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VOLUME 18 ISSUE 7/8 july/august 2013



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july/august 2013 Volume 18 | Issue 7/8 This ISSUE... Special Focus: Glaucoma 4

Cover Story: New surgical techniques and technologies discussed


Cataract surgery can be a good option to aid glaucoma management


Can BAK accelerate the glaucoma disease process?

10 New alternatives for glaucoma drug therapy are close to reality

Cataract & Refractive



12 Advantages of femtosecond laser-assisted cataract surgery highlighted 13 Study looks at main reasons for removing phakic IOLs 14 Device useful in screening for suspect keratoconus 15 Expert stresses listening to patients is crucial prior to lens selection

Cornea 23 Phaco after DMEK can provide good refractive outcomes, study shows

Retina 25 New findings show AREDS formulation may be improved

Ocular 30 Understanding the impact of a visual condition on driving crucial to road safety, conference hears



News 31 Lowering IOP with canaloplasty 32 ESASO Fellowships a good option for young ophthalmologists 33 Amsterdam session will highlight how residents can make the most of their education 34 European Board of Ophthalmology Diploma examinations a great success

Features 36 Eye on Travel 37 Book Review 38 Resident’s Diary 39 Ophthalmologica Highlights 40 Practice Development

38 editorial staff



Published by The European Society of Cataract and Refractive Surgeons Publisher Carol Fitzpatrick

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Janice Robb

41 Circulation Manager Angela Morrissey

Pippa Wysong Gearóid Tuohy

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

Colour and Print W&G Baird Printers

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post Leigh Spielberg

41 Industry News 42 EU Matters 45 JCRS Highlights 48 Calendar

Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email:

Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2012 and 31 December 2012 is 37,563.







Medical Editors

Volume 18 | Issue 7/8

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

SCHLEMM’S CANAL SURGERY It is hoped that the new interest in Schlemm’s canal surgery, now rekindled, will continue to grow

by Clive Peckar


arly attempts to open Schlemm’s canal and allow direct drainage of aqueous, via the collector channel drainage system, using an ab-interno approach, goniotomy/ trabeculotomy (Otto Barkan, 1956), or by opening the canal ab-externo and “cheese-wiring” the inner wall of Schlemm’s canal with a nylon suture (Redmond Smith, 1960) or by trabeculectomy (Cairns, 1968) failed; as the openings so created healed. Trabeculectomy carried out with a loosely sutured flap, however, became adopted as a “bleb-dependent sub-conjunctival fistularising procedure”, replacing Holth’s procedure (1909) and Scheie’s procedure (1958). Interest in Schlemm’s canal surgery then became dormant, until Robert Stegmann, in1991, working with African patients, in whom trabeculectomy had a very low success rate, successfully developed his technique of visco-canalostomy1. In this procedure he approached Schlemm’s canal ab-externo and dilated it, in part, with high viscosity sodium hyaluronate, while by-passing the trabecular meshwork, using a “trabeculo-descemetic window”, ± micropunctures, and an intra-scleral reservoir/“lake”. In 2004 he improved his technique further, introducing “canaloplasty”, in which he dilated 360° of Schlemm’s canal, using a 250µ microcatheter, developed from arterial catheterisation technology, prior to holding it open, with a 10/0 polypropylene suture. This technique was further refined, in 2008, with the introduction of 9mm polyimide “canal expanders”. Canaloplasty thus became the first physiological surgical procedure, for open-angle, angle recession and congenital glaucoma, which bypassed the trabecular meshwork, and angle, and prevented canal collapse, by dilating and holding open Schlemm’s canal and its ostia, together with those of the collector channels, allowing aqueous to drain directly into the aqueous veins. Whilst these procedures have been increasingly adopted by glaucoma surgeons in many parts of Europe, and the US, they have not been taken up universally due to the relative technical difficulties of the procedures and the perception that they are “not cost-effective”. Interestingly in Germany, where canaloplasty is available through the public healthcare system, it has been demonstrated to be more cost effective than trabeculectomy2, when the number of interventions and hospital/clinic visits are taken into account, and to have a better Quality of Life, and greater patient satisfaction, than trabeculectomy3. Another objection to the use of intracanalicular stents has been that they will be occluded by fibrosis, as suggested by Peng Khaw in the Cover Story (see page 4). This comparison with other “tube” procedures does not take into account the fibrinolytic activators present in the endothelial cells of Schlemm’s canal, its collector channels and aqueous veins, all of which have higher levels of tissue plasminogen activator (t-PA) and lower levels of t-PA inhibitor, compared with vascular endothelium4. It is these activators combined with the fibrinolytic action of sodium hyaluronate that is, in part, responsible for the surgical success of visco-canalostomy1 and canaloplasty5,6. EUROTIMES | Volume 18 | Issue 7/8

International Editorial Board In the Cover Story of this issue (see page 4) we examine the views of a number of glaucoma surgeons on the development of MIGS (Minimally Invasive Glaucoma Surgery) and highlight some of the recent devices which allow aqueous direct access into Schlemm’s canal. Canal surgery performed with the MIGS ab-interno approach, under gonioscopic vision, has many theoretical advantages and avoids the difficult ab-externo dissection and suturing. However, although the early results using these devices have been encouraging, it should be noted that many of these early studies were combined with phacoemulsification, which alone significantly reduces intraocular pressure (see article page 8), and longer term studies, which also exclude the confounding effect of phacoemulsification, will determine how effective these newer devices are, and whether they can be inserted sufficiently atraumatically, without pre-dilating the canal, to prevent fibrosis. It is hoped that this new interest in Schlemm’s canal surgery, now rekindled, will continue to grow.

References: 1 Stegmann R, Pienaar A, Miller D. Viscocanalostomy for open-angle glaucoma in black African patients: J Cataract Refract Surg 1991; 25: 316-322. 2 Brüggemann A, Müller M. Trabeculectomy versus Canaloplasty - Utility and CostEffectiveness Analysis: Klin Monbl Augenheilkd 2012:229(11):1118-23.

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA

3 Salgado J, Sauer J, Körber N, Grehn F, Klink T. Quality of Life in glaucoma surgery: canaloplasty versus trabeculectomy: European Glaucoma Society Congress, Copenhagen June 2012.

Vikentia Katsanevaki GREECE

4 Shuman A, Polansky J, Merkel C, Alvarado J. Tissue Plasminogen Activator in Cultured Human Trabecular Meshwork Cells: Invest Oph & Vis Sci 1988: 29(3):401-5.

Anastasios Konstas GREECE

5 Grieshaber M, Pienaar A, Oliver J, Stegmann R. Canaloplasty for primary open angle glaucoma: long-term outcome: Br J Ophthal 2010:94(11):1478-82. 6 Bull H, von Wolff K, Körber N, Tetz M. Three-year canaloplasty outcomes for the treatment of open-angle glaucoma: European study results: Graefes Arch Clin Exp Ophthalmol 2011:249:1537-45.

Thomas Kohnen GERMANY Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA

Clive Peckar FRCOphth is a medical editor for EuroTimes

Oliver Zeitz germany

An exciting Discovery in Dry eye is


Only frOm Optive速 Brought to you by Allergan: An innovative and trusted market leader for over a decade

eU/0256/2013a Date of Preparation: May 2013

Cover Story



Fitting MIGS techniques into a new glaucoma treatment paradigm by Roibeard O’hEineachain

What distinguishes MIGS from traditional glaucoma surgery is that it is a much, much safer and often more physiologic type of procedure Ike Ahmed MD

The results are encouraging. But one little thing remains uncertain with all internally placed implants, did I really hit Schlemm’s canal? Manfred Tetz MD

EUROTIMES | Volume 18 | Issue 7/8


inimally invasive surgical techniques that leave the sclera and conjunctiva intact, collectively known as MIGS (minimally or micro-invasive glaucoma surgery), are playing an increasingly important role in the treatment of glaucoma. Current glaucoma treatment guidelines suggest a graduated approach of increasing invasiveness as the disease progresses. Starting with medical therapy, refractory patients commonly progress to laser trabeculoplasty and from there to filtration surgery. However, between those glaucoma patients who respond well to non-incisional treatments, like topical medication and laser trabeculoplasty, and those patients who require filtration surgery to achieve a low target IOP, there are a range of patients who don’t fit neatly into either category but who may respond well to MIGS. “What distinguishes MIGS from traditional glaucoma surgery is that it is a much, much safer and often more physiologic type of procedure. It is therefore something that we’re more comfortable using in patients earlier in the disease and potentially also in patients who are at a higher risk for more complications from standard trabeculectomy-type surgery. And that is probably the biggest hallmark of MIGS, it is an ultra-safe procedure,” said Ike Ahmed MD, University of Toronto, Toronto, Ontario, Canada, who originated the MIGS acronym. The MIGS techniques include a range of ab interno implants, and an electric microcautery device. They are designed to provide an outlet for aqueous into the venous system by way of Schlemm’s canal and the collector channels, through the suprachoroidal space, or through a subconjunctival bleb. The procedures are performed through small incisions and with gonioscopic visualisation. They are primarily indicated in patients who have visually significant cataracts as well as glaucoma.

Courtesy of Ike Ahmed MD


Figure 1: iStent

“Restricting the use of MIGS to cataract patients was the regulatory pathway that was selected with the procedures and MIGS procedures work well in terms of synergy with cataract surgery so it's a nice adjunct there. But we are currently also involved in a number of studies where we are looking at these devices for use in patients who are phakic and not undergoing cataract surgery. That is the next step with MIGS,” said Dr Ahmed. The MIGS techniques generally reduce IOP to a lesser degree than trabeculectomy but by an amount that may nonetheless be sufficient to prevent optic neuropathy progression in some glaucoma patients. The MIGS techniques appear to have a better risk profile than trabeculectomy, which for several decades has been the gold standard for the treatment of glaucoma patients in whom topical medication controls IOP inadequately.

Two of the most serious complications of trabeculectomy are hypotony maculopathy, occurring most commonly in the early postoperative period, and bleb-associated endophthalmitis, which tends to occur much later. In eyes that have undergone trabeculectomy, the reported incidences of hypotony maculopathy range from 1.3 per cent of 18 per cent. Endophthalmitis after trabeculectomy has a reported incidence of 7.5 per cent at five years. The use of antifibrotic agents appears to increase the risk of both complications. Timely intervention to raise IOP to a safe level will preserve the vision of most eyes with hypotony maculopathy , but if the condition goes undetected it will result in scar formation in the chorioretinal wrinkling that the hypotony causes, with a permanent reduction of visual function as a result. The visual outcomes of bleb-associated endophthalmitis are almost universally

Tube, or not tube? Because of trabeculectomy’s potential complications and because of the limitations and the side effects of topical medications, numerous teams of investigators around the world have since developed alternative surgical techniques for lowering IOP that are less invasive and have a better safety profile than conventional filtration surgery. They include laser trabeculoplasty – which current guidelines accept as an intermediate treatment option between topical medication alone – and filtration surgery – and a broad range of drainage implants. Among the newest in the latter category are several implants designed for use in MIGS. The older generation of drainage implants, namely the Baerveldt, Ahmed and Molteno tubes consist of a plate placed subconjunctivally from which extends a drainage tube that is inserted through the sclera into the anterior chamber. These devices essentially drain aqueous out of the eye into subconjunctival reservoirs created by external plates. The traditional indications for the tube implants have been for eyes that seemed likely to have unsuccessful results with trabeculectomy, as in cases where there is extensive scarring from previous surgery. However, the past decade or so has seen an increased adoption of the device, for example, a survey of American Academy of Ophthalmology members showed that the proportion of their surgeries using tube implants rose from 17 per cent in 1998 to 54 per cent in 2008. (Desai et al, Ophthalmic Surg Lasers Imaging. “Practice preferences for glaucoma surgery: a survey of the American Glaucoma Society in 2008”, 2011 May-Jun;42(3):202-8). In Tubes Versus Trabeculectomy Study (TVTS), trabeculectomy resulted in greater IOP reduction but also significantly more complications in the early postoperative period than did implantation of the Baerveldt device (37 per cent vs. 21 per cent, P = .012). The cumulative probability of failure during five years of follow-up was 29.8 per cent in the tube group and 46.9 per cent in the trabeculectomy group (P = .002). The rate of reoperation for glaucoma was nine per cent in the tube group and 29 per cent in the trabeculectomy group (P = .025) (Gedde SJ, et al, Am J Ophthalmol “Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five years of follow-up”. May 2012;153:5:789-803 e782). On the other hand both techniques had similar rates of late postoperative complications making tube shunts less attractive to use in mild to moderate glaucoma. MIGS, the new kid on the block

In contrast, use of the new MIGS devices involves only a small amount of disturbance of ocular tissues and consequently has much fewer side effects. The iStent® (Glaukos Corporation[see Figure 1]) and the Hydrus™ (Ivantis [see Figure 2]) and the Trabectome® (Neomedix) are all designed to direct EUROTIMES | Volume 18 | Issue 7/8

aqueous out through Schlemm’s canal. They therefore have a mechanism in common with some more invasive ab externo forms of a Schlemm’s canal surgery, such as viscocanalostomy and canaloplasty. They also share an inherent limitation with those techniques in that they cannot bring pressures below episcleral venous pressure 12 mmHg. On the positive side, the techniques do not result in the creation of a bleb. The iStent is composed of nonferromagnetic titanium and is designed to provide a channel for the outflow of aqueous directly from the anterior chamber to Schlemm’s canal, bypassing the trabecular meshwork. The ab interno device was approved by FDA in 2012 for use with cataract procedures . The FDA trial showed that among patients receiving the implant while undergoing cataract procedures, 73 per cent maintained an IOP of 21 mmHg or lower without medication at 12 months’ followup. That compared to only 50 per cent of those who underwent cataract surgery alone. More recent research by Ike Ahmed MD and his associates demonstrated that two stents can consistently reduce IOP to less than 15 mmHg (G Belovay et al, J Cataract Refract Surg, “Using multiple trabecular micro-bypass stents in cataract patients to treat open-angle glaucoma”, 2012 November; 38:1911-1917). Manfred Tetz MD, Berlin, reported similar results at this year’s ESCRS Winter Meeting using the new collar-button design of the iStent. At 12 months postoperatively, mean IOP was 14.5 mmHg and the mean number of ocular hypotensive medications patients needed decreased from 1.8 medications preoperatively to 0.3 medications or less at all postoperative time periods The manufacturers of the Hydrus implant describe the device as an intracanalicular scaffold. It is designed for placement into Schlemm’s canal from the inside of the eye. It therefore resembles in design and purpose the Stegmann canal expander, a device implanted by an ab externo approach. However, unlike the ab externo device, the Hydrus has a special injector system and does not require any disturbance of scleral or conjunctival tissue. In a study Dr Tetz presented at the XXX Congress of the ESCRS in Milan last year, patients with mild to moderate openangle glaucoma who were concurrently undergoing cataract surgery underwent implantation of the Hydrus device. At 12 months, washed out IOP was 15.5 mmHg, a decrease of 9.1 mmHg from preoperative washout values. “The results are encouraging. But one little thing remains uncertain with all internally placed implants, did I really hit Schlemm’s canal? And did I put the implant first full-length inside Schlemm’s canal? In most cases with modern implants with the Hydrus and the iStent you're reasonably sure, but with the Grieshaber Stegmann canal expander you implant it from the outside after opening up the canal, so you’re 99 per cent sure that you really placed it in Schlemm’s canal,” Dr Tetz said. The Trabectome opens access to Schlemm's canal by ablating a portion of the trabecular meshwork of the eye with an electrosurgical hand piece. It received FDA approval in 2004. In a prospective trial by the Trabectome Study Group involving


Courtesy of Ike Ahmed MD

poor, with studies showing 94 per cent achieving visual acuities of 20/200 or worse. (Poulsen EJ et al, J Glaucoma “Characteristics and risk factors for infections after glaucoma filtering surgery”, 2000;9:438-443).

Figure 2: Hydrus micro-stent

more than 300 patients, the mean IOP fell from preoperative values of 20.0 mmHg to 15.5 mmHg at one year’s follow-up. The mean number of drops patients needed fell from 2.65 ± 1.13 at baseline to 1.29 at one year. (BA Francis et al J Cataract Refract Surg, “Combined cataract extraction and trabeculotomy by internal approach for coexisting cataract and open-angle glaucoma. 2008 Jul;34(7):1096-103). The CyPass (Transcend Medical, Menlo Park, Calif.) uses a different approach, directing the outflow of aqueous into the suprachoroidal space. The CE Mark approved device consists of a tube 6.35mm in length and with an outer diameter of 0.51mm composed of a polyimide material. Like the other MIGS implants it is placed in the eye using an ab interno approach positioned in a superciliary cleft created with the implantation device. The one-year results of the CyCLE study presented at the annual AAO Meeting in Chicago last year revealed that implantation of the device reduced mean IOP by 35 per cent to 16.3 mmHg and a reduced mean medication usage by half. What remains to be seen is whether the device will continue to work over the long-term, Dr Tetz said. “My current opinion is that the suprachoroidal approach doesn't seem to work well enough in the long-term. I think with a number of studies we have good one-year data and you see that most of the devices close off after one and a half years,” he added. The Xen microfistula implant, AqueSys, is an investigational device delivered through an ab interno incision to create an external subconjunctival filtration pathway, similar to trabeculectomy. It is composed of a soft

The older generation of drainage implants, namely the Baerveldt, Ahmed and Molteno tubes consist of a plate placed subconjunctivally from which extends a drainage tube that is inserted through the sclera into the anterior chamber

Courtesy of Peng T Khaw MD, PhD


Figure 3: Moorfields Safer Surgery System changes in surgical technique leading to better outcomes

I find that trabeculectomy using the Moorfields Safer Surgery System is probably my surgical therapy of choice particularly in those who need very low pressures Peng T Khaw MD, PhD

pliable collagen-derived gelatin material and is placed ab interno through a selfsealing corneal incision and implanted with a 27-gauge needle, visualising the meshwork with a gonio mirror. Therefore, the scleral and conjunctival tissues are left intact. “The AqueSys is actually an MIGS replacement for trabeculectomy. It compares very well because the amount of trauma going to the delicate structures is usually lower and the smaller the trauma area, the less likely it is you will get scarring and closure,” Dr Tetz said.

Trabeculectomy down but not out Although trabeculectomy has had

a long history of producing a high rate of complications, recent years have seen the introduction of a modified surgical technique that greatly reduces the risks for hypotony and endophthalmitis. Moreover, it is the only treatment known which can reduce IOP below 10.0 mmHg, which is necessary in some patients with normal tension glaucoma, Peng T Khaw MD, PhD,

Moorfields Eye Hospital London, UK, told EuroTimes in an interview. “It is true that trabeculectomy gets a lot of bad press. It's not perfect, it requires too much time and skill to do. It is not the solution to glaucoma and in the long run we need much better things to sort out glaucoma. However, I find that trabeculectomy using the Moorfields Safer Surgery System is probably my surgical therapy of choice particularly in those who need very low pressures,” he said. He explained that the Moorfields safer surgery system for trabeculectomy greatly reduces the incidence of hypotony in the early postoperative through the use of adjustable sutures (Figure 3). It also reduces late postoperative bleb-associated complications by creating a broader more diffuse filtration area (Figure 4). He added that an audit performed also at Moorfields Eye Hospital by Hari Jayaram and Debbie Kamal showed that performing trabeculectomy procedures with lower target IOPs of around 10.0 mmHg appeared to stabilise the optic neuropathy and visual field status of patients with normal tension glaucoma whose condition was previously progressing despite wellcontrolled IOP. He noted furthermore, that accurate assessment of the comparative value of MIGS techniques must await longer term follow-up than has yet been reported. “All of the implants in the past have one problem they all failed for one reason - the body reacts to what you've done and tries to close it off. Whether it’s an iStent, or a Hydrus or a Cypass, they're all susceptible in the long-term to being blocked off by scarring. There have been other suprachoroidal shunts, they all are susceptible to scarring and I'm pretty sure even the Schlemm’s canal ones are going to get some scarring,” he said. Clive Peckar FRCOphth UK told EuroTimes he does not agree with Peng Khaw’s assessment regarding the long-term efficacy of stents in Schlemm’s canal. He pointed out that studies using gonioscopic imaging of early prototype intracanalicular devices show that they continue to maintain the patency of Schlemm’s canal for over

...studies using gonioscopic imaging of early prototype intracanalicular devices show that they continue to maintain the patency of Schlemm’s canal for over 10 years... Clive Peckar FRCOphth

10 years, due to the intrinsic fibrinolytic activity within Schlemm’s canal. (See Figure 5, Gonioscopic view of 3mm polyimide trans-ostal stents,10 years after surgery, IOP: 40-15 mmHg). He pointed out that the ab externo approach, used in canaloplasty, permitted the atraumatic dilatation of Schlemm’s Canal and it’s collector channels to be performed prior to the insertion of intracanalicular stents, such as the Stegmann Canal Expanders (Ophthalmos). However, the ab interno approaches, such as the Hydrus and the iStent, are more prone to be blocked by fibroses, induced by canal endothelial trauma, following insertion into the undilated 25 micron deep “slit” that is Schlemm’s canal. As with all Schlemm’s canal surgeries they are limited by episcleral venous pressure, in their IOP-lowering capability. He also pointed out that over the 16 years he has been performing Schlemm’s Canal Surgery, the only consistent and reproducible way of dilating the canal and collector channels atraumatically, was to use the ab externo approach, and that there is some evidence to suggest that, without dilatation, ab interno devices might only function optimally when positioned opposite large collector channel ostia. Dr Peckar noted that clinical studies with the Stegmann Canal Expanders™ began in 2010. They have an additional advantage, over the tension suture canaloplasty technique, in that they do not depend on Schlemm’s canal being catheterised throughout its complete circumference. He added that there is now some evidence of a further lowering of IOP around two years after surgery, related to increased permeability of the Trabecular Meshwork, due to the presence of the Expanders (See Figure 6, stream of red blood cells passing through the ribs of Stegmann Canal Expander two years after surgery, IOP: 39-16 mmHg).

Courtesy of Peng T Khaw MD, PhD

Glaucoma treatment at a crossroads Regarding the future of

Figure 4: Dramatic improvement in bleb appearance (right) with simple modification of technique (Moorfields Safer Surgery System)

EUROTIMES | Volume 18 | Issue 7/8

glaucoma treatment, Dr Ahmed noted that, developing in tandem with MIGS techniques, there have been a range of new technologies for delivering glaucoma medication to the eye in ways that may reduce irritation and may also be less reliant on a patient’s willingness to adhere to their prescribed regimens. That could in turn delay progression and the need for surgery. “There is some really interesting and exciting work being done with drug delivery and sustained release systems including ocular surface sustained-release inserts, punctal plugs, subconjunctival


Cover Story


Courtesy of Clive Peckar FRCOphth

OCULUS Centerfield® and Easyfield®

Figure 5: Gonioscopic view of 3mm polyimide trans-ostal stents,10 years after surgery, IOP: 40-15 mmHg

injections anterior chamber drug pellets and intravitreal injections, all with different long-lasting medications. By delivering the medication to the site of action they reduce the need for compliance and adherence and reduce side effects.” In contrast, Dr Tetz told EuroTimes he foresaw an era when IOP-lowering medical therapy would be increasingly replaced by largely atraumatic surgical techniques. He pointed out that medical therapy can be quite invasive in the way it damages tissue during long-term use. Moreover, selective laser trabeculoplasty is not as selective as its name would suggest, since it causes micro-scarring to Schlemm’s canal and therefore reduces the efficacy of subsequent Schlemm’s canal surgery. “The safer and more controlled surgery becomes, the more I see it as taking over parts of the drop market. Medication will still have a role but it will be more and more directed towards neuroprotection," Dr Tetz said. Dr Khaw said that he thought that what glaucoma surgeons should strive for is a 10-miniute technique that will reduce IOP to 10 mmHg for at least 10 years.

Using Threshold Noiseless Trend (TNT) for efficient progression analysis Figure 6: Streams of red blood cells passing through the ribs of Stegmann Canal Expander TM two years after surgery, when flow is reversed by pressing on gonioscopy lens flange. (Blurred view due to Arcus Senilis): IOP: 39-16 mmHg

“If we meet that challenge it could save millions of people around the world from going blind so that's our challenge for the next decade,” Dr Khaw asserted.

contacts Ike Ahmed – Manfred Tetz – Peng T Khaw – Clive Peckar –


Gene therapy for inherited retinal disease

It has been estimated that one in 150 people in developed regions have severe visual impairment due to a retinal condition, ranging from extremely rare “orphan” hereditary retinal degenerative diseases to diabetic retinopathy. Individuals diagnosed with retinitis pigmentosa (RP) or Leber’s congenital amaurosis have a poor visual prognosis and potential treatments are limited. For decades scientists and ophthalmologists have sought ways to stop the progression of these diseases though, until recently, without success. In the past five years, gene therapy has emerged in ophthalmology as an exciting new approach in the treatment of many retinal disorders that are considered incurable. Nearly 30-plus trials are currently under way around the world into degenerative retinal diseases such as Leber’s, Stargardt’s, RP, Usher’s syndrome and others. The story will look at the more promising of these, outline the latest results, discuss delivery methods and potential problems/obstacles to progress, and likely future avenues of research.

EUROTIMES | Volume 18 | Issue 7/8

• Full-fledged perimetry in

compact design • SPARK strategy for fast and

reliable examinations

• Automated glaucoma staging systems • Threshold Noiseless Trend (TNT) for

high sensitivity progression analysis


Special Focus



Early lens removal recommended for optimal glaucoma management

by Howard Larkin in San Francisco


ndications for cataract surgery should be broadened in glaucoma patients given that this procedure is known, on average, to lower IOP in both those with angle-closure or open-angle glaucoma, Kuldev Singh MD, PhD told a Glaucoma Day session at the 2013 American Society of Cataract and Refractive Surgery Symposium. Current guidelines generally call for delaying cataract removal until there is substantial impact on the patient’s activities of daily living, noted Dr Singh, who is professor and director of the glaucoma service at Stanford University School of Medicine. Dr Singh made the case that there are circumstances when cataract surgery may be a good option prior to substantial visual disturbance in those who have coexistent glaucomatous disease, particularly when medical and laser therapy for the disease have been unsuccessful. “Cataract removal prior to trabeculectomy is often better than trabeculectomy first,” added Dr Singh, “given that trabeculectomy commonly accelerates cataract formation and cataract surgery following trabeculectomy can jeapordise the functioning trabeculectomy often resulting in bleb failure.” Cataract removal may also lower the risk of future filtration procedures as lens-related complications are fairly common following trabeculectomy and pseudophakic patients may not be as likely to have such problems as phakic individuals. “If you had a drug that lowered IOP by 4.0 mmHg for at least three years and helped patients see better, it would undoubtedly be a blockbuster,” said Dr Singh, “and this is the profile of modern cataract surgery in the glaucoma patient.”

Most common procedure Dr Singh pointed out that cataract surgery is already the most common IOP-lowering procedure performed worldwide. In the US, fewer than 150,000 glaucoma procedures are performed annually, including trabeculectomy, drainage tube shunts, viscocanalostomy, other non-penetrating procedures, endocyclophotocoagulation and ab interno ablation techniques. By comparison, of the 3.5 million cataract procedures performed annually, an estimated 15 per cent are in patients with glaucoma or ocular hypertension who are receiving IOPlowering therapy. ad-half page vertical-Eurotimes-ENG EyeCeeO PRL-1306v03 pva RZ.indd EUROTIMES | Volume 18 | Issue 7/8


11.06.13 16:41

In other words, the approximate 500,000 patients undergoing cataract surgery, a procedure which commonly results in a decreased dependence upon postoperative glaucoma medications, is three to four times as great as the number undergoing all other surgical glaucoma procedures. Indeed, one can make the argument that from a public health perspective, reducing the global backlog of 20 million potential cataract cases may have a greater positive impact in decreasing glaucoma-related disability than using the same resources to combat glaucoma, particularly in the developing world where treatment of glaucoma is suboptimal in so many ways, Dr Singh said. For patients with ocular hypertension, cataract surgery alone may be enough for long-term IOP control, Dr Singh said. For those with mild-to-moderate glaucoma, cataract surgery alone or in combination with some of the novel ab interno surgical procedures may be a viable option. For those with severe glaucomatous disease, combined cataract surgery and trabeculectomy will remain the gold standard in the near future. Dr Singh noted that early cataract surgery is already accepted practice in Asia for closed-angle glaucoma, and well designed randomised clinical trials have supported this approach which results in deepening of the anterior chamber angle. For primary open-angle glaucoma, however, the mechanism by which IOP is lowered following cataract surgery is less well understood Dr Singh said. It may be that further opening of the trabecular meshwork by removing the lens is beneficial even when the angle is already open or that there is an inflammatory response leading to rejuvenation of the trabecular meshwork similar to the presumed mechanism of action with laser trabeculoplasty. What is clear is that cataract surgery, on average, lowers IOP in open-angle glaucoma, and surgeons should consider using this procedure with or without other IOP-lowering procedures in patients with glaucoma, Dr Singh said. He did caution, however, that the average IOP reduction is not representative of all cases and IOP spikes after cataract surgery may result in the necessity for urgent glaucoma surgery which should not be withheld in such cases.


Kuldev Singh –


Special Focus


The moment a subtle change in pathology becomes a turning point in care. This is the moment we work for.




FastTra c


l Track

Preservative promotes inflammation, but does it accelerate glaucoma?


exclusiv e Cirrus ly on Hd-OC T

by Howard Larkin in San Francisco


he common preservative benzalkonium chloride (BAK) has long been known to exacerbate inflammatory ocular surface disease. But does BAK also accelerate the glaucoma disease process? While research has not demonstrated that it does, recent studies suggest mechanisms by which it might, Douglas J Rhee MD of Harvard Medical School told the 2013 American Society of Cataract and Refractive Surgery Symposium. An anti-microbial detergent, BAK is toxic to both pathogens, corneal epithelial cells and trabecular meshwork endothelial cells. Epithelium disruption also increases corneal permeability, boosting the effectiveness of some topical glaucoma medications, particularly timolol. BAK does enter the eye – a potential problem because it can be highly toxic to endothelial cells, Dr Rhee noted. “If you infuse a rabbit with 0.05 per cent BAK in the anterior chamber for 10 seconds, you get total and permanent endothelial cell destruction.” (Maurice D, Perlman M. Invest Ophthalmol 1977; 16:646.) Recent mass spectrometry ion imaging studies confirm that topical BAK does indeed penetrate. It has been detected in the corneal endothelium, iris and trabecular meshwork, causing inflammation, Dr Rhee said (Brignole-Baudouin F et al. PLoS One 2012;7:e50180. Desbenoit et al. Anal Bioanal Chem 2013). BAK also has been shown to kill trabecular meshwork cells in vitro (Ammar DA, Kahook MY. Mol Vis. 2011;17:1806-1813). However, this may not be relevant to glaucoma progression, Dr Rhee added. “For most patients, inflammation in the trabecular meshwork is not the primary disease point; it is basically cell death and changes in the extracellular matrix.” More research is needed to determine the possible effect of chronic BAK use on trabecular meshwork pathology, he said.

Ocular surface disease Evidence for BAK exacerbating ocular surface disease is much stronger, Dr Rhee said. Several studies of ocular surface disease in glaucoma patients since 2008 report rates from 30 per cent to 70 per cent, averaging around 50 per cent, compared with about 30 per cent for controls. In addition, the number of daily EUROTIMES | Volume 18 | Issue 7/8

More research is needed to determine the possible effect of chronic BAK use on trabecular meshwork pathology Douglas J Rhee MD

eye drops and duration of topical treatment are risk factors for ocular surface disease in glaucoma patients. (Rossi GC et al. Eur J Ophthalmol. 2012. Dec 17 e. pub. Labbe A et al. Cornea 2012;31:994-999. Ghosh S et al. Clin Experiment Ophthalmol. 2012;40:675681. Valente C et al. J Ocul Pharmacol Ther. 2011;27:281-285. Leung EW et al. J Glaucoma 2008;17:350-355.) Eyes with filtering blebs also have a higher incidence of surface disease (Neves Mendes CR et al. Curr Eye Res. 2012;37:309-311), and surface disease is associated with poorer quality of life in glaucoma patients (Skalicky ES et al. Am J Ophthalmol. 2012;153:1-9). Long-term BAK use also promotes conjunctival inflammation, decreasing trabeculectomy success, Dr Rhee noted. However, this may be reversed with preoperative steroids (Broadway DC et al. Arch Ophthalmol. 1996; 114: 262-7). Avoiding BAK may help reduce both surface and conjunctival inflammation risks, Dr Rhee said. Preservative-free glaucoma treatment options include timolol maleate (Timoptic), dorzolamide/ timolol combination (Cosopt) and tafluprost (Zioptan). In addition, alternatively preserved options include brimonidine 0.1 and 0.15 per cent (Alphagan P), preserved with Purite, a stabilsed oxycholoro complex; and travoprost 0.015 per cent (Travata), preserved with Sofzia, an ionic buffer containing borate, sorbitol, polylene, glycol and zinc, Dr Rhee said. “These are a little gentler than BAK, but their exact chemical structure is proprietary.”


Douglas J Rhee –

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EYE CHAT Exclusive interviews Up to date information Problem solving


Devices that extend dosing by hours to up to 12 months near market

by Howard Larkin in San Francisco


When disaster strikes Dr Oliver Findl talks to Dr Paul Rosen about how to prepare for complications in eye surgeries


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everal devices that release glaucoma medications for periods ranging from a few hours to one year are close to reality, Ike K Ahmed MD of the University of Toronto, Canada, told Glaucoma Day at the 2013 ASCRS Symposium. They hold potential for targeting IOP-lowering and neuroprotective agents more directly to their sites of action, and reducing poor patient adherence and debilitating side effects often seen with eye drops. “We certainly know we have issues with putting drops in, and remembering to put drops in, and red eyes. These are problems we encounter every day. We ignore them, we try to deal with them, but we’d like to see better alternatives,” Dr Ahmed said. Even with good adherence, persistence of medication at the site of action is often an issue with topical administration, he added. Recent research suggests that patients, too, may prefer alternatives to daily drops, even if it means undergoing periodic subconjunctival injections, and higher costs, Dr Ahmed said. Patients in Singapore who admit non-adherence, who are on more medications or have higher frequency of dosing are more likely to accept alternates (Chong RS et al. J Glaucoma Volume 22, No 3, March 2013).

Balancing performance and risk

Ideally, an extended release system should be relatively easy to use or implant, work long enough to be worth the extra trouble and be effective in reducing intraocular pressure (IOP) and improving diurnal control, Dr Ahmed said. The level of invasiveness and risk profile also should compare favourably to existing therapies. “As clinicians we will have to figure out what exactly will be attractive for our patients.” Devices close to market use a variety of novel delivery concepts to achieve these ends. One improves the performance of eye drops with mucus penetrating particles (Kala Pharmaceuticals). These nanoparticles keep drugs on the ocular surface longer by defeating the mucosal barrier, making them resistant to being washed away by tears, which extends duration of action.

We certainly know we have issues with putting drops in, and remembering to put drops in, and red eyes Ike K Ahmed MD

Others repurpose previously developed devices. A latanoprost-eluting contact lens (Massachusetts Eye and Ear Infirmary) works for two weeks to a month. Drug-eluting punctual plugs (Ocular Therapeutix), could deliver prostaglandins or corticosteroids for two to three months. Drug-eluting intravitreal depots (Ocular Therapeutix), the Durasert implant (pSividia Corp), implantable collagen wafers and gels injected in the vitreous or anterior chamber extend release from four to six months. A biodegradable implant installed subconjunctivally or intravitreally with a 21-gauge needle may deliver a combination of drugs for three to six months (PolyActivia). The Replenish ophthalmic micropump is attached to the eye and delivers drugs for 12 months. It is recharged wirelessly and can be refilled with a 31-gauge needle for even longer use. Microneedles, injected gels and collagen depots that sit on the ocular surface under the upper eyelid are also in development. “With our current regulatory environment we are probably four or five years away from many of these. But this is very exciting for us and our patients to provide new alternatives for glaucoma drug therapy,” Dr Ahmed concluded.

contact Ike K Ahmed –

Don’t Miss Eye on Technology, see page 31 EUROTIMES | Volume 18 | Issue 7/8

Glaucoma Day ESCRS

Friday, 4th October 2013

Amsterdam, The Netherlands

Available Online: Registration and Hotel Bookings Scientific Programme organised by

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Glaucoma Filtration Surgery: Limiting Variables and Improving Outcomes SPONSORED BY


Cataract & refractive



Jacek P Szaflik –


Head-to-head comparison highlights advantages of femtosecond laser-assisted cataract surgery by Roibeard O’hEineachain in Warsaw

Courtesy of Jacek P Szaflik MD, PhD

surgery that required air injection, after which it became fully attached and clear. “Femtosecond laser capsulotomy and nucleus fragmentation can be performed in presence of endothelial lesions and mild to moderate corneal oedema. In cases with very oedematous cornea attention should be paid whether the capsulotomy is complete. The accurate capsulotomy ensures maintaining good stability of the implant in the capsular bag during the remaining surgery. Employing the femtosecond laser technology facilitates cataract surgery during combined procedure,” Prof Szaflik said.

Increased safety due to repeatability and significant reduction in phacoemulsification power is among the biggest advantages of femtosecond laser-assisted cataract surgery. Flexibility and easiness of control are important features of the LenSx® femtolaser


he LenSx® (Alcon) femtosecond laser system is highly flexible in the performance of cataract surgery and may provide some important safety advantages over conventional ultrasound phacoemulsification, said Prof Jacek P Szaflik MD, PhD, Medical University of Warsaw, Poland. “The biggest advantages are repeatability of capsulorrhexis shape and size and lens fragmentation that is individually adjusted for the type of cataract and preference of the surgeon, and the reduction in phacoemulsification power decreases the risk of endothelial cell loss and macular oedema,” Prof Szaflik told a symposium of the Polish Society of Cataract and Refractive Surgery at the 17th ESCRS Winter Meeting. He presented a prospective analysis comparing the results in 80 patients who underwent femtosecond laser cataract surgery using the LenSx platform with those of a matched group of patients who underwent standard phacoemulsification. The patients’ cataracts ranged from grade 1 to grade 5. The analysis showed that the amount of phacoemulsification energy used per procedure was 43 per cent lower among

Don’t Miss ESASO update, see page 32 EUROTIMES | Volume 18 | Issue 7/8

those undergoing a femtosecond laser procedure than it was among those who underwent manual phaco. Furthermore, among the femtosecond laser group endothelial counts were lower than preoperative values by only 1.8 per cent at one month and by only 3.2 per cent at six months. By comparison, among eyes in the manual phaco group endothelial cell counts fell by 5.8 per cent at one month and by 17.25 per cent at six months.

Femto-cataract plus DSAEK Prof Szaflik also presented results achieved in a series of 46 patients who underwent combined DSAEK and cataract surgery with the femtosecond laser. Fuchs’ dystrophy was the indication in 45 eyes, and two eyes had primary endothelial dysfunction. Prof Szaflik and his associates used the LenSx femtosecond laser (Alcon) to create the capsulotomy and chop the nucleus. They implanted round endothelial grafts of 8.5mm diameter or oval grafts sized 8.0mm by 9.0mm. Although docking was not possible in one case and three capsulotomies had to be created manually in three cases, the surgeries were uneventful. There was one case of graft detachment two days after the

The femto procedure When using the femtosecond laser, Prof Szaflik and his associates perform the capsulotomy, nucleus fragmentation, corneal tunnels and side incisions with the laser and then complete the surgery using a torsional micro-coaxial phacoemulsification technique. They perform the procedure under local anaesthesia using a palpebral speculum. When the patient looks at the fixation light the interface becomes fixed to the eye and they increase suction to immobilise the eye. Afterwards, they use the laser’s integrated OCT device to check the orientation and position of the cuts in the cornea and the position of the anterior capsule. They also adjust the range of lens fragmentation to avoid cutting the posterior capsule. The lens fragmentation patterns include longitudinal slices that can be combined into a pizza pie configuration and cylindrical cuts. They can be used alone or in combination, Prof Szaflik noted. “Basically we enter the data so we can precisely define what kind of cuts, what kind of procedure we want to perform, the diameter of the capsular axis, the method of lens fragmentation and the parameters of arcuate incisions. It looks a little complicated but after a couple procedures it becomes very easy to manage and it's pretty user-friendly,” he added. Learning curve Prof Szaflik noted that they had some difficulties with some of their first cases but he said that problems became less common as they gained experience with

Using femtolaser for cataract removal during triples involving endothelial keratoplasty facilitates the surgery

The new design of the laser has a smaller patient interface and it also allows a shortened time for the laser at a lower energy, so the quality of the cuts is far improved Jacek P Szaflik MD, PhD

the system. In addition, the new patient interface (LenSx® SoftFit™) seems to have eliminated the difficulties. In five cases they could not complete docking because of a discrepancy between the size of the patient’s interface piece and the periorbital anatomy and they had to abandon the laser procedures. Four of the abandoned cases were among the first 50 treated and one was among the following 80 eyes. They also had incomplete capsulotomy in eight cases, six among the first 50 cases and three among the following 80 cases. Anterior radial tear occurred in one case, necessitating a manual capsulorrhexis. In one case with a mature white cataract, they could not visualise the posterior pole of the lens with the built-in OCT system and could therefore perform only the capsulorrhexis and corneal incisions. “The new design of the laser has a smaller patient interface and it also allows a shortened time for the laser at a lower energy, so the quality of the cuts is far improved. We’ve also had no problems with docking with the new interface and we’ve also had no incomplete capsulotomies, although even with the old system that didn't happen anymore after we had some practice,” Prof Szaflik added.


Pierre Fournié – Emilie Bardet –


Cataract & refractive


Frequent postoperative visits mandatory to monitor the possibility of complications by Dermot McGrath in Paris

Focusing specifically on the anglesupported lenses, 63 per cent of these IOLs were removed because of endothelial cell loss, 20 per cent for endothelial decompensation, 13 per cent for cataract and four per cent for other reasons, including pupil ovalisation, retinal detachment and decentration. The average delay before explantation was 10.20 years. For the iris-fixated IOLs, endothelial loss was responsible for explantation in 64 per cent and cataract in the remaining 36 per cent, with an average time of 7.73 years before explantation. Turning to the posterior chamber IOLs, cataract was implicated in the vast majority of cases (92 per cent), with the remainder removed for various reasons such as vaulting and retinal detachment. The mean time before explantation was 5.72 years. Dr Fournié noted that while the Toulouse study accorded with the scientific literature in terms of known complications associated with specific types of phakic IOL, there were some limitations to be borne in mind. “We need to be aware of the limitations of this type of study. This was a retrospective study that took account of

Figure 1: Cataract after first generation of posterior chamber IOL

Courtesy of Pierre Fournie MD


ndothelial cell loss and cataract were the two most common reasons for the removal of phakic IOLs cited in a long-term French study presented at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR). In a retrospective review of 10 years of phakic IOL explantations carried out at the University Hospital, Toulouse, Pierre Fournié MD reported that 129 phakic implants in total were explanted between 2003 and 2012. The study looked at three broad categories of phakic implants: anglesupported anterior chamber IOLs, irisfixated anterior chamber lenses and posterior chamber IOLs. The average patient age at the time of explantation was 48.95 years. Looking at the breakdown of the overall explantation data, the removals included 33 iris-fixated lenses, 46 angle-supported IOLs and 50 posterior chamber IOLs. The cause for removal of all lens categories combined was cataract in 52 per cent (Figure 1), endothelial cell loss in 35 per cent, endothelial decompensation in seven per cent (Figure 2) and various other reasons in six per cent.


Figure 2: Endothelial decompensation with an angle-supported anterior chamber IOL

different broad categories of implants. However, there are noticeable differences between different implants of the same class in terms of their design and material. Nor did the study take account of possible changes in IOL design and material from one generation of implant to the next,” he said. Similar findings were also reported in a series of 32 phakic implants explanted

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EUROTIMES | Volume 18 | Issue 7/8

at the University Hospital of Bordeaux between 2007 and 2011, according to Emilie Bardet MD. “Phakic implants remain a therapeutic alternative in refractive surgery for severe ametropias in patients where LASIK surgery is not a viable option. However, frequent postoperative visits are mandatory in order to monitor the possibility of postoperative complications, of which endothelial cell loss and cataract remain the most common,” she said. Looking at the explants in greater detail, the list included: one AcrySof (Alcon) angle-supported lens (three per cent) removed after nine years for endothelial decompensation; six irisfixated Artisan (Ophthec/AMO) IOLs (18 per cent) removed after a mean of nine years for endothelial decompensation, eight angle-supported I-CARE (Corneal/ Allergan) lenses (25 per cent), removed after a mean of four years for endothelial decompensation; 14 angle-supported GBR (IOLTECH, Zeiss) lenses removed after a mean of 8.5 years for endothelial decompensation; one Sticklens (IOLTech/ Zeiss) sulcus fixated IOL (three per cent), removed after three years for cataract; and two ICL sulcus-fixated (Staar Surgical Company) lenses (six per cent), removed after a mean of three years for cataract. Dr Bardet noted that concerns about the angle-supported lenses in particular led to their withdrawal from the French market between 2007 and 2008. The Alcon Cachet lens was also withdrawn from sale in 2012 because of concerns relating to sudden reduction in endothelial cell counts in implanted patients.




Cataract & refractive

Georges Baikoff – Jean-Luc Febbraro –


Epithelial thickness profiles may prove to be useful diagnostic tool in screening for keratoconus by Dermot McGrath in Paris


device capable of accurately measuring epithelial thickness may prove beneficial in the planning of corneal refractive surgery as well as being a potentially useful tool in screening for suspect keratoconus, according to Georges Baikoff MD. Dr Baikoff told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) that the ability to characterise the epithelial thickness profile may help to increase the accuracy of corneal refractive surgery as epithelial changes are known to play a role in refractive regression. “Everything in OCT is good. Dan Z Reinstein MD has paved the way with his studies with the Artemis on the importance of epithelial dynamics. We now know that epithelium abhors a vacuum and its refractive effect should be taken into account when planning surgery. The epithelial pachymetric maps complete the topographic information and should also be borne in mind for the diagnosis of suspect keratoconus,” said Dr Baikoff who is in private practice in Marseille, France. Explaining the principle behind epithelial thickness mapping, Dr Baikoff said that a thickness map is derived from the corneal power scan using the RTVue SD-OCT device (Optovue Inc). Each corneal power scan contains five consecutive sets of pachymetry scans of eight meridians of the cornea. A scanning algorithm then detects the epithelial interface based on averaged data, and uses this information to build up epithelial profile maps. He presented data from a retrospective study of scans of 145 myopic eyes, 67 hyperopic eyes and 106 keratoconic eyes. He noted that in normal eyes the average thickness of the corneal epithelium, including tear film, is about 52 microns with a standard deviation of about three or four microns. For myopic eyes treated by LASIK, the epithelial maps showed that the thickness of the central zone typically increased compared to the periphery. “The epithelial pachymetry map is therefore concordant with the treatment zone. This raises several questions: is it constant? Is there a correlation with the initial extent of the myopia? Is there a correlation with the initial keratometry value? And is there a relation in cases of regression?” he asked. Looking at the myopic LASIK treatments, the mean postoperative central epithelial thickness was 57 microns

The epithelial pachymetric maps complete the topographic information and should also be borne in mind for the diagnosis of suspect keratoconus Georges Baikoff MD

EUROTIMES | Volume 18 | Issue 7/8

Courtesy of Georges Baikoff MD


Our study showed that the intraoperative pachymetry measurements seem to be viable and include information on total corneal thickness, flap thickness and residual corneal bed Jean-Luc Febbraro MD compared to 52 microns before LASIK, a statistically significant difference, said Dr Baikoff. “In myopic LASIK, the thickness of the central epithelium and the delta value, which denotes the difference between the maximum and minimum thickness values, vary according to the extent of the refractive treatment. However, the thickness of the central epithelium and the delta value are independent of the preoperative keratometry,” he said. Turning to corneal regression, Dr Baikoff noted that the thickness of the central epithelium was found to increase in cases of refractive regression and that being able to distinguish epithelial from biomechanical causes of regression may help in planning retreatment surgery. “In this particular case, for instance, we see that there would be no benefit in retreating with a transepithelial PRK, effectively treating 15 microns on an epithelium that is greater than 50 microns,” he said. Epithelial thickness profiles may also prove to be a useful diagnostic tool in screening for keratoconus, as it is known that the epithelium thins over the region of the cone in keratoconus, sometimes leading to epithelial breakdown. As it is difficult for the surgeon to distinguish forme fruste keratoconus from other types of mildly irregular corneal topographies, the pachymetry map can provide important additional data to confirm or reject the diagnosis and determine if the patient is a good candidate for refractive surgery, said Dr Baikoff. “Our scans showed an almost perfect concordance between the summit of the cone, the thinning of the corneal stroma and the thinning of the epithelium,” he said. The potential benefits of using OCT pachymetry intraoperatively in LASIK patients were also highlighted in a separate study by Jean-Luc Febbraro MD. Dr Febbraro’s prospective study evaluated the central corneal thickness and flap thickness in 66 eyes of 49 myopic and 17 hyperopic patients who underwent femto-LASIK procedures using the Wavelight Alcon FS200 and EX500 excimer laser. The myopic patient group had a mean preoperative spherical equivalent of -4.53 D and astigmatism of -0.56 D, while the hyperopic patients had a preoperative mean of +2.56 D and astigmatism of -1.29 D. Flap thickness was programmed for 120 microns for all patients, with a 9.2mm flap diameter for myopes and 9.5mm for hyperopes.

Results showed the mean achieved post-LASIK flap thickness for the hyperopic group was 127.94 microns, with a standard deviation of 22.30 microns after treatment compared to 94.94 microns before treatment. For the myopic group, the flap thickness was 119.26 microns after treatment, with a standard deviation of 43.56 microns, compared to 102 microns before treatment. Although the flaps for both the myopic and hyperopic treatments were slightly thinner than programmed, intraoperative pachymetry should still prove to be an invaluable addition to the refractive surgeon’s toolkit in the future, said Dr Febbraro. “Our study showed that the intraoperative pachymetry measurements seem to be viable and include information on total corneal thickness, flap thickness and residual corneal bed. With this data to hand, we can then customise the ablation depth and ensure more accurate and safer surgery,” he said.



Cataract & refractive


How much is enough depends on reading habits, even language by Howard Larkin in San Francisco


ith multifocal intraocular lens near vision adds ranging from +2.5 to +4.0 D now available, the question arises: how much is enough? The answer depends on several factors, including reading habits and even language, Hiroko Bissen-Miyajima MD, Tokyo, Japan, told the American Society of Cataract and Refractive Surgery Symposium. She suggests reading the literature first, but listening to patients is critical to sorting out which lens is best for whom.

While the +2.5 D add provided the best quality distance vision of the three, it was not as good as a monofocal, leaving some patients complaining of “waxy” vision

Hiroko Bissen-Miyajima MD

Different power, different vision

Dr Bissen-Miyajima, who is a consultant for Hoya, has long experience implanting a variety of multifocal lenses with different add powers. To illustrate the differences, she presented a clinical study she and colleagues at the Tokyo Dental College Suidobashi Hospital did comparing +4.0, +3.0 and +2.5 D add versions of the diffractive Alcon ReSTOR single-piece acrylic lens. In Europe, the lenses were introduced in 2005, 2008 and 2012, respectively. All versions delivered 1.0 or 20/20 visual acuity at distance, with the +4.0 delivering the best near visual acuity but the worst intermediate vision, and the +2.5 the best intermediate and worst near vision. Less than five per cent of patients implanted with the +4.0 required reading glasses for small print, compared with more than 50 per cent implanted with the +2.5 needing reading glasses, Dr Bissen-Miyajima reported. So, if the +4.0 lens provides the best near vision and highest possibility of spectacle independence, why is the trend in new lenses towards lower near add power? “Because patients require good distance vision. The trade-off for a higher near add is reduced distance vision quality, with lower contrast sensitivity and more glare and haloes. While the +2.5 D add provided the best quality distance vision of the three, it was not as good as a monofocal, leaving some patients complaining of ‘waxy’ vision,” Dr Bissen-Miyajima explained.

An adequate add Dr Bissen-Miyajima counselled discussing with patients the trade-offs between more add power and distance vision quality before surgery. Reading habits and even the language in which patients read are important, she noted. EUROTIMES | Volume 18 | Issue 7/8

For example, Japanese people tend to read at a distance closer to 30cm than 40cm, and Japanese characters are more detailed, requiring better visual acuity to read than Roman alphabet used in English and most other European languages, Dr Bissen-Miyajima noted. As a result, many Japanese prefer a +4.0 add. On the other hand, her husband reads closer to 50cm and mostly in English, so a +3.0 is fine for reading and provides better intermediate and distance vision. +3.0 is the most commonly implanted power in the US, she said. Those receiving +2.5 lenses should be informed they will likely need reading glasses for small print. A patient’s strong desire for multifocal lenses may even overcome typical clinical parameters for using them, Dr BissenMiyajima added. She normally would not implant a multifocal in a one-eyed patient. But she did implant one in the left eye of a 97-year-old man with 0.1 or 20/200 in his right eye due to optic nerve atrophy following intracapsular cataract surgery 30 years before. He achieved 0.9 or about 20/22 at distance and 0.7 or about 20/30 after surgery – and was thrilled. “He had a strong wish for modern technology,” Dr Bissen-Miyajima said. “The final answer is: One size does not fit all.”

contact Hiroko Bissen-Miyajima –



5 -9 O C TOBER

X X X I c o ngress of t he esc r s

This year’s programme not to be missed! Main Symposia Saturday 5 October

Tuesday 8 October

Refractive Surgery in Risky Corneas: Is it Really Safe for the Patient?

The Management of High Hyperopia

ESCRS/EuCornea Symposium Chairpersons:




Wednesday 9 October Treating Astigmatism with Cataract Surgery

Sunday 6 October Femtosecond-assisted Cataract Surgery: Euphoria Amid Skepticism and Financial Restraints Chairpersons:

O. Findl AUSTRIA D. Spalton UK


Monday 7 October Unravelling the Mysteries of Myopia Chairpersons:



Binkhorst Medal Lecture Douglas Koch USA The Ablated Cornea: What Have We Done?

Sunday 6 October

Clinical Research Symposia Saturday 5 October • Treatment of Macular Edema Chairpersons:


• Basic Research on the Crystalline Lens

• Effects of Phakic IOLs Chairpersons:


• Corneal Stem Cells: A Future for Therapy

and IOLs Restoring Accommodation

of Corneal Disease





Other Highlights Saturday 5 October • Refractive Surgery Didactic Course

• Young Ophthalmologists Programme Chairpersons:

• Video Symposium on Challenging Cases Chairperson:

O. Findl AUSTRIA S. Morselli ITALY K. Vannas FINLAND

R. Osher USA

Sunday 6 October • Questions for the Cataract and Refractive Surgeon in 2013 Journal of Cataract & Refractive Surgery Symposium Chairpersons:

E. Rosen UK (European Editor) T. Kohnen GERMANY

• Video Awards Session Chairperson:

• Workshop on Visual Optics Chairpersons:

(European Associate Editor)

• Focus on Challenges in Cataract & Refractive Surgery Netherlands Intraocular Implant Club Symposium Chairpersons:

R. Packard UK

I. Pallikaris GREECE M.J. Tassignon BELGIUM

• Young Ophthalmologists Session: Taking Training into Your Own Hands Chairpersons:


O. Findl AUSTRIA N. Hirnschall AUSTRIA T. Rudolph SWEDEN

Monday 7 October • Controversies and Ethical Issues in Clear Lens Extraction (CLE) Combined Symposium of Cataract & Refractive Surgery Societies Chairperson: Co-chairs:


94 45

Instructional Courses FREE OF CHARGE

WETLABS €100 per course




Saturday 5 October

Lunchtime Symposia Lunchtime symposia include box lunches

13.00 – 14.00 Leading the Way in New Laser Technology Bausch + Lomb Technolas Laser Suite Moderator: TBC

Sponsored by

New Technologies for Premium Cataract Surgery – an Interactive Approach Moderator: O. Findl AUSTRIA O. Findl AUSTRIA Key success factors for using toric IOLs S. Beatty IRELAND From advocate to skeptic – why I no longer use blue light filtering IOLs E. Marques PORTUGAL New multifocal options for providing spectacle independence

Sponsored by

Croma Satellite Meeting Moderator: TBC

Sponsored by

Ziemer Satellite Meeting Moderator: TBC

Advances in Cataract Surgery Moderator: TBC - Femtosecond cataract surgery: Imaging in LENSAR-assisted cataract surgery - Femtosecond cataract surgery: Experiences with LENSAR - Biometry and topography: Experience with Topcon’s Aladdin system

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The Toric Solution: Exceeding Expectations in Patients with Astigmatism

Master Your Refractive Outcomes with the LENSTAR LS 900

Moderator: M. Packer USA

Moderator: T. Olsen

M. Packer USA Available options for accurate toric IOL positioning, from markers to latest alignment technology D. Black AUSTRALIA Long term performance of toric IOLS in the management of astigmatism


Sponsored by

Heidelberg Engineering Satellite Meeting Moderator: TBC

S. Kwitko BRAZIL M-flex® T and patient selection in the management of astigmatism

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D. Kent IRELAND Clinical experience with the Rayner toric IOL platform

OCULUS Pentacam® and Corvis® ST: Applications of Scheimpflug Technology for Refractive, Cataract and Glaucoma Surgery

T. Kohnen GERMANY ‘Why use the T-flex® IOL?’ - A comparison of outcomes, rotational stability and ease of use

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Satellite Meeting Schedule

X X X I congress of the escr s



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Saturday 5 October

Complex Cataract Cases, the Simple Truths

Sophisticated Cataract Surgery Quantity and Quality of Vision


Moderator: R. Osher USA

Moderator: D. Spalton UK

R. Osher USA Pearls for the challenging situation

D. Spalton UK Phacoemulsification in the 21st century Meeting patient expectations

Evening Symposia Innovations in Premium Refractive Surgery Moderator: A. Agarwal INDIA

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Live Surgery: Advancements in Techniques and Technologies

S. Masket USA Hanging loose: dealing with loose zonules and malpositioned IOLs B. Malyugin RUSSIA Small pupils: Does size really matter?

R. Bellucci ITALY Preventing common complications of cataract surgery

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Croma Satellite Meeting Moderator: TBC

Moderator: D. N. Serafano USA

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Refractive Cross-linking: The Future Moderator: TBC - Accelerated/high power applications - The future of refractive cross-linking - Myopia and astigmatism correction - Trans-epithelial cross-linking protocols - New and novel uses

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Sunday 6 October

Lunchtime Symposia Lunchtime symposia include box lunches

13.00 – 14.00 Alcon Satellite Meeting Moderator: TBC

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O. Findl AUSTRIA Correlating visual outcomes with OCT findings

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Discover Precise Approaches by Experiencing Latest Zeiss Refractive Laser Technologies Moderator: J. Güell SPAIN R. Wiltfang GERMANY Exploring new horizons of refractive surgery with next generation of excimer technology B. Meyer GERMANY Clinical results with a new MEL® excimer laser ablation algorithm D. Reinstein UK PRESBYOND® laser blended vision with new excimer technology M. Nubile ITALY Preserved corneal neural architecture for reduced dry eye symptoms in SMILE refractive treatments J. Dishler USA Initial U.S. Clinical trial results: new SMILE procedure for RELEX® spherical myopia correction

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Leading Technology in Refractive Surgery Moderator: J. Marshall


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DORC goes Anterior: EVA a New Dimension in Cataract Surgery and Other Anterior Innovations Moderator: A. Mohr GERMANY R. Lehmann GERMANY EVA, a new dimension in cataract surgery I. Dapena THE NETHERLANDS Latest update in DMEK surgery A. Mohr GERMANY Posterior instruments for anterior surgery / my EVA experiences A. Mohr GERMANY New developments in capsular staining K. Klabe GERMANY Glaucolight F. Kerkhoff THE NETHERLANDS My experiences with IOL fixation forceps

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Alcon Satellite Meeting

Redefining Convention: Laser Applications for Vitreolysis and Glaucoma

Moderator: TBC

Moderator: TBC

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X X XI congress of the escr s


Satellite Meeting Schedule Setting Expectations for Your Cataract Patients with Co-Morbidities: New Technologies that Help You Manage the Cataract and the Disease Moderator: TBC


Monday 7 October

Lunchtime Symposia Lunchtime symposia include box lunches

13.00 – 14.00 Alcon Satellite Meeting

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Moderator: TBC

New Frontier of Cataract Diagnosis Moderator: S. Daya UK Speakers: D. Gatinel FRANCE F. Ekkehard GERMANY O. Kermani GERMANY

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5 -9 O C TOBE R

The Appliance of Science in the Fight Against Blindness: Affordable New Technology to Treat and Prevent Sight Loss in the Developing World Moderator: R.Walters UK

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NeXt Generation of LENTIS® Premium IOLs Moderator: TBC

Technologies and Techniques for Optimizing Corneal Inlay Outcomes

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Moderator: F. Carones ITALY

IRIDEX MicroPulse™ for the Ultimate Skeptic. Seeing is Believing

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Moderator: E. Midena ITALY

Moderator: R. Bellucci ITALY

Moderator: J. Stevens UK R. Lerche GERMANY Visual outcomes after LASIK using iDesign in a high volume practice M. Shafik EGYPT Treatment of refractive errors in patients with complex corneas using iDesign P. Binder USA Femtosecond laser vs manual clear corneal incisions in cataract surgery

D. Spalton UK Introducing INCISE® IOL B. Dick GERMANY INCISE® IOL in clinical practice S. Morselli ITALY Redefining MICS, for every procedure R. Bellucci ITALY Conclusion: The future of MICS

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Evening Symposia

D. Gossage USA 532 nm MicroPulse laser for repeatable glaucoma therapy and fovea-friendly therapy for retinal disorders

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Improvised Connections

Prevention of Post-Operative Endophthalmitis. What’s New?


Moderators: P. Barry IRELAND R. Nuijts THE NETHERLANDS

Congress Centre at 18.00)

J. Szaflik POLAND Management of risk factors to prevent POE

Alcon Satellite Meeting

J. Güell SPAIN European practice concerning intracameral use of cefuroxime

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E. Midena ITALY Clinical efficacy and safety profile of 810 nm and 577 nm subthreshold MicroPulse laser for center involving DME

Moderator: TBC

A. Behndig SWEDEN Intracameral in capsule rupture?

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Mo Pleasure

sunday 6 October 7.30pm Bimhuis, Amsterdam, The Netherlands Tickets €10 Limited Capacity Tickets available at The EsCRs Registration Desk, Amsterdam RAi, The Netherlands



Helping Patients to see the Maximum

The Cutting Edge of MICS: Introducing INCISE IOL





2 Days. 12 Symposia. 6 Courses. 12 Free Paper Sessions.





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Infections New Contact Lenses in Irregular Astigmatism What I do differently this year than last year Cicatrizing Ocular Surface Disease Laser Assisted Lamellar Keratoplasty Ocular Surface Reconstruction & Keratoprosthesis

Courses Stem Cell Therapy for Ocular Surface Reconstruction  What Can Go Wrong in Lamellar Surgery  Current State of CXL (Corneal Collagen Cross-linking) Controversies and Hot Topics 

Ocular Tumours

Iatrogenic Corneal Disease

Posterior Lamellar Keratoplasty

Cornea Infections and Inflammatory Disease: An Asian Perspective

Ocular Traumas

New Research in Cornea

Courses 

Techniques for Evaluating Dry Eye

Corneal Imaging Update

Eye Banking and Corneal Transplantation

EuCornea Medal Lecture Friday 4 October 17.00 – 18.00 At the Opening Ceremony The Cornea: How Many Endothelial Cells Are Necessary?

Gabriel van Rij THE NETHERLANDS 

Satellite Meetings Lunchtime Symposia 12.45 – 13.45

Friday 4 October

Allergan Satellite Meeting

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Saturday 5 October

Improving Outcomes with Objective Pre-op Dry Eye Diagnosis and Management Sponsored by

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Study indicates lens removal an unnecessary precaution when performing DMEK by Roibeard O’hEineachain in Warsaw


erforming Descemet’s membrane endothelial keratoplasty (DMEK) without removal of the natural lens will produce a better visual outcome than will a combination procedure, with no additional risk to the graft, said Jack Parker MD, at the 17th ESCRS Winter Meeting. “Phacoemulsification after DMEK can be performed with minimal risk of graft dislocation and can provide good refractive and visual outcomes with an acceptable decrease in endothelial cell density,” said Dr Parker, Netherlands Institute for Innovative Ocular Surgery in Rotterdam. Dr Parker presented the results of a study that involved a consecutive series of 106 phakic eyes that underwent DMEK for Fuchs' endothelial dystrophy or bullous keratopathy. Six to nine months after their keratoplasty procedures, five patients developed cataracts and underwent phacoemulsification. None of the other graft recipients developed cataracts throughout a follow-up period of 22 months. Among the patients who developed cataracts, all phacoemulsification surgeries were uneventful and there were no dislocations or detachments of the DMEK graft. Furthermore, six to 12 months after the cataract procedures all eyes achieved a best-corrected visual acuity of 20/30 or better and were within 0.5 D of the predicted refraction. Moreover, mean endothelial cell density remained within safe limits, decreasing from 1535 cells/mm2 before, to 1158 cells/mm2. In addition, all corneas remained clear throughout the study period and there were no significant changes in pachymetry values during a follow-up period ranging from six to 12 months. The performance of the DMEK procedures involved first stripping a 9.5mm flap of Descemet’s membrane with its layer of endothelium from the posterior stroma of a prepared donor corneal buttons and storing the flaps in organ culture. Then, through a 3.0mm tunnel incision in the limbus of the graft recipient’s eye a circular portion of Descemet’s membrane, 9.0mm in diameter, is excised with an inverted Sinskey hook. After placing the graft into the anterior chamber, the graft is manipulated onto the iris with air and liquid. Then a bubble of air is injected beneath the graft to lift it up against the recipient’s stroma. The anterior chamber is then filled completely with air for 45 to 60 minutes, and afterwards air–liquid exchange is used to pressurise the eye.

Combined procedures based on misguided principle Dr Parker noted that many surgeons who

perform endothelial grafts will commonly combine the procedure with lens removal in order to avoid the need for a second procedure later on, should they accidentally induce a cataract during the keratoplasty procedure. The theory is that a subsequent cataract procedure might compromise the graft. However, the combined procedures can actually result in a poorer visual outcome than DMEK grafts alone. EUROTIMES | Volume 18 | Issue 7/8

“While combined procedures may be possible, they may not be desirable. Specifically the past data seems to suggest that patients do better after DMEK if the natural lens is left in place” “While combined procedures may be possible, they may not be desirable. Specifically the past data seems to suggest that patients do better after DMEK if the natural lens is left in place. They can see more letters on the eye chart. Visual rehabilitation is faster and they are subjectively more pleased with their vision because they retain the ability to accommodate. All of these findings are well reported and established,” he said. He cited a study he and his associates carried out which compared two age-matched groups of Descemet’s membrane endothelial graft recipients. One of the groups included 53 patients who had undergone a combined procedure and were pseudophakic, the other group included 52 patients who underwent DMEK alone, retaining their natural lenses. At six months’ follow-up, there was no statistically significant difference between the corrected distance visual acuities of the two groups, although the highest visual acuities occurred among the phakic eyes (Parker et al, J Cataract Refract Surg, 2012; 38: 871-877). He noted that the results of the current study take the argument a step further by showing that the fears that some may have regarding cataract surgery subsequent to a DMEK procedure may be unfounded. For example, the cataract surgery did not appear to compromise vision in the graft recipients. All had visual acuity of at least 0.6 and four had a visual acuity of 0.8 or better. Neither was visual rehabilitation after cataract surgery delayed among the graft recipients, as the cornea remained clear through surgery and follow-up. Most importantly, there were no instances of the endothelial graft becoming sucked off the posterior corneal surface, as some have imagined might occur during phacoemulsification. Instead, all grafts remained completely adherent to the stroma. Furthermore, the rate of endothelial cell loss increased only slightly after the cataract procedure. "The first key point to remember is that phakic eyes do better than pseudophakic eyes after DMEK, even if they later have to undergo a subsequent phaco procedure. Therefore we should not engage in combined procedures as a matter of course. When we operate on phakic eyes we should leave them phakic and if they subsequently develop a cataract, that's okay. We can deal with that well and safely in a subsequent procedure,” Dr Parker concluded.


Jack S Parker –

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ESONT Meeting

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X X X I c o n gre s s o f the e s c r s

Meet the experts Growing a Small Ophthalmological Practice Arthur Cummings

Building your own practice

Managing a Large Eye Clinic

Assumptions and truths

Thomas Kohnen

From Resident to Childcare to Private Practice Eva-Maria Kohnen (pictured right) & Ina Hengerer

From Small to Big – A Personal Voyage Manfred Tetz

Measuring performance

What they Don’t Teach you in Medical Training About the Business of Healthcare Paul Ursell

Recruiting Staff and Getting Rid of People Who Don’t Fit Kris Morrill

Practice Management

Weekend 2013

1–3 November

Analyse Your Practice Position by Setting Clear Targets Eckhard Weingaertner

Managing a Directorate Paul Rosen

Frankfurt, Germany

How Medical Marketing Can Help Build a Thriving Clinic Rod Solar

Register online and see full programme:

€300 Registration fee Discounts available for additional practice members




EX-PRESS® Marker


Carotenoid substitution will provide a better formulation as it can be taken by patients regardless of their smoking history by Cheryl Guttman Krader



EUROTIMES | Volume 18 | Issue 7/8

Designed by Robert D. Fechtner, MD and Albert Khouri, MD of Newark, NJ

For exact device placement! Courtesy of NEI

n October 2001, results from the Age-Related Eye Disease Study (AREDS) were published and found that progression to advanced age-related macular degeneration (AMD) was reduced by about 25 per cent in high-risk individuals receiving high doses of antioxidant vitamins (C and E), beta-carotene and zinc. A follow-up study published in April 2013 showed the protective effect of the “AREDS formulation” persisted at 10 years. However, new findings released from AREDS2 at the 2013 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) suggest the AREDS formulation may be improved by including lutein 10mg plus zeaxanthin 2mg (L/Z) and removing beta-carotene, said Emily Y Chew, MD, who reported the AREDS2 results. Dr Chew is chair of AREDS2 and deputy director, Division of Epidemiology and Clinical Applications at the National Eye Institute, sponsor of AREDS & AREDS2. She told EuroTimes, “We feel this carotenoid substitution is prudent and will provide a better formulation because it can be taken by patients regardless of their smoking history.” Several lines of evidence provided a rationale for investigating various modifications to improve the efficacy and safety of the AREDS formulation. As its primary goal, AREDS2 evaluated the effects of adding high supplemental doses of L/Z and/or the omega-3 fatty acids docosahexanoic acid (350mg) + eicosapentanoic acid (650mg) (DHA/EPA) on the risk of progression to AMD. Thus, in a primary randomisation, 4,203 patients ages 50 to 85 with intermediate AMD bilaterally or intermediate AMD in one eye and advanced AMD in the fellow eye were randomised 1:1:1:1 to receive the original AREDS formulation alone (control) or supplemented with L/Z, DHA/EPA, or L/Z and DHA/EPA. Based on concerns about the safety of beta-carotene and high dose zinc, a secondary randomisation allocated consenting participants into four groups to receive the original AREDS formulation or modifications with no betacarotene and/or less zinc (25mg instead of 80mg). The primary analysis showed the five-year probability of progression to AMD ranged from 29 per cent to 31 per cent across all four study groups, and hazard ratio calculations showed none of the nutrient additions to the AREDS formulation significantly affected progression to AMD. However, a main effects analysis found treatment with L/Z reduced the risk for progression to AMD by 10 per cent compared with no L/Z (P=.04). The benefit was mostly for reducing the risk of progression to neovascular AMD (11 per cent risk reduction). There was no significant impact on progression to central geographic atrophy. “In trying to evaluate an additive effect of L/Z and the omega-3s, it makes more sense to use the main effects analysis that compares the population half randomised to the additional nutrient versus the half that was not. Here we found a benefit with L/Z,” Dr Chew told EuroTimes. Pre-specified subgroup analyses stratifying patients by baseline dietary history found participants in the lowest

AREDS2 tested vitamins and fish oil vs AMD

quintile of L/Z dietary intake had a 26 per cent lower risk of AMD progression if they were treated with L/Z than if they were not (P=.01). Additionally, post hoc subgroup analyses found reductions of 18 per cent in AMD progression risk (P=.02) and of 22 per cent for neovascular AMD (P=.01) favouring participants receiving L/Z and the AREDS formulation without beta-carotene versus those treated with the original AREDS formulation and no L/Z (P=.02). “Beta-carotene significantly suppressed the absorption of concomitantly administered L/Z, and that interaction may have confounded the ability of AREDS2 to accurately determine the effects of adding L/Z,” noted Dr Chew. Otherwise, the main effects and other exploratory analyses found no treatment effects for adding DHA/EPA, lowering the zinc dose, or removing beta-carotene. A safety analysis including only non- and former smokers found an increased incidence of lung cancer development in the beta-carotene versus no beta-carotene group (two per cent vs. 0.9 per cent; P=.04), with >90 per cent of the cases occurring in former smokers. “These are important findings as data from our studies and others show that former smokers represent about half of the AMD population,” Dr Chew said. Whereas in AREDS, zinc versus no zinc was associated with increased rates of GI disorders and hospitalisations for genitourinary disorders, the frequency of these events was similar in AREDS2 in the low and high dose zinc groups. There were no statistically significant differences between the primary randomisation study groups in rates of mortality or serious adverse events. The AREDS formulation had no effect on the progression of lens opacities, but observational data suggested treatment with L/Z might be beneficial. With about 75 per cent of AREDS2 participants evaluable for cataract progression, L/Z supplementation had no statistically significant effect on the primary endpoint of progression to cataract surgery or in any of the secondary outcomes that looked at development of any cataract, development of any severe cataract, or a 15-letter visual acuity loss.

contact Emily Y Chew –

• • • • •

U-shaped 2.75mm marking pattern delineates flap perimeter Ultra-thin lines for accurate traceability Side marks indicate insertion site - even with flap lifted Produced in titanium for maximum durability Handle set at 45º angle for proper approach and visibility

EX-PRESS® is a registered trademark of Alcon®

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26–29 September 2013 10 Main Sessions 30 Instructional Courses 5 Surgical Skills Courses 19 Free Paper Sessions EURETINA Lecture

Leonidas Zografos SWITZERLAND Radiotherapy in Ocular Oncology

Kreissig Lecture Mark Blumenkranz USA

Evolving Concepts in Innovation and Academic Technology Transfer in Retina: Digital Medicine and the Lessons Learned in Silicon Valley





Leading Societies from around the globe will offer delegates a thoroughly international insight into medical and surgical retina. This includes sessions by: • • • • • • • • • • • • • • • • • • • •

Asia Pacific Vitreoretinal Society (APVRS) ASRS ARVO Brazilian Retina and Vitreous Society Club Jules Gonin Egyptian Vitreoretinal Society ESASO ESCRS EuroLam EVER EVICR.NET French Israeli Association of Ophthalmology German Retina Society International Congress of Ocular Oncology (ICOO) Italian Bioengineering Society Italian Retina Society RETINAWS Spanish Vitreoretinal Society Turkish-Israeli Symposium Vitreoretinal Society of India

membership UNLOCK A WORLD OF BENEFITS INCLUDING: Reduced Registration Fees Annual EURETINA Membership Directory Access to EURETINA on Demand

EURETINA is delighted to announce the 2nd Retina Race

Access to Ophthalmologica

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Access to Online Members Area

Date: Saturday 28 September, 06.30 Location: Planten un Blomen Park (beside CCH Congress Centre) Registration Fee: Ð30 in aid of Orbis

For more information

Friday 27 September Morning Symposia 10.00 – 11.00

13th EURETINA Congress 26– 29 September 2013

Management of Challenging Surgical Cases with the Latest Technology Moderator: B. Corcostegui SPAIN Sponsored by

What Would you Do Next? Case Challenges in the Management of Insufficiently Responsive Chronic Diabetic Macular Oedema Moderator: TBC


In this interactive session, expert speakers will evaluate “real-life” patient cases of insufficiently responsive chronic DMO - providing their perspective and expert insight together with the clinical data to guide rational treatment decisions in this difficult-to-treat patient group

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Lunchtime Symposia Boxed lunch included

13.00 – 14.00 EYLEA® in wAMD: What Have We Learned and What Can We Expect? Moderator: TBC - European experience with EYLEA® – What have we learned? - Fresh insights from EYLEA® clinical trials

Thursday 26 September Lunchtime Symposia Boxed lunch included

- Long-term experience with EYLEA – Treatment beyond the first year

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13.00 – 14.00 Allergan Satellite Meeting Moderator: TBC

Light: Applications and Advances in Illumination Moderator: TBC

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Cutting Through Complexity: Applications of an Innovative New Cutting Technology in Meeting Demands of Complex Cases Moderator: S. R. Sadda Sponsored by

Advanced Technologies for Retinal Diagnosis and Treatment Moderator: TBC


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Friday 27 September

Saturday 28 September

Saturday 28 September

Lunchtime Symposia

Morning Symposia

Lunchtime Symposia

Boxed lunch included

10.00 – 11.00

Boxed lunch included

13.00 – 14.00

13.00 – 14.00 New Advances in Retinal Imaging Moderator: S. R. Sadda


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Evening Symposia 18.15 Vision Loss in Diabetic Patients: Options and Considerations for Restoring Sight Moderator: A. Kampik GERMANY A. Kampik GERMANY Patients with DME: key characteristics and common comorbidities TBC Why treat early in DME? Evidence from recent clinical trials TBC What does effective treatment for DME mean for the patient?

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Morning Symposia 10.00 – 11.00 Jetrea(R): Pharmacologic Vitreolysis for the Treatment of VMT and Macular Hole with One Single Injection Moderator: TBC Sponsored by

Evolving Data, Evolving Perspectives: Myopic CNV and Anti-VEGF Therapies Moderator: T. Lai CHINA T. Lai CHINA Exploring myopic CNV; the disease burden A. Tufail UK Unmet needs and challenges in the treatment of myopic CNV TBC Anti-VEGF therapy for myopic CNV: what’s the latest evidence?

EYLEA®: A New Option for the Treatment of CRVO Moderator: TBC - EYLEA® in CRVO – new insights from clinical trial data - Applying clinical trial findings to the individual patient - Practical experience with EYLEA® in CRVO

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Lunchtime Symposia Boxed lunch included

Sophisticated Diagnostics and Treatment of AMD, DME and Glaucoma M. Nagpal

Moderator: C. Eckardt GERMANY - DORC EVA, new surgical platform with unique fluidics system

13.00 – 14.00

Moderator: G. Staurenghi

EVA, the New Innovation in Vitreoretinal Surgery



Diagnosis and management of various macular pathologies including DME and AMD using Retromode imaging, Multiwavelength pattern scanning laser and Anti-VEGF

- Flow controlled vitrectomy in standard and complex vitreoretinal surgery - New LED illumination in Vitreoretinal Surgery - How to remove vitreous quickly and safe - New Generation high speed twin duty vitrectomes - EVA and 27G vitrectomy for complex VR surgery - Ultra Speed Transformer, upgrade your vitrectomy system

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Anti-VEGF Therapies in Wet AMD – Minimizing Risks and Maximizing Outcomes

Argus II Retinal Implant, The First Approved Treatment for RP: 25 Years of Experience Reaching the First 100 Patients

Moderator: P. Dugel USA

Moderator: S. Rizzo

P. Dugel USA Ranibizumab – Defining desired standards for ocular anti-VEGF therapy F. Holz GERMANY Does less equal more? A comparison of individualized versus fixed-regimen ranibizumab dosing P. Beaumont AUSTRALIA Anti-VEGF therapies – the link between molecular structure and clinical profile P. Dugel USA Achieving best practice in wet AMD – typical patient scenarios

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T. Wolfensberger SWITZERLAND Historical impact and evolution of retinal prostheses M. Arevalo THE NETHERLANDS Argus II retinal implant: Reaching artificial vision via surgical approach F. Arevalo SAUDI ARABIA Argus II system experience in the Middle East S. Rizzo ITALY Interim results from the largest single site pool of Argus II patients

Sponsored by





Patricia Logan –


While many ABI issues will resolve with time or are treatable, some patients will never be able to drive again by Priscilla Lynch in Dublin


hile acquired brain injury (ABI) can have significant implications on a patient’s ability to drive, many patients do recover and there are a variety of established treatment options. At a conference on traffic medicine here, Patricia Logan FRCSI, FRCOphth, Beaumont Hospital, Dublin, discussed diagnosis and treatment options for common neuro-ophthalmology issues caused by ABI. She pointed out that the general public commonly believes that visual ability is simply linked to the eyes, and sometimes find it hard to understand the role of the “complex” visual pathway, and how eyesight can be negatively affected by an ABI or neurological medical condition. Sudden onset of diplopia, loss of visual acuity and field, and oscillopsia are the main visual issues that neuro-

EUROTIMES | Volume 18 | Issue 7/8

ophthalmologists deal with, Ms Logan told the meeting. ABI-related visual issues can occur due to severe head trauma, stroke, tumours, certain diseases such as multiple sclerosis (MS), and as a result of neurosurgery. She said that typically these issues have a rapid and sudden onset and can occur in young, otherwise healthy patients with good visual acuity and can significantly affect driving ability. While many ABI issues will resolve with time or are treatable, some patients will never be able to drive again, which may impact on their ability to work, and this can be devastating for them, Ms Logan noted. Many of these patients who may not recover perfect visual ability can adapt quite well, which needs to be recognised in relation to their driving ability, she pointed out.

“Vision is the most important source of information when driving, so visual assessment for driving is a major public health issue” Treatment Those who develop diplopia are commonly treated with prism therapy and occlusion therapy or occasionally eye muscle surgery, depending on the amount of muscle damage. However, not all will recover binocular vision, Ms Logan said. She explained that cranial nerve palsies, such as third cranial nerve palsy, can result from head injuries, aneurysms, haemorrhages, tumours or diabetes, and affect eye orientation, causing diplopia and affecting driving ability. Some palsies resolve spontaneously after a period of time. Others can be treated in a similar fashion to diplopia by patching, prisms or surgery, she elaborated. “Many stroke patients with visual field loss may recover it within six months, though if they don’t significantly improve within six months then they are not likely to improve any further,” she explained. Non-progressive lesions may stabilise and allow adaptation. Progressive lesions, on the other hand, require monitoring and frequently have more negative outcomes in relation to ability to drive, she explained. “So if someone has a visual field defect due to a progressional lesion from a tumour it’s very hard to predict how their vision will turn out so that requires constant monitoring,” she said. Other serious visual issues that can be caused by tumours include bitemporal hemianopia; a reduction in vision in both the right and left visual fields, which can obviously be quite dangerous for driving. Discussing treatment approaches to serious ABI visual pathway issues, Ms Logan said visual rehabilitation may help to improve patients’ refixation saccades, while prism therapy may also increase their useful field of vision. However, both rarely allow patients to fulfil the required driving visual criteria. Patients with conditions like MS may experience a sudden loss of visual acuity from optic neuritis and have painful eye movements.

“Fortunately about 85 per cent of these patients recover, so again it is a matter of time,” Ms Logan noted. However, in patients who experience traumatic (eg, head injury), compressive (eg, tumour), or especially ischaemic optic neuropathy, the outcomes can be less positive and quite difficult to resolve, she informed the meeting.

Visual driving guidelines As president of the Irish College of Ophthalmologists (ICO) Ms Logan also discussed the new medical fitness-to-drive guidelines that were formally launched in Ireland in February. “The eye doctors of Ireland welcome and fully support this collaboration between the Irish Road Safety Authority and the Department of Traffic Medicine in the Royal College of Physicians of Ireland in providing clear guidelines on the visual criteria for driving,” Dr Logan commented. She reiterated that understanding the impact of a visual condition on driving is a vital aspect of road safety. “Vision is the most important source of information when driving, so visual assessment for driving is a major public health issue. The measurement of visual acuity, contrast sensitivity, fields of view, twilight vision and vision under glare conditions are of the utmost importance,” she stated. Ms Logan voiced her support for Irish proposals for a validated on-road driving assessment for patients who do not strictly fulfil the visual criteria, but whom the treating consultant believes is competent to drive. She also supported proposals for the creation of a special driving licence restricted to daylight driving for certain visually impaired patients.


Dr Soosan Jacob –


eye on technology


Canaloplasty has its learning curve but is much safer than trabeculectomy by Dr Soosan Jacob MS, FRCS, DNB


Relative contraindications

Canaloplasty may be used for openangle, pigmentary and pseudo-exfoliative glaucomas. It can be used after failed deep sclerectomy/viscocanalostomy. It is less dependent than trabeculectomy on EUROTIMES | Volume 18 | Issue 7/8

Figure 1A: Superficial and deep flaps are created, Schlemm’s canal is de-roofed and a Descemetic window is created

Figure 1B: The Glaucolight micocatheter tip is seen

Figure 1C: The self-illuminated tip is visualised as it passes 360 degrees around the Schlemm’s canal

Figure 1D: 10-0 prolene suture is pulled back into the canal and knotted to stretch the canal. Viscoelastic is applied under the flap and flap and conjunctiva are closed

Courtesy of Soosan Jacob MS, FRCS, DNB

on-penetrating glaucoma surgery has come to the forefront because of the advantages it offers over penetrating surgeries by being bleb-independent. It has a lower complication rate and is rarely associated with a flat anterior chamber/bleb-related complication after surgery. Described by Epstein and Krasnov in the form of paralimbal deep sclerectomy and sinusotomy, it has evolved into an elegant technique by Robert Stegmann. Further refinements have followed, canaloplasty being one of them. The Glaucolight is a new surgical device for performing canaloplasty which combines viscocanalostomy with stretching suture technology for circumferential dilatation of Schlemm's canal. Devised by Gabor Scharioth from Germany, Glaucolight is a specially designed flexible microcatheter for catheterisation of Schlemm’s canal and for inserting a suture to keep the inner wall permanently stretched 360°. This prevents collapse of Schlemm’s canal and re-estabilishes physiological aqueous outflow through trabecular meshwork, Schlemm’s canal, collector channels and episcleral venous system. It has a 150µm light fibre and an integrated, sterile LED lightsource for illumination and visualisation of fibre tip. “I prefer non-penetrating glaucoma surgeries and the stretching suture technology because as a resident in the early 1990s I experienced the higher rate of complications associated with trabeculectomies,” said Dr Scharioth. "Surgeons were discouraged from performing glaucoma surgery because of having to handle postoperative complications. I was trained 15 years ago to perform viscocanalostomy and since then have never performed a trabeculectomy again. This approach is much more physiological because natural outflow is re-established instead of being bypassed. Complications are lesser than with trabeculectomy and combination with phaco is better. Being blebindependent, patient satisfaction is improved and visual recovery is fast."

preoperative inflammation/allergy from topical therapy. Relative contraindications include previous trabecular laser surgery, goniosynechiae, narrow angles, silicone oil-related secondary glaucoma, congenital glaucoma, ICE syndrome etc. Indications can be extended towards narrow angles if combined with phaco (either simultaneously or after phaco, if phaco alone fails). Absolute contraindications for canaloplasty include previous trabeculectomy, trabecular surgery (eg, trabeculotomy, iStent, Trabectome), neovascular glaucoma, closed angle and Sturge-Weber-Syndrome. "Canaloplasty is better than other non-penetrating glaucoma surgeries," said Dr Scharioth. "For the first time the entire Schlemm's canal is treated. During catheterisation, thin septae in the canal are opened allowing easy 360° passage in the canal. Placing the stretching suture keeps the canal open and allows circumferential flow of aqueous in the canal. Causes for failure in viscocanalostomy (eg, collapsed surgical ostia of Schlemm's canal, collapsed Schlemm's

canal, absent collector channels near deep sclerectomy, collapsed Descemetic window etc) are solved. With canaloplasty, selection of surgical site is independent of location near good collector channels. The Schelmm's canal is permanently kept open. Episcleral venous pressure is the limiting factor and therefore postoperative IOP achieved is independent of preoperative IOP." Steps for performing canaloplasty consist of creating a 5 x 5mm superficial scleral flap (1/3rd scleral thickness) going anteriorly for about 1-1.5mm into perilimbal cornea, followed by deep sclerokeratectomy close to suprachoroidal space below the flap. Scleral spur is identified and Schlemm's canal is de-roofed. Blunt dissection at Schwalbe’s line is advanced towards clear cornea to create a Descemetic window (Figure 1A) and the deep flap is excised. Endothelium of Schlemm's canal and juxtacanalicular trabecular meshwork are peeled. The Glaucolight is then used to catheterise Schlemm’s canal (Figure 1B). The illuminated tip allows visual

confirmation of catheter location in the right plane (Figure 1C). After 360 degree cannulation, a 10-0 prolene suture is pulled into the canal by fixing it to the Glaucolight tip which is then withdrawn in reverse direction. Knotting the suture under tension stretches Schlemm's canal (Figure 1D). OVD is injected under the flap to decrease bleeding and scarring. Scleral flap and conjunctiva are closed. Postoperatively, hyphema is a common occurrence. It is not a complication but rather a sign of reflux bleeding through trabecular meshwork in the period of early postoperative relative hypotony. Serious complications such as hypotony or associated maculopathy/choroidal detachment that sometimes occur after trabeculectomy are extremely rare. A bleb does not form and therefore blebrelated complications such as blebitis, endophthalmitis etc, are unlikely. Postoperative inflammation is low as the anterior chamber has not been entered. Possible complications can include Descemet’s membrane detachment or a postoperative IOP rise which is often steroid induced. Discontinuing steroids and changing to non-steroidal antiinflammatory drugs is generally sufficient. Late postoperative IOP rise could be secondary to decreased trans-trabecular flow and is addressed by goniopuncture (Nd-YAG Descemetotomy) which opens up the flow or possibly by selective laser trabeculoplasty. Regarding the learning curve, Dr Scharioth advises that experienced anterior segment surgeons need 15-20 cases to master canaloplasty. “I advise everyone who wants to learn it to visit a surgeon who is experienced in canaloplasty and then, if available, start with the help of an application specialist. Surgery should be recorded, reviewed and compared with that of an experienced surgeon. No one would expect to be successful in mastering phacoemulsification by watching a video and starting off. The same is to be said about canaloplasty,” he said. Dr Scharioth said canaloplasty is a major step forward in solving the problem of glaucoma. “I believe that in the future, surgery will be the first line of treatment and medical therapy will become only an addon in most cases,” he said. “Canaloplasty has its learning curve but is much safer than trabeculectomy. It saves a lot of time postoperatively, gives a smoother postoperative course and increases the outcome and satisfaction of our patients.” * Dr Soosan Jacob is a senior consultant ophthalmologist at Dr Agarwal’s Eye Hospital, Chennai, India.






ESASO has recently diversified its range of Fellowships


ligible candidates for Fellowships are young ophthalmologists who graduated from the ESASO programme with the Diploma of Specialist Superior in Ophthalmology (DiSSO) and are willing to pursue their careers to reach a higher level of specialisation. Accredited university hospital departments and selected institutions train them according to the curricula of the ESASO Fellowships to ensure that expected outcomes are reached and set objectives are achieved.

ESASO Fellowship The standard full-year Fellowship includes a portfolio of project-based components maintained by the institutional partners of ESASO, securing its guidelines on quality, innovation, productivity and social and ethical behaviour. These Fellowships are either in Medical or Surgical Retina or Corneal and Refractive Surgery planned in 2013/14. During the first trimester, the Fellow will achieve proficiency in the execution techniques for diagnostic procedures; will be involved in clinical/treatment decisions; and will master a good theoretical knowledge of operating techniques. In addition to the work-based experience, the Fellow will develop the research programme over the course of the year. The second trimester will allow the Fellow to further build skills for the execution of all diagnostic procedures, to achieve a competent autonomy in handling the clinical and therapeutic aspects of a patient’s care, and to begin executing surgery procedures under the programme director’s supervision. In the final trimester, the Fellow will achieve a thorough knowledge and mastery of the technical skills and of the diagnostic and clinical routines, acquire a sound proficiency in surgery procedures as confirmed by the number of operations carried out and complete her/his research programme. They will also gain generic organisational and leadership skills. ESASO Clinical Product Development Fellowship

The ESASO Leadership Training Programme

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19.06.13 14:28

for Clinical Product Development is a Fellowship that is part of ESASO’s Advanced Specialist Training Programme. The course curriculum and practical experience offered is essential for those who wish to become leaders in the ophthalmic device/pharmaceutical industry. The ESASO Fellowship for Clinical Product Development will foster the creation of a global leadership team in this segment of the healthcare industry, with special emphasis on representation in emerging markets. The programme also will enhance partnerships with academic institutions from which Fellows have been recruited.

Visiting Fellowship and Hands-on Training in Cataract Surgery In

Spring 2013, ESASO signed its collaboration agreement with the L V Prased Eye Institute (LVPEI), Hyderabad, India. The aim of the partnership is to combine their specificity curricula in order to create a part of ESASO’s specialised postgraduate training programme for young ophthalmologists specialising in cataract surgery. This short-term Fellowship is designed as a special hands-on training on cataract surgery that will be held at LVPEI. ESASO will send one young ophthalmologist to LVPEI on a monthly basis. The duration of this Fellowship is four weeks. Eligible candidates must be subscribed in the ESASO modular programme and must have completed at least one module (preferentially a module on cataract surgery). The Fellow will be accompanied by a tutor surgeon and will be performing at least one cataract surgery daily. In minimum the fellow will complete 24 surgeries in cataract phacoemulsification with IOL implantation at the end of the four weeks. Weekly, the fellow will report his/her activities to the Head Office in Lugano. The Visiting Fellowship and Hands-on Training in Cataract Surgery will be certified by ESASO and LVPEI. * Apply for the ESASO educational programme and see the ESASO website for more information (



young ophthalmologists


Young Ophthalmologists session will target current trainees and recently graduated residents by Leigh Spielberg


he XXXI ESCRS Congress in Amsterdam, The Netherlands will include a Young Ophthalmologists session that will focus on how residents can optimise their experience as ophthalmologists-in-training and make the most of their education. The session will be held on Sunday 6 October from 8am to 9.30am. Residency is a busy period in which a great deal is asked of trainees. On the other hand, residency is unique: a broad spectrum of interesting pathology is encountered, surgical techniques are nurtured and experienced staff physicians are always around to answer questions and help save a difficult operation. But how does one make the most of the training years? It is with this in mind that the Young Ophthalmologists Session, “Taking Training into your Own Hands” was conceived. “It is a unique session. The topics were selected and the speakers were invited by the Young Ophthalmologists Committee, which consists of current and very recently graduated residents. This will help ensure its relevancy to current trainees,” said Dr Oliver Findl, one of the session’s chairmen and chairman of the ESCRS Young Ophthalmologists Forum. “We expect it to be dynamic and interactive,” he said.

Facts, figures, rumours

Dr Thiemo Rudolph of Göteborg University in Sweden, who is also co-chairing the session with Dr Findl, will start off with a talk entitled, “Ophthalmology Training in Europe: Facts, Figures & Rumours.” Europe consists of dozens of countries, each with their own system of resident training. Some offer intensive surgical training while others offer almost none. Some require yearly national examinations and others accept the European Board of Ophthalmology Diploma exam as a certification qualification. Dr Nino Hirnschall, (of Moorfields Eye Hospital), will follow with his talk,“Chance Favours Prepared Minds: Expand Your Knowledge Online.” There is an abundance of medical information available online, but the quality thereof varies immensely. What are the best sources? And how can they be accessed? In short: how can you best utilise your valuable time and energy to both lay the groundwork of basic medical EUROTIMES | Volume 18 | Issue 7/8

The topics were selected and the speakers were invited by the Young Ophthalmologists Committee, which consists of current and very recently graduated residents

For reFractive and cataract Surgery reaching a new level in corneal tomography Patented Dual Scheimpflug system provides highly accurate pachymetry and ray-tracing, even when the measurement is decentred.

Oliver Findl and surgical knowledge and stay up to date with the most important of the recent developments? Dr Paul Rosen, of Oxford Eye Hospital, will discuss what many residents find the most interesting and crucial part of their training. In his talk, “Developing my Surgical Skills,” Dr Rosen will outline how residents can maximise their operating competence within the confines of their training centres. Dr Findl, of the Hanusch Hospital in Vienna, will talk about money. In his talk, “How to Get Financial Support for My Training,” Dr Findl will present ways in which residents can supplement their hospital income to make residency training possible, or even more enjoyable. Where can funds be acquired? Are there grants available? What about travel expenses for international conferences? Finishing the discussion will be Dr Wim Weber of The Netherlands. His presentation, “Taking an Idea and Turning it into a Paper,” will spell out how to develop a research plan, set up a study, analyse the data, write a manuscript and get it published. * For full details of the programme visit:

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Highest ever number of candidates take European Board of Ophthalmology Diploma (EBOD) examinations this year by Dermot McGrath in Paris


Christina Grupcheva (Bulgaria) chair of the EBO Education Committee

ontinuing the impressive growth of recent years, over 440 candidates from 24 European countries took part in the 2013 European Board of Ophthalmology Diploma (EBOD) examinations. “It is my pleasure to announce that the 2013 examinations have once again attracted the highest ever number of candidates. I think this emphasises the growing significance and importance of the EBO qualification for so many of our young ophthalmologist residents and specialists,”

NEW EBO PRESIDENT Dr Catherine Creuzot-Garcher is building on the work of her predecessors and plans to continue the excellent work of EBO

Catherine Creuzot-Garcher MD, PhD, FEBO is professor of ophthalmology and chair at the University Hospital of Dijon, Burgundy, France. Her main fields of interest are ocular surface disease and surgical retina.


ince January 2013, Catherine Creuzot-Garcher MD, PhD, FEBO, has been settling into her new role as president of the European Board of Ophthalmology (EBO). Describing her election as president of the EBO as an “honour and a privilege”, Dr Creuzot-Garcher told EuroTimes that her principal goal for her two-year term of office is to continue to build on the sterling work achieved by other leaders of the organisation. “I am just another stone in the wall that has been built over many years thanks to

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the efforts of previous presidents such as Jean Jacques De Laye, Tero Kivela, MarieJosé Tassignon, Marko Hawlina and Wagih Aclimandos. It is a great privilege to follow in their footsteps and I will do my utmost to continue the upward momentum of the EBO in the months and years ahead,” she said. One of the key tasks of Dr CreuzotGarcher will be to maintain and extend the EBO’s role as the guardian of ophthalmic training standards across its European member countries. “A European assessment of knowledge is mandatory,” believes Dr Creuzot-Garcher. “It will strengthen the overall quality of teaching. Students and teachers can share their feelings and can improve their teaching methods. All of us can learn from each other. The aim of EBO is to improve the quality of teaching with a direct benefit for our patients. The difficulty is that while the organisation of various European health systems is quite different, the level of knowledge of our students should still be the same,” she said. In particular, Dr Creuzot-Garcher said that she will strive to build on the phenomenal success of the annual EBO Diploma examination which is designed to assess the knowledge and clinical skills

said Catherine Creuzot-Garcher, president of the European Board of Ophthalmology. Held every year in Paris, the EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices. Addressing the successful candidates at the award ceremony, Philippe Denis, president of the French Society of Ophthalmology (SFO), paid tribute to the hard work of the EBO team.

requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices. “I will closely follow the direction given by previous presidents in terms of safeguarding the professionalism and integrity of the EBOD exam. To ensure this, we need to maintain the highest standards, with very controlled rules for the oral examinations in order to have homogeneous results among different juries. I would also like to go further with the potential evaluation of the level of knowledge in the ophthalmic subspecialties,” she said. As Dr Creuzot-Garcher sees it, one of the main challenges for EBO will be to foster sustained but manageable growth in the EBOD examination in the coming years. “There is definitely potential for the exam to grow even more, especially if the exam is recognised as equivalent to the national exam in more European countries. This is already the case in Switzerland and Belgium and it is strongly recommended in many other countries such as France, Austria, Slovenia and Finland. If it grows even more, we may have to consider the organisational and infrastructural implications of that. Up until now, the French Society of Ophthalmology (SFO) has kindly provided us with excellent facilities in order to welcome students and examiners for the EBOD exams every year,” she said. Another target will be to increase the number of EBO accredited teaching centres across Europe and enhance cooperation with other ophthalmic societies, said Dr Creuzot-Garcher.

“Ophthalmic education is very important and I would like to pay tribute to the work of EBO. We all know that the participation of ophthalmology residents in the EBO exam is constantly progressing and we know that the level of education is also improving, so this is good news for the future of ophthalmology,” he said. Congratulating the successful candidates on their achievements, Prof Christina Grupcheva, chair of the EBO Education Committee, reminded the gathered assembly of the history and purpose of EBO. “We started with 44 people sitting the exam 18 years ago and reaching a huge number of 440 candidates in 2013. This is a more difficult task than one might think because we all come from different backgrounds and we study things in slightly different ways. But with time, we have found a way to achieve our goal and we are finally at the stage where we can say that we are delivering a common European education,” she said.

Marko Hawlina honoured by EBO Marko Hawlina MD, PhD, FEBO, was honoured at this year’s EBO examination as the third recipient of the Peter Eustace Medal for his contribution to the cause of ophthalmic education in Europe. The Peter Eustace Medal was established by the EBO in 2010 in honour of Prof Peter Eustace from Ireland who established the first EBO Diploma examination in Milan in 1995. Prof Hawlina received his PhD in retinal electrophysiology from London University under the mentorship of Prof Hisako Ikeda. His residency in ophthalmology was carried out at the University of Ljubljana and at St Thomas’ Hospital in London. Prof Hawlina is head of the research group of University Eye Hospital Ljubljana and Chair of Ophthalmology at Medical Faculty of University of Ljubljana, Slovenia and president of the Slovenian Society of Ophthalmology. For many years, Prof Hawlina has been active in developing communications between ophthalmic training centres in eastern and western Europe and managing grants for young ophthalmologists, principally from eastern Europe.

EBOD 2013


Multinational flair

Setting a standard

Tillmann P Eckert MD was the recipient of the Alan Ridgway award and the prize for Best Overall EBOD classification. “Since I have been an ophthalmologist for nearly 20 years there are quite a lot of important basics that I had forgotten years ago. My main motivation for the EBO examination, besides the diploma, was the opportunity to refresh my knowledge in ophthalmology in the months before the exam. Of course I wanted to do my best and pass the exam but I was really surprised when the results were announced during the ceremony. The EBO exam has been a really positive experience. What made it exceptional is the multinational flair with many colleagues from different parts of Europe and the location in Paris. My future plans in ophthalmology principally involve trying to keep pace with the steady and fascinating increase of knowledge in our field.”

Sorcha Ní Dhubhghaill from Ireland shared third place in the Overall EBOD classification. “I was quite surprised and extremely pleased with the EBOD results. Irish trainees are sitting the exam more and more nowadays. The EBOD qualification is a more widely recognised exam that can really support your applications to departments all over Europe. By setting a standard, employers can be reassured that external trainees can be trusted. As a young ophthalmologist looking to travel and learn from other centres in Europe, the EBOD is a very powerful and welcome addition to my CV. After the exam it was interesting to note how many people had been taught by the examiners, giving them little tricks and tips that will help them down the road. You sometimes forget that the exam itself is a learning process too. I recently moved over to the University of Antwerp, Belgium where taking the EBOD is expected. Since my Dutch is quite basic it was great to be able to take the exam in my native English so we are all on an equal footing. I was happy not to embarrass my Irish mentors and trainers in front of the Belgians. I’d like to stay in Antwerp longer and use this opportunity to learn how to achieve the work-life balance they have mastered here.”

A proud achievement Ebru Gorgun from Turkey shared second place in the Alan Ridgway Award and second place in the Overall EBOD classification. “I wanted to see both my level of academic knowledge and my position compared to my colleagues in Europe. The EBO exams were largely a positive experience and I was so proud to be so successful. Positive responses and congratulations from my colleagues increased my pride when I was back home since the EBOD is considered to be an important examination within Turkish ophthalmology. I would recommend all ophthalmologists who have completed their residency to take this examination both to test their academic level and become aware of areas of difficulty. Also being certified for such a board examination will contribute to their career advancement as well. The plan for my career in ophthalmology is to continue to develop my academic background, keeping my knowledge up-to-date and transferring this academic knowledge and experience to the next generation of ophthalmologists.”

An important qualification Ramin Khoramnia from Germany came second in the Overall EBO classification. “It is very important for European doctors to have a European degree these days, because European thinking is becoming more and more important. In a united Europe, the exams in the different European countries should be comparable to guarantee the same quality of the doctors in every country. I think that you get very well prepared for the EBO exam at the University of Heidelberg. At this clinic, we have a lot of subspecialties that many other clinics cannot offer such as refractive surgery, uveitis, rehabilitation, inherited retinal diseases, etc. As all these subspecialties are covered by the EBO exam, you certainly have an advantage if you have done your specialisation at an institution which covers the full spectrum of ophthalmology. The EBO exam is not an easy exam, but it is very interesting and enriching to participate. I would highly recommend others to take the EBO exam. A common exam is the best way to make sure that you have the same knowledge as your colleagues in the neighbouring countries. For the future, I would like to continue working at the University Clinic of Heidelberg.”

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Keep up to date Jens Lindegaard from Denmark shared third place in the Overall EBOD classification. “I am a second-year fellow in cataract and corneal surgery. I spend most of my time exploring this field and in order to keep up with the other areas in ophthalmology I found it very useful to take the EBO exam. I enjoy keeping up to date and even though I do a lot of reading it was great to be pushed into studying again. I always like the challenge of exams and luckily I do not feel stressed. There was a great diversion in the questions with some very challenging questions also. The ‘viva voce’ part is a great way to explore and discuss questions. The examiners were very positive and friendly. All in all it has been a very positive experience that I highly recommend to other residents and fellows to take part in. Especially because you get to study all parts of ophthalmology and end up feeling that there are not any large ‘hidden areas’. Currently I am focusing on getting more experience in performing corneal surgery, an area which has a lot to offer.”

Future career options Anish Shah from the UK shared third place in the Overall EBOD classification. "To have come joint third out of over 440 candidates across 24 countries is very good news, and hopefully means I’ve done enough reading! My motivation in taking the EBO exam was to gain another qualification, and to force myself to revise material already prepared for the British FRCOphth exam which I passed last year. British trainees rarely sit the EBO exam because it has no direct relevance to the UK training system and is considerably easier than our Royal College exam. At €400 it is also relatively expensive as a ‘trial run’ when they could just attempt our own exam earlier than normal – and stand a chance of passing it. However, for the European trainees who do not currently have a different national level qualifying exam, I would recommend it. I am going to start subspecialist training in vitreoretinal surgery next year. The employment situation for certain subspecialties in UK ophthalmology is currently dire, with some doctors having completed PhDs and multiple fellowships and still failing to obtain consultant posts. So my plans are very wide open, and would include the possibility of pursuing future career options outside the UK if appropriate."





Of windmills, canal boats and Heineken – use a free half-day to explore and sample Amsterdam-area landmarks by Maryalicia Post


n the run-up to the last time that the ESCRS Congress convened in Amsterdam in 2001, I reported enthusiastically on a visit to Zaanse Schans, which is located in the town of Zaandam, a 20-minute train ride from Amsterdam’s Central Station. Recently, in the run up to the XXXI ESCRS Congress, I paid Zaanse Schans another visit, and found it just as enchanting now as when I visited it to write my first travel article for EuroTimes. Zaanse Schans is a cross between an open-air museum and a functioning hamlet. The tiny settlement, a 15-minute walk from the Zaandam railway station, is made up of picturesque green wooden houses and windmills; three windmills and some of the houses are open to visitors. Its wooden shoe workshop, cheese store, pewter making shop, and pancake restaurant are usually thronged, giving Zaanse Schans an undeniably touristic aspect.

Picturesque Zaanse Schans

Working windmill at Zaanse Schans

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But it’s equally undeniable that a visit offers a unique glimpse of picture-postcard Holland. In the days before steam power, Zaanse Schans was Holland’s first industrial centre. In the 17th and 18th centuries, energy was supplied by thousands of windmills on the banks of the dykes. A museum in a contemporary building overlooking the entrance to Zaanse Schans tells the history of the area and, in a separate pavilion, the story of the Verkade chocolate company. For an overview that can be printed out as a guide to the houses visit: Zaandam is not a pretty town. Its main asset is proximity to Zaanse Schans. But if you have time to spare in Zaandam, visit the Zaandam Molen Museum, a fiveminute walk from the station. All you’d want to know about windmills is there, plus fascinating working models and a museum shop. The museum is closed on Mondays. For details, visit: Zaandam is also the site of a Monet Tour that begins near the station. Tiles set in the pavement mark it out. In 1871, Monet and his family stayed in Zaandam for six months, during which time Monet produced 24 paintings including the ‘Blue House’ and the windmills of Zaanse Schans. You might also visit the “Tsar Peter House,” not a mansion as you might expect, but a rustic wooden cottage. There, Peter the Great, travelling incognito to study the Dutch shipbuilding industry, lodged with a local blacksmith for eight days in 1697. When the tsar’s identity became known, he retreated to Amsterdam. The blacksmith’s house is now a National Monument, preserved under a brick shelter. The house reopened in March of this year, after extensive renovations. The house is closed on Mondays. For details, visit:

Take the Helm If you linger on any Amsterdam bridge, looking down into the water, you’ll be intrigued by the traffic – not just large tour boats, but smaller private boats, too. It’s easy to be at the helm of one of the smaller boats yourself. At Boaty, a short walk from the RAI, you can rent an electric boat any day of the week from midMarch to late October. Rental periods are for a three-hour or four-hour time slot or for a full day. You don’t need a license, and full instructions are provided along with a route

map. Go pretty much where you like on the canal system – or follow one of Boaty’s three suggested routes: Amsterdam city centre, Amsterdam “with a twist,” or go out of town on a tour that takes you down the Amstel into the countryside. Suggestions for coffee stops are included. Each tour lasts just over two hours and can be previewed at Boaty’s Internet site:

Behind the brew The Heineken people have spared no effort to make the “Heineken Experience” – a tour through their brewery – fully interactive. From the entrance, where you can be photographed as the face on a Heineken poster, through the simulated ride down the assembly line as a bottle of beer, to the end where you can bottle your own Heineken, every effort is made to ensure that the telling of the facts about beer, Heineken beer in particular, is as entertaining as possible. At the start of the visit, you learn something about the founders and a little bit about the prestigious Heineken prize for science that was founded in 1960. Then, you tour the brewery looking into the roasting ovens, peeking into the stables where the Heineken cart horses live, taking part in a tutorial on the ingredients involved in beermaking, and learning how to evaluate a glass of beer as wine tasters evaluate their vintages. And, of course, you take that “ride” down the assembly line. Along with your ticket, you get a bracelet with markers on it, two of which can be exchanged for glasses of Heineken and one of which is for a gift at the souvenir shop that you reach after a boat ride at the end of the tour. Allow about two hours for the brewery, and 15 minutes for the boat ride, which leaves on the hour from the landing stage across the way from the brewery. It’s a pleasant cruise down a canal, into the Amstel River. It ends at a landing stage near the Hermitage, a branch museum of the Hermitage in Saint Petersburg, Russia. If you should skip the souvenir shop and visit the Hermitage instead, no one will know. Order Heineken Experience tickets online to avoid the queues. Open daily from 11:00 to 19:30 with last entry at 17:30. For details, visit: For information on what to see at the Hermitage Museum and online entrance tickets, visit:

Classic Heineken poster

The Heineken Brewery

A beer tutorial at the Heineken Brewery




Technology-driven care

Since the invention of the technology in the early 1990s, optical coherence tomography (OCT) has redefined the way retinal disease is treated. Indeed, treating non-surgical retinal disease without the use of an OCT has become unthinkable. Thanks to its rapid, non-invasive, real-time nature, a retinal cross-sectional image can be obtained during every patient visit in order to help guide diagnosis and follow-up. It is difficult to overstate the importance of the OCT. It is “a fundamentally new type of medical diagnostic imaging technology” which is now “part of the standard armamentarium in eye care” and “marks the beginning of a new field that might be called structural imaging of the eye.” Indeed, it is reasonable to say that the vast majority of ophthalmologists can read an OCT image, despite its relatively recent introduction into the field of eye care. The four editors of this third edition of “Optical Coherence Tomography of Ocular Diseases” were all instrumental in the conception and development of OCT technology. Published by Slack Incorporated, this text covers OCT in depth over three sections. The first section, “Principles of Operation and Interpretation,” includes two chapters: a 25-page introduction to the technology itself and a 40-page guide to OCT image interpretation. In the following 300 pages, the second section, “OCT in Retinal Diseases,” deals with what are the most common indications for the use of the OCT. The retinal disorders are covered thoroughly over the course of nine chapters. Each chapter begins with a short description of each common disease, such as idiopathic epiretinal membrane, which describes the clinical presentation, biomicroscopic appearance and the role of the OCT in its treatment. The chapters then continue with case studies that include a clinical summary, OCT images and fundus and/or fluorescein angiographic images. The result is a streamlined, efficient learning text that can also be used as a reference text for clinical cases. The second section begins with a chapter on “Vitreoretinal Interface Disorders,” followed by chapters on: retinal vascular diseases; diabetic retinopathy; CSCR; AMD; miscellaneous macular degenerations; chorioretinal inflammatory disease, retinal dystrophies; and such miscellaneous retinal diseases as posterior segment trauma and optic nerve pit. EUROTIMES | Volume 18 | Issue 7/8

Particularly interesting and informative is the chapter on “Chorioretinal Inflammatory Diseases.” These are the disorders that we rarely see in the clinic, but absolutely do not want to miss. The book’s third section covers the rest of the eye under the title of “OCT in Glaucoma, Neuro-Ophthalmology, and the Anterior Segment.” The section devotes one chapter to each of these three topics. The chapter on the use of the OCT in glaucoma focuses on the questions commonly asked regarding imaging modalities in glaucoma, such as “How well do optic disc abnormalities visualised on OCT correlate with clinical assessment and visual field abnormalities?” and “How can imaging supplement visual field results in patient follow-up?” These questions are addressed in a series of case studies. It is interesting to note that images from nearly every model of OCT machine are used in the case studies, from the grainy early machines to the razor-sharp newer editions. The advantages of this decision are twofold: first, it allows the reader to become accustomed to each image type, and it confirms the notion that the older devices are often adequate for basic diagnosis and follow-up of common pathology. This book is ideal for ophthalmology residents, vitreoretinal and glaucoma fellows as well as general ophthalmologists looking to further refine their OCT skills.

BOOKS EDITOR Leigh Spielberg PUBLICATION OPTICAL COHERENCE TOMOGRAPHY OF OCULAR DISEASES, THIRD EDITION EDITORS Joel S Schuman, Carmen A Puliafito, James G Fujimoto & Jay S Duker PUBLISHED BY SLACK If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland ad-half page vertical-Eurotimes-ENG-1305v01 pva RZ.indd 1

29.05.13 16:38




Contagious eye diseases can send ophthalmologists home too by Leigh Spielberg


s the front tire of my mountain bike slipped off the trail and I soared over the handlebars and into the bushes, I thought, “That was weird. I totally misjudged the height of that drop-off. There’s something wrong with my depth perception.” I got back onto my bike and continued the descent. Niels was waiting for me at the bottom of the course. “Wow, your right eye is pretty red. Did you get some dirt in there when you fell?” he asked. “No, I don’t think so. I’ll be fine,” I replied. There’s an unwritten rule that we don’t complain when we’re out there on the course. Niels, my colleague in our ophthalmology residency, is the only other person I know who is crazy enough to be out there at sunrise on a freezing Sunday morning. Neither of us wants to hear the other whine about anything at all. I didn’t feel any foreign body sensation when falling off my bike. What I did recall was the unilateral epiphora that started the moment I left my house that morning on my way to the trails. At the time, I didn’t think anything of it. Freezing wind will make any eye tear relentlessly. Only its unilaterality was unusual, but I didn’t give it much thought at the time. When I got back home, I looked in the mirror. The right eye was clearly redder, but the hyperemia was primarily nasal and interpalpebral. I took a picture of both eyes with my iPhone and forwarded it to Niels. “It looks like episcleritis,” he replied. Indeed it did, so I stopped thinking about my eye for the rest of the evening. The next morning, my eyelids were stuck together. I couldn’t open my eye until I rinsed it. I saw a wet, very hyperemic eye with crusty eyelashes in the mirror, looking back at me. At that point, it became a different story. I went to the Rotterdam Eye Hospital’s emergency room and signed myself in as a new patient. There is an official “red-eye examination room” in the emergency room, a sort of conjunctivitis quarantine. It helps prevent transmission from one patient to the next. Karin, another resident, carefully examined me, avoiding any chance of contamination. “Whoa, that’s obviously an adenovirus. Bummer. I’ll take a sample for PCR, just to make it official, and prescribe you some iodine drops,” she said. EUROTIMES | Volume 18 | Issue 7/8

Courtesy of Eoin Coveney


Dr Wefers Bettink, the emergency room staff physician, confirmed Karin’s clinical diagnosis. “I’m sorry, but you’ll have to go home. We don’t want to start an adenoviral epidemic here in the eye hospital. We’re not taking any chances. I’ll contact the chairman of our infection prevention committee and we’ll keep in touch via email. Don’t come back to the hospital until your PCR is negative and you’re cleared by the committee.” It’s an odd feeling to come to work on a Monday morning and to be sent home for an indeterminate length of

time. In a moment I was transformed from ophthalmologist-in-training to ophthalmology patient. I must say, I prefer being the doctor than the patient. The next day, I received a phone call saying that my PCR was positive for adenovirus. I would remain at home, as a patient, for three weeks, taking care of myself instead of treating others. I tried to see it as a surprise vacation, but I had nothing planned! No travel, no week-long visits from friends or family, no interesting activities to look forward to. If my wife and I were not the parents of two

very young children, we would have booked a last-minute flight to Portugal for a few weeks of warm-weather fun. After all, she was on maternity leave. But that’s not so simple to organise with a 16-month-old daughter and a 7-week-old son. Plus, my eye didn’t look or feel so fantastic, and using iodine drops, which had to be stored in the refrigerator, six times per day isn’t exactly a joyful experience. Fortunately, my infection was relatively mild. But I was contagious! I was welcome neither at home nor at work. My wife has a deep distrust of viruses and has always hated the sight of a red, hyperemic eye. As a dermatologist, she treats some rather nastylooking diseases, but a red eye is just one of those things she can’t stand. “Just be happy the PCR wasn’t positive for chlamydia,” said Peter, another resident. “Then you’d really know what it’s like not to be welcome at home.” True, but having any highly communicable disease is an unpleasant experience. It must have been terrible to have had leprosy in ancient times, or the plague in the middle ages. You’re not really welcome anywhere. Everything I touched seemed tainted. I didn’t take any risks. I placed bottles of 70 per cent hand alcohol in various locations at home and used them until my skin started cracking. “Maybe you should consider using moisturising lotion,” my wife suggested when the skin over my knuckle started to bleed. Despite what I know about the virus, and about how easily it is transmitted from patient to doctor, I felt a little bit ashamed that I had become infected. Had I not been careful enough? Could I have prevented it? Now my colleagues had to work extra to cover for me, my wife was anxious, and my children were at risk for an unpleasant ordeal. But hey, it can happen to anyone – even an ophthalmologist.

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




Bevacizumab effective in proliferative diabetic retinopathy

Ranibizumab provides sustained visual improvements

In eyes with high-risk proliferative diabetic retinopathy (HR-PDR), intravitreal bevacizumab injections plus panretinal photocoagulation results in less deterioration of vision and reduces foveal thickness better than panretinal photocoagulation alone, according to the results of a randomised, masked, controlled trial. In the prospective study, 42 patients received the combined treatment in one eye and panretinal photocoagulation alone in the other. Compared to baseline, mean visual acuity was significantly worse throughout six months’ follow-up in the photocoagulation alone group but was stable in the group receiving bevacizumab. In addition, mean foveal thickness increased significantly in the control group but did not change in the bevacizumab group.

A variable dosing regimen of ranibizumab produced stable improvements in vision in 174 treatment-naïve eyes of 156 patients with neovascular AMD throughout three years of follow-up, according to a retrospective case-note review study. The median baseline visual acuity improved significantly from 50 letters to 55 by the end of 12 and 24 months (p = 0.04), and fell by just one letter at three years. In addition, the mean number of injections fell from 4.8 during the first year to 2.9 in the second year, and to 2.4 in the third year. The mean gain in visual acuity was inversely proportional to the baseline visual acuity and did not correlate with the number of injections.

n RC

Preti et al, Ophthalmologica, “Structural and Functional Assessment of Macula in Patients with High-Risk Proliferative Diabetic Retinopathy Submitted to Panretinal Photocoagulation and Associated Intravitreal Bevacizumab Injections: A Comparative, Randomised, Controlled Trial” 2013 July; DOI: 10.1159/000348605.

Ranibizumab more cost effective than Pegaptanib The results of a retrospective multicentre study indicate that the cost of preserving one line of vision over that achieved by photodynamic therapy with verteporfin is €1,225.98 for ranibizumab and €2,286.18 for pegaptanib in eyes with neovascular AMD. The study involved 788 eyes of 763 patients who underwent treatment for AMD in the Czech republic. There was a significant loss of vision over one year in eyes treated with PDT but vision remained stable in those receiving pegaptanib or ranibizumab. Pegaptanib was highest for the annual cost €5,467.63/patient), compared to €4,247.47 for ranibizumab therapy and €2,783.65 PDT with verteporfin. et al. Ophthalmologica “Cost and Effectiveness of Therapy for Wet Age-Related Macular Degeneration in Routine Clinical Practice” 2013 July DOI:10.1159/000350802.


n R

Muniraju et al, Ophthalmologica, “Three-Year Visual Outcome and Injection Frequency of Intravitreal Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration”, 2013 July; DOI: 10.1159/000350238.

Smoking does not increase risk of PDR Smoking neither increases nor decreases the risk of proliferative retinopathy in Type 1 diabetic patients according to the results of a 25-year follow-up study. The study involved 201 individuals from a population-based cohort of diabetic patients who underwent ophthalmoscopy at baseline and by nine 45-degree colour field fundus photos at the 25-year follow-up examination. n G

Thorlund et al, Ophthalmologica, “Is Smoking a Risk Factor for Proliferative Diabetic Retinopathy in Type 1 Diabetes”, 2013 July; DOI:10.1159/000350813.

At the heart of EVA is a revolutionary fluid control system called VacuFlow VTi using Valve Timing intelligence technology. It just effortlessly delivers the precise flow and fast vacuum required by you, the surgeon. Put simply, EVA VacuFlow VTi technology puts you in absolute control, all of the time.

n Kolar

EUROTIMES | Volume 18 | Issue 7/8

José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA

109-..._ADV_Meet_EVA_tbv_Eurotimes_120x300.indd 1

31-10-12 09:13




ESCRS Practice Management Programme in Frankfurt will offer advice on building your own private or public practice

by Howard Larkin


o build a practice you have to put your patients’ interests first and you absolutely have to deliver,” says Arthur Cummings MD, FRCS. He should know. With partner Richard Corkin, he has built the Wellington Eye Clinic into one of Ireland’s most successful private ophthalmology practices. Dr Cummings and other successful surgeons and practice managers will share their insights and experience at the ESCRS Practice Management Weekend, November 1-3, in Frankfurt, Germany. Building Your Own Practice – Assumptions and Truths, is the theme. While it’s important to spread the word about your excellent service and outcomes, Dr Cummings cautions against exaggerated or unsupportable claims, like promising 20/20 uncorrected vision. “Under-promise and over-deliver. It is very important to give people an indication of what you can do, and leave it at that.” Patients with reasonable expectations that are subsequently exceeded then become your most persuasive advocates, Dr Cummings says. “Good service leads to strong word-of-mouth. People are far more inclined to come to you if they hear about you from a friend or family member than if they read about you. Word-of-mouth is a much stronger lead.” A staff well-trained in reinforcing your practice message also helps seal the relationship, Dr Cummings adds. “From the very first call, it should be friendly and engaging. When they walk

in, they see a warm, friendly face and the technicians, nurses and doctors all convey the same message. When someone asks a question, you want to reinforce the good impression. It can be very disturbing to a patient when they get a different message from one person than the rest of the staff.”

Academic, public or private?

With state financial support for health slipping, practice development skills are just as important in an academic or public practice as they are in private practice. Just ask Thomas Kohnen MD, PhD, professor of ophthalmology and deputy chairman at Goethe University, Frankfurt, Germany, who will share his experience building an academic practice in today’s competitive ophthalmology market. Once again, the key to attracting patients is excellent service and outcomes, Prof Kohnen says. He also emphasises the importance of establishing partnerships with private industry, independent surgeons and entrepreneurs to advance academic research. Yet working in a regimented academic setting can be difficult, especially for young surgeons with family responsibilities. EvaMaria Kohnen MD and Ina Hengerer MD, also both of Germany, discuss work-life balance in moving from residency to clinical practice. They both found private practice a more flexible alternative to public settings. Manfred Tetz MD, Berlin, will discuss his journey building Eye Centre Spreebogen from a small start-up into a large clinic providing a complete range of surgical,

“Look for people with professional qualifications and experience. The classic mistake is to hire your wife or your brotherin-law not because they know how to run a practice, but because they want a job.” Kris Morrill, medeuronet

medical and diagnostic ophthalmology. He believes that offering a complete service line helps a practice weather the vicissitudes of a changing economy, demographics and patient needs – a strategy that he has used to grow 10 per cent annually for more than a decade.

Measuring performance

Improving performance means measuring performance, says Eckhard Weingaertner MD of EuroEyes, Berlin, Germany. He recommends tracking, analysing and creating improvement plans for both clinical and business processes. “Refractive outcomes are especially important – visual acuity, night vision and

From the Archive PresbyLASIK techniques yielding encouraging results


everal multifocal and aspheric approaches to LASIK are showing promise in the treatment of presbyopia in hyperopes, myopes and emmetropes, according to studies presented at the 12th Winter Refractive Meeting of the ESCRS. In a study presented by Kenneth A Greenberg MD, all patients achieved EUROTIMES | Volume 18 | Issue 7/8

simultaneous uncorrected binocular visual acuities of 20/25 or better for distance and J3 or better for near, 12 months after undergoing customised bilateral hyperopic/multifocal LASIK ablations. The multicentre study involved 28 presbyopic hyperopes with a mean age of 56 years. Their preoperative sphere ranged from + 0.50 D to + 3.50 D and their

preoperative cylinder ranged from 0.0 D to +1.50 D, said Dr Greenberg. n

From EuroTimes, Volume 13 issue 7/8 July/August 2008



Arthur Cummings – Eckhard Weingaertner – Kris Morrill –

so on, but patient satisfaction is also very important. The patient can be 20/20, but to recommend you they also have to be happy with the experience,” Dr Weingaertner says. In addition to surgeon performance and clinical outcomes, Dr Weingaertner suggests establishing performance measures for staff, such as conversion rates for patient counsellors and cost per lead for marketing staff. Monitor calls coming in to make sure staff are polite and answer questions. He also recommends tracking effectiveness of marketing approaches, such as advertising on radio, buses and phone books. “Marketing is very expensive. If you don’t know which tool is good you can waste a lot of money.” In technical areas, the cost-effectiveness of new technology also should be considered, Dr Weingaertner says. While the latest laser is nice to have, it may make more sense to wait a year for the price to come down.

Staff counts, too Just as important as making sure your staff does the right thing is making sure you have the right staff, says Kris Morrill, a practice management consultant with medeuronet, based in Strasbourg, France. She will present on hiring the right people for the job, and the sensitive matter of getting rid of employees who don’t fit in. Many staffing problems can be avoided by adhering to hiring best practices, Ms Morrill says. “Look for people with professional qualifications and experience. The classic mistake is to hire your wife or your brotherin-law not because they know how to run a practice, but because they want a job.” Getting rid of a relative can be tough, but so can letting go any employee. Ms Morrill will also offer tips on protecting yourself from unfair dismissal claims when terminating an employee. Consultant Rod Solar of LiveseySolar Practice Builders, London, UK, wraps up the programme with a seminar on medical marketing. “You can’t not market your practice, Mr Solar says. “It is mandatory to grow and create awareness of your services.”


industry news

Recent developments in the vision care industry

Auto ref/keratometers

NIDEK has launched a new series of auto ref/keratometers, the ARK-1s, ARK-1a, and ARK-1. “The ARK-1s is the most advanced, providing additional measurements including visual acuity measurement with/ without glare test, opacity assessment and accommodation measurement,” said a company spokesman. “The ARK-1a includes opacity assessment and accommodation measurement. With a number of technological advancements, these units surpass conventional auto refractor/ keratometers. The ability to measure central area refraction and wide area refraction of up to 6mm diameter determines the effect of pupil size on refraction. “The artificial intelligence algorithm automatically reduces the accommodation measurement time in cases with slow or weak accommodation. Measurement of keratometry with mire rings reduces lid artifacts during measurement,” the NIDEK spokesman said. n

Enhanced acrylic IOL

allows surgeons to perform microincision cataract surgery less than 2mm, delivering less invasive surgery for a more rapid visual recovery,” said a company spokesman. “The new lens offers a number of features to deliver an enhanced experience for both the surgeon and patient and ultimately better outcomes,” he said. “The INCISE IOL’s aspheric advanced optics are designed to enhance visual quality. The combination of an enhanced acrylic, improved Stellaris system capabilities and a new single use INCISE Viscoject Bioinjector enables 1.8mm in-the-bag and 1.4mm wound assist implantation enabling surgeons to benefit from a controlled sub-2mm MICS procedure,” said the spokesman. n

Intraocular suturing

The Geuder 25-gauge instrument set for intraocular suturing has been developed by Prof Dr Lars-Olof Hattenbach of Ludwigshafen and Geuder. “The new instrument set consists of a 25-gauge micro needle holder and a 25-gauge tying forceps,” said a company spokeswoman. “The hybrid instrument series for the first time facilitates stitching within the anterior chamber via a paracentesis and it is not necessary any longer to have to insert and remove long needles in an uncomfortable way,” she said. n

New website

Bausch + Lomb has announced the launch of its new INCISE microincision IOL. “This enhanced acrylic IOL, in combination with the capabilities of the Stellaris Vision Enhancement System, EUROTIMES | Volume 18 | Issue 7/8

Medeuronet, a company focusing on driving success for med-tech innovation, has announced the launch of its new website at “The new website is designed to showcase medeuronet’s unique approach to the establishment of medical device innovation in Europe,” said a medeuronet spokeswoman. “The website presents medeuronet’s full range of services and also details medeuronet’s portfolio of innovative medical technologies in ophthalmology, as well as the strategic partners that work with medeuronet to deliver market success for med-tech innovation,” she said. n

During the XXXI Congress of the ESCRS

Practice Development Programme 2013 6–7 October

Amsterdam, The Netherlands

Building and designing an office

Smart recruiting

How to attract new patients

• Building and designing an office for your ophthalmological practice

• How to evaluate the effectiveness of a

marketing plan and tailoring it to your individual needs

• Develop your business skills for a successful practice

For any enquires please go to:






Ophthalmologists should be wary of laws that affect interpretation of employment contracts by Paul McGinn


phthalmologists – whether as employer or employee – should seek legal advice if in doubt about how to interpret their employment contracts in light of a recent decision by the EU’s highest court. The decision, by the European Court of Justice, arose over a lawsuit by a Dutch executive against his former Belgian employer. At issue in the case was whether the Belgian employer – a subsidiary of the multinational company – could rely on the terms of an employment contract to limit the amount of money that it had to pay to Anton Las when it dismissed him as its chief financial officer. The contract, which was drafted in English, provided that Mr Las would receive nine months’ salary if dismissed without notice. Lawyers for Mr Las argued that the terms of the employment contract should not apply because the contract did not comply with Belgian law, which stipulated that any employment contract concluded in Flanders be written in Dutch. On that basis, Mr Las made a claim for 20 months’ salary and for a number of additional payments. On first blush, Mr Las appeared to have a strong case that the employment contract was void because it violated the “Flemish Decree on Use of Languages,” which had been adopted in 1973. According to the decree, “the language to be used for relations between employers and employees, as well

“...the establishment of free and informed consent between the parties requires those parties to be able to draft their contract in a language other than the official language of that Member State” European Court of Justice

as for company acts and documents required by law, shall be Dutch.” The decree also provided that “all documents intended for their staff shall be drawn up by employers in the Dutch language.” The decree further provided that any “documents or acts that are contrary to the provisions of this decree shall be null and void.” In light of the wording of the decree, Mr Las brought his former employer to the Labour Tribunal in Antwerp to request the tribunal to declare the employment contract null and void and to determine how much compensation he should receive.

Preliminary ruling Before deciding the case, the tribunal asked the Court of Justice, which sits in Luxembourg, to make a preliminary ruling on whether the Belgian law unreasonably interfered with established EU legal principles, particularly the right to move freely as a worker within the EU. The right to move freely to work, which is enshrined in Article 45 of the Treaty

on the Functioning of the European Union, provides that “such freedom of movement shall entail the abolition of any discrimination based on nationality between workers of the Member States as regards employment, remuneration and other conditions of work and employment.” For its part, the Belgian government defended the decree by arguing that the law promoted the use of the Dutch language in Flanders, protected the rights of Dutchspeaking employees working in the region, and helped the Belgian government administer labour affairs in the region. In examining the Belgian decree, the Court of Justice acknowledged that the Belgian government’s objectives were legitimate and, in principle, could have justified restrictions on the exercise of such a fundamental right as the freedom of workers to move within the EU. “However, in order to satisfy the requirements laid down by European Union law, legislation such as that in issue in the

main proceedings must be proportionate to those objectives,” the court held. In balancing the legitimate objectives of the Belgian government with the freedom of worker movement, the court noted that the penalty stipulated in the Belgian decree was too harsh because it mandated that any document drawn up in a language other than Dutch be considered null and void. The court added that “parties to a cross-border employment contract do not necessarily have knowledge of the official language of the Member State concerned. In such a situation, the establishment of free and informed consent between the parties requires those parties to be able to draft their contract in a language other than the official language of that Member State.” To that end, the Court of Justice suggested that had the Belgian decree required an employment contract to be drawn up in Dutch and in a second language that both parties understood, it might have viewed the decree more benignly. Laws that “would permit the drafting of an authentic version of such contracts in a language known to all the parties concerned, would be less prejudicial to freedom of movement for workers than the legislation in issue in the main proceedings while being appropriate for securing the objectives pursued by that legislation,” the court ruled. On that basis, the court ruled the Belgian decree unlawful because it went “beyond what is strictly necessary” to attain the Belgian government’s objectives and thus “cannot therefore be regarded as proportionate.” * For details about the decision, Anton Las-v- PSA Antwerp NV, visit the Court of Justice website at

Journal Watch New treatment for adult amblyopia Dichoptic training, in which patients view similar video game images at differing contrast levels, appears to benefit adult patients with amblyopia. Chinese researchers devised a system using the popular Tetris video game and special goggles. The goggles allowed the patients to see brightly colored squares at full contrast with one eye, and stacks of squares at reduced contrast with the better seeing eye. Eighteen patients played the games for 10 one-hour session over a period of two weeks. After eight weeks the researchers observed significant improvements in visual acuity, EUROTIMES | Volume 18 | Issue 7/8

from a mean of 0.51 logMAR to 0.34 logMAR, a statistically significant change. No such change was observed in patients who played monocularly. Adults with amblyopia typically show little response to conventional occlusion therapy. The researchers hypothesise that the contralateral eye provides an inhibitory signal that suppresses cortical inputs from the amblyopic eye. They believe that the results seen in this study could suggest that alleviating suppression of the amblyopic eye through dichoptic stimulus presentation induces greater levels of plasticity than forced

use of the amblyopic eye alone, indicating that suppression is a key gating mechanism that prevents the amblyopic brain from learning to see. Researchers believe the approach could also benefit younger patients, and a multicentre clinical trial of dichoptic video game treatment is in the early stages. n J

Li et al., Current Biology, “Dichoptic training enables the adult amblyopic brain to learn”, Volume 23, Issue 8, 22 April 2013, Pages R308–R309.

The Premier Innovative Educational Retreat for Anterior Segment Surgeons and Administrators


EL CONQUISTADOR a Waldorf Astoria Property

• Accessible faculty leads an open exchange of techniques and solutions • Strategize in a relaxing environment on the “Island of Enchantment” • High-energy sessions for physicians and practice managers • A family-friendly setting with a private beach, golf, horseback riding, water park, all near the El Yunque rainforest

EPOS/WSPOS European Paediatric Ophthalmological Society / World Society of Paediatric Ophthalmology & Strabismus

PAEDIATRIC SUB-SPECIALTY DAY Organisers: Nicoline Schalij-Delfos, Marije Sminia, David Granet, Ken K Nischal

WEDNESDAY 9 OCTOBER 2013 08.30 – 17.15

During XXXI Congress of the ESCRS 5–9 October 2013 Amsterdam RAI, Amsterdam, The Netherlands

Immediately preceding The 39th Meeting of EPOS in Leiden, The Netherlands from 11–12 October 2013 for Registration and Hotel Bookings

A View Through the Child’s Eyes SESSION I: Paediatric ocular surface disease

SESSION II: Visual rehabilitation of the aphakic child

SESSION III: Novel therapies in glaucoma: can we use them in children?

D. Bremond Gignac FRANCE

Chr. Lloyd UK


Incidence and management of BKC in children? H. deConinck BELGIUM

My choice for a secondary IOL in the presence of capsular support

The role of axial length in the decision to operate on paediatric glaucoma

The use of steam goggles in BKC in children


K.Nischal UK/USA

A. Mataftsi GREECE


Punctal plugs in children: are they safe?

Choices for IOL implantation when there is inadequate capsular support

M. Fernandes INDIA


An illuminated microcatheter for 360 trabeculotomy

The use of the iris claw IOL for the correction of aphakia

M. Tekavčič Pompe SLOVENIA

N. Ziakas GREECE

S. Biswas UK

Microsporidia and exotic infections in children W. Moore UK

Keratitis: common and not so common causes P. Nucci ITALY

Limbal vernal kerato-conjunctivitis S. Jones UK

What is the normal tear break up time in children? S.Hamada UK

Can we use Avastin in children with corneal NV’s? A. van der Lelij THE NETHERLANDS

Cross-linking in children

Retroplacement of the secondary IOL in children


Aphakic and pseudophakic glaucoma


Endoscopic cyclophotocoagulation vs high frequency ultrasound guided cyclophotocoagulation

Can we implant infants safely?

E. Gajdosova UK


Goniotomy for aphakic glaucoma

Clear visual axis after surgery for Pseudo-Peters / PHPV

E. da Silva PORTUGAL

D. Granet USA


Visual rehabilitation of the child with JIA and aphakia

The role of nanoparticles in pediatric glaucoma Hints and tricks about OCT use in paediatric glaucoma


10 Essentials about the paediatric CL


C. Luchansky USA

10 videos of 5 minutes each showing a sign or surgical experience of a classical or unusual nature. The audience will be asked to vote on best video.

Using BIFOCAL CL’s in the aphakic child C. Frambach THE NETHERLANDS

Paediatric CL’s: how to handle the parents



JCRS Highlights

Journal of Cataract and Refractive Surgery

Phaco after DMEK? Unlike Descemet’s-stripping automated endothelial keratoplasty (DSAEK) or Descemet’s-stripping endothelial keratoplasty (DSEK), phacoemulsification before or during Descemet’s membrane endothelial keratoplasty (DMEK) may initially be avoided. However, these patients may require cataract surgery in the future. Researchers at a tertiary referral centre conducted a comparative case series study to evaluate the refractive and visual outcomes, the potential graft damage during or after phacoemulsification, and other complications of phacoemulsification after DMEK. A review of a series of 106 consecutive phakic DMEK eyes showed that five eyes (4.7 per cent) required phacoemulsification a mean of 9.2 months ± 3.7 (SD) (range four to 14 months) after the initial DMEK. All phacoemulsification procedures were uneventful, and no dislocations and/or detachments of the Descemet’s graft were observed. At six to 12 months, all eyes reached a corrected distance visual acuity of 20/30 (0.6) or better and were within ±0.50 D of the target refraction. Endothelial cell density decreased from a mean of 1535 ± 195 cells/ mm2 before phacoemulsification to 1158 ± 250 cells/mm2 six to 12 months after phacoemulsification. No significant changes in pachymetry values were observed, and all corneas remained clear throughout the study. The researchers conclude that phacoemulsification after DMEK can be performed with minimal risk for graft detachment. The postoperative refractive outcomes were predictable, and visual acuity is likely to improve. n F

Musa et al, JCRS, “Outcomes of phacoemulsification after Descemet's membrane endothelial keratoplasty”, Vol. 39, Issue 6.

Improved accuracy Aspheric aberration-correcting IOLs have the potential to reduce the amount of spherical aberration in the eye, allowing higher contrast and acuity, especially under low light conditions. However, the improved optical properties lead to less pseudoaccommodation and increase the influence of defocus. For this reason it is essential to predict the IOL power as precisely as possible. German investigators looked at the possible benefits of biometry (Lenstar) and ray-tracing IOL calculation (Okulix ray-tracing software [version 8.79]) for aspheric aberration-correcting IOLs. The study evaluated 308 eyes of 185 patients. The median absolute error was 0.28 D for the Hoffer Q, 0.27 D for the Holladay, 0.28 D for the SRK/T, and 0.24 D for ray-tracing EUROTIMES | Volume 18 | Issue 7/8

calculation. Using ray-tracing calculation, 95 per cent of eyes were within ±0.71 D of the predicted refraction as opposed to ±0.85 D with the Hoffer Q, ±0.82 D with the Holladay, and ±0.84 D with the SRK/T. The investigators believe this approach is a significant improvement over the conventional method.

JCRS Symposium Questions for the Cataract–Refractive Surgeon in 2013 Sunday, October 6, 2013 14:00–16:00

n P

Hoffmann et al, JCRS, Intraocular lens calculation for aspheric intraocular lenses, Pages 867-872 June 2013 vol. 39, Issue 6

KAMRA and LASIK Previous studies indicate that the KAMRA corneal inlay, implanted under a corneal lamellar flap or pocket, is a safe and effective treatment for presbyopia. Tomita and colleagues have also previously reported that inlay implantation in combination with a LASIK procedure for simultaneous correction of ametropia and presbyopia is safe and effective. In the current study they evaluated the visual outcomes after implantation of a KAMRA small-aperture corneal inlay into a femtosecond-created corneal pocket under the previous flap to treat presbyopia in patients who had previous LASIK. The study enrolled 223 eyes (223 patients) with a mean age of 53.6 years (range 44 to 65 years) and a mean manifest spherical equivalent of −0.18 D (range −1.00 to +0.50 D). The mean uncorrected distance visual acuity in the operated eye decreased one line from 20/16 preoperatively to 20/20 six months postoperatively (P<.001). The mean uncorrected near visual acuity improved four lines from J 8 to J2 (P<.001). At six months, significant improvements were observed in patient dependence on reading glasses and patient satisfaction with vision without reading glasses. n M

Tomita et al, JCRS, “Small-aperture corneal inlay implantation to treat presbyopia after laser in situ keratomileusis”, Vol. 39, Issue 6.


Emanuel S. Rosen, MD, FRCSEd Thomas Kohnen, MD, PhD, FEBO Will Femtosecond Laser–Assisted Cataract Surgery Represent a Real Paradigm Shift in Future Cataract Surgery? H. Burkhard Dick, MD, PhD, David F. Chang, MD Is Excimer Laser Treatment of Suspected Keratoconic Eyes Justified? Noel Alpins, MD, FACS, David R. Hardten, MD What Is the Best Solution for Presbyopic Cataract or RLE Eyes? Hiroko Bissen-Miyajima, MD, Graham Barrett, MD

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

During the XXXI Congress of the ESCRS, Amsterdam, The Netherlands


Free access to surgical education from the 2013 ASCRS Symposium on your smartphone, tablet, and laptop. American Society of Cataract and Refractive Surgery




Additional Programming Cornea Day ASCRS Glaucoma Day ASOA Workshops Technicians & Nurses Program

Call for Submissions

August 15–September 25, 2013




Dates for your Diary


2014 JULY

Indian Intraocular Implant & Refractive Surgery Convention 6-7 July Chennai, India

26th APACRS Annual Meeting 11-14 July Singapore

5th World Glaucoma Congress 17-20 July Vancouver, Canada

SEPTEMBER XXXVII UKISCRS Annual Meeting 5-6 September Manchester, UK

14th International Paediatric Ophthalmology Meeting

12-13 September Dublin, Ireland Email:

NEW ENTRY EVER 2013 Congress 18-21 September Nice, France

SEPTEMBER 13th EURETINA Congress 26-29 September Hamburg, Germany


4 October Amsterdam, The Netherlands

4th EuCornea Congress

4-5 October Amsterdam, The Netherlands

XXXI Congress of the ESCRS 5-9 October Amsterdam, The Netherlands

EPOS/WSPOS Paediatric Sub Speciality Day 9 October Amsterdam, The Netherlands

43rd ECLSO Congress 25-26 October Munich, Germany



NEW ENTRY Queen Victoria Hospital NHS Foundation Trust - Corneoplastic Professional Education Meeting

5th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

1 November Lingfield, UK

NEW ENTRY Practice Management Weekend 1-3 November Frankfurt, Germany

8-10 January Vienna, Austria

NEW ENTRY 4th EURETINA Winter Meeting 25 January Rome, Italy


AAO Annual Meeting 16-19 November New Orleans, USA

93rd SOI National Congress 27-30 November Rome, Italy

NEW ENTRY The MCLOSA 20th Annual Scientific Meeting 29 November London, UK

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18th ESCRS Winter Meeting 14-16 February Ljubljana, Slovenia

APRIL ASCRS•ASOA Symposium and Congress 25-29 April Boston, USA

MAY SOI International Congress 21-24 May Milan, Italy

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ANNOUNCING AVEDRO’S 2nd International Congress for Advanced Corneal Cross-Linking SAVE THE DATE September 7, 2013 — Rome, Italy

REGISTER TODAY! Visit to register, or scan QR Code now Abstract Submission Deadline: Friday, July 19, 2013 Registration Fee: €375 INTERNATIONAL THOUGHT LEADERS WILL DISCUSS: The Future of Refractive Cross-linking

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Experience with 10mW/cm2 to 45mW/cm2

Myopia and Astigmatism Correction

Trans-epithelial Cross-linking Protocols

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John Marshall, MBE, PhD

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Vol. 18 - Issue 7-8  

A European Outlook on the World of Ophthalmology

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