJANA, SLOVENIA

Frankfurt Retina Meeting 10-11 MAINZ, GERMANY www.eckardt-frankfurt.de

www.ukiscrs.org.uk

2012

16-17 MIAMI, USA

The 3rd World Congress on Controversies in Ophthalmology (COPHy)

13-16 BUSAN, KOREA

www.apaobusan2012.com

20-24 CHICAGO,IL, USA www.ascrs.org

22-25 ISTANBUL, TURKEY

www.comtecmed.com/COPHy/2012

April

May

May

June

International Symposium on Glaucoma – New Insights and Updates

ARVO Annual Meeting

10th SOI International Meeting

16th Afro Asian Congress of Ophthalmology & 5th Mediterranean Retina Meeting

2012

2012

21 BELGRADE, SERBIA

www.glaucoma–belgrade2012.org

118th SFO Congress 27-30 PARIS, FRANCE

2012

2012

6-10 FORT LAUDERDALE, FL, USA www.arvo.org

UKISCRS Cornea & Cataract Day 2012

23-26 MILAN, ITALY www.sedesoi.com

13-16 ISTANBUL, TURKEY www.afroasian2012.org

14 LIVERPOOL, UK www.ukiscrs.org.uk

www.sfo.asso.fr

June

June

25th International Congress of German Ophthalmic Surgeons

14-17 NURNBERG, GERMANY www.doc-nuernberg.de

July

September

ISER 2012 XX Biennial Meeting of the International Society for Eye Research

3rd EuCornea Congress

2012

2012

2012

10th EGS Congress

17-22 COPENHAGEN, DENMARK www.eugs.org

Aegean Cornea XI

2012

6-8 MILAN, ITALY www.eucornea.org

29-1JULY CRETE, GREECE

22-27 BERLIN,GERMANY

September

September

September

November

2nd World Congress of Paediatric Ophthalmology and Strabismus

12th EURETINA Congress

UKISCRS – XXXVI Annual Congress

AAO•APAO Joint Meeting

www.aegeancornea.gr

2012

7-9 MILAN, ITALY www.wcpos.org

2012

6-9 MILAN, ITALY www.euretina.org

XXX Congress of the ESCRS

www2.kenes.com/iser/pages/home.aspx

2012

27-28 BRIGHTON, UK

2012

10-13 CHICAGO, IL, USA www.aao.org

www.ukiscrs.org.uk

8-12 MILAN, ITALY www.escrs.org

Advertising Directory: Alcon: Pages: 7, IBC, OBC; ASCRS/Eyeworld: Pages: 40-41, 45; Carl Zeiss Meditec: Page: 23; Croma-Pharma: Page: 33; D.O.R.C International BV: Page: 19; Katena: Page: 22; Keratoconus Solutions: Page: 3; Medicel AG: Page: 24; Moria: Page: 27; NIDEK: Page: 17; NHS: Page: 13; Oertli Instruments AG: Page: IFC; Ophthalmic Women Leaders: Page: 42; PhysIOL: Page: 25; ThromboGenics: Page: 15; VuExplorer: Page: 30; Ziemer: Page: 28.

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