Vol 17 - Issue 10

VOLUME 17

SOCIAL

MEDIA

FOR

OPHTHALMOLOGISTS

ISSUE 10

OCTOBER 2012

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ESCRS

EUROTIMES

october 2012 Volume 17 | Issue 10 This ISSUE...

Cover Story 4

Marketing your practice with the help of social media

Cataract & Refractive 8 Study shows good results with femtosecond laser capsulotomy 9

Screening of laser vision patients important

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The changing face of cataract surgery

11 Improvements in laser technology aiding astigmatism correction

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Micro-incision cataract surgery made less painful

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Error budget analysis can help achieve better clinical outcomes

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Topography-guided ablation useful for treating astigmatism

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Patient expectations with new IOLs should be managed

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Good long-term refractive stability with new accommodating IOL

Cornea 18 Ocular surface disease is becoming more treatable 19 Tracking degenerative nerve disease

Glaucoma

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20 21 22 23

Link found between low levels of magnesium and glaucoma Promising early results with drainage device Canaloplasty in patients with glaucoma and co-existing cataract A look at biomechanical risk factors could be key to preventing disease

Retina 24 Trial could help prevent CME after cataract surgery 25 Retinopathy and its link to development of heart failure 26 Steroid implant more effective in longstanding DME patients

Ocular 28

Nanotechnology innovation set to make positive impact

29

Promising treatments for periocular cancers

News 30 Treating Fuchs’ corneal dystrophy 32 Outgoing EBO president reflects on his term of office 33

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42

Performing paediatric cataract surgery

Features 35 Ophthalmologica Highlights

40 Industry News

36 EU Matters

41 JCRS Highlights

38 Eye on Travel

42 Resident’s Diary

39 Book Review

44 Calendar

With this month’s issue... Milan 2012 report from 3rd eucornea congress, 12th euretina congress,

2nd world congress of paediatric ophthalmology & strabismus & XXX congress of the ESCRS

editorial staff

ESCRS

EUROTIMES

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

Assistant Designer Janice Robb Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

Leigh Spielberg Pippa Wysong Gearóid Tuohy Colour and Print Times Printers Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org

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 2011 and 31 December 2011 is 32,332.

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EUROTIMES

Editorial

ESCRS

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EDITORIAL

Medical Editors

Volume 17 | Issue 10

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

SOCIAL MEDIA

Instead of letting our patients advise us on the development of social media, we should be leading them

by Paul Rosen

International Editorial Board

I

n July one of the largest private medical insurers in the UK announced that it would reduce the reimbursement for cataract surgery by 65 per cent at the end of that month. This should be taken in the context of the fact that there has been no increase in reimbursement for 20 years and therefore with inflation, the value has already dropped by three to four per cent per annum. In addition, private/self pay provision of cataract surgery in the UK is a low volume, premium service. The justification suggests that modern cataract surgery is of a lower skill and complexity than it used to be.

We also should remind ourselves that the surgical fee doesn’t only pay for the surgeon’s time, but also runs the practice/business to support the patients. Unfortunately, the perception for many patients is that all fees will be covered by their insurers and that the contract is between insurer and provider (surgeon); in reality, it is between patient and surgeon.

The second outcome is to alter the referral pathway such that patients pass from the optometrist directly to the insurer who will then pass them to a selected group of hospitals for surgery. We are therefore drifting into managed care which many believe will ultimately result in a descent to the lowest common denominator; patients no longer have the choice they expect – people can pay €4,000 per annum for their insurance and therefore expect a premium service, and not to be part of a commoditised pathway.

The insurers are, however, facing increasing costs as the breadth of healthcare in general increases with advancing technology. This presents a problem for patients, providers and third-party payers (insurers) of healthcare.

A key to resolving these issues is communication, which is where social media potentially has an important role to play. (However, it should be noted that this is very distinct from collusion which is forbidden by competition law; each individual surgeon must make their own mind up as to how they interact with their patients/ customers.)

This month’s Cover Story looks at Social Media and how it impacts on the day-to-day working lives of ophthalmologists.

This was one of the hot topics during the recent ESCRS Practice Development Workshops in Milan and it is a subject we will return to at the Practice Development Weekend which is being held in Dublin this month.

As we point out in the Cover Story, the majority of ophthalmologists continue to rely on traditional methods to market their practices and communicate with colleagues, but Facebook, LinkedIn and You Tube are becoming increasingly important as our patients are getting more and more of their information online.

I would also suggest that as we are using cutting-edge technology every day when we operate on our patients, they will also expect us to use the most advanced communication tools available, a process which we need to lead rather than be led.

EUROTIMES | Volume 17 | Issue 10

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY There may be concerns over privacy and ethics: Paul McGinn, a barrister in Dublin, Ireland and an editor of EuroTimes, points out, “the watchwords are the three Rs – read, reflect, and when in any doubt, refer the question to competent legal counsel.”

Health services need a strong financial base to survive and provide the support that patients deserve. This is particularly relevant in ophthalmology where technological advancement has been stunning, and this is one of the reasons ESCRS is continuing to develop its Practice Development Programme. However, these advances need to be communicated to patients and all the other stakeholders.

The popularity of the programme is such that between the Milan congress and the Dublin weekend, we will have presented five days of workshops and masterclasses. I would like to thank the members of ESCRS who have helped us develop the programme and also the professional marketing and communications consultants who have presented at our meetings.

The programme up to now has been aimed at ophthalmologists and other healthcare professionals who are established in private practice or university or hospital settings. Our mission for 2013 is to continue to target this group, but also to develop a new module aimed at younger ophthalmologists in training to prepare them for the business challenges which lie ahead as shown by the example at the beginning of this editorial.

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

* Paul Rosen FRCS, FRCOphth, is the chairman of the ESCRS Practice Development Committee.

Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Cover Story

PRACTICE DEVELOPMENT

SOCIAL MEDIA MARKETING

Expanded word-of-mouth and information may be best use for interactive online connections

by Howard Larkin

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If someone is out there complaining, they are going to do it whether you know about it or not. Wouldn’t you rather know so you can address it?

Arthur Cummings, Wellington Eye Clinic

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We are experimenting with social media now, but we know anecdotally people already use it for research when they are looking for services

Ed Toland, Wellington Eye Clinic

A

fter more than two years on Facebook, Arthur Cummings MB ChB, MMed(Ophth), (Pret), FCS(SA), FRCSEd, can name only one patient he knows for sure that first heard of him through social media.

“She searched for ‘keratoconus’ on the web and it came up within our Facebook page. She had seven children so she was familiar with social media. She saw what current patients were saying and she got a good feel for the practice before she ever saw us,” says Dr Cummings, who runs the Wellington Eye Clinic, Dublin, Ireland, with partner Richard Corkin MB ChB (Cape Town), FCS (Ophth) SA, MRC (Ophth).

Despite the relative lack of response so far, Wellington’s leaders are sticking with social media, including Facebook and an extensive YouTube video channel, for several reasons. For one, they consider social media less of a business development tool and more of an educational service and a way to keep in touch with existing patients and friends of the clinic, Dr Cummings says. For another, they believe that social media will become much more important for establishing a practice’s credibility as it matures.

“Social media is like websites were a few years ago. Everyone thought they had to have one, but it took a number of years for it to become clear what you should be doing and how you should position yourself. We are experimenting with social media now, but we know anecdotally people already use it for research when they are looking for services,” says Wellington’s practice manager, Ed Toland.

Social versus commercial media

Wellington’s experience is not unusual, says Rod Solar of consultants LiveseySolar Practice Builders Ltd, London, UK. Social media is in its infancy, and its value can be difficult to prove; however, it holds great potential. Also, emerging research holds EUROTIMES | Volume 17 | Issue 10

clues as to how it might best be harnessed, Mr Solar says. The key is to understand the different ways that people use and view social media compared with more commercial approaches such as advertising and websites. Fundamentally, it all comes down to trust.

Mr Solar points out that the main difference between social media and a company website is that social media attracts members who share specific interests and activities, or who are interested in the activities and interests of a specific community, for the purpose of sharing information. Users are there to talk to each other and information moves from many users to many users. As a result, users are regularly engaged and information can go “viral”, passing quickly from one network of users to another.

A website, on the other hand, generally attracts people who are looking for information about a specific product or service. Information moves primarily from one source to many users. “Conversation can be one-sided on the web, but it can be multi-sided in social media. That is the biggest difference,” Mr Solar notes. Blogging and message boards can incorporate elements of social media by cultivating a subscriber base, but absent a connection to a blogging network or true social network site there is little opportunity for such content to reach new users.

As a result, social media is typically seen as less biased and more trustworthy.

According to a 2011 Nielsen survey of 28,000 consumers in 56 markets worldwide, 70 per cent of respondents trusted completely or somewhat consumer opinions posted online, second only to “recommendations from people I know” at 92 per cent. In third place, were branded websites tied to editorial content such as newspaper articles, which were trusted by 58 per cent of respondents.

Factor in the high trust people place in physicians – at about 90 per cent, doctors

consistently top surveys of which profession can be trusted to “tell the truth” – and social media is a natural, Mr Solar says. “It is the perfect marriage of trusted source and trusted media. There is no reason for doctors not to engage in social media.”

Be social on social media However, Mr Solar warns that the same research suggests that advertisements and other frankly commercial messages are not appropriate for social media. In the Nielsen global survey, just 36 per cent reported trusting ads on social networks, lower than for emails users signed up for, TV ads, print ads, billboards, radio ads or even TV product placements.

The most successful social media campaigns keep things light and not overtly promotional, says Kris Morrill of medeuronet, a medical marketing consultancy in Strasbourg, France. “The ophthalmologists who are using them successfully are not promoting services.

It is about sharing tidbits, things that are educational, as well as news about the practice in order to help generate word-of-mouth.”

Mr Solar agrees. “The biggest mistake doctors make with social media is treating it like an extension of their website,” he says.

Rather than go on about your qualifications or the clinical details of eye diseases, he suggests easy to digest, actionable content that people might share, such as “five risks of laser surgery, ” an interactive tool to tell if you may be a candidate for surgery or a quiz. “Use videos, images, charts, graphs and statistics. People love to share these.”

Above all, post content regularly and when people post comments or ask questions, respond. “You have to be comfortable interacting with users. You’re not going to get very far sitting back and waiting for people to come to you,” Mr Solar says.

Wellington adheres to this approach. On YouTube, informational videos on refractive procedures starring Drs Corkin and Cummings have drawn the most views. A tutorial on taking eye drops has clocked up 12,000 views in two years. By comparison, a personal account of Dr Cumming’s recent LASIK surgery is moving up fast, with more than 600 views in six months. “People like to know that you understand what they are going through,” Dr Cummings says.

The clinic’s Facebook page and other social media are maintained and monitored daily by Isobel Brennan, an employee with a strong interest in social media. The content includes observations on sporting events and other local topics, as well as many comments from patients, and photos and comments from staff. It now boasts more than 570 “likes”.

Using a similar approach, sehkraft Augenzentrum Maus in Cologne, Germany has generated similar results, gaining 375 “likes” since January 2010, says Carmen Wagner, the clinic’s representative. It’s hard to pin down exactly how many referrals Facebook generates, but “we comment or tell our community about events, and seconds later we have ‘likes’,” she says.

Ms Wagner also sees it as an effective way to interact more directly with patients and potential patients. For example, patients can post their comments voluntarily about their procedures on social media, and those comments are 99 per cent positive. It helps get the good word out in a country that does not allow patient testimonials in advertising or on websites.

Such techniques allow you to establish a brand for your practice by bringing it to the attention of large numbers of people in a credible context, notes David Evans, CEO of Ceatus Media Group, San Diego, US. But

EUROTIMES | Volume 17 | Issue 10

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because it does not target people specifically seeking your service, most visits will be fairly low-grade. “There is a pretty high visit rate to websites from social media, but the time on site is low. But people are on social media to be social, not because they are looking for LASIK providers.” It can take 90 days or more for a patient to decide whether to have an elective procedure. In the meantime, they will do plenty of research on your website and others. By the time they call you, they will likely say “your website” or “the Internet” is where they heard of you, making it hard to quantify the impact of social media.

But integrating Facebook, as well as Google-plus and Yelp reviews, and keyword ads on web searches can increased traffic on websites, says Christian Monea, CEO of King LASIK, which operates at six locations in British Columbia and Alberta in Canada, and Washington state and Oregon in the US. In addition to directing patients to the website, social media and review site links have helped move King LASIK to the first page on organic web searches.

Mr Monea estimates King spends $8,000 to $10,000 monthly on all forms of Internet marketing, including country-specific websites and Google key word ads, and outsources social media content to ensure new content goes up five days a week.

“Last month 53 patients had surgery from

Internet leads; that’s more than 100 eyes, or about $160,000 in revenue. Spend $10,000 to get $160,000? I would take that any day.”

By comparison, $30,000 spent on radio ads typically generates about $60,000 in revenues.

Mr Monea has found that offering patients incentives to post online can help. King LASIK launched its Facebook presence with a contest to win an iPad. The tactic was fairly successful and the practice continues to offer prizes to social media contributors. He believes it is essential to take advantage of the “wow factor” as soon after surgery as possible.

Getting started Like any marketing effort, social media requires planning as well as ongoing effort and monitoring to succeed, Ms Morrill says. She emphasises integrating social media with websites and other marketing efforts, and suggests looking at other ophthalmology and medical sites to see how they do it – and emulate those who are building sizable followings.

Very short items posted once or twice a week work best, she says.

Mr Solar recommends determining your purpose first. Whether it is increasing marketing effectiveness, increasing customer satisfaction, reducing marketing costs or reducing support costs, you won’t know if you’re succeeding if you don’t have a goal.

Be prepared to speak with your target audience, not to them, Mr Solar says. You’ll also need to engage them by encouraging users to participate – remember, it is a many-to-many medium. The most successful social media channels are those that are the most open, with members sharing their views, uploading content and connecting with each other.

Be prepared to generate consistently valuable content. This can take some effort and a little time from surgeons, but if you batch it all at the beginning, you can generate enough content in a couple of days to keep the site fresh for a year, Mr Solar says. He suggests developing a set of questions people ask – about procedures, safety, symptoms, outcomes, whatever it is that people actually ask you and your staff – and then sit down and answer them

“

You have to be comfortable interacting with users. You’re not going to get very far sitting back and waiting for people to come to you

Rod Solar, LiveseySolar Practice Builders Ltd.

“

The most successful social media campaigns keep things light and not overtly promotional Kris Morrill, medeuronet

contacts

Cover Story

PRACTICE DEVELOPMENT

Arthur Cummings – abc@wellingtoneyeclinic.com Ed Toland – ed.toland@wellingtoneyeclinic.com Rod Solar – rod@liveseysolar.com Kris Morrill – kmorrill@medeuronet.com Carmen Wagner – wagner@sehkraft.de David Evans – devans@ceatus.com Christian Monea – cmonea@kinglasik.com

Courtesy of Rod Solar

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Rod Solar interacting with practice staff

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It’s hard to pin down exactly how many referrals Facebook generates, but “we comment or tell our community about events, and seconds later we have ‘likes’

Carmen Wagner, sehkraft Augenzentrum Maus

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You are either socially engaging with your patients or you are not; there really is no middle ground

David Evans, CEO of Ceatus Media Group

all on tape. One of his clients came up with nearly 200 questions that were taped in a few hours. They are then released as short videos on social media and on the practice website, with transcripts on the website as well, providing several months of fresh content.

Lastly, track your program’s impact. Tools such as Google analytics, as well as new tools from Facebook and third-party vendors can help track social network efficacy in marketing by identifying click-throughs to your web page and providing unique phone numbers or offer codes for those who call.

Keep in mind that building a social network takes time, Mr Evans says. If you’re interested, plan for the resources it will take and give it a year. But recognise that someone will have to work at it. “You are either socially engaging with your patients or you are not; there really is no middle ground.”

Small practices may conclude they do not have the resources to engage consistently, Mr Evans notes. Still, it may be worthwhile to put up Facebook, LinkedIn, Goggle-plus, and a Twitter account with minimal content, just to acquire the name for future use.

Negative comments One risk of free-wheeling social media is that not all comments will be positive. But most will.

A one-week survey of all US social network activity involving healthcare providers, insurers and pharmaceutical firms on their own sites and in online communities conducted by PriceWaterhouseCoopers found that only five per cent were negative.

But when negative comments arise, they may actually present an opportunity to convert a complaint into a commendation, Mr Monea says. He recommends approaching patients who complain offline to find out what the problem is and what can be done to resolve it. In one case a complaining patient not only removed the complaint, he replaced it with a positive Don’t miss Eye on Travel, see page 38 EUROTIMES | Volume 17 | Issue 10

“Some people check Facebook nine or 10 times a day.

When someone is willing to tell a story or post a picture, that can reach 300 or 400 ‘friends’ instead of one or two of their closest friends” Christian Monea, CEO of King LASIK

comment about how responsive the practice was.

Dr Cummings says he has had no negative comments – but he’s prepared.

He even views them as a gift of sorts. “If someone is out there complaining, they are going to do it whether you know about it or not. Wouldn’t you rather know so you can address it?”

In some cases, such as the Yelp review site, it may not be possible to remove or even contact a negative reviewer. But that doesn’t bother Mr Monea – as long as most of the reviews are positive. “If you have 40 or 45 reviews that are good, and one or two that are negative, people will take that into account. But if it is 50-50, people will give the negative reviews more credence.”

Privacy and ethics Protecting patient privacy and avoiding ethical or regulatory violations are also concerns with social media. Patients – and physicians – may not realise it, but information shared through social networks usually belongs to the network, and may be sold to advertisers.

This is, in fact, the business model of commercial social networks.

When this information is clinical, it could be an ethical or even a legal problem, even when it seems innocuous. For example, asking in an online quiz whether people have had symptoms of dry-eye or other diseases could unwittingly reveal protected information. It is your ethical and legal responsibility to understand

the terms under which you participate in social media and protect your patients from unauthorised disclosures of their personal data, says barrister Paul McGinn, Dublin, Ireland. “As with all contracts, the watchwords are the three Rs – read, reflect, and when in any doubt, refer the question to competent legal counsel.”

The same goes for potential violations of ethical standards, such as bans on patient testimonials, through links to social media.

While you cannot control what patients say on social sights, it’s possible that a direct link to a page with testimonials from your website could be construed as a violation.

The best course may be to check with your national ophthalmic society or medical registration agency, Mr McGinn says.

Similarly, patients raising clinical questions online could present problems if handled incorrectly. Mr Evans says the best way to handle the problem is to avoid soliciting any clinical information. Mr Solar agrees. “Online clinical questions should be handled just as you would handle questions in your waiting room. Ask the patient to see you in private for a consult.”

On balance, the potential benefits greatly outweigh the risks, Mr Monea says.

“Some people check Facebook nine or 10 times a day. When someone is willing to tell a story or post a picture, that can reach 300 or 400 ‘friends’ instead of one or two of their closest friends. The question is, how do you harness that type of communication power?”

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ESCRS

Update

Cataract & refractive

FS IOL centration

Precision laser anterior capsulotomy may improve visual outcomes

by Howard Larkin in Orlando

F

emtosecond laser capsulotomy provides a measurable improvement in spherical equivalent compared with manual capsulorrhexis, a new study shows.

The result is very close to the theoretical improvement expected with a perfect capsular opening, and suggests that femtosecond technology could be a vital tool for investigating other factors affecting cataract surgery visual outcomes by removing the lens position error induced by irregular capsulorrhexes, Warren E Hill MD, Mesa, Arizona, US, told the annual meeting of the American Academy of Ophthalmology.

“We did this study as something of a sanity check. We know a perfect capsulorrhexis improves visual outcomes, but we don’t know how much. What this work did is provide numbers that show how much,” Dr Hill said.

Dr Hill noted that a less than optimal capsulorrhexis may allow for changes to

the effective lens position, affecting its distance from the principal plane of the cornea and its effective power. A very small capsulorrhexis may result in the lens being displaced posterior, creating a hyperopic shift, while a large rhexis can allow the lens to move forward as the forces of capsular bag contraction are brought to bear, resulting in a myopic shift.

And while other factors also affect visual outcomes, including the accuracy of biometry, lens power calculation formulae and half-dioptre power steps in available IOLs, Dr Hill’s research indicates that the capsular opening is the surgical factor with the most influence overall.

In absolute terms, capsule opening on average contributes 0.42 D error compared with a 0.02 error for the measurement of axial length by optical biometry, 0.25 D for autokeratometry and 0.17 D for the tolerance of IOL manufacturing for the specific IOL mentioned.

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The theoretical contribution of each factor to the absolute error is determined by taking the square root of the sum of the squares of the mean absolute error each factor. By this method, Dr Hill predicted that eliminating the contribution of capsule opening deviations would reduce the observed average absolute error of 0.58 D by about 0.18 D, to about 0.38 D. Partnering with Harvey Uy MD, Manila, Philippines, Dr Hill tested the hypothesis in a prospective study in which Dr Uy performed a standardised cataract procedure with the only difference being that one group received anterior capsulotomies using a LensAR system and the other received manual capsulorrhexis.

For all patients, axial length and keratometry readings were done with the IOLMaster, or ultrasound for axial length if it couldn’t be done with the IOLMaster. Lens power was calculated with the same formula.

Phacoemulsification was carried out with an Alcon Infiniti using OZil, and an AcrySof SA60AT lens was implanted.

A first analysis at six months found a mean spherical equivalent of 0.02 in 44 lasertreated patients compared with -0.21 in 62 manually treated patients (p=0.034), with 81 per cent of the laser group and 75 per cent of the manual group within 0.5 D of the target.

A later analysis involving 249 laser and 123 manual patients showed a mean deviation of -0.21 D for the laser compared with 0.55 D for the manual group (p<0.001). This

“We did this study as something of a sanity check. We know a perfect capsulorrhexis improves visual outcomes, but we don’t know how much. What this work did is provide numbers that show how much” Warren E Hill MD

EUROTIMES | Volume 17 | Issue 10

contacts

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Warren E Hill – hill@doctor-hill.com Juan Batlle – batlle@codetel.net.do Stephen Slade – sgs@visiontexas.com

translates to an observed absolute error of 0.42 for the laser group and 0.59 for the manual group, Dr Hill said. In this larger group, 78.7 per cent of the laser patients and 52.8 per cent of the manual eyes were within 0.5 D of the target (p=0.003).

“It’s absolutely uncanny that the numbers we got from the study so closely match what we predicted. Yes, the capsulorrhexis does affect the refractive outcome, and yes, the femtosecond laser does an amazing job with the capsulorrhexis,” Dr Hill said.

Overall, the results suggest that a perfectly round, centred and sized capsulotomy contributes about 0.15 to 0.2 D, Dr Hill said.

He also noted that at six months Dr Uy also observed less fibrosis and contraction around the capsule opening in the eyes treated with the femtosecond laser.

Unmasking hidden factors Beyond directly improving visual outcomes, reducing deviations induced by irregular capsule openings will make it possible to better study how other factors influence lens position and refractive outcomes. For example, the difference in ½ and ¼ dioptre steps in lens power on visual outcomes is virtually impossible to measure because there is so much variability due to IOL power calculation formulas, which remain the weakest link in the calculation process.

“The great thing about the femtosecond laser is it will unmask a lot of this. Instead of mathematical noise, we will be able to isolate variables,” Dr Hill said.

A study presented by Juan Batlle MD, Santo Domingo, Dominican Republic, comparing 29 eyes with manual capsulotomy with 39 eyes with femtosecond laser capsulotomies cut by an OptiMedica laser found that the lenses in the laser group were better centred one month after surgery.

“This data shows we are able to consistently perform a perfectly centred, perfectly cantered capsulorrhexis with a standard diameter.

It is almost like a cookie cutter; we can do it every time in a predictable fashion.” Dr Batlle emphasised the importance of the “Liquid Optic Interface” in the achievement of a “completed” capsulotomy with 100 per cent penetration of the femtosecond laser energy avoiding “skip lesions” when using the ordinary applanation technology.

The next step is to use the technology to better predict effective lens position, he added.

Stephen Slade MD, Houston, US, suggested that the precision of capsulotomy placement would make it possible to determine how centring the opening on the visual axis, capsule anatomy or corneal centre might affect lens position compared with centring on the pupil centre, as is now common practice. Centring the lens on the optical axis certainly improves the performance of multifocal lenses. Tailoring the size might also help fine-tune depth of placement.

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Update

Cataract & refractive

SCREENING PATIENTS

Document results now to avoid problems later

by Priscilla Lynch in Southport

S

urgeons should carefully document the screening results of all their laser vision correction patients prior to surgery to avoid any medico-legal issues down the line, advised Saj Khan FRCSEd(Ophth), Corneoplastic Unit and Eye Bank, East Grinstead, UK. He told the XXXV UKISCRS Congress that he takes the basic premise when approaching the screening of laser vision correction patients that none are suitable for treatment unless proven otherwise.

“In an ideal world we would be able to offer everybody perfect unaided visual acuity post treatment and we would perform treatments that have no complications,” he commented.

Since that is not possible, ensuring accuracy of the necessary measurements to achieve the optimum desired outcome, with the bottom line of safety for the patient is the way to go, Dr Khan advised. For surgeons themselves this approach is also in their best interests, in terms of reputation and for medico-legal reasons.

Discussing the diagnostic modalities he most commonly uses on his laser vision correction patients, Dr Khan listed topography, tomography, wavefront analysis, specular microscopy, anterior segment optical coherence tomography and retinal OCT of the disc/macula.

The key issues Dr Khan screens for through tomography/topography include irregular astigmatism, asymmetric bow tie, inferior steepening, I-S pachymetry difference, displaced apex, thinning, steep Ks (keratometry) and posterior elevation.

He said that while much equipment nowadays can do more than one screening task, he prefers having more than one machine that can do the same thing. For example, Dr Khan stated the slit scanning system is not as good a tomographic data generator as the Scheimpflug imaging system of the Pentacam.

“So having another form of tomography device is essential for confirming the data that you have. Generally there are a lot of people who say that once you have moved on to the newer generation of technology you shouldn’t bother with the older one but it is always reassuring to know you have consistency,” he told the meeting.

Surgeons’ biggest fear when doing refractive surgery is the risk of ectasia and

EUROTIMES | Volume 17 | Issue 10

that is difficult to screen for even with the latest improved technologies, he noted.

“There are many things we look for that we believe are indications for patient’s risk of ectasia but we’re still looking for that Holy Grail that will eliminate the risk completely,” Dr Khan commented.

He said the Visante OCT system is a good modality for providing detailed images of the anterior segment and the cornea in particular, which has changed the surgeon's ability to assess volume within the cornea and also utilise that information to help plan how to overcome any issues.

He said he doesn’t typically use the imagery from the OCT unless he has concerns about discrepancies between the Pentacam and the Orbscan. However, while it is a bit slower to use, the OCT gives a different detail and added security when extra reassurance is needed.

Furthermore, Dr Khan said he probably uses the fundal examination more than some of his colleagues as he finds it very reassuring.

While screening modalities continue to improve and some claim to give a complete picture of what needs to be considered, none of these things can be taken in isolation, Dr Khan maintained.

Litigation protection Dr Khan also strongly advised surgeons to take pictures/ copies of the screening findings of all potential patients. “As our world becomes more litigious and we worry about medicolegal ramifications later on in life, having a documented diagnostic examination that you can keep long term is likely to save a lot of people who would otherwise rely on people to trust their integrity, which is unfortunately happening less and less.

“You’ll always find somebody who is prepared to challenge you if you can’t give them objective evidence that what you did at the time was entirely consistent with accepted practice and believed to be safe for the patient,” he contended.

Overall for his practice, Dr Khan said the key benefits of the diversity and accuracy of modern diagnostic imaging devices is that they maximise the potential for getting the desired outcome from both the patient’s and surgeon’s perspective.

contact

Saj Khan – SKhan@centreforsight.com ad ET versario 1-2hoch ENG 1202v5 pva RZ.indd 1

16.07.12 12:25

Cataract & refractive

FEMTOSECOND LASERS

Femtosecond laser cataract surgery – evolution or revolution?

by Dermot McGrath in Abu Dhabi

W

hile most surgeons agree that the femtosecond laser will ultimately change the face of cataract surgery, its impact on clinical outcomes and its cost-effectiveness in daily clinical practice are still open to discussion, stressed two surgeons in a debate held during the World Ophthalmology Congress.

For Zoltan Nagy MD, the first surgeon to perform femtosecond laser cataract surgery, the benefits of the technology are all too apparent.

“With the femtosecond laser, there are multiple steps of lens surgery which can be planned and guaranteed. There is better centration of the capsulotomy, it makes capsulorrhexis creation more predictable, and it is effective in liquefying up to grade two cataracts. It can create any type and size of corneal wound, and there is better lens position, and lens centration with this technology. It also delivers better quality of vision, with less higher order aberrations, reduced endothelial cell damage and less cystoid macular oedema following surgery,” he said.

Nevertheless, Dr Nagy, professor of ophthalmology at Semmelweiss University, Budapest, is quick to give short shrift to the idea that the femtosecond laser will sound the death knell for traditional phacoemulsification.

“I am often asked if the femtosecond laser will replace phacoemulsification. The answer is certainly not, but it will improve it by converting a manual multi-step, multi-tool procedure into a predictable and consistent surgical technique,” he said.

Dr Nagy also dismissed the idea that the advanced automated technology of the femtosecond laser represents a potential threat to the primacy of the surgeon at the heart of the medical process.

“Ophthalmologists cannot be replaced by ophthalmic technicians no matter how good the technology is. Surgical experience and wisdom are still needed and even more so than before. Femtosecond cataract surgery is a rapidly developing new technology which will play an increasingly important role in the future, both in refractive lens exchange and in cataract surgery,” he said.

Looking at complications associated with phacoemulsification cataract surgery, Dr Nagy pinpointed three potential sources of

EUROTIMES | Volume 17 | Issue 10

contacts

Update

Zoltan Nagy – zoltan.nagy100@gmail.com Yehia Mostafa – yehiasalah323@gmail.com

“

Ophthalmologists cannot be replaced by ophthalmic technicians no matter how good the technology is Zoltan Nagy MD

Courtesy of Yehia Mostafa MD

10

“

Intumescent cataract

Manual capsulorrhexis is well established and very reproducible once rules are followed allowing proper centration Yehia Mostafa MD

problems: the corneal incision, capsulotomy and lens fragmentation.

“Corneal incisions can have a refractive impact in terms of induced astigmatism and the risk of infection also needs to be kept in mind. The capsulorrhexis is also a potential source of error, especially with the precision required for the latest premium lenses.

For the capsulotomy, posterior capsule opacification or even vitreous loss may result if it is not performed correctly.

Similarly, errors in lens fragmentation may result in delayed visual recovery, loss of endothelial cells or even corneal decompensation,” he said.

Rigorous patient selection is important to obtain optimal outcomes with the femtosecond laser, said Dr Nagy. Patients with small and non-dilating pupils should be excluded from surgery, while relative contraindications include patients on anti-coagulation therapy, white cataracts and very brown or black cataracts. "In white tumescent cataracts the femtolaser is very useful in creating capsulorrhexis.

In mature cataracts femtolaser is also useful performing the rhexis and the role of femtolasers in fragmentation of the crystalline lens is still under investigation," Dr Nagy said.

In several studies carried out by Dr Nagy, femtosecond laser-assisted surgery using the LenSx laser (Alcon) was shown to deliver enhanced surgical accuracy and reproducibility compared to manual methods.

All anterior capsulotomies achieved accurate centration and intended diameter, with no radial tears or adverse events.

Corneal incisions were also highly reproducible, with precise dimensions and geometry. Dr Nagy noted only 10 per cent of manually created capsulorrhexis achieved a similar diameter accuracy of +/-0.25 mm as the LenSx laser.

Furthermore, there was significantly better IOL centration and a better anterior capsule-IOL overlap in the femtosecond laser group compared to the manual CCC control group. Fewer higher order aberrations and an improved postoperative quality of vision were also found with the LenSx treated patients.

In praise of phaco While femtosecond lasers are a clear technological breakthrough with exciting potential, it is still too early to write the obituary for traditional phacoemulsification, according to Yehia Mostafa MD. “Phacoemulsification remains a great technology that has proven itself over many years. It is reproducible and unlike the femtosecond laser it can be used for any type or grade of cataract or any pupil size. It can even be used on unclear corneas. It is a machine that is affordable and which gives the surgeon the control he or she needs to deliver excellent results for their patients,” he said.

Dr Mostafa, professor of ophthalmology at Kasr Al Aini Faculty of Medicine of Cairo University, Egypt, said that ongoing advances in phaco technology allied to new IOL designs were raising the bar in terms of clinical outcomes for cataract patients.

"Corneal incisions less than 2.4mm are astigmatically neutral and still we can go as small as 1.8mm incisions. Tight, well constructed, well hydrated wounds avoid the risk of infections.

"Manual capsulorhexis is well established and very reproducible once rules are followed allowing proper centration.

Decreased posterior capsule opacification is achieved with overlapping edges of anterior rhexis over the optic periphery as proved by various studies together with the material and edge design of the IOL optic.

“The short operation time during phacoemulsification, five to 10 minutes, decreases the risk of contamination.

And the avoidance of anterior chamber fluctuations decrease vitreous movements and consequently cystoid macular oedema.

Using one machine and one microscope for a properly planned surgery makes it easier for the surgeon and patient with less chance of pitfalls,” Dr Mostafa said.

Improved fluidics “Phaco technology has matured over the years and we now have better safety and efficiency through better power modulation and improved fluidics. This decreases the amount of energy being delivered into the eye and protects the corneal endothelium.

Nuclear cataracts one and two almost require no power at all and it is a mere phacoaspiration. The introduction of torsional or transverse phacoemulsification has also enabled us to emulsify almost any type of nucleus with less risk to the cornea and the posterior capsule,” he said.

Dr Mostafa said that one of the advantages of traditional phacoemulsification is its versatility.

“Even with compromised corneas, small pupils, extremely mature cataracts and posterior subcapsular cataracts, it is still possible to perform a proper capsulorrhexis, to easily remove the nucleus with the least impact on the corneal endothelium thanks to the newer modalities of power modulation and fluidics and improved techniques,” he said. There is no contraindication for conventional phacoemulsification except total corneal opacity or total subluxation of lens.

Summing up, Dr Mostafa said that phacoemulsification remains a tried, cost effective and trusted technology that is continuing to deliver excellent clinical results for patients worldwide.

11

Update

Cataract & refractive

technology

Advanced laser technology driving improved astigmatic corrections

discover in cataract and vitreoretinal surgery

by Dermot McGrath in Paris

A

dvances in femtosecond and excimer laser technologies are continuing to yield vastly improved results for astigmatic correction in both myopic and hyperopic patients, according to a French study presented at the French Implant and Refractive Surgery Association (SAFIR) annual meeting.

“Thanks to improvements in femtosecond and more particularly excimer laser technology we are now seeing very good visual and refractive outcomes for both sphere and cylinder that remain stable over time,” Philippe Chastang MD told delegates.

Dr Chastang, Cabinet d'Ophtalmologie La Motte-Picquet and Fondation Ophtalmologique Rothschild, Paris, France, noted that LASIK has been the technique of choice in recent years to correct astigmatism up to around 6.0 D. “Hyperopic treatments seem to have benefited the most compared to what was possible five years ago. And while the astigmatic results overall are still not quite as good as for purely spherical treatments, the gap is closing all the time,” he added.

The introduction of the femtosecond laser has enabled refractive surgeons to adjust the flap cut to the geometry of the photoablation and deliver greater control over the placement of the hinge and the shape of the cut, Dr Chastang said.

The biggest breakthrough, however, has been in the domain of excimer laser technology. “We now have flying spot lasers, with advanced eye tracking capability, ablation profiles with larger optical treatment zones and improved correction of cyclotorsion,” he said.

The issue of cyclotorsion is one which has caused problems for refractive surgeons over many years, said Dr Chastang.

“We know the effect of axis alignment errors on LASIK treatments. An error of seven degrees equates to a 25 per cent reduction in the efficacy of the laser treatment, 15 degrees equates to 50 per cent and 30 degrees means the effect has been completely nullified,” he said.

In order to assess the progress made in astigmatic corrections in recent years, Dr Chastang carried out a retrospective study of 71 eyes with a cylinder greater than 2.0 D treated over a three-year period. The study included 44 myopic eyes with astigmatism EUROTIMES | Volume 17 | Issue 10

“Hyperopic treatments seem to have benefited the most compared to what was possible five years ago” Philippe Chastang MD

from 2.0 D to 4.75 D and 27 hyperopic eyes with astigmatism from 2.0 D to 5.0 D. The IntraLase femtosecond laser (Abbott Medical Optics) was used to create 100 to 110 micron flaps with diameters ranging from 8.8 to 9.3mm. Photoablation was carried out using the Wavelight Allegretto 400 Hz laser (Alcon Laboratories), which incorporates sophisticated eye-tracking capabilities, said Dr Chastang.

Eye tracker He noted that the WaveLight laser uses an advanced eye tracker that recognises any eye movement and actively tracks pupillary diameters from 1.5 to 8.0mm. The NeuroTrack feature prevents cyclorotation by giving the patient a target to look at that incorporates square elements and prevents the eye from rotating.

A projected crosshair line over the patient’s eye informs the surgeon of the exact alignment of the patient’s head and eye, while the tracker uses the vestibulo-ocular reflex to track all eye movements actively and compensate for the cyclotorsion.

Dr Chastang said that 82 per cent of patients with myopic astigmatism and 85 per cent of those with hyperopic astigmatism achieved between -0.5 D and +0.5 D residual spherical equivalent after six months. The postoperative subjective cylinder showed 77 per cent of myopic patients and 85 per cent of hyperopic patients had less than 0.50 D of cylinder.

“What we can see is that the hyperopic results have improved considerably on previous generations of laser technology and are now relatively comparable to myopic cylinder corrections,” he said.

Dr Chastang has no financial interest in the products mentioned in this article.

contact Philippe Chastang – contact@docteurchastang.com

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12

Update

Cataract & refractive The Surgeon’s Edge

Disposable Ophthalmic Products

LESS PAINFUL MICS

Intracameral anaesthesia eases the pain of wound-assisted IOL insertion

by Roibeard O’hEineachain in Dublin

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EUROTIMES | Volume 17 | Issue 10

Micro-incision cataract surgery

“

Visthesia was associated with significantly less pain and discomfort during IOL insertion

David Shahnazaryan MRCSI

Courtesy of David Shahnazaryan MRCSI

icro-incision cataract surgery (MICS) performed with a combined viscoelastic anaesthesia formulation can be significantly less painful than surgery performed with topical anaesthesia alone, particularly during the IOL insertion phase of the procedure, according to the results of a study presented at a conference of the Irish College of Ophthalmologists by David Shahnazaryan MRCSI, Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

The study involved 68 eyes of 68 consecutive patients scheduled for MICS. They included 39 women and 29 men with a median age of 73.5 years. The Dublin investigators randomly allocated the patients to undergo MICS with either topical anaesthesia or topical anaesthesia in addition to intracameral anaesthesia with a commercial formulation combining 1.0 per cent lignocaine with a viscoelastic (Visthesia ®, Zeiss). In all procedures Dr Shahnazaryan and his associates inserted the IOLs using 2.2mm incisions and a wound-assisted technique.

During admission, patients signed consent forms and were familiarised with the visual analogue pain scale. All received an instillation of topical anaesthesia with 0.5 per cent proxymethacaine five minutes before surgery. All provided a pain score at three time points, namely, directly before surgery, directly following IOL insertion and at the conclusion of surgery at which point they gave an overall pain score for procedure.

“The rationale behind this study is that because of the small size of the wound in micro-incision cataract surgery most of the tips of the IOL injectors cannot be inserted through the wound. That means we have to use the wound-assisted IOL insertion which could be associated with more pain perhaps due to wound stretching,” Dr Shahnazaryan said.

Although the mean overall pain score in both groups was less than three, which corresponds to mild pain or discomfort, it was significantly less in the Visthesia group, at 1.6, compared to 2.8 in the topical anaesthesia alone

group (p=0.009). Furthermore, none of the patients in the Visthesia group reported a pain score greater than four during IOL insertion, whereas eight patients (24 per cent) in the topical anaesthesia alone group reported a score greater than four at the same time point in their procedures.

The duration of surgery was comparable in both groups, with mean values of 16.44 minutes in the Visthesia group and 16.35 minutes in the topical anaesthesia alone group.

Moreover, a statistical analysis revealed no correlation between the duration of surgery and the pain score in either group.

The effective phaco time was also comparable in both groups, with mean values of 5.7 seconds in the Visthesia group and 5.8 seconds in the topical anaesthesia alone group. There was also no correlation between the effective phaco time and the pain score in either group.

“Visthesia was associated with significantly less pain and discomfort during IOL insertion. However, it is about several times more expensive and perhaps the addition of one per cent lignocaine intracameral could achieve similar effect at less cost,” Dr Shahnazaryan concluded.

contact

David Shahnazaryan – drshahnazaryan@gmail.com

13

Update

Cataract & refractive

Henderson Instruments for toric IOLs

ERROR BUDGET ANALYSIS

Achieving improved outcomes after corneal refractive surgery requires reconsideration of subjective refraction

marking pattern

Mark the patient

by Cheryl Guttman Krader in Fort Lauderdale

E

rror budget analysis of corneal laser refractive surgery procedures suggests several targets for achieving better clinical outcomes in the future, said Michael Mrochen PhD, at the 2012 annual meeting of the Association for Research in Vision and Ophthalmology.

Through a systematic evaluation of factors that influence the refractive and quality of vision outcomes after corneal laser surgery, Dr Mrochen reviewed specific technical and physiological sources for error, and he arrived at the following conclusions regarding their resolution.

“Achieving improved outcomes after corneal refractive surgery will require reconsideration of subjective refraction as the gold standard for treatment planning and outcome evaluation, along with improved diagnostics to determine the relevance of epithelial smoothing and the biomechanical response, and the development of eye-specific assumptions and models for transferring the attempted optical correction onto the cornea,” said Dr Mrochen, IROC Science to Innovation, Zurich, Switzerland.

Explaining the foundation of his error budget analysis for corneal laser surgery, Dr Mrochen noted first that the field encompasses four categories – spherocylindrical corrections, presbyopia treatment, correction of higher order aberrations (HOAs), and therapeutic treatments.

Taking all of these treatments into account, he identified four key areas of focus – refractive predictability, predictability of HOA correction, visual quality/depth of field, and biological factors. Then, he reviewed sources of error within each as well as obstacles to their removal.

Refractive predictability

Dr Mrochen observed that currently, refractive predictability of modern wavefrontoptimised or wavefront-guided laser surgery is excellent considering that achieved SE is within 0.5 D of target in 90 per cent to 95 per cent of eyes. Although ideally, 99 per cent to 100 per cent of eyes would fall within this predictability range, the ability to achieve that goal is limited by the measurement reproducibility of subjective refraction, said Dr Mrochen.

He explained this limitation by citing a study by Raasch et al. [Ophthalmic Physiol Opt 2001;21:376-83], which analysed test-retest refraction data, and showed that even in normal eyes, there was repeatability within 0.5 D only 92 per cent of the time. In irregular eyes with keratoconus, repeatability of the two measurements was much worse.

“If the reproducibility of the refraction itself is similar to that of the laser refractive outcome, we need to question whether subjective refraction is precise enough to use for a gold standard as we attempt to further optimise the predictability of our refractive outcomes. In other words, the reproducibility of the subjective refraction is masking our outcome analysis,” he said.

Data on outcomes from wavefront-guided ablations show that in eyes with preoperatively low levels of HOAs, the surgical treatment usually induces HOAs whereas EUROTIMES | Volume 17 | Issue 10

Using this marker the surgeon impresses three dot-shaped landmarks at the 3, 6, & 9 o’clock positions. The tips of the prongs are flattened to prevent damage to the epithelium even if the patient inadvertently moves.

some HOA correction can be achieved in eyes with higher pre-existing levels. Nevertheless, HOAs in the latter eyes remain under corrected, indicating room for improvement in HOA treatment predictability. As an added source of error, it has been shown that in eyes with higher HOA levels, the predictability of HOA correction is coupled with the refractive component of the correction and worsens as the amount of spherical correction increases.

Dr Mrochen noted that correction of HOAs affects visual performance through its association with quality of vision.

In addition, it has relevance to presbyopia treatments considering the current interest in ablations designed to induce spherical aberration as a means to increase depth of field. “While in theory, inducing spherical aberration is a viable method for improving near vision in presbyopes, its clinical feasibility is limited by the unpredictability of inducing specific HOAs,” said Dr Mrochen.

K3-7908 Henderson Alignment Marker

Orient the gauge to the marks To correctly position the gauge, the surgeon simply aligns the notches on the inside edge of this instrument with the dots produced by the Henderson Alignment Marker. Also available with teeth for better fixation.

Biological factors

An effect of epithelial remodelling on deviation from the desired outcome must also be taken into account in aiming to improve results of laser refractive surgery, said Dr Mrochen, and he credited Dan Z Reinstein MD, for his extensive work in this area.

“We still do not know if epithelial remodelling after stromal ablation has clinical relevance, but there is good indication it may be a factor influencing the predictability of correcting HOAs. Smoothing of the cornea by epithelial remodelling over the ablated surface may be masking our intended correction, and at the present time, we cannot overcome that issue, because of the limitations in diagnostics,” he said.

Within the realm of biological factors that can affect outcome predictability of corneal laser refractive surgery, the biomechanical response of the cornea is another issue that needs to be considered. However, there are also uncertainties in this area as currently, it is neither possible to accurately predict the biomechanical response to surgery in the individual eye nor to reliably measure it using available diagnostic systems.

“The biomechanical response of the cornea might lead to aberrations, such as spherical aberration, or create an unstable and unpredictable situation, such as when performing a topography-guided therapeutic treatment in an eye where residual stromal bed thickness may be less than 300 microns. However, at the present time, we cannot reliably model these factors and predict their impact on outcome,” Dr Mrochen said.

As a final point, Dr Mrochen reviewed the weaknesses in developing the laser algorithm and transferring the planned ablation profile to the cornea. “Achieving better outcomes with corneal laser surgery in the future will require the ability to model the ablation so that it is specific for an individual eye,” Dr Mrochen said.

contact

Michael Mrochen – michael.mrochen@irocscience.com

K3-7904 Henderson Degree Gauge K3-7905 Henderson Degree Gauge, with teeth

Mark the axis of astigmatism

Once the gauge is oriented, the surgeon simply aligns the marks of this instrument with the desired degree lines on the gauge. This produces two thin lines along the axis of astigmatism which can be used to correctly align the toric IOL. K3-7912 Henderson Toric IOL Marker

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contact

Update

Cataract & refractive

George Kymionis – kymionis@med.uoc.gr

TOPOGRAPHY-GUIDED ABLATION

Technique is suitable for many, but not all, cases of irregular astigmatism

by Roibeard O’hEineachain in Prague

T

opography-guided corneal ablation is proving to be a useful technique for an increasing number of cases of irregular astigmatism, but there remain cases that require different approaches, said George D Kymionis MD, PhD, University of Crete, Heraklion, Crete, Greece.

“Topography-guided ablation is a promising technique and it seems to have high efficacy predictability and safety in patients with irregular corneas, but it is not suitable for all cases,” he told the 16th ESCRS Winter Meeting.

Dr Kymionis noted that topographyguided ablation differs from the more typical refraction-guided ablations in that they take corneal irregularities into account with the aim of providing the cornea with a more optically ideal shape.

“With refractive surgery using refraction-guided ablation, if you have a case with 5 D of myopia, you put the data into the excimer laser and the excimer laser would correct 5 D of myopia. With topography-guided ablation it's not that simple. The topographer sends the topography data with all of the cornea's irregularities to the excimer laser and the excimer laser ablates the cornea according to all of these irregularities,” Dr Kymionis explained.

Typical irregular astigmatism candidates for topography-guided ablation include patients with eccentric ablation and small optical zones after refractive surgery, patients with irregular astigmatism after penetrating keratoplasty, trauma or keratitis, and patients with keratoconus, Dr Kymionis said.

In cases where the irregularity has resulted from previous LASIK, the usual technique is to re-lift the flap and perform a repeat procedure. In most other indications photorefractive keratectomy (PRK) with mitomycin-C is the procedure of choice, he added.

Case studies To illustrate the benefits that topography-guided ablations can achieve, Dr Kymionis described several cases where the approach had resulted in improved refraction and visual quality.

Courtey of George D Kymionis MD, PhD

14

“With refractive surgery using refraction-guided ablation, if you have a case with 5 D of myopia, you put the data into the excimer laser and the excimer laser would correct 5 D of myopia” George D Kymionis MD, PhD

For example, in one patient, previous refractive surgery had induced irregular astigmatism. A subsequent topographyguided ablation enlarged the cornea’s optical zone and thereby reduced all of the patient’s symptoms, including haloes and glare.

Another case Dr Kymionis described had bullous keratopathy following phacoemulsification. A Descemet’sstripping automated endothelial keratoplasty procedure restored the endothelium, but there remained some residual irregular astigmatism because of a burn at the incision site.

“The phaco-burn induced a significant corneal flattening at the area of the incision, which caused 3.8 D of irregular astigmatism.

Don’t miss Resident’s Diary, See page 42 EUROTIMES | Volume 17 | Issue 10

After we performed the topography-guided ablation there was half a dioptre of irregular astigmatism,” Dr Kymionis said (see figure).

Modified technique for PRK Dr Kymionis noted that topography-guided PRK in irregular corneas requires a modified technique for removing the epithelium and applying mitomycin C. He pointed out that in irregular corneas the epithelium acts as a masking agent with the result that epithelium thickness varies according to the amount of irregularity present. So, for example, in an eye with keratoconus the epithelium may be 50 microns thick over most of the cornea but only 30 microns over the apex of the cone.

“If you remove the epithelium with a mechanical brush or alcohol you cannot achieve good results. Therefore, my standard way to treat these patients is to remove the epithelium using PRK at 50 microns depth, with a seven millimetre optical zone,” he said.

Regarding the application of mitomycin-C, Dr Kymionis said that as most irregular corneas have undergone previous surgery, greater exposure to mitomycin-C may be necessary to exert adequate control over the healing process.

He therefore recommended applying the agent to the cornea for two minutes at the end of the procedure.

Combining with cross-linking

Until recently, the great majority of corneal surgeons have regarded keratoconus and post-LASIK ectasia as contraindications for topography-guided ablations. The view was that it was unwise to remove tissue from an already weakened and thinned cornea.

Therefore, implantation of intracorneal ring segments or deep anterior lamellar keratoplasty or penetrating keratoplasty were the preferred options in such cases, he said. However, the advent of corneal collagen cross-linking (CXL) has resulted in a new way of thinking of such cases, he noted.

“In these corneas we have two major problems. We have the irregular astigmatism that we can treat with topography-guided ablation and we have the problem of corneal instability that we can treat with CXL. If we combine both of them we can fix these corneas,” he said.

However, he cautioned that performing such ablations is inadvisable in keratoconic eyes with a preoperative thickness at the thinnest point of less than 450 microns.

Dr Kymionis noted that there remain some other types of irregular corneas that are also not amenable to topographyguided ablations. They include corneas less than 450 microns in thickness, for which intracorneal ring segments are a better option, and eyes with deep corneal scars which are best treated with deep anterior lamellar keratoplasty, he added.

contact

Ivan Ossma – ossma@mac.com

Update

Cataract & refractive

IOL COMPLICATIONS

Managing occasional postoperative refractive error, PCO, enhance results

by Howard Larkin in Chicago

W

ith 473 lenses implanted over nine years, Ivan Ossma MD, MPH reports excellent visual outcomes and low complication rates with the dual-optic Synchrony (AMO, Santa Ana, California, US) accommodating intraocular lens (IOL).

But careful management of residual myopia and YAG capsulotomies for the few who develop posterior capsular opacification (PCO) further improve outcomes, he told the ASCRS annual symposium.

While the dual-optic lens provides a functional range of vision with very low incidence of unwanted optical phenomenon and low PCO rates, patient expectations should be managed, Dr Ossma said.

Patients should be counselled that they may require a refractive enhancement for residual myopia and induced cylinder, may need spectacles for near vision, and may experience transient myopia after surgery.

The current Synchrony lens is a one-piece silicone design with a 5.5mm 32 D anterior optic connected by spring haptics to a 6.0mm negative posterior optic of various powers, producing net power ranging from 16.0 D to 28.0 D. The lens is implanted completely in the capsular bag and is designed to move with contraction of the ciliary muscles, theoretically producing 3.5 D accommodation with 1.5mm of anterior lens movement.

To avoid complications with the lens, the capsulorrhexis must be well-centred and 4.5mm in diameter, Dr Ossma said. For the lens to move, the edge of the anterior

lens must be covered by the remaining capsule. Also, the underside of the capsular bag should be polished to remove cells and minimise any fibrotic changes that would reduce the flexibility or clarity of the bag.

However, transient myopia in the early postoperative and occasional myopic surprises are seen, Dr Ossma said. In his most recent 151 patients, mean myopia at one week was -0.56 D with some close to -1.5 D. “Over the past nine years the lesson I have learned is that in the first six weeks post-op, expect -0.5 to -1.25 D myopia.”

For patients with more than -1.25 D at six weeks, Dr Ossma counsels them, and prescribes spectacles if necessary and reassesses at 12 weeks. If the patient is more than -0.75 D and unhappy, he offers a laser enhancement of myopia and any induced astigmatism targeting a spherical equivalent of -0.25 D. Patients undergoing laser enhancements achieve the same range of visual outcome as those who receive the lens only, he noted.

For those patients prescribed spectacles, he counsels wearing them for all activities to help the patient learn to accommodate in the first two months after surgery, rather than using myopia for close work. Over the first three months, the myopia tends to abate, ending up in Dr Ossma’s patients at about -0.3 to -0.4 D, he said.

In his last 151 patients, followed for four years, Dr Ossma found five required posterior YAG capsulotomies for PCO, a rate of 3.3 per cent. Mean time to YAG was 833 days +/- 186 days, ranging from 584 to 1023.

“This lens has the lowest PCO rate of any I have seen.”

Still, some surgeons are concerned that a YAG capsulotomy could interfere with the Synchrony lens’ movement in the eye. Dr Ossma’s experience suggests otherwise.

“We do a low energy, small diameter, continuous, rounded YAG,” Dr Ossma said. The procedure significantly improved best corrected distance visual acuity, from logMAR 0.12 to logMAR -0.04, or from about 20/25 to better than 20/20. At the latest visit, visual acuity at all ranges was not statistically different between the five eyes that underwent YAG and the 146 that did not, suggesting that the procedure does not adversely affect the functional outcome of the Synchrony lens.

Dr Ossma emphasised the need for low energy and a small posterior capsulotomy.

His usually run from 2.5mm to 3.5mm.

Improved design Dr Ossma also presented six-month outcomes data for the next-generation dual-optic lens, called the Synchrony Vu. It is designed to improve near vision by enhancing the depth of focus without compromising the monofocal optical quality of the lens.

The new lens’s front optic incorporates an aspheric central blended zone that mimics the increase in negative spherical aberration that comes with natural accommodation, Dr Ossma said. The design takes advantage of pupil constriction during near viewing to maximise near visual benefit, but maintain optical quality under mesopic conditions.

The lens was implanted in 87 eyes of 45 patients in two sites by three surgeons.

Mean age at the time of surgery was 62 +/- 8.62 years. At six months, monocular measurements were made including manifest refraction, intermediate (80cm) and near (40cm) visual acuity without and with distance refractive corrections, mesopic contrast sensitivity measurements without and with glare, and visual acuity were also measured binocularly.

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“

The next generation Synchrony IOL with enhanced optic shape offers very good visual outcomes without any compromise to retinal image quality Ivan Ossma MD, MPH

Out of 81 eyes available for analysis, 91.4 per cent were within 1.0 D of spherical refraction and 88.9 per cent were within 1.0 D of astigmatism. Intermediate visual acuity of 20/25 or better was achieved by 95.3 per cent of eyes uncorrected and 93.8 per cent with distance correction. Near visual acuity of 20/40 or better was achieved by 97.4 per cent eyes uncorrected and 92.1 per cent with distance correction. Binocularly, 90 per cent or more subjects achieved 20/25 intermediate and 20/40 near visual acuity. This represents an improvement of about 15 per cent for near vision over the previous Synchrony design. Mesopic contrast sensitivity with or without glare was not statistically different from patients implanted with the parent Synchrony lens.

As for spectacle use, about 12 per cent reported using them at least occasionally for near vision, with three per cent always using them for near, while just three per cent reported using spectacles occasionally for distance, with none using them always or most of the time for distance.

“The next generation Synchrony IOL with enhanced optic shape offers very good visual outcomes without any compromise to retinal image quality,” Dr Ossma said.

However, he still emphasised the need to appropriately manage patient expectations, particularly with regard to transient myopia and the possibility of need for a refractive enhancement.

15

Update

Cataract & refractive

Accommodation without haptics

New capsule-filling IOL provides accommodative effect and long-term refractive stability

T

he WIOL-CF, a new accommodating IOL designed to mimic the geometry and plasticity of the crystalline lens, can provide stable refraction and some measure of accommodation, reports Ioannis Pallikaris MD, Institute of Vision and Optics, University of Crete School of Medicine, Heraklion, Crete, Greece.

“The WIOL-CF appears to be a very promising alternative solution for patients that lead an active life and require good vision for near, intermediate and far. In our patient series all patients obtain some level of accommodation which remained stable throughout the follow-up,” he told the 16th ESCRS Winter Meeting.

Dr Pallikaris presented the results of a study involving 50 eyes of 25 patients who underwent routine cataract surgery and implantation of WIOL-CF accommodative intraocular lens. He noted that at a mean

“

The only thing is that you really have to be careful while putting the lens inside the cartridge to make sure that you don’t insert the lens upside down Ioannis Pallikaris

follow-up of two years the mean logMAR uncorrected distance visual acuity improved from 0.34 preoperatively to 0.16.

In addition, corrected distance visual acuity improved from 0.25 to 0.08, 71 per cent of eyes gained lines of corrected distance visual acuity, and no eyes lost any lines.

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Furthermore, the uncorrected near visual acuity – as tested with Birkhauser reading charts at a distance of 33.0cm under photopic conditions – was J3 or better in all eyes, J2 or better in 72 per cent of eyes, and J1 or better in 40 per cent of eyes, Dr Pallikaris said.

He noted that the IOL has no haptics and a diameter ranging from 8.6mm to 9.0mm. The lens has a meniscoid anterior surface and a hyperbolic posterior surface.

Its optical design is intended to provide up to 2.5 D of accommodation. The IOL is implantable through a 2.8mm incision in its dehydrated state using a cartridge, and expands to its fully rehydrated state within the first 48 postoperative hours.

“The only thing is that you really have to be careful while putting the lens inside the cartridge to make sure that you don't insert the lens upside down, although this is easy enough to do this given the shape difference between the front and back,” Dr Pallikaris said.

He noted that the IOL’s hydrogel material has a high water content to provide high biocompatibility and permeability. Moreover, the lens has a negatively charged surface that helps prevent protein deposits, cell attachment and opacification of the posterior capsule.

Moreover, the posterior surface of the lens comes into contact with posterior capsule in much the same manner as does the natural crystalline lens, which, together with its sharp-edged continuous rim, provides further protection against PCO.

Courtesy of Ioannis Pallikaris MD

by Roibeard O’hEineachain in Prague

ESCRS

16

WIOL-CF

WIOL-CF posterior side identified

“No complications occurred during surgery or afterwards. A larger series of patients with longer follow-up will be necessary in order to confirm the study’s encouraging results,” Dr Pallikaris concluded.

Visit: www.eurotimesturkey.org WIOL-CF dimensions

EUROTIMES | Volume 17 | Issue 10

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contact

Update

Cornea

Günther Grabner – g.grabner@salk.at

SURFACE REPAIRS

Expanding range of options is making ocular surface disease more treatable

by Roibeard O’hEineachain in Prague

A

clear treatment protocol is emerging for treating severe ocular surface disease, with therapies ranging from amniotic membrane transplantation to the implantation of keratoprostheses, said Günther Grabner MD in a keynote lecture in a Cornea Day session at the 16th ESCRS Winter Congress.

“In most cases you can do autologous stem cell transplantation plus amniotic membrane plus, if required, penetrating keratoplasty. When there is a bilateral loss of stem cells but a wet surface, a Boston keratoprosthesis is the treatment of choice, but if the eye is dry I think nothing beats the modified osteo-odonto keratoprosthesis,” said Dr Grabner, Paracelsus Medical University, Salzburg, Austria.

Dr Grabner noted that amniotic membrane has a wide variety of uses in ocular surface reconstruction. It can be used as an “inlay”, as a sort of replacement basement membrane, as an “onlay” where it can serve as a bandage contact lens, and it can be placed in multiple layers as an alternative to superficial lamellar keratoplasty. There have also been reports of its use in the treatment of bullous keratopathy and neurotrophic ulcers as well as in pterygium surgery and revision of filtering blebs.

Nowadays it is also widely used as a substrate for cultured limbal cells for use in limbal autograft procedures. The usual indications for such techniques are limbal stem cell deficiency resulting from burns, chemical injury, trauma or disease. The loss of limbal stem cells leads to permanent epithelial defects stromal scarring and symblepharon, Dr Grabner noted.

“In cases with unilateral complete stem cell loss, amniotic transplantation is not sufficient because it will not replace the stem cells. What we need to do is in autologous limbal stem cell transplantation plus/minus penetrating keratoplasty,” he added.

The most frequently performed limbal stem cell transplant procedure is a conjunctival limbal autograft from the fellow eye. The advantage of autografts is that they entail no risk of immune rejection and, unlike limbal allografts, do not require the use of intensive long-lasting systemic immunosuppression. The main, however minimal, disadvantage is that they require surgery on the normal eye.

“

In cases with unilateral complete stem cell loss, amniotic transplantation is not sufficient because it will not replace the stem cells. What we need to do is in autologous limbal stem cell transplantation plus/minus penetrating keratoplasty Günther Grabner MD

EUROTIMES | Volume 17 | Issue 10

Ex-vivo expansion of limbal stem cells on an amniotic membrane substrate can maximise the amount of limbal stem cells available for transplantation, he noted. He and his associates have initiated a study that will examine the feasibility of using buccal stem cells as an alternative in such cases.

Role of keratoprostheses In patients with bilateral limbal stem cell insufficiency, limbal allografts from a family member or a cadaver eye are one alternative. However, such transplants again involve intensive immunosuppression and have a fairly low rate of success. As a result, corneal surgeons are increasingly turning to the use of keratoprostheses in such cases, he said.

There are several designs of keratoprosthesis available but there are only two that are widely used today. They are the Boston KPro type 1, developed at the Massachusetts Eye and Ear Hospital developed by Claes Dohlman, and the osteo-odonto-keratoprosthesis (OOKP) first developed

by Strampelli in the 1960s and later improved upon by Falcinelli.

The decision of which type of keratoprostheses to use depends on the condition of the eye and the condition of the patient, Dr Grabner said. The standard Boston KPro has a nut and bolt design and consists of two 0.9mm-thick PMMA plates clamped onto a donor button of corneal tissue which is sutured into the recipient's eye, he said. Its indications can include eyes with limbal stem cell insufficiency, but its use requires a wet eye with good blinking function.

The OOKP uses an osteodental lamina overlaid with buccal mucous membrane as a skirt for its PMMA optic. It can also be used in eyes with limbal stem cell insufficiency and severe keratoconjunctivitis sicca, Dr Grabner said.

However, owing to the difficult and time-consuming nature of its implantation, the OOKP is usually reserved for patients with bilateral corneal blindness resulting from severe end stage corneal disease, for eyes injured by chemicals or burns, and for severely dry eyes.

Implantation of the Boston K-Pro type 1 is only slightly different from a standard penetrating keratoplasty, he noted. As a result, it has become the most widely used keratoprosthesis in the world, with around 1,000 implanted every year and close to 100 surgeons implanting them. One drawback with the Boston K-Pro type 1 is that it requires the patient to commit to lifelong use of topical antibiotics and bandage contact lenses, he said.

Most other types of keratoprostheses have fallen into disuse, Dr Grabner noted. For example, the AlphaCor keratoprosthesis, which has indications similar to those of the Boston K-Pro is no longer promoted by its manufacturer, possibly because of the poor retention rate some authors have reported with the implant. However, the Temprano keratoprosthesis – which uses a piece of autologous tibia bone as a skirt – remains a useful option in patients with dry eyes who have no teeth that could be used for an OOKP.

Courtesy of Günther Grabner MD

18

Case 1, lye burn, 2 failed PKP, VA hand motion

Case 1, 18 months’ post-op, VA 0.8

Patient with OOKP after healing

Dr Grabner cautioned that implants like the OOKP put the patient at an additional risk for glaucoma. However, the risk of onset or progression of glaucoma induced in this way will be much lower when IOP is controlled from early on with a glaucoma drainage implant, he noted.

“If you have a bilateral dry eye case I think nothing beats the OOKP and this is what you should advise your patient to have. You certainly need specialised centres and if you put a cosmetic shield on top of it, it is very difficult to tell which one of the eyes is the one with the keratoprosthesis,” he added.

19

Update

cornea

CONFOCAL MICROSCOPY

Confocal microscopy may help in tracking degenerative nerve disease

by Dermot McGrath in Abu Dhabi

C

“Several papers have shown that there is a reduction in nerve fibre pattern in the subepithelial plexus in diabetic patients” Rudolf F Guthoff MD

EUROTIMES | Volume 17 | Issue 10

4TH EUCORNEA CONGRESS 4-5 OCTOBER 2013

www.eucornea.org Courtesy of Rudolf F Guthoff MD

onfocal high-resolution biomicroscopy is finding growing utility as a clinical tool for in vivo description and quantification of corneal nerves implicated in degenerative nerve diseases such as diabetic neuropathy, according to Rudolf F Guthoff MD. “In degenerative nerve disease, the subepithelial nerve plexus can be evaluated and hopefully quantified much better than before thanks to the latest advances in confocal microscopy. By using 3-D mapping and reconstruction in diabetic neuropathy, alterations can be noticed earlier by in vivo confocal microscopy than by measurements of corneal sensitivity, peripheral nerve dysfunction and skin biopsies,” he said.

Prof Guthoff, professor of ophthalmology at Rostock University Eye Department, Rostock, Germany, told delegates attending the World Ophthalmology Congress that high-resolution biomicroscopy (Heidelberg Retinal Tomograph II in conjunction with the Rostock Cornea Module) will enable degeneration and repair mechanisms under various conditions to be examined so that the findings can be correlated with those from conventional slit-lamp biomicroscopy.

“In vivo confocal microscopy is still quite a challenge for us. It was developed 50 years ago but it is still not an instrument in everyday clinical use. However, we believe that looking at nerves and trying to quantify them in the cornea might be something that we can all benefit from in our daily practices,” he said.

Prof Guthoff noted that the cornea is innervated primarily by sensory fibres arising from the ophthalmic nerve, a terminal division of the trigeminal nerve. Human corneal nerves are non-myelinated and vary in thickness between 0.2mm and 10mm.

The nerve fibre bundles, which enter the anterior and central stroma in the corneal periphery, run parallel to the corneal surface in a radial pattern before making an abrupt 90-degree turn in the direction of Bowman’s membrane.

The laser scanning confocal microscope uses a 670 nm red wavelength diode laser and offers up to 400 times magnification with an axial resolution of approximately one micrometre. To create an image, a beam of light scans the cornea, creating a 384 x 384 point image in a 400 micron square at a magnification of 63X. Most anatomical layers and cell types may be viewed easily including superficial, intermediate and basal epithelial cells, nerve plexi, stromal

AMSTERDAM 2013

Reconstruction of the sub-basal nerve plexus using volume data sets of CLSM images [source: Institute for Applied Computer Science and Automation (Karlsruhe Institute of Technology) and Department of Ophthalmology (Universität Rostock), Germany]

layers with keratocytes, Descemet’s membrane, endothelial cells and immune response cells. Cross-sectional views may also be seen in oblique scans.

Initial research efforts have been directed at monitoring and quantifying nerve fibres in diabetic neuropathy, explained Prof Guthoff.

“Several papers have shown that there is a reduction in nerve fibre pattern in the subepithelial plexus in diabetic patients. As a model for degenerative changes, diabetic neuropathy is clinically manifest subclinical disease of the peripheral nerve that can affect both the somatic and the autonomic nerve system. The signs are varied, but it is very difficult to quantify them,” he said.

Focusing on the subepithelial nerve plexus, the goal has been to use the Heidelberg Retinal Tomograph II in conjunction with the Rostock Cornea Module to try to quantify subepithelial nerve fibres using clinically relevant parameters such as length, density and tortuosity, said Prof Guthoff.

“We do have numerical elements to describe nerve fibre patterns. Neuropathic components in ocular surface disease can be identified by pattern analysis of the subepithelial nerve plexus. We have shown that it works nicely in the lab in a small series of patients. There is also evidence from animal experiments that confocal in vivo microscopy can quantify the effect of neurotrophic growth factors for nerve fibre degeneration in vivo,” he concluded.

contact Rudolf F Guthoff – rudolf.guthoff@med.uni-rostock.de

20

Update

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EUROTIMES | Volume 17 | Issue 10

glaucoma

MAGNESIUM THERAPY

Strong theoretical basis for role of magnesium deficiency in glaucomatous disease

by Roibeard O’hEineachain in Copenhagen

E

yes with primary open-angle glaucoma (POAG) have lower levels of magnesium than do eyes without the condition. Moreover, their condition appears to respond well to treatment with a medication containing magnesium, said Lusine Arutyunyan MD, Helmholtz Research Institute of Eye Diseases, Moscow, Russia, delivering a paper that reported a study initiated by Prof Elena Iomdina of same institute.

“Trace element analysis revealed a deficiency of magnesium in all the media and tissues of glaucomatous eyes we looked at. In addition, our first results with magnesiumbased treatment showed a positive effect on IOP and the biomechanical properties of corneal scleral capsule and on the structural and functional conditions of eyes with primary open angle glaucoma,” Dr Arutyunyan told the 10th European Glaucoma Society Congress in Copenhagen.

In one study, the Moscow Helmholtz Institute researchers obtained 0.1ml to 0.2ml samples of aqueous humour as well as scleral tissue samples from 18 POAG patients aged 49 to 86 who were undergoing sinus trabeculectomy with preventive posterior scleral trepanation. They also obtained aqueous samples from 16 cataract patients without glaucoma. They then performed trace element analysis of the fluids and tissue using a mass spectrometer with ionisation in inductively coupled plasma (ELAN DRC II, Perkin Elmer, USA).

They found that the mean magnesium concentration in scleral samples of eyes with initial/moderate POAG was 19.3 mg/l, and in eyes in the advanced stages of the disease it was 17.5 mg/l, she noted. That compares to a mean magnesium concentration of 177 mg/l in normal anterior sclera (p < 0.001), she said.

Magnesium levels were also lower in aqueous samples from eyes with glaucoma, where the mean concentration was 5.9 mg/l in initial to moderate POAG and as low as 3.0 mg/l in eyes with advanced disease. That compared to a mean magnesium concentration of 6.7 mg/l in eyes without glaucoma.

Magnesium therapy To assess the potential of magnesium therapy in the treatment of glaucoma, Dr Arutyunyan and her associates conducted a trial in which 28 POAG patients ranging in age from 42 to 72 years received Magnerot (Wörwag Pharma), a magnesiumcontaining drug, at a dosage of two tablespoons, amounting to one gram of magnesium, three times a day during the first week, then one to two tablespoons two to three times a day. A further 16 POAG patients did not receive magnesium therapy. All received standard IOPlowering medication.

Dr Arutyunyan noted that at final follow-up, the tear film concentration of magnesium in the eyes of magnesiumtreated patients had increased from a baseline value of 0.0034 mg/l to 0.28 mg/l, approaching the normal value of 0.66 mg/l. In addition, computer perimetry showed that there was a significant increase of the mean total visual field, from 426.5 degrees to 452.5 degrees among magnesium-

treated patients (p < 0.05). The improvements in visual field occurred mainly in patients with moderate glaucoma.

Overall, among patients receiving magnesium therapy the visual fields improved in 71.9 per cent, remained unchanged in 20.8 per cent, and got worse in 7.3 per cent.

By comparison, among patients in the control group, visual fields improved in 33 per cent of patients, remained unchanged in 25 per cent, and got worse in 42 per cent.

The magnesium-treated patients also had a significant reduction in mean IOP from initial values and a significantly lower mean IOP than the control group by the end of the trial (p < 0.05). That is, in the magnesium treatment group IOP measured with the ORA (Reichert) and calculated according to Goldmann tonometry was 18.6 mmHg before treatment and 15.3 mmHg after treatment. By comparison, the mean IOP in the control group was 16.7 mmHg at baseline and 18.5 mmHg at the end of the trial.

Trace elements imbalance Dr Arutyunyan noted that there are several ways in which a magnesium deficiency might bring about glaucomatous changes in the eye.

Magnesium deficiency can cause impairment of the neural, circulatory and connective tissues throughout the body and including the eye, she noted. “We know that magnesium is needed to protect neuron elements of the retina and the optic nerve against neurodegeneration and to regulate the metabolism of pathologically changed connective tissue structure of glaucomatous eyes,” she said.

She noted that magnesium deficiency can lead to trace element imbalance which in turn impairs the enzyme system of neural mitochondria, provoking caspase activation, leading ultimately to apoptosis. In addition, magnesium deficiency excites the glutamate and NMDA receptors that contribute to apoptosis.

Moreover, research has shown that magnesium deficiency can increase the viscosity of blood to the point that it decreases the blood supply to the glaucomatous eye.

Furthermore, magnesium deficiency activates the cross-linking of collagen and elastin which, combined with the impairment of matrix metalloproteinase activity, brings about a granularisation of the connective tissue, increasing scleral rigidity in glaucoma as a consequence, she pointed out.

Commenting on the study, Keith Martin PhD, Cambridge University Centre for Brain Repair, Cambridge, UK, said that there is a strong theoretical basis for a role of magnesium deficiency in glaucomatous disease. However, he pointed out that the positive effect of magnesium therapy on visual fields seen in this pilot study will require confirmation by a placebo-controlled trial. He cautioned that the dosages used in the trial might be toxic to some patients, particularly those with renal complaints.

contacts Lusine Arutyunyan – luslev@yandex.ru Elena Iomdina – iomdina@mail.ru Keith Martin – krgm2@cam.ac.uk

contact

Marco Nardi – marco.nardi@med.unipi.it

21

Update

glaucoma

CyPass device

CyPass offers a clear advance on an ab externo approach using gold shunt devices

by Dermot McGrath in Abu Dhabi

Figure 2 – The CyPass is inserted in the proper position (left); after retracting the inserter aqueous humour is allowed to reach freely the suprachoroideal space (right)

“

It is minimally invasive, atraumatic surgery and it usually leaves us with all future surgical options still open Marco Nardi MD

for less experienced glaucoma surgeons. The device is implanted ab interno in a minimally invasive way into the supraciliary and suprachoroidal space to increase uveoscleral outflow. Using the special delivery system, the surgeon inserts the implant below the scleral spur at the iris root, through a clear corneal incision or through the primary phacoemulsification incision in combined cataract procedures (Figure 2). The distal end of the device penetrates into the suprachoroidal space, while the proximal collar remains in the anterior chamber (Figure 3), said Dr Nardi.

There are also many advantages associated with gonioscopic surgery compared to other approaches, added Dr Nardi.

“It is minimally invasive, atraumatic surgery and it usually leaves us with all future surgical options still open. The fact that it leaves an intact superior conjunctiva means that filtering procedures can still be performed at a later stage in case of failure.

It also offers faster recovery and healing and less complications than other ab externo procedures. Another advantage is that it is very straightforward to use with no steep learning curve, and it works very well in

Figure 1: left – Fibrosis and failure of a gold shunt (hystological aspect); right – bending and exposure of a gold shunt

EUROTIMES | Volume 17 | Issue 10

Courtesy of Marco Nardi MD

A

novel glaucoma drainage device that utilises an ab interno approach is delivering promising early results in terms of increasing outflow and decreasing IOP, according to a study presented at the World Ophthalmology Congress.

“Although we do need further studies with longer follow-up, my first impression of the CyPass device (Transcend Medical) is that it works very well at enhancing the aqueous outflow through the supraciliary space and avoids many of the complications associated with an ab externo approach,” said Marco Nardi MD. Dr Nardi described the CyPass as a micro-implantable device about 6.5mm in length with a small lumen of 300 microns that is designed to improve uveoscleral outflow by providing access and drainage of the aqueous from the anterior chamber to the suprachoroidal space. The implant is inserted with a special inserter that enables it to be easily placed into the suprachoroidal space, he said.

Dr Nardi added that in his clinical experience the CyPass offers a clear advance on an ab externo approach using gold shunt devices.

“The gold shunt has taught us a lot about the suprachoroidal space. When the gold shunt works properly, it really does function well. In our experience, however, we have had a lot of failures and complications of the gold shunts (Figure 1) that seem to increase over time. So when we had the possibility of using an ab interno approach we were happy to give it a try,” he said.

Implanting the device is very straightforward and entails no learning curve

Figure 3 – Postoperative appearance of the CyPass at the slit lamp one day after surgery (left); the same patient: CyPass in the angle, gonioscopic view (right)

combined procedures as well,” he said.

Looking to the future, Dr Nardi said that surgeons now have some exciting options to try to help their glaucoma patients.

“First I think it is wise to try a gonioscopic procedure (reopening the Schlemm channel or diverting aqueous in the suprachoroideal space); this is because gonioscopic procedures are really atraumatic, practically free of complications, do not

need postoperative manoeuvres, making the follow-up of these patients very easy.

Moreover, if these devices do not function as expected, superior conjunctiva is untouched (if not better than before because of the withdrawal of anti-glaucoma drops and the use of topical steroids after surgery) so it is easy to proceed to a filtering procedure, eventually followed by a drainage device if necessary,” he concluded.

contact

Update

glaucoma

Clive Peckar – clivepeckar@premiereyeclinic.co.uk

canaloplasty

Cataract patients with glaucoma may benefit from physiological drainage rehabilitation approach

Courtesy of Clive Peckar MSc, FRCS, FRCSEd, FRCOphth

22

by Roibeard O’hEineachain in Prague

P

rocedures designed to maintain the patency of Schlemm’s canal may be safer than fistularising procedures like trabeculectomy in the treatment of patients with glaucoma and cataract, said Clive Peckar MSc, FRCS, FRCSEd, FRCOphth, Spire Cheshire Hospital, UK. “I am confident after 15 years of experience of Schlemm’s canal surgery that canaloplasty has real benefits, with low rates of complications, and you should consider adding it to your armamentarium for the management of patients with both cataract and glaucoma,” he told the 16th ESCRS Winter Meeting, during a symposium in Prague.

Dr Peckar said that he generally performs phacocanalostomy in patients with cataract and open-angle glaucoma. In exceptional cases with marked cataract and minimal open angle glaucoma, as well as in patients with narrow inlet angles, he generally performs phacoemulsification alone initially to see if that will produce an adequate reduction in IOP, he said.

However, he advised strongly against performing a canaloplasty in eyes where a cataract procedure was likely to be necessary within the following six months, because of the high hydrostatic pressure that occurs during the phacoemulsification.

Figure 1: Trans-ostial canalicular polyamide stents, implanted 1999: (10 years’ postop) IOP reduced from 40 to 15 mmHg

Figure 2: Phaco-Viscocanalostomy versus Phaco-Canaloplasty: IOPs

An evolving technique Dr Peckar noted that, unlike techniques such as trabeculectomy and drainage implant procedures, Schlemm’s canal surgery does not depend on a fistularising bleb to reduce IOP. Instead it re-establishes aqueous drainage by maintaining the integrity of Schlemm’s canal and opening its collector channels, he said.

Schlemm’s canal surgery has undergone a continual evolution since Robert Stegmann MD first introduced viscocanalostomy back in 1996. That procedure involves baring a portion of Descemet’s membrane, creating an intra-scleral reservoir (or “lake”), and injecting viscoelastic material into the adjacent openings (“ostia”) created in Schlemm’s canal.

The problem with viscocanalostomies was that they tended to fail over the long term in about three to five per cent of Caucasian patients and in 15 per cent of patients of African descent due to ostia or lake closure, Dr Peckar said. That led to the next innovation, which was the use of intra-ostial polyamide stents in 1999. Gonioscopic imaging of some of the first stents implanted shows that they have maintained the patency of Schlemm’s Canal at 10 year’s follow-up, Dr Peckar noted (Figure 1). The stents were followed by the introduction of canaloplasty with a tension suture in 2005 and by intracanalicular stenting in 2010.

The canaloplasty with tension suture technique involves the passage of a catheter, 200 µm in diameter with 250 µm at its tip, through the entire circumference of Schlemm’s canal.

The catheter injects two microlitres of high viscosity sodium hyaluronate (Healon GV) every two clock hours. A helium neon laser illuminates the catheter’s tip so that the surgeon may observe its progress during the procedure.

When the leading tip of the catheter emerges, the surgeon ties a suture to the tail end of the catheter and draws it through Schlemm’s canal and then ties and tightens a knot in the suture's two ends. The flap is then closed and sutured watertight so that no bleb will form, he noted.

“The advantage of this particular procedure is that, not only does it give you access to the whole canal, but it also allows you to dilate and stretch the canal and open up the collector channels, to aid physiological outflow. Once you have tied the sutures, under tension, you can see the aqueous permeating through the Descemet’s window, and when you carry out micro-angiography (also known as channelography) you can see the dyed aqueous going through the collector channels while leaving the ciliary veins untouched,” Dr Peckar said.

Phaco-canaloplasty safe and effective Dr Peckar noted that in his hands phaco-canaloplasty and phaco-viscocanalostomy are both effective in terms of IOP reduction. In a series of 108 patients who underwent phacoviscocanalostomy, mean IOP with maximal medication fell from a preoperative value of 22.0 mmHg preoperatively, to 16.0 mmHg postoperatively. Similarly in a series of 51

Don’t miss Ophthalmologica Highlights, See page 35 EUROTIMES | Volume 17 | Issue 10

Figure 3: Stegmann Canal Expander™, on 6/0 blue carrier, being inserted into nasal ostium (blood can be seen exiting temporal ostium)

“

I am confident after 15 years of experience of Schlemm’s canal surgery that canaloplasty has real benefits, with low rates of complications...

Clive Peckar MSc, FRCS, FRCSEd, FRCOphth eyes that underwent phaco-canaloplasty, mean IOP with maximal medication fell from 24 mmHg preoperatively to 14 mmHg postoperatively (Figure 2).

The complication rates with both viscocanalostomy and canaloplasty procedures tend to be fairly low, he said. In a joint paper by Dr Peckar and Norbert Körber MD in Cologne, there were no instances of choroidal detachment or flat anterior chamber (Peckar C. O. and Körber N., Spektrum der Augenheilkunde (Sept 2008) ; 22/4: 240-246).

A transient hyphaema occurred in two per cent of 121 eyes that underwent viscocanalostomy and in 10 per cent of eyes undergoing canaloplasty. The biggest problem in the combined series was that in nine per cent of eyes undergoing canaloplasty it was not possible to pass a suture 360° because of an irregularly shaped Schlemm’s canal, he said.

“We sometimes think of Schlemm’s canal as a big circle around the eye but it can be quite irregular and at any point in the circumference you could come up with an angle that is difficult to overcome.”

The recent introduction of intracanalicular stents overcomes that difficulty. The new stents are 9.0mm long, are completely flexible and have a shape similar to the spine of a miniature snake (Stegmann Canal Expander™). Each is designed to occupy a quarter of Schlemm’s circumference maintaining dilatation and allowing access to the collector channels. They are placed following dilatation with the same type of microcatheter as is used in the tension suture technique (iTrack™) using a 6/0 carrier to position the Expander (Figure 3).

“The advantage of the intra-canalicular stents is that although we may be unable in some cases to use a tension suture, it will still usually be possible to thread a Canal Expander into each side,” Dr Peckar added.

Update

i

BIOMECHANICS

Both the scleral and optic nerve head connective tissues may play key role in glaucoma

by Roibeard O’hEineachain in Copenhagen

T

he biomechanical risk factors for glaucoma may play a central role in the pathophysiology of the disease and modifying some of those risk factors may prevent the disease’s onset and progression, according to research presented at the 10th European Glaucoma Society Congress.

“Some risk factors for human glaucoma that we already know about are longer axial length, larger diameter of the optic nerve head, thinner central corneal thickness and lower corneal hysteresis. These are biomechanical features of the eye,” said Harry Quigley MD, Wilmer Eye Institute, Johns Hopkins Medical School, Baltimore, Maryland, US. The underlying cause of the innate differences in the structure of eyes more prone to glaucoma may also underlie glaucoma’s characteristic pattern of damage to the optic nerve head. Differences in the sclera, in particular, may play a central role, Dr Quigley added.

“Many glaucoma patients have normal eye pressure. One reason for that may be that their sclera transmits abnormal force to the optic nerve at normal eye pressure,” he added.

He noted that the difference between glaucoma and other optic neuropathies, such as ischemic optic neuropathy, is that although there is axonal loss in both conditions, only in glaucoma is there a connective tissue-mediated backward and outward movement of the lamina cribrosa. The result is the much larger cup/disc ratio in glaucomatous eyes than is the case with ischemic optic neuropathy of similar severity, Dr Quigley said.

Research supports the theory that the initial glaucomatous damage sets in motion a chain of events, starting with the injury of axons and a consequent blocking of axonal transport, which in turn blocks trophic factors from reaching the axons, which in its turn initiates the apoptosis of retinal ganglion cells, he added.

Of mice and men Dr Quigley noted that animal studies with the mouse model of glaucoma that he and his associates have conducted have shown that the standard pigmented B6 variety of mouse had 50 per cent less axonal loss than did the CD1 breed of mouse, which has a longer axial length. The experiments involved artificially inducing ocular hypertensive conditions in the animals, he said.

In addition to having longer eyes, the CD1 mice also had thinner scleras, both near the limbus and in the peripapillary area, Dr Quigley noted. The mice that were less susceptible actually thickened their sclera in five out of the six zones, he said.

Further research, comparing the CD1 mouse and a mutant myopic strain, with a variant gene for the collagen 8 molecule, showed that the mutant strain had practically no axonal loss at all when challenged with artificially induced ocular hypertension. He noted that collagen 8 is an important component of many ocular structures, including the cornea. This may help explain why thin corneas are a risk factor for glaucoma, he added.

“It’s not so much that the cornea is thin and the lamina EUROTIMES | Volume 17 | Issue 10

cribrosa is thin, but it is that eyes that have a thin central cornea may have developed that way because of differences, polymorphisms in their collagen 8 genes, that also affect the sclera and how the sclera responds to ocular pressure,” Dr Quigley added.

If similar variations in human collagen 8 are found in human glaucoma patients it may open the way to new treatment strategies for the disease, possibly based on a principle similar to that of collagen cross-linking in the corneas of eyes with keratoconus.

“One treatment to the sclera could alter the sclera for a considerable period of time, potentially even permanently altering how the sclera responds to the intraocular pressure,” Dr Quigley said.

Research done in a monkey model of glaucoma supports the importance of connective tissue remodeling with the sclera and lamina cribrosa as important in the disease, said Claude Burgoyne MD. He added that viewing glaucomatous damage from an engineering perspective can offer a fresh perspective on the disease.

“The dynamic interplay between intraocular pressure and cerebro-spinal fluid pressure creates engineering stresses and strains within the tissues which also influences the flow of blood through the sclera and the lamina on its way to the optic nerve head,” Dr Burgoyne said.

The pathophysiology of glaucoma has a connective tissue component and axonal or neural tissue component, which are intricately linked by the behaviour of astrocytes and glial cells. The risk factors that influence how connective tissues are damaged include ischemia, physical compression from engineering stresses and strains as well as expansion, all which are likely to be mediated by or contributed to by the astrocytes and glia.

He noted that in experiments involving a monkey model of glaucoma, artificially induced ocular hypertension not only induced a bowing of the sclera and lamina, it also resulted in a thickening of the sclera. In later stages of the disease the sclera became thinner.

“Our working hypothesis is that connective tissue remodelling is a core component of both the physiology and pathophysiology of ageing and the pathophysiology of glaucomatous damage to the optic nerve head tissues,” he added.

He added that their research has also shown that, as glaucoma progresses, the insertion point of the lamina cribrosa migrated back to the eye’s pia and becomes detached from the sclera. Should these changes also occur in humans with glaucoma, detection of the changes with enhanced OCT imaging could enable earlier and more definitive diagnosis of the disease, he said.

contacts

Harry A Quigley – hquigley@jhmi.edu Claude F Burgoyne – cfburgoyne@deverseye.org

TELL ME AND I’LL FORGET;

SHOW ME AND I MAY REMEMBER; INVOLVE ME AND I’LL

UNDER

STAND - Old Chinese Proverb

i

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23

contact

Update

RETINA

Rudy Nuijts â&#x20AC;&#x201C; rudy.nuijts@mumc.nl

CME PREVENTION

Details of ESCRS study testing steroids, NSAIDs and anti-VEGF for preventing CME

by Howard Larkin in Chicago

A

three-year ESCRS-funded multicentre trial now getting under way could help prevent cystoid macular oedema (CME) after cataract surgery, a costly complication that is becoming more common as the incidence of diabetes rises, Rudy M Nuijts MD, PhD, told the ASCRS annual symposium.

The goal of the Preventing Macular Edema Post Cataract Surgery (PREMED) study is to provide evidence-based clinical guidelines for preventing CME after cataract surgery in patients with and without diabetes, said Dr Nuijts, who will direct the study with colleagues at the University Eye Clinic Maastricht, The Netherlands. The hope is to come up with CME prophylaxis and treatments that are more effective and easier to administer.

Prophylaxis especially could help ameliorate a projected spike in pseudophakic CME secondary to rising rates of diabetes resulting from ageing and overweight, Dr Nuijts said. For example, in The Netherlands, the number of people with diabetes is expected to more than double by 2025 from the current one million, or about seven per cent of the population.

Though diabetics currently make up only about 16 per cent of cataract patients, they are estimated to make up about half

EUROTIMES | Volume 17 | Issue 10

of postoperative CME cases. In published studies, post-cataract surgery CME rates as determined by OCT imaging range from four per cent to 20 per cent among healthy people, Dr Nuijts said. By contrast, pseudophakic CME rates run up to 31 per cent of diabetic patients with nonproliferative diabetic retinopathy without CME at baseline. Reported rates of clinically significant CME, defined as best corrected visual acuity worse than 20/40, range from zero to 5.8 per cent.

Beyond the risk of poor visual outcomes, CME increases costs by 41 per cent over uncomplicated cases, according to one study, Dr Nuijts noted. With cataract surgery rates already running from 200 to 1,600 per 100,000 annually in European countries and expected to increase, prevention is both clinically and economically desirable.

Improving on eye drops Currently, topical NSAIDs are the treatment of choice for cataract surgery-related CME. Several large randomised controlled trials and meta-analyses have found topical NSAIDs effective in both preventing and treating pseudophakic CME. But as a drug delivery modality, eye drops suffer from inherent drawbacks, Dr Nuijts noted. These include possible fluctuations in intraocular

Courtesy of Rudy M Nuijts MD, PhD

24

medication concentrations, patient nonadherence rates approaching 50 per cent, and the resulting need for nurses to assist in administering drops.

Several other compounds and delivery modalities for treating CME show promise for enhancing NSAID effectiveness or provide equally effective but easierto-administer alternatives. Case series have shown topical corticosteroids may potentiate the therapeutic effects of topical NSAIDs and that periocular injections of corticosteroids may be effective for treating CME refractory to topical treatment. One small randomised study has shown intravitreal corticosteroid injections improve anatomical, but not visual, outcomes in diabetic patients. Also, investigational studies suggest that antiVEGF compounds may be effective in eyes that have failed other treatments. However, none of these has been extensively studied for CME prophylaxis, Dr Nuijts said.

PREMED will be the first rigorous test of a variety of approaches tailored to patients with and without diabetes. Injections will be examined in both groups in part because they have the potential for eliminating the problems of eye drops.

The non-diabetes arm, consisting of 2,400 patients, will compare a control group receiving both topical corticosteroids and NSAIDs with a group receiving topical corticosteroids only, and a group receiving subconjunctival injections of corticosteroids.

The study is designed to address the questions of what value may be added by combining NSAIDs with corticosteroids, and whether a single peri-operative subconjunctival injection is non-inferior to eye drops.

The diabetes arm, involving 520 patients, will compare the control topical

corticosteroid and NSAID therapy with a group receiving subconjunctival corticosteroids, a group receiving intravitreal bevacizumab, and a group receiving both types of injections. The study is designed to answer the questions of what value intravitreal or subconjunctival injections add to topical medication, and what value combining intravitreal and subconjunctival injections may add.

All patients will receive a phacoemulsification for cataract and placement of an intraocular lens.

Intracameral cefuroxime will be administered at surgery followed by topical antibiotics for six days. Patients with severe diabetes will be excluded, as will patients at high risk for pre- or postoperative inflammation, Dr Nuijts said.

Follow-up visits will be at one week, six weeks and three months. Mean logMAR best corrected visual acuity, OCT subanalysis of macular thickness changes, intraocular pressure, vision- and healthrelated quality of life changes, and adverse events will be assessed. A cost-effectiveness analysis also will be conducted.

The primary endpoint in both groups will be the presence of macular oedema on OCT or clinically significant macular oedema at six weeks. Macular oedema is defined as an increase in central subfield mean thickness in the 1mm area compared with baseline.

Clinically significant macular oedema is defined as an increase of more than 10 per cent compared to one week post surgery combined with a decrease in best corrected visual acuity of two or more lines on the ETDRS chart.

Dr Nuijts believes that PREMED will give cataract surgeons valuable information on controlling CME that is simply not available today.

25

Update

RETINA

RETINOPATHY

Retinopathy as a sign of future heart failure

by Roibeard O’hEineachain in Dublin

P

atients with retinopathy are at a higher risk of developing left ventricular dysfunction than individuals without retinopathy, said Iris Walraven from the Department of Ophthalmology, VU University Medical Center, Amsterdam, the Netherlands.

An analysis of 183 participants from the Hoorn study in the Netherlands showed that those who were present with retinopathy in the year 2000 had a 6.0 per cent lower left ventricular ejection fraction and an 8.3 per cent higher ventricular mass index than patients without retinopathy at baseline, when reviewed eight years later, Ms Walraven told the 22nd Meeting of the European Association for the Study of Diabetes’ Eye Complications Study Group.

“In the general population of the Netherlands, the presence of retinopathy was prospectively associated with a 6.0 per cent decrease in left ventricular ejection fraction, independent of diabetes status and traditional risk factors,” Ms Walraven said.

She noted that the Hoorn study is a population-based cohort study initiated in 1989 that was designed to determine the prevalence of Type 2 diabetes and its associated risk factors. In this part of the study, the Hoorn study investigators determined the presence of retinopathy by retinal photography using the EuroDiab classification system.

Ms Walraven noted that heart failure often develops progressively, with a preceding (asymptomatic) period of left ventricular systolic or diastolic dysfunction.

Patients with heart failure have a median survival time of only 2.1 years and there is no cure for the condition.

However, lifestyle and drug interventions have shown to be effective in preventing or delaying the onset of heart failure in individuals at risk. She noted that left ventricular dysfunction can be divided into systolic dysfunction, which implies impaired pump function of the left ventricle, and diastolic dysfunction, which implies inadequate filling of the left ventricle.

To investigate associations of retinopathy with changes in left ventricular systolic and diastolic function, the researchers performed echocardiography and carried

“

Should we screen everyone who has retinopathy for left ventricular dysfunction?

I would be careful how I answered that question...”

Iris Walraven

out a linear regression analysis adjusting the results for age and gender and traditional risk factors for heart failure.

“The pathogenesis of heart failure is still unclear. It is known that a person who smokes, who is overweight, has hypertension and/or has diabetes is at an increased risk of developing heart failure.

However, these traditional risk factors do not explain the complete risk and even in the absence of these risk factors there still can remain a significant risk of developing heart failure,” Ms Walraven said.

One theory that has gained some support in recent years is that there is a link between microvascular dysfunction and coronary dysfunction. The idea is that microvascular dysfunction reflects a lowgrade inflammatory state of the body, which is itself a risk factor for the development of heart failure. Furthermore, recent research has shown that microaneurysms, a frequent feature in eyes with retinopathy, are also found in post-mortem hearts that suffered from heart failure.

“The next question is, should we screen everyone who has retinopathy for left ventricular dysfunction? I would be careful how I answered that question and say that the next step is to validate this study in a larger study population,” Ms Walraven added.

contact Iris Walraven – i.walraven@vumc.nl

Don’t Miss Research update, see page 33 EUROTIMES | Volume 17 | Issue 10

contact

26

Update

RETINA

DIABETIC MACULAR OEDEMA

Steroid implant’s effect strongest in eyes with chronic disease

by Roibeard O’hEineachain in Dublin

P

atients with longstanding diabetic macular oedema appear to have a stronger response to treatment with a low-dose fluocinolone acetonide implant (Iluvien®, Alimera) than do patients who have had the condition for only a short time, according to a subgroup analysis of participants in the two FAME (Fluocinolone Acetonide in Macular Oedema) trials, presented at the 22nd Meeting of the European Association for the Study of Diabetes’ Eye Complications Study Group (EASDec).

“A significant benefit-to-risk ratio has been demonstrated in this sub-population of patients with chronic diabetic macular oedema. This finding is the basis of the approval of Iluvien in the UK. Its approved indication is for the treatment of visual impairment due to chronic diabetic macular oedema that is insufficiently unresponsive to available therapies,” said Abosede Cole MD, Bristol Eye Hospital, UK, who presented the study’s findings.

The new implant is injected into the eye using a 25-gauge injector, she noted.

The FAME studies included 956 patients randomised on a two-to-two-to-one basis to receive 0.5 microgram insert, 0.2 microgram insert or sham injections. Dr Cole noted that the patients in the three treatment groups were well balanced in terms of age, sex and disease characteristics.

EUROTIMES | Volume 17 | Issue 10

Overall, the mean duration of their diabetic macular oedema was 3.79 years and all had undergone at least one prior laser treatment.

Furthermore, in all of the patients involved in the study, the oedema involved the central macula and central retinal thickness was 250 µm or more. The mean centre-point thickness in all three groups was well in excess of 400 µm, she said. The patients’ best-corrected visual acuity prior to treatment was 19 to 68 letters, she added.

Lower dose better Dr Cole noted that the FAME study achieved its primary endpoint. That is, at two years’ follow-up, the proportion of patients achieving an improvement from baseline of 15 or more ETDRS letters was 28.7 per cent in the low-dose group and 28.6 per cent in the high-dose group. That compared to only 16.2 per cent in the sham group injection group (P = 0.002). There were significantly greater improvements in visual acuity in the Iluvien treated patients than in the sham injection patients from three weeks after commencing therapy, she said.

As regards side effects, 75 per cent of phakic patients in both Iluvien-treated groups required cataract surgery. However, the visual benefit those patients achieved after surgery was similar to that of those who were pseudophakic at baseline. Around

40 per cent of the patients required some intraocular pressure medication, Elevated ocular pressure requiring incisional surgery occurred in 4.8 per cent, 7.6 per cent, and 0.5 per cent of the low-dose, high-dose and sham groups, respectively. The results indicated that both dosages were equally effective, although the lower dosage had a superior safety profile, she noted.

“This raised the question of whether there was a specific subgroup of diabetic macular oedema patients who had a better risk-benefit ratio. If such a subgroup did exist there would have to be a statistically significant better visual acuity outcome at 24 and 36 months and this subgroup should be identifiable prior to the use of Iluvien,” Dr Cole said.

The Fame study investigators therefore divided the entire patient population into two subgroups. One group included 536 patients whose diabetic macular oedema had been present for three years or longer at baseline, which they labelled chronic diabetic macular oedema, and the other group included 416 patients whose diabetic macular oedema had been present for less than three years.

Effect most pronounced in chronic patients The new subgroup

analysis showed that, among patients who had diabetic macular oedema for longer

Abosede Cole – a.cole@nhs.net

than three years, 34 per cent of those receiving the 0.2 micrograms per day version of the implant had an improvement of 15 or more letters of best-corrected visual acuity, compared to only 13.4 per cent of controls (p<0.001). By comparison, among the total group the proportion of those receiving the low dose implant achieving a 15-letter gain was only 28.7 per cent, and that of the controls was 16.2 per cent.

“The reason for this is not well understood, there are various hypotheses which haven't yet been proven. It may be that the role of inflammation may be more important in patients who have had diabetic macular oedema for longer.

However, that is just a hypothesis,” Dr Cole said.

The main safety issue of the implant, as with all steroids, is its potential to cause glaucoma, she said. However, although intraocular pressure elevation did occur, it did not diminish the visual acuity outcomes even among those patients who required surgery, she said.

“A sustained dosage of 0.2 micrograms per day of fluocinolone acetonide provided rapid and sustained improvement in best corrected visual acuity and retinal thickness in patients with diabetic macular oedema for up to 36 months. The greatest benefit was seen in patients with chronic diabetic macular oedema. The development of cataract was very common in the fluocinolone acetonide-treated patients and fewer than five per cent required incisional IOP lowering procedures,” Dr Cole added.

am ur 13th EURETINA Congress

26â&#x20AC;&#x201C;29 September 2013

www.euretina.org

28

Update

OCULAR

NANOTECHNOLOGY

Next evolution in nanotechnology offers exciting new possibilities

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EUROTIMES | Volume 17 | Issue 10

N

anotechnology is set to make a positive impact on many aspects of ophthalmology including drug and gene therapy delivery methods, delegates attending the World Ophthalmology Congress were told at a special session on new technology in ophthalmology. “This is new and exciting technology which allows us to manipulate matter at the smallest scale. We will be able to make technology that looks at harnessing some of the processes in living systems to generate energy to power devices that could be implanted inside bodies and allows us to improve human biological systems at the molecular level,” said Carlo Montemagno PhD in a broad overview of the coming nanotechnology revolution.

Dr Montemagno, Dean of the College of Engineering and Applied Science at the University of Cincinnati, US, defined nanotechnology as involving the creation and use of materials and devices at the size scale of intracellular structures and molecules.

He explained that while early nanotechnology was aimed at making particles and targeted vessels for drug delivery, the next evolution in the technology is where the real excitement lies.

“We have been doing lots of stuff with technology that seems obvious, making particles and targeted vessels for drug delivery and also small machinery devices that evolve and that are analogous to electronic circuits in terms of the way they are produced and manufactured. However, the real power of the technology is going to the next level of being able to process information and embed metabolism within the machines and material and to move it to a much higher level of functionality,” he said.

One possible route to achieving this higher level of functionality has been suggested

by Robert H Singer’s research into the reproductive behaviour of yeast cells, said Dr Montemagno. “Yeast cells are very interesting organisms in their own right that reproduce by budding. Only a female yeast cell can bud, and whether it buds or not depends on the presence of a single protein. The problem is how a female yeast cell can produce a male offspring. If she produces the protein during reproduction, she becomes a he, and the budding process does not work any more,” said Dr Montemagno.

For the budding to occur, messenger RNA

Courtesy of Carlo Montemagno PhD

by Dermot McGrath in Abu Dhabi

Images show a device Dr Montemagno and colleagues are developing to biologically process information using nanotechnology

is produced, put onto carrier molecules, then onto a kinesin onto a microtubule, and then transported down to the budding cell where the protein is actually produced, he explained. “There is a purposeful transport of information, occurring through the stochastic interactions of basically seven molecules.

This is a higher order of behaviour that sends information down from the mother cell to her son, emanating only through molecular interactions,” he said.

There are a number of prerequisites for the engineering of functional cytometabolic systems that may achieve this higher-level functionality of living molecules, said Dr Montemagno. “We need to satisfy three criteria for such a system: first of all, couple protein functionality, which then needs to be environmentally stable and can withstand handling, manipulation, transport and storage. Finally, it has to be something on a scale that can be commercialised,” he said.

Dr Montemagno predicted that nextgeneration nanomaterials will involve engineered “metabolic” properties incorporating integrated power, amplified sensing, biomechanical synthesis, and information processing.

contact Carlo Montemagno – carlo.montemagno@uc.edu

29

Update

OCULAR

OCULAR CANCERS

Topical treatments promising for some non-melanoma lesions

by Howard Larkin in Orlando

T

opical treatments show promise for treating several nonmelanoma periocular lesions, Robert C Kersten MD, University of California-San Francisco, US, told the American Academy of Ophthalmology.

For patients with lentigo maligna, or extensive superficial or in situ squamous cell carcinomas, the topical immune sensitizer imiquimod, with close follow-up, may help avoid the cost, morbidity and cosmetic disfigurement of surgical excision.

For non-cancerous infantile hemangioma, early trials suggest topical timolol is an effective treatment without the systemic side effects of traditional steroid therapy, Dr Kersten said.

Avoid side-effects Initially approved by the US FDA for treatment of genital warts in 1997, imiquimod was approved for actinic keratoses and superficial basal cell carcinomas in 2004, Dr Kersten noted.

Overall, it has proven more effective as a topical treatment for non-melanoma skin lesions than 5-flourouracil. To avoid side effects such as burning itching, pain crusting and ulceration, imiquimod is applied as a five per cent cream five days a week with two days vacation for six to 12 weeks, Dr Kersten said.

Imiquimod boosts immune response to lesions by binding to toll-like receptor 7, inducing transcription of interferon-a, interferon-g and tumor necrosis factor.

A five-day-a-week regimen for six weeks results in about 80 per cent clearance of superficial squamous cell carcinomas.

However, placebo control studies also show a six per cent to nine per cent clearance histologically 12 to 18 weeks after biopsy, of squamous cell carcinomas which were biopsied but received no further pharmacologic treatment, Dr Kersten noted.

“The immune system may work on its own better than we expect to clear small lesions.”

Imiquimod was less effective with nodular basal cell lesions, resulting in late recurrence. This suggests that the topical compound may not penetrate far enough to completely reach the lesion, Dr Kersten said.

For squamous cell in situ lesions, topical Don’t miss EU Matters, see page 36 EUROTIMES | Volume 17 | Issue 10

“The immune system may work on its own better than we expect to clear small lesions” Robert C Kersten MD imiquimod achieved about an 80 per cent clearance rate in follow-up of six to 31 months, making it a suitable alternative to surgery, Dr Kersten said. For invasive squamous cell lesions, the 71 per cent clearance rate is not sufficient due to the highly invasive nature of this condition.

Current recommendations for imiquimod are for actinic keratoses, squamous cell in situ and superficial basal cell carcinoma of the trunk and extremities. Small series case reports suggest that ocular side effects are mild, with 15 patients developing conjunctivitis and six per cent ocular stinging, but no permanent side effects in one 47-patient study, Dr Kersten said.

“The good news is the side effects of imiquimod appear to be very manageable.”

Imiquimod also has achieved a 50 per cent clearance rate with lentigo maligna, Dr Kersten said. While this seems low, it is useful because it eliminates half of the population that must be followed for progression to malignant disease, he added. About six per cent to seven per cent of patients progress, with older patients having less risk, which makes monitoring an acceptable strategy rather than subjecting all patients to surgery.

contact Robert C Kersten – robert.kersten@ucsf.edu

News

eye on techNOLOGY

FUCHS’ DYSTROPHY

Posterior lamellar keratoplasty techniques share disadvantages of longer learning curve

by Soosan Jacob MD

D

escemet’s membrane endothelial keratoplasty (DMEK) combined with cataract extraction is a useful option for treating patients with Fuchs' corneal dystrophy that avoids some of the disadvantages of other approaches.

These patients have traditionally undergone a triple procedure with cataract extraction and penetrating keratoplasty (PKP). However, PKP is known to have disadvantages such as surface and suture related problems as well as neurotrophic problems. It also has the disadvantage of having a full thickness 360-degree avascular wound that takes at least one year to heal. It has the greatest risk of traumatic wound rupture. Despite often having a clear graft, functional vision might still be compromised because of unpredictable refractive errors and astigmatism.

Recent advances in posterior lamellar

corneal transplantation have been especially advantageous to patients with early corneal decompensation either secondary to Fuchs’ or secondary to aphakic or pseudophakic bullous keratopathy.

In the absence of stromal scarring, these patients can undergo a lamellar keratoplasty technique. This closed system surgery decreases the risk of expulsive haemorrhage. Postoperatively, the refraction and visual rehabilitation for the patient are much faster and there is no irregular astigmatism. The innervation of the cornea is maintained and there are no surface or suture related complications. As the endothelial cells are only exposed to the anterior chamber (AC), there is less chance of graft rejection.

All posterior lamellar keratoplasty techniques share the disadvantages of a longer learning curve and greater endothelial cell loss during surgery

EYE CHAT Exclusive interviews Up to date information Problem solving

Corneoplastic approach to irregular astigmatism Dr Oliver Findl speaks with Beatrice Cochener MD, PhD, University of Brest, France, who describes a corneoplastic approach to irregular astigmatism with IOLs, collagen cross linking, refractive laser and corneal grafting.

podcast

www.eurotimes.org

Scan this QR code to gain access to EuroTimes podcasts

EUROTIMES | Volume 17 | Issue 10

Also available on iTunes

Courtesy of Soosan Jacob MD

30

Figure 1: Descemet’s membrane endothelial keratoplasty (DMEK) graft being prepared

secondary to graft handling. This can result in a greater incidence of primary graft failure.

In Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK), endothelium with a thin stromal carrier is used as the graft. The overall pachymetry is increased and the grafted endothelium has to function well enough to keep the patient’s own stroma as well as the carrier stroma in the non-oedematous state. It can also lead to a hyperopic shift in refraction postoperatively. DSAEK requires specific instrumentation for graft preparation, though pre-cut tissue is available from some eye banks.

DMEK does not have these disadvantages. It has the advantages of not requiring any special instrumentation for graft preparation thus allowing more widespread acceptance and usage. However, the Descemet’s membrane is more difficult to handle, as it is devoid of any stromal carrier. It also has been found to have a higher rate of graft dislocation as compared to DSAEK and a higher incidence of re-bubbling.

The DMEK graft is prepared from a high quality donor cornea. This is done by partially trephining the graft and then using the Sinskey hook to lift up the edge of the cut Descemet’s membrane.

Once an adequate edge is lifted, a nontoothed forceps is used to gently grab the Descemet’s membrane at its very edge. The Descemet’s membrane is then separated from the underlying stroma in a capsulorrhexis-like circumferential manner (Figure 1). It is stained with trypan blue and replaced in the sterile corneal storage medium while the recipient eye is prepared.

Phacoemulsification is carried out as usual. The corneal epithelium may be removed to aid visualisation. Cortex is removed and the IOL is implanted within the bag. All residual viscoelastic is removed (Figures 2A, B). Intracameral pilocarpine may be used to constrict the pupil. The recipient Descemet’s membrane is then stained with trypan blue. A blunt 8.5mm trephine is used to place a mark on the corneal surface and a reverse Sinskey hook is used to score and then strip the membrane (Figure 2C). The stripped membrane is inspected to verify that no tags are left behind. Corneal stab incisions may be made to milk out fluid from the interface at the end. These are put outside the pupillary zone but within the zone that would be covered by the graft.

The cartridge of a Staar ICL injector is then filled with balanced salt solution while blocking the extreme tip of the cartridge with a small amount of viscoelastic to

“Recent advances in posterior lamellar corneal transplantation have been especially advantageous to patients with early corneal decompensation either secondary to Fuchs’ or secondary to aphakic or pseudophakic bullous keratopathy”

31

prevent sudden accidental extrusion of the graft. The cartridge tip is held occluded with a finger and the graft is gently placed into the saline in the cartridge in such a manner that one rolled edge lies superiorly (Figure 3A). The cartridge is fixed to the injector and gentle tapping of the finger occluding the cartridge allows the graft to slide forwards. The cartridge is then introduced through the clear corneal incision and the graft is gently introduced into the AC by plunging the soft tipped injector, taking care not to fold the graft (Figure 3B).

Wound-assisted implantation is avoided and the anterior chamber maintainer (ACM) flow is titrated carefully to prevent backflow and extrusion of the graft. The graft orientation is then checked. As the Descemet’s membrane has elastic properties, the edges of the graft always curve towards the side of the Descemet’s membrane. The ACM is turned off and can be removed at this stage or later. The graft is unfolded gently by tapping with a small air bubble (Figure 3C). Once unfolded, a larger air bubble is injected under the graft to float it up against the stroma. Proper unfurling and positioning of the graft is confirmed and if required adjusted. Any interface fluid is removed via the pre-placed

Figure 2B: Phacoemulsification, cortex aspiration and IOL implantation are done. All the viscoelastic is removed

HPMC 2%

For cataract and other ophthalmic surgeries Figure 2C: Descemet’s membrane (DM) is stained with trypan blue and is scored and stripped from the overlying stroma using a reverse Sinskey hook

stab incisions in the cornea. The anterior chamber is filled with an adequately large air bubble to allow the graft to adhere well (Figure 3D). The patient is made to lie face up for about an hour at the end of which, air is released just enough to avoid over-fill and pupillary block postoperatively.

Graft dislocation may occur postoperatively and the patient may require re-bubbling. Even though the rate of graft rejection is less in DSAEK and DMEK as compared to PKP, it can still occur and patients should be informed about the warning signs of rejection.

Corneal hydration that lets you stay focused on the surgery • In clinical trials, physicians reported significantly greater optical clarity with CORNEA PROTECT®

than with BSS (median grade 1.0 vs 2.0, p=0.03)1 • Just 1 drop provides corneal hydration for up to 20 minutes • No statistically significant difference between CORNEA PROTECT® and BSS in fluorescein staining

scores 1 hour after surgery1

Median Application Frequency of CORNEA PROTECT® vs BSS (Balanced Saline Solution) During Cataract Surgery (n=101)1 Median Application Frequency

Figure 2A: Eye with Fuchs’ corneal dystrophy and cataract

10

BSS

9

10

8 7 6 5 4 3 2 1 0

CORNEA PROTECT®

1

Reference: 1. Chen Y-A, Hirnschall N and Findl O. Corneal wetting with a viscous eye lubricant to maintain optical clarity during cataract surgery. Submitted to J Cataract Refract Surg under review.

Figure 3B: It is then injected into the anterior chamber (AC) in such a way that the edge is rolled anteriorly. The Descemet’s membrane now faces the corneal stroma and endothelium faces posteriorly towards the IOL

Figure 3C: A small air bubble injected into the AC above the graft is tapped so as to unroll the graft

Figure 3D: An air bubble is then injected under the graft to float it superiorly against the stroma. Graft positioning is verified and interface fluid is milked out through pre-placed stab incisions in the corneal stroma

EUROTIMES | Volume 17 | Issue 10

CORNEA PROTECT® is a registered trademark of Croma-Pharma GmbH.

Croma-Pharma GmbH • www.croma.at

ad cornea protect 120x300 ENG 1112v1 gpf eurotimes.indd 1

0123

ACP002Ab

Figure 3A: The DMEK graft is loaded gently into the cartridge of a Staar ICL injector filled with balanced salt solution

20.12.11 16:10

News

european BOard of ophthalmology

POSITIVE IMPACT

“

There is no doubt that the most enjoyable part of my tenure as president has been the opportunity to work with a fantastically dedicated, competent and dynamic team...

Outgoing EBO president reflects on productive and enriching term of office

by Dermot McGrath

A

s his two-year term of office as president of the European Board of Ophthalmology (EBO) draws to a close, Wagih Aclimandos FRCS, FRCOphth, FEBO describes his time in the hot seat as a challenging but ultimately rewarding and enjoyable experience.

“Two years might seem like a long time when you have just been nominated, but it goes very quickly indeed once you actually inhabit the role of president. While there is so much to do, there is no doubt that the most enjoyable part of my tenure as president has been the opportunity to work with a fantastically dedicated, competent and dynamic team on the EBO Executive Board,” he said.

Prof Aclimandos also paid tribute to the behind-the-scenes work of individuals such as Danny Mathysen, the EBO’s statistical expert, and the team at Agenda Communications. “Working in that very professional and yet friendly climate makes hard work enjoyable and no doubt increases the whole team productivity, with absolutely no distraction or time wasted,” said Prof Aclimandos.

Looking at the evolution of the

organisation during his term of office, Prof Aclimandos said that he derives immense satisfaction from the fact that the EBO is becoming increasingly recognised as an educational institution of stature.

“This was very apparent on my recent visits to large institutions in France including the university hospitals of Lille and Amiens and the Fondation Rothschild and the Quinze-Vingts Hospital in Paris.

I was interested to hear about the positive impact that the EBO has had on training in France. All residents now aspire to pass the EBO examination. One of the indirect impacts that this has had on their training is that they appreciate the importance of having diverse training that helps them pass the exam rather than concentrate the bulk of their training on one sub-specialty,” he said.

The annual EBO examination in Paris also continues to attract an increasing number of candidates from across Europe, said Prof Aclimandos. “The number of candidates sitting the exam continues to grow all the time. The organisation of the exam and its validation process has also continued to improve. I believe that the standard of the exam has gone up and the

THE SWISS TR OCAR SYSTEM AL FE VITREO-RETIN SA D AN E IS EC PR FOR

Wagih Aclimandos FRCS, FRCOphth, FEBO level of professionalism in terms of how the exam is conducted has certainly evolved significantly,” he said.

Prof Aclimandos said that the achievements of the past few years are down to tireless teamwork from EBO’s dedicated Executive Board members. “I was privileged to have the constant help and support of the secretary general Peter Ringens over the past two years. One of our goals was to consolidate the agreement with the American Academy of Ophthalmology that was started while Prof Howlina was EBO president regarding the co-editing of the AAO series of textbooks. I attended several meetings in Florida last year and I am pleased that this venture is going well,” he said.

Prof Aclimandos said that the EBO has also continued its drive towards catering for greater ophthalmic specialisation. “We have formed several sub-speciality groups, which

SURGERY

with MVR blade 23G and 25G models 1-step techniques and self-sealing cap for

EUROTIMES | Volume 17 | Issue 10

contact

32

Wagih Aclimandos – wagih.a@ntlworld.com

in addition to co-editing the AAO series of books, have been asked to look at the need and potential format of sub-specialty exams.

The process is slow but progressing. The work of the Continuing Medical Education (CME) committee led initially by Gordana Sunaric-Megevand and now by Talin Barisani-Asenbaeur has been a great success – indeed, in some respects the EBO has become a victim of its own success in this field,” Prof Aclimandos said.

That success is also seeping into other areas of expertise covered by the EBO such as course accreditation and e-learning, said Prof Aclimandos.

“Attitudes are certainly changing across Europe as evidenced by the enormous demand for accreditation of courses by the EBO. Prof Marie-Jose Tassignon has also made huge strides in the e-learning modules provided by the EBO and this too has been a great success. The Residency Exchange Committee that allocates grants for trainees and trainers has also been immensely successful, although we will be sorry to lose Vytautas Jasinskas who has been so instrumental in strengthening this domain for the EBO,” he said.

Looking to the future, Prof Aclimandos said that the EBO’s president-elect Catherine Creuzot-Garcher MD, is ideally equipped to continue the next phase of the organisation’s development. “I am gratified that my successor Catherine Creuzot-Garcher is totally committed to seeing the initiatives of the past few years develop further. Catherine has done a great job on the EBO Educational Committee and I am very optimistic that together we will achieve our goals,” he said.

News

research

INFANTS WITH CATARACT

Clinical relevant anatomy, histology and cell biology of the vitreolenticular interface

by M J Tassignon MD, PhD and J Van Looveren MD

W

hen performing paediatric cataract surgery a primary posterior capsulorrhexis is a necessity, independently of the choice of intraocular lens implantation.1 However, when performing this procedure in newborns and young children a variable amount of adherence of the anterior hyaloid face to the centre of the posterior lens capsule was found. The adherence increases the difficulty of separating surgically both the anterior hyaloid from the posterior capsule structures (Figures 1 A-B). During this manoeuvre, the integrity of the anterior hyaloid face could not always be preserved, sometimes even necessitating an unintended anterior vitrectomy.2-3 Numerous studies have tried to unravel the regression process of the tunica vasculosa lentis during gestation. This complex event is believed to be influenced by many factors such as eye growth, hypoxia, apoptosis and autophagia,4-5 but normal lens development also seems to influence this process.6 As a consequence, alterations in the formation of Berger’s space are expected to occur frequently in young age groups presenting with congenital cataract.

In eyes presenting with persistent fetal vasculature or even minimal fetal vascular remnants (without a fibrovascular plaque behind the posterior lens capsule) membrane-like structures between the posterior lens capsule and anterior hyaloid face are a well-known feature.4,7 From all currently known hereditary cataracts many can be associated with other ocular anomalies of the anterior and/or posterior segment, but the isolated dysgenesis of the vitreolenticular interface has rarely been investigated.8-9 Since scanning electron microscopy already has been used to study the early morphogenesis of persistent hyperplastic vitreous in dogs and humans,10-11 we wonder whether we would succeed in visualising the subtle persistent adhesions on the posterior lens capsule. We therefore collect the posterior capsule for further analysis including differences in gene expression in eyes with vitreolenticular dysgenesis compared to eyes with normal Berger’s space formation.

It is important to elucidate the pathogenesis of congenital vitreolenticular EUROTIMES | Volume 17 | Issue 10

Figure 1 A shows the aspect of the anterior vitreolenticular interface after having removed the lens content in a child’s eye

dysgenesis associated with congenital cataract. This knowledge will likely lead to improvements in surgical procedures in the future. The genetic insights may even lead to prenatal detection of congenital anomalies of the lens and its anterior interface.

We performed a consecutive case series of all paediatric cataract surgeries performed in our centre during the course of one year.

All surgeries were videotaped and posterior capsulorrhexis procedures were analysed focusing on the presence of vitreolenticular adherences and the ease by which they could be dissected using viscoelastics.

Unfortunately, regular histology evaluation is of poor interest since they only show collagen, fibroblasts and rare epithelial cells (Figures 2A, B, C, D, E).

Electron microscopy The removed posterior capsule presents collagen, multiple fibroblasts and rare epithelial cells.

Extracted posterior lens capsules presenting various types of adhesions to the vitreous were further analysed using scanning electron microscopy. Immediately after extraction the samples were oriented and fixated in gluteraldehyde. The fixated tissue was dehydrated using critical point drying and sputter-coated with gold before examination under the microscope.

Our specific attention was focused on the presence, nature and interaction of the adhesions on the posterior side of the collagen/laminin meshwork of these posterior lens capsules.

Our intention is to extract mRNA out of the preoperatively extracted posterior lens capsules and surrounding lens material using the Oligotex Direct mRNA Mini Kit of Qiagen. If possible, after reverse transcription and using microarray we intend to subsequently measure

Figure 1 B Shows the dissection of the posterior capsule from the remnants of the tunica vasculosa lentis

simultaneously the gene expression of thousands of genes to identify genes which expression is changed in eyes with vitreolenticular dysgenesis compared to eyes with normal Berger’s space formation.

This work will be done in collaboration with the Department of Ophthalmology of Giessen, Justus Liebig University (Prof Dr Birgit Lorenz) and the Center of Paediatric Ophthalmology of Ahmedabad, India (Prof Dr Abhay Vasavada).

References 1. Guo S., Wagner R.S., Caputo A (2004). Management of the anterior and posterior lens capsules and vitreous in pediatric cataract surgery. J. Pediatr. Ophthalmol. Strabismus.

41(6):330-337.

2. Shah S.K., Vasavada V., Praveen M.R., Vasavada A.R., Trivedi R.H., Dixi N.V. (2009). Triamcinolone-assisted vitrectomy in pediatric cataract surgery. J. Cataract Refract. Surg.

35(2):230-232.

3. Praveen M.R., Vasavada A.R., Koul A., Trivedi R.H., Vasavada V.A., Vasavada V.A. (2008). Subtle signs of anterior vitreous face disturbance during posterior capsulorhexis in pediatric cataract surgery. J. Cataract Refract. Surg. 34(1):163-167.

4. Shastry B.S. (2009). Persistent hyperplastic primary vitreous: congenital malformations of the eye. Clin. Experiment.

Ophthalmol. 37(9):884-890.

5. Young S.Y. (2010). Autophagy-induced regression of hyaloid vessels in early ocular development. Autophagy. 6(7):922928.

6. Mitchell C.A., Risau W., Drexler H.C.A. (1998). Regression of vessels in the tunica vasculosa lentis is initiated by coordinated endothelial apoptosis: a role for vascular endothelial growth factor as a survival factor for endothelium.

Developmental Dynamics. 213:322-333.

7. Müllner-Eidenböck A., Amon M., Hauff W., Klebermass N., Abela C., Moser J. (2004). Surgery in unilateral congenital cataract caused by persistent fetal vasculature or minimal fetal vascular remnants: Age-related findings and management challenges. J Cataract Refract. Surg. 30:611-619.

8. Hejtmancik J.F. (2008). Congenital cataracts and their molecular genetics. Semin. Cell Dev. Biol. 19(2):134-149.

9. Graw J. (2004). Congenital hereditary cataracts. Int. J. Dev. Biol. 48:1031-1044.

10. Boevé M.H., Vrensen G.F.J.M., Willekens B.L.J.C., Stades F.C., Van der Linde-Sipman J.S. (1993). Early morphogenesis of persistent hyperplastic tunica vasculosa lentis and primary vitreous (PHTVL/PHPV). Graefe’s Arch. Clin. Exp. Ophthalmol.

231:29-33.

11. Sellheyer K., Spitzans M. (1987). Ultrastructure of the human posterior tunica vasculosa lentis during early gestation.

Graefe’s Arch. Clin. Exp. Ophthalmol. 225:377-383.

Figures 2A, B, C, D, E show histological analysis of posterior capsules of children presenting with congenital cataract

33

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35

Review

OPHTHALMOLOgica

Vision loss after antiVEGF likely to be endophthalmitis

A review of the published case series of endophthalmitis following intravitreal injection indicates that those presenting with visual acuity 20/200 or less more than 24 hours after the injection were very likely to have endophthalmitis, while those presenting with a similar loss of vision during the first 24 hours were more likely to be due to different causes. The study's investigators used a Pubmed search of the literature and retrieved 12 case series, which together with their own case series included a total of 133 patients. The researchers found that the records showed that among those cases where antibiotics were deemed unnecessary the mean time to presentation was one day, but in those who received antibiotics the mean time to presentation was three days, whether or not their biopsy was positive for bacterial pathogens. n (Hoevenaars

et al, Ophthalmologica 2012, DOI: 10.1159/000339584.)

Improving vision

Removing the scleral encircling bands after they have served their purpose in scleral buckling surgery for retinal detachment is safe and easy and may improve vision by decreasing corneal astigmatism and enhancing macular sensitivity, a new study suggests. The prospective study involved 40 patients who had undergone scleral buckling surgery and who subsequently underwent removal of the scleral encircling bands. At a follow-up of six months, the patients had significant improvements in their uncorrected and best-corrected visual acuity and a significant reduction in astigmatism.

rhegmatogenous retinal detachment (RRD) and hole re-opening. Another case with persistent hole also developed RRD. In contrast, in seven of the nine cases without hole closure and the one where the hole re-opened had vitrectomy, all had hole closure and vision improvement. n (Chen

et al, Ophthalmologica 2012 DOI: 10.1159/000337840.)

Eyes may have natural anti-angiogenic response

The vitreous of eyes with retinal or choroidal neovascularisation appear to have higher levels of both pro-angiogenic factors and anti-angiogenic factors compared to eyes without the neovascularisations, according to a new study. The study involved 29 patients from whom vitreous samples were obtained in order to quantify the angiogenesis-associated proteins present via enzyme-linked immunosorbent assays.

The researchers found that vitreous levels of the anti-angiogenic VEGF receptor 1 (sVEGFR-1) were significantly higher in eyes with AMD with CNV and in eyes with proliferative diabetic retinopathy than in control eyes. In addition, the concentrations of the anti-angiogenic protein, pigment epithelium-derived factor (PEDF) were decreased and that of proangiogenic angiopoietin 2 were increased.

The authors concluded that higher amounts of sVEGFR-1 may point to activation of an endogenous anti-angiogenic system in the protein network. n (Huber

et al Ophthalmologica 2012 (DOI: 10.1159/000339952.)

et al, Ophthalmologica 2012 (DOI: 10.1159/000336895.)

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EUROTIMES | Volume 17 | Issue 10

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36

Feature

EU MATTERS

NEVER PRESUME

Ophthalmic surgeons should consider different rules by which they are authorised to practise

by Paul McGinn

A

new ruling from the EU's highest court should remind ophthalmic surgeons to think twice before they presume they can legally operate every aspect of their clinics just because they are authorised to treat patients.

In the case, the European Court of Justice found that an Italian pharmacist could not rely on his authorisation as a retail pharmacist to sell drugs to the public to carry on business as a wholesale pharmacist.

Under the 2001 EU Directive on the Community Code Relating to Medicinal Products for Human Use, a pharmacist who already holds a license to sell pharmaceutical products to the public must also possess an additional special licence to operate as a wholesale distributor of medicinal products.

Under the Directive, which was transposed into Italian domestic law in 2006, the wholesale distribution of medicinal products is subject to the requirement to hold an authorisation granted by the region or the autonomous province. Any person in breach of the national legislation is liable to punishment

in the form of imprisonment for a term of six months to one year and a fine of up to €100,000.

Against that background, certain pharmacists in Italy were reported for engaging in activity as wholesale distributors in medicinal products without proper authorisation. In criminal proceedings brought against a Sicilian pharmacist, Fabio Caronna, the District Court in Palermo requested the Court of Justice to decide, as a preliminary matter: 1. Does the requirement laid down in the directive to obtain authorisation for the wholesale distribution of medicinal products apply to pharmacists who, as natural persons, are already authorised under national law to supply such products to the public?

If the answer to question 1 was 'yes', then the Italian court asked the Court of Justice to consider a second question: 2. To qualify as a wholesale pharmacist, must a pharmacist who is already authorised as a retail pharmacists satisfy all the requirements imposed for wholesale distribution or is it sufficient for the retail

From the Archive Binkhorst lecturer suggests link between preservatives in eyedrops and CMO

By Ana Hidalgo-Simon MD, PhD

N

ice - This year's Binkhorst medal was awarded to Kenasaku Miyake MD for his keynote lecture outlining the potential association between common anti-glaucoma medications and cystoid macular oedema (CMO) in patients who have undergone cataract surgery.

Dr Miyake highlighted examples of clinical studies published in peer-reviewed journals which found connections between anti-glaucoma medications and CMO. A wide range of products, including most of the widely used anti-glaucoma medications, have been linked to CMO after cataract surgery in recent years. * From EuroTimes Volume 7 Issue 10 October 2002

EUROTIMES | Volume 17 | Issue 10

pharmacist only to fulfil the conditions laid down by domestic law for retail supply?

In his defence, which interestingly was accepted by Italian prosecutors who recommended that charges against Mr Caronna be dropped, Mr Caronna argued that the wording of the EU Directive allowed him to presume that he, as a retail pharmacist, was not subject to the extra requirement for a special wholesale licence.

Mr Caronna’s lawyers submitted that the directive requirement that “any person involved in the wholesale distribution of medicinal products should be in possession of a special authorisation” did not apply to him as a pharmacist who was already in possession of a retail authorisation.

The Court of Justice rejected that argument, saying that a retail pharmacist was clearly “any person” and that if Mr Caronna’s lawyers arguments were accepted, there would be no legal distinction between wholesale pharmacists and retail pharmacists. And that distinction was central to the provisions of the Directive.

In fact, the court noted that on its reading of the Directive, the only pharmacists who did not require a separate authorisation for wholesale distribution were those pharmacists who confined their practice to retail pharmacy.

The Court of Justice added that there was also an economic issue to consider, finding that “to allow pharmacists to engage in activity as wholesale distributors in medicinal products without special authorisation would confer on them an unjustified competitive advantage”.

On that basis, “the Directive must be interpreted as meaning that the requirement to obtain authorisation for the wholesale distribution of medicinal products is applicable to a pharmacist who, as a natural person, is also authorised under domestic law to operate as a wholesaler in medicinal products,” the court concluded in answer to Question 1.

Satisfy requirements In considering Question 2 about the need for the retail pharmacist to satisfy all of the requirements imposed on wholesale pharmacists, the court noted that the EU Directive includes special provisions for the authorisation of wholesalers of medicinal products, which include requirements for suitable premises, installations and equipment, documentation and qualified staff to ensure that drugs are properly stored and distributed.

“Given that the retail of medicinal products has different characteristics from the wholesale distribution of such products, it cannot be presumed from the simple fact that pharmacists satisfy the conditions governing retail supply in their respective Member States that they also satisfy the conditions laid down by harmonised rules at European Union level for wholesale distribution,” the court held.

“Accordingly, in order to ensure that the Directive’s objectives are achieved, in particular those relating to the protection of public health, the removal of barriers to trade in medicinal products within the European Union and the need to exercise control over the entire chain of distribution of medicinal products, referred to in recitals 2 to 5 and 35 in the preamble to the Directive, the minimum requirements for the wholesale distribution of medicinal products must be fulfilled in a uniform and effective manner by all persons who engage in that activity in all Member States.”

“Consequently, the answer to Question 2 is that a pharmacist who is also authorised under domestic law to operate as a wholesaler in medicinal products must satisfy all the requirements imposed on applicants for and holders of authorisation for the wholesale distribution of medicinal products.”

For details about the case, “Case C 7/11,” visit the Court of Justice website at: www.curia.eu.

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38

Update

EYE ON TRAVEL

The OLD TOWN

Take a picturesque walk around a Warsaw section that’s resonant with history

by Maryalicia Post

Y

ou don't have to know anything about the city's history to enjoy a visit to Warsaw's Old Town. A picturesque cobbled street leads from Castle Square – dominated by the Royal Castle and the towering Zygmunt monument – into the 13th century Market Square where the colourful facades of medieval houses form the backdrop to busy restaurants, cafes, pubs and shops.

A statue of a mermaid, the iconic protector of Warsaw, stands in the centre of Market Square; she figures on the city's Coat of Arms and in most tourist photographs, too, as the area is Warsaw's number one tourist attraction.

It's easy to let an evening slip by here, having a drink and enjoying the

atmosphere. But take the time to follow on to the Barbican, a massive brick rampart with a park-like walk on top. Duck through a covered archway – a shelter for musicians and souvenir sellers – and you pass from the 13th century Old Town to the 15th century “New Town” on the other side.

This quarter is quieter and less touristic.

Local residents exercise their dogs or enjoy a coffee in one of the lace-curtained cafes on the streets near New Town Square. There are a few gift shops featuring amber from the Baltic Sea. The road leading straight ahead from the Barbican is lined with restaurants, but the best reason for going right to the top of the New Town is to have dinner at Le Regina Hotel. The hotel’s Rotisserie Restaurant

Journal Watch Recombinant growth hormone and IOP Paediatric patients treated with recombinant human growth hormone may be at increased risk for elevated intraocular pressure (IOP), a recent clinical study suggests. Recombinant human growth hormone is used in the paediatric population to treat short stature due to growth hormone deficiency, including idiopathic growth hormone deficiency, Turner syndrome, Noonan syndrome, Prader-Willi syndrome, short stature homeobox-containing gene (SHOX) deficiency, chronic renal insufficiency, idiopathic short stature and children small for gestational age. The observational cohort study compared IOP in 55 children being treated with the hormone and 24 age-matched controls.

Children with concurrent eye disease or family history of eye disease were excluded from the study. All children underwent ocular slit lamp assessment and Goldmann applanation tonometry. Charts were reviewed for cause of therapy, peak stimulated growth hormone level prior to therapy, treatment duration, insulinlike growth factor1, and rhGH dosage.

Mean age at examination was comparable at 11.4 ± 3.3 years and 10.3 ± 2.6 years, EUROTIMES | Volume 17 | Issue 10

respectively. The mean treatment duration was 37.5 ± 22.8 months and mean rhGH dose was 0.04 ± 0.01 mg/kg/d. Mean IOP was statistically significantly increased in the treatment group compared with the control group and compared with agematched nomograms. IOP was positively correlated with treatment duration and higher rhGH dosage. Previous research has found side effects in fewer than five per cent of children treated with growth hormone. However, a previous report described a paediatric patient who developed severe glaucoma during treatment with the hormone, which eased when treatment was discontinued. The researchers caution that the current study is preliminary. They report that a longerterm follow-up study is already under way. n I. Youngster et al., Journal of Pediatrics, “Treatment with Recombinant Human Growth Hormone during Childhood is Associated with Increased Intraocular Pressure”, in press, published online June 25, 2012.

serves contemporary and French cuisine with a strong Polish influence at lunch and dinner. Lovely ambience as well. To book a table, telephone: +48 22 531 60 00.

And what if you do know something of Warsaw's history? Then this walk has considerable added resonance. Everything you see – from the cobbled street, to the squares, to the historic houses, to the brick rampart and the 'New Town' beyond – has been rebuilt from paintings and sketches predating World War II. In 1980, UNESCO designated the Old Town as a World Heritage site.

In 1944, Warsaw had been reduced to rubble by Hitler's express order. The methodical and terrible revenge was carried out block by block by a German “Destruction Detachment.” The order not to leave a stone upon a stone was Hitler’s personal reprisal for the Warsaw Uprising.

To understand why the city was targeted visit the Museum of the Warsaw Rising. It opened in a disused power station in 2004, the 60th anniversary of the event. A heartstopping interactive exposition, it lets you explore the cause, effect and aftermath of the two months in 1944 when the people of Warsaw tried to wrest their city back from the Nazis. Sound effects put you in the thick of it. There are eyewitness accounts and mock-ups of a resistance printing press and sewer escape routes. The visit ends with a five-minute 3-D film, “The City of Ruin,” a computer-generated “flight” over what was left of Warsaw in 1945. The film is based on the evidence of over 2,000 photos of the devastation.

Colourful facades in the Old Town

Outside the building is a wall of photographs and names of the resistants, including those of many children. A monument to the “Little Insurgent” stands by the Barbican wall of the Old Town. It represents a boy in a captured Nazi helmet and represents a 13-year old hero called Antek whose specialty was immobilising robot tanks, and who died fighting in August 1944.

Famously, the Russians camped on the other side of the Vistula River, while both the uprising and the reprisal took place.

When the Nazis were routed, the Soviets came in on their heels and stayed for the next 44 years. Not until they left could the Rising be commemorated.

The Warsaw Rising Museum is open Monday and Wednesday from 08:00-18:00, Thursday from 08:00-20:00, and Saturday and Sunday from 10:00-18:00. Closed on Tuesday. The museum is located in the Wola district at 79 ul. Grzybowska.

Try a meal Comrade-style

The Little Insurgent

Warsaw’s Milk Bars were a Soviet attempt to provide a cheap and nourishing meal to the city’s workers.

Heavily subsidised, the prices were low enough that everyone could have one warm meal a day. Originally, they served only dairy-based food (hence “milk bar”) and the cutlery was chained to the table. Many of these utterly basic canteens have closed down, but the few that have survived offer an authentic glimpse of life under Communism.

Expect the atmosphere to be glum and the welcome non-existent, but the portions to be large, surprisingly tasty and cheap. The menu is posted up on a sign near the cashier. If you can’t make sense of it, try pointing to what someone else is having. You pay first, then collect your meal at one hatch and, after you finish, return your used plate through another. There’s a Milk Bar on the New Town side of the Barbican archway. Look for the words, “Bar Mleczny.”

39

Feature

Book REVIEW

Managing keratoconus

Keratoconus remains one of those tricky pathologies that continues to confound.

Except in extreme cases, there are no highly specific signs or symptoms. Systemic associations are rare.

The Rizzutti sign is simple but rarely sought. The Munson sign, Fleischer ring and Vogt lines indicate more advanced pathology, by which time the diagnosis is quite obvious. The patient might experience stable or progressively worsening visual acuity. Once other, more common causes of vision loss have been ruled out, the clinician might consider keratoconus based on the astigmatism discovered by autorefraction.

Once a tomographic map has been made, the basic diagnosis is usually pretty simple.

But now what? This is where the real work begins, trying to make sense of the colourful printout. Is it mild, moderate or severe?

Stable or progressive? What’s the prognosis?

Classification? Management?

Fortunately, new and up-to-date reference texts are being published every few months.

Dr Sinjab’s most recent effort is one of these.

Keratoconus: When, Why and Why Not – A Step by Step Systematic Approach, takes the clinician through the various steps necessary once the diagnosis has been made.

The book is only four chapters and 140 pages long. The first half is made up of information on classification and management. The second half is made up of case studies and self-assessments.

Chapter 1 instructs the reader on how to classify the keratoconus using the various morphologic, tomographic and AmslerKrumeich systems. The author even offers his own new system based on his first 400 cases of intracorneal rings with at least six months’ follow-up, which reveals prognostic factors affecting the response to the rings.

Management of keratoconus is the topic of the second chapter. Treatments are divided into non-interventional – glasses and contact lenses – and interventional modalities. This is where the book gets interesting. Each surgical procedure is discussed and interesting questions are posed. Why has conductive keratoplasty been largely abandoned?

Answer: due to its unpredictability. In which situation is a penetrating keratoplasty most useful? Answer: in cases with significant corneal scarring. Indications for surgery are discussed, as are absolute and relative contraindications, considerations for preoperative discussion and postoperative follow-up and practical notes useful for during surgery.

EUROTIMES | Volume 17 | Issue 10

Although it comes later in the chapter, management parameters and a systematic plan for managing keratoconus is where the book’s title comes into play: “When, Why and Why Not?” The author’s systematic approach is outlined in a series of flow charts that take a series of factors into consideration to determine a surgical plan. They include the following six (groups of) factors: 1. corneal transparency and Vogt’s striae; 2. age; 3. progression; 4. contact lens tolerance; 5. refractive error; 6. visual acuity, measured in various ways. Determining these factors and then following the flow charts allows the clinician to determine the ideal treatment modality.

The reader is then invited to practise this new knowledge and systematic approach in a series of nine case studies. Each case covers four to five pages, starting with a patient’s clinical history, slit lamp examination, refractive values and corneal tomography.

This is followed by three steps: analysing step; management suggestions; and discussion step. These steps are particularly useful in the next chapter, “Self Assessment,” a pared-down version of chapter 3 in which the reader is required to solve the cases alone, with only minimal assistance from the author.

This book is ideal for ophthalmology residents interested in developing their clinical and decision-making skills during their cornea rotation; cornea fellows expected to start making these decisions independently; and general ophthalmologists looking to sharpen their treatment regime for keratoconus.

BOOKS EDITOR Leigh Spielberg

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PUBLICATION Keratoconus: When, Why and Why Not: A Step by Step Systematic Approach AUTHOR Mazen M Sinjab PUBLISHED BY Jaypee Highlights If you a have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

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24.07.12 13:23

40

Feature

industry news

Recent developments in the vision care industry First electronic toric marker

ASICO is introducing the world’s first electronic Toric marker which the company says will maximise an accurate Toric mark.

“These markers are designed to enhance toric marking accuracy from 5° mean error to 0.2° error. This will in turn improve the lens effectiveness from 83 per cent to 99.4 per cent,” said a company spokeswoman.

ASICO says the design of the ASICO electronic toric marker allows surgeons to use both the sense of sight and sound to ensure an accurate mark by looking at a signal light and listening to a beeping sound when the marker is aligned perfectly horizontal. n www.asico.com

Single-use instruments

After the launch of disposable instruments for cataract surgery then keratoplasty, Moria has announced the extension of its ONE® range with three single-use instruments for LASIK and FemtoLASIK surgery.

These are a Kratz wire speculum (reference #17227 – pictured), a Sinskey manipulating hook (reference #17223) and a manipulating hook (reference #17230).

“The Moria ONE® range of single-use instruments is ideally suited for LASIK surgery,” said a spokesman for the company. These instruments are sterile, individually packaged in sealed peel-apart pouches, in a box of 10. Each reference can be ordered separately,” he said. “The instruments are convenient and provide an exceptional value and they also eliminate the time and expense of re-processing soiled instruments,” said the spokesman. n www.moria-surgical.com

Global survey

Bausch + Lomb has released the findings of the company’s first-ever Barometer of Global Eye Health, a global survey of more than 11,000 consumers in 11 countries.

“Among the survey’s findings are that people would rather lose 10 years of their life (67 per cent) than lose their eyesight.

And they would be more willing to take a 50 per cent pay cut than lose 50 per cent of their vision,” said a Bausch + Lomb spokesman. “More than 70 per cent of Americans are not getting annual eye exams,” he said, “and 44 per cent believe that they do not need an eye test unless there is a problem.”

The global survey was developed in co-operation with eye care professionals from around the world and further validated by an additional 147 professionals from 26 different countries. n www.bausch.com.

ad-EUR-1-2 hoch-1202v2-pva EUROTIMES | Volume 17RZ.indd | Issue1 10

29.02.12 13:43

Precision Laser System

OptiMedica Corp has announced expanded international market adoption of its Catalys Precision Laser System with new installations at the premier Shinagawa LASIK Center in Tokyo and Santa Maria Eye Clinic in Sakaide, Kagawa, Japan.

“The Catalys Precision Laser System allows surgeons to perform custom cataract procedures with unparalleled precision, exceptional patient comfort and a markedly streamlined workflow.

Dr Minoru Tomita and Dr Kunihiro Nagahara, of the respective centres, have joined a rapidly growing installed base of Catalys customers that include more than 20 centres in seven countries,” said a company spokeswoman. n www.optimedica.com

Review

JCRS HIGHLIGHTS

Journal of Cataract and Refractive Surgery

Refractive surgery on high

unchanged. As private non-governmental activities in space flights continue to increase, it will be necessary to take a closer look at ophthalmic issues in respect to vision and ophthalmic surgery. n T Kohnen, JCRS, “Effects of refractive surgery in extreme altitude or space”, Volume 38, Issue 8, Pages 1307-1308.

CR Gibson, JCRS, “Visual stability of laser vision correction in an astronaut on a Soyuz mission to the International Space Station”, Volume 38, Issue 8, Pages 1486-1491.

than in emmetropic eyes. However, the researchers caution that the anterior chamber might become critically shallow during accommodation in some myopic eyes, and this should be taken into account when planning phakic intraocular lens implantation to correct high myopia. n B Malyugin et al., JCRS, “Accommodative changes in anterior chamber depth in patients with high myopia”, Volume 38, Issue 8, pages 1403-1407.

OCT study of accommodation

What happens to central anterior chamber depth (ACD) in patients with high myopia during accommodation? Russian researchers looked at this question, obtaining ACD measurements in the non-accommodative state and during accommodation using the Visante AS-OCT device. Accommodative changes in the ACD were significantly less pronounced in eyes with high myopia

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

Photo: Cees van Roeden/Wonderful Copenhagen

Should refractive surgery patients be climbing mountains, much less going into earth orbit? Reports dating to the 1990s of mountain climbers who had undergone radial keratotomy (RK) developing dangerous amounts of hyperopic shift raised a red flag. There is strong evidence that the effect of altitude exposure on postRK eyes is caused by hypoxia rather than hypobarism and that breathing a normoxic inspired gas mix will not protect against the development of hypoxic corneal changes.

Previous RK recipients who insist on participating in mountaineering ventures at 2744 m (9000 feet) or higher should bring multiple spectacles with increasing plus lens power. However, more recent reports suggest that patients who undergo LASIK or surface ablation procedures do all right in extreme environmental conditions.

Studies of Mount Everest climbers who had LASIK have concluded that LASIK may be

a good choice in high altitude activities but those achieving extreme altitudes should be aware of possible fluctuation in vision.

Data suggest that a small refractive shift in the myopic direction may be present at extreme altitudes. Post-LASIK dry eye may play a role in this environment with such low ambient humidity. Climbers who do not ascend beyond moderate altitudes should not experience a post-LASIK refractive shift. What about space travel?

Researchers reported as early as 1999 that an astronaut who had undergone bilateral cataract surgery with IOL implantation maintained excellent and stable vision while in orbit. NASA recently approved of the use of LASIK for potential astronauts. In this issue, Gibson et al. describe the effects of photorefractive keratectomy (PRK) in an astronaut during a 12-day Russian Soyuz mission to the International Space Station. They found that PRK is likely a safe, effective and well-tolerated procedure in astronauts during spaceflight. After return, refraction, keratometry, corneal topography and wavefront aberrations were largely

Photo: Nowstockphoto

Welcome to the SOE 2013 Congress in Copenhagen

EUROTIMES | Volume 17 | Issue 10

Online Registration and Abstract submission will open 1 November, 2012.

Please stay updated on the SOE 2013 Congress website

www.soe2013.org

41

Feature

RESIDENT’s DIARY

A TINY DARK ROOM

From the clinician’s thrill of diagnosis to the patient’s depths of devastation

by Leigh Spielberg

S

ome diagnoses elevate you, hold you aloft for a moment of wonder, and then drop you like a brick, leaving you flat on the pavement, crushed.

I was working in the emergency room when we received a referral from an ophthalmologist: I hereby refer to you Mr Smits with an inferior “ablatio” retinae.

That was it.

The quotation marks around ablatio caught my interest. Had they been used because the doctor in question found it quaint that our hospital uses the old Latin term for a retinal detachment (RD)? Or was there something else going on?

The patient was in his early 40s, fit, wellgroomed, and particularly inquisitive and curious. The left eye saw 20/200 and the right eye 20/20. A quick look through a semi-dilated pupil of the left eye showed a large, bullous RD in the inferonasal quadrant. Macula on.

Wait, what? Macula on and 20/200 vision?

"Did you see flashes?"

"Nope."

"Floaters?"

"Nope."

"Trauma?"

"Nope."

The autorefractor showed +2 D hypermetropia OD and "no target" OS. Not myopic, not syndromic, no family history of RD. Okay, I thought, RDs can happen in hypermetropic eyes. Sometimes.

Rarely. But why "no target"? Why couldn’t the autorefractor refract? Interesting case!

I took a closer look at the posterior pole and saw fluid under the fovea. I dropped mydriatics in both eyes, sent him to photography for an OCT. I moved on to the next patient on this busy Friday afternoon.

When I continued with Mr Smits, dilated exam showed no tobacco dust in the vitreous.

Okay, I thought, that can happen sometimes. But wait, no horseshoe tears either? Okay, a macula-on RD with submacular fluid in a young, hypermetropic eye with no flashes, no floaters, no retinal tears and literally not a single risk factor for detachment. This doesn't make sense.

Look closer Spielberg, you must be missing something. Wait, what's that under the retina?

I looked at the patient and cleared my

EUROTIMES | Volume 17 | Issue 10

throat. "I'd like to do another test to get some more information," I said. "It's an ultrasound, like what the obstetricians use to see a baby in a pregnant woman."

"Okay," he replied. "The more information, the better, right?"

"Right."

Our hospital is highly focused on open communication, transparency and continual, up-to-date information for the patients. Simply said, the Dutch don't beat around the bush. This is reflected in the hospital's architecture. There are big, wideopen white spaces and few closed doors to be found.

The ultrasound room is an exception.

Tiny and dark, the room is so small that the ultrasound is behind the patient, who can't see the screen while we're making the images. I love Dutch straightforwardness, but at this moment, I was happy that the patient was still in the dark.

I began the imaging. I’m not yet an experienced ultrasonographer, but this pathology was like a goal without a keeper: I couldn't miss. It was huge, this thing under his retina, like a big grey hilltop loosely covered in cloth. "Look up,” I said. “Down, left, right, straight ahead." It was visible from every angle.

I thought to myself, I've never seen a choroidal melanoma, much less diagnosed one. Or is it maybe just a spontaneous choroidal haemorrhage? Spontaneous choroidal haemorrhage? Does that even exist? Okay, concentrate. Low internal reflectivity, biconvex, homogenous.

Obviously a melanoma. Or is it a metastasis?

Or a haemorrhage after all? Wishful thinking.

While the pictures printed, he asked me, "Do you have the information you were looking for?" Yes, I thought, I now have more information. But no, this is not the information I really wanted to see.

A few moments later, images in hand, we were on our way to the retina department. It is always a nice feeling to be able to consult the senior staff when confronted with serious or rare pathology.

The retinal specialist examined the patient and suggested we consult the ocular oncologist. After studying the medical file, the ultrasound images and the fundus, the oncologist said, "I'd like to get some additional information, so we'll plan a few

Credit: Eoin Coveney

42

more tests within the next few days."

“Is it serious?” the patient asked.

“That’s unclear at this point. We’ll have to wait until we have the results of all the examinations before we can say anything for sure.”

Despite the Dutch tradition of upfront disclosure, our hospital believes that a serious diagnosis like ocular melanoma should be conveyed to the patient under the best possible circumstances. We have a special consultation for this. It is run by the ocular oncologist and supported by specially trained nurses and staff who all take the time to explain the nature of the disease, the process of enucleation, the postoperative follow-up and the cosmetic aspects of the prosthesis. The patients are given the contact information of past patients who are willing to share their own stories. Coffee is served. The goal is to soften the impact of the whole ordeal, and it works well.

Nevertheless, cancer is cancer, and it's never a joyous occasion. I had arranged to see the patient after this appointment. Two

years of residency isn’t long, but it’s long enough for me to have discovered that the doctor who leads a patient into the deep, dark regions of a tragic diagnosis is often the only one who can bring him back to the realm of the living, psychologically speaking.

He was taking it relatively well, considering these circumstances, but whether that clear drop under his left eye was gel from the fundus lens or the result of emotion, I didn’t dare to guess. Today was, after all, the first day of the rest of his life. * The patient’s name has been changed to protect his privacy.

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

Where do you go for questions on: • • • • •

Fluid in interface years after LASIK Loose zonules MRSA endophthalmitis Prevention of epithelial ingrowth with flap lifts IOL target for captured optic

• Late onset corneal haze after PRK • YAG capsulotomy in the ASC

These are just some of the hundreds of everyday issues and questions ASCRS members discuss on eyeCONNECT. It’s where members tap into the awesome knowledge base of the ASCRS community for quick answers to pressing problems. eyeCONNECT gives members the assurance that they’re making the best choices possible. And it’s available only through ASCRS – the ONE society focusing exclusively on cataract and refractive surgery.

The power of the ASCRS community.

Can you afford to practice without it?

Subscribe to ASCRS’ eyeCONNECT today and connect with colleagues in a worldwide virtual community.

Visit www.eyeCONNECTIONS.org and click the Discussions tab.

Login (using the same user name and password as for the ASCRS website), click “My Subscriptions,” choose the list(s) you wish to subscribe to, the delivery method, and click “save.”

Not yet a member of ASCRS? Visit www.ASCRS.org and join online today.

Click the “Membership” tab.

EyeCONNECTLogin

44

Reference

calENdaR of EVENTs

Dates for your Diary

October

October

October

October

VI Congress of the Latin American Society of Cataract and Refractive Surgeons

Practice Development Weekend

EVER 2012 Congress

http://pddublin.escrs.org

www.ever.be

Modern Technologies in Cataract and Refractive Surgery – 2012

2012

2012

2012

2012

5-7 DUBLIN, IRELAND

4-6 BUENOS AIRES, ARGENTINA

10-13 NICE, FRANCE

8th International Symposium on Uveitis

www.congresos-rohr.com/alaccsar2012

8th Annual Congress of the CSCRS

25-27 MOSCOW, RUSSIA www.mntk.ru

19-22 HALKIDIKI, GREECE www.ISU2012.org

5-7 DUBROVNIK, CROATIA www.cscrs.hr

November

November

December

January

AAO•APAO Joint Meeting

19th Annual Scientific Meeting of the MCLOSA and Regional Scientific Meeting of the IOSS

5th Amsterdam Retina Debate

4th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

2012

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

New Horizons in Cataract Surgery 16 LONDON, UK

2012

2012

7 AMSTERDAM, THE NETHERLANDS www.amc.nl/retinadebate

30 LONDON, UK

2013

9-11 VIENNA, AUSTRIA

www.mclosa.org.uk/annualmtg.html

www.ophthalmictrainings.com

www.newhorizons2012.co.uk

January

2013

28th Congress of APAO & 71st Annual Conference of AIOS 17-20 HYDERABAD, INDIA www.apaoindia2013.org www.aios.org

February

February

February

3rd EURETINA Winter Meeting

17th ESCRS Winter Meeting

27th International Congress of HSIOIRS

2013

1-2 ROME, ITALY

2013

15-17 WARSAW, POLAND www.escrs.org

2013

28-3 MARCH ATHENS, GREECE www.hsioirs.org

www.euretina.org

June

July

September

October

European Society of Ophthalmology (SOE) 2013

26th APACRS Annual Meeting

13th EURETINA Congress

4th EuCornea Congress

www.apacrs.org

www.euretina.org

www.eucornea.org

2013

8-11 COPENHAGEN, DENMARK www.soe2013.org

2013

11-14 SINGAPORE

5th World Glaucoma Congress 17-20 VANCOUVER, CANADA www.worldglaucoma.org

2013

26-29 HAMBURG, GERMANY

2013

4-5 AMSTERDAM, THE NETHERLANDS

XXXI Congress of the ESCRS

5-9 AMSTERDAM, THE NETHERLANDS www.escrs.org

Advertising Directory: Abbott Medical Optics: Page: 3; Angiotech: Page: 12; ASCRS / Eyeworld: Pages: 34, 37, 43; Croma-Pharma: Pages: 9, 31, 40; CXL: Page: 21; D.O.R.C.: Page: 11; Katena: Page: 13; Medicel: Page: 32; NIDEK: Page: 25; Oculus: Page: 28; Oertli Instruments Ag: Page: IFC; OWL: Page: 8; Schwind: Page: OBC; SOE: Page: 41; VSY: Page: 29; Ziemer: Page: 39

17th ESCRS Winter Meeting Warsaw, Poland 15 – 17 February 2013 Abstract Submission Deadline: 31 October 2012

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS

www.escrs.org

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