Vol 17 Issue 4

VOLUME 17 ISSUE 4 APRIL 2012

paediatric ophthalmology

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EUROTIMES

april 2012 Volume 17 | Issue 4

Cover image supplied courtesy of Miraflex. www.miraflex.info

This issue...

Special Focus: Paediatric Ophthalmology 4 8 10 11 13

Cover Story: Refractive surgery in children Newsmaker interview with WCPOS co-chair/founder David B Granet More studies needed on drug for ROP Good long-term results reported following LASIK in children Paediatric retinal surgery problems highlighted

Cataract & Refractive

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10 37

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14 Femtosecond laser vs. Microkeratome for LASIK 15 Interactive tutorial prior to cataract surgery has benefits 16 Wet labs and video key to ophthalmology surgical training advancement 18 Endophthalmitis risk factors outlined 19 Cataract surgery on Alzheimer’s patients not without risk 21 Study shows good outcomes with LAL 22 New technologies and surgical techniques for astigmatism management 23 Hydrogel bandages may improve early visual outcomes after cataract surgery 24 Different lasers for different procedures discussed

Cornea 25 Iontophoretic riboflavin delivery could reduce administration time 26 Keratoprosthesis surgeons talk about their procedures of choice 27 Lamellar surgery on the increase in Singapore 28 More studies needed for survival of corneal grafts 29 Femtosecond laser versatility creates many possibilities 30 Keratoconus research may provide clues for cause of disease

Glaucoma 32 33

What is best procedure when trabeculectomy fails?

MIGS could be alternative for mild-to-moderate glaucoma

Retina 34 35 36

Access to care in rural Canada Grading system for diabetic retinopathy Vitrectomy benefits in DME

Ocular 37

Benefits of new photoreceptor in assessing clinical blindness discussed

Global Ophthalmology 38

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41

ORBIS and ESCRS help fight childhood blindness

Features 41 Bio-ophthalmology 42 Resident’s Diary 44 JCRS Highlights 45 Book Review 46 Outlook on Industry

47 Ophthalmologica Highlights 49 Eye on Travel 50 Industry News 52 Calendar

With this month’s issue... My Phakic Lens Experience: Why we prefer AcrySof® CACHET® Phakic Lens

editorial staff

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

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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

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Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

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As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2011 and 31 December 2011 is 32,332.

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GUEST EDITORIAL

Medical Editors

Volume 17 | Issue 4

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

CHANGING PERCEPTIONS

We want WSPOS to be a global organisation that reaches out to ophthalmologists of all age groups

by Ken Nischal FRCOphth

International Editorial Board

T

he second World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) meeting in Milan, Italy will send out the message that expertise does not reside in one part of the world.

At our first meeting in Barcelona in 2009, people who ordinarily did not get the chance to present on the world stage were given the opportunity to speak to their colleagues. When they did so, it changed the perceptions of some of the paediatric ophthalmologists in the developed world.

This helps to give WCPOS a collegial ethos. When you are collegial, you can really discuss important and controversial matters.

We recognise that the majority of eye care delivered to children in the world is by adult ophthalmic surgeons who see children, as well as dedicated paediatric ophthalmologists.

It is really important that adult ophthalmic surgeons who are taking the time to look after children feel that they are able to discuss their expertise and their problems with paediatric ophthalmologists.

In turn, paediatric ophthalmologists can learn from their adult counterparts about techniques that they are not aware of.

At our first meeting, we had 970 delegates from 133 countries.

This year in Milan, our second meeting will be held alongside the annual congresses of ESCRS, EURETINA and EuCornea. WCPOS will have joint symposia with these societies. For the first time ever in a paediatric ophthalmology meeting, we are also going to have wet labs using pig eye models that are as close to children’s capsules as they can be.

Because our first meeting was so successful, we have also been able to broaden our programme to three days and in those three days we will offer a variety of subjects that were not covered last time including early visual rehabilitation. This is very important because reading disorders are becoming more prevalent all over the world. Our two keynote speakers are giants in ophthalmology. They are Emilio Campos and Gerry Shields and we are delighted and honoured that they have agreed to speak at our meeting.

I also hope to see many young ophthalmologists attending our meeting. We want the World Society of Paediatric Ophthalmology and Strabisumus (WSPOS) to be a global organisation that reaches out to ophthalmologists of all age groups. The future of paediatric eye care lies in individuals who are enthused and energetic and committed to paediatric ophthalmology and strabismus.

We are offering an opportunity for people who are not sure if they are interested in paediatric ophthalmology to come and learn about a broad spectrum of subjects that we hope will instill enthusiasm in

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE them to take up the challenges that we are going to discuss.

Finally, I would like to thank EuroTimes, the official magazine of ESCRS, for giving WCPOS the opportunity to speak to its 32,000 readers. I am delighted that this issue of EuroTimes has a special focus on paediatric ophthalmology and I urge you to read the excellent articles that have been written to publicise our meeting and also to give the wider ophthalmic opportunity a new insight into paediatric ophthalmology.

Thank you and I look forward to seeing you in Milan.

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

* Ken Nischal is co-chair/founder of WCPOS. EUROTIMES | Volume 17 | Issue 4

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Cover Story

paediatric ophthalmology

COMING OF AGE

Corneal and lenticular approaches can improve outlook for paediatric refractory amblyopes and high ametropes

by Roibeard O’hEineachain

“

If you laser the refractive error away the vast majority of children that had not previously responded to conventional treatment will respond to it afterwards

William F Astle MD, FRCSC

“

My findings were that I didn’t have any complications and my youngest was aged two Michael O’ Keefe FRCS

EUROTIMES | Volume 17 | Issue 4

I

ncreasing evidence suggests that refractive surgery can improve the visual outcomes and binocularity of selected children with amblyopia, accommodative esotropia, and high myopia in whom conventional therapies have failed. However, the long-term risks are unknown and critics of such approaches have questioned the quality of the evidence.

The conventional treatments for amblyopia and high ametropia include optical correction with glasses or contact lenses and, in the case of amblyopia, patching or atropine in the better eye. In the majority of cases those interventions can produce satisfactory results with a corrected visual acuity of 20/40 or better in both eyes.

However, in a small proportion of children the treatment will fail, despite the best efforts on the part of their parents, their physicians, orthoptists and optometrists.

The failure can be due to a number of reasons. For example, amblyopic children with high degrees of anisometropia can have overwhelming difficulties with spectacles because of the disparity between the sizes of the two images they present to their two eyes. Moreover, children with very high myopia require thick glasses that can cause a disturbing prism effect.

Contact lenses can produce excellent optical results in many such cases but require a lot in the way of supervision on the part of the parents and cooperation on the part of the children. Compliance with spectacle and contact lens use and patching can also be extremely difficult hurdles to overcome in some children with neurobehavioural disorders, such as autism and Down’s syndrome.

The main types of refractive surgery that have been performed in children have been LASIK, surface ablations such as LASEK and PRK, and the implantation of phakic IOLs, such as the iris-fixated Artisan and Artiflex IOL. The results of many studies have indicated that the techniques can produce satisfactory outcomes, but they all have their potential drawbacks.

Courtesy of Michael O’ Keefe FRCS

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Two-year old girl with left rigid phakic IOL in-situ (Artisan)

For example LASIK could in theory present a greater risk of flap complications in children than in adults, not only from eye-rubbing but also from the normal rough-and-tumble in which children commonly engage. Moreover, the depths of ablation required in many cases could put the patients at risk for ectasia. For the same reason, surface ablation procedures could entail an increased risk of haze. Phakic IOLs, meanwhile, might pose a higher risk to the corneal endothelium than would be the case in adults, given the additional decades the IOL would be in the eye.

So far, so good Those who practise paediatric refractive surgery maintain that their experience shows that concern about the risks, while understandable, has been somewhat exaggerated. Moreover, they argue that the studies conducted to date indicate that not only does refractive surgery appear to be effective in the treatment of amblyopia and high ametropia, but it is also

as safe in children as it is in adults, with little evidence of the most feared potential consequences.

“All clinicians should consider this therapy for children where traditional methods fail. If you laser the refractive error away the vast majority of children that had not previously responded to conventional treatment will respond to it afterwards,” said William F Astle MD, FRCSC, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada, in an interview.

He said that in his experience of treating paediatric patients over the past 12 years with surface ablations such as PRK and LASEK for refractory anisometropia amblyopia and bilateral myopia, treatment has resulted in an overall improvement in best-corrected visual acuity and stereopsis with fairly predictable refractive outcomes with minimal to no haze.

For example, a five-year follow-up review of 56 eyes of 39 paediatric patients who underwent PRK or LASEK at a mean age

Long follow-up with LASIK Dr Michael O’ Keefe FRCS, Mater Private Hospital, Dublin, Ireland, said that his 10-year results with LASIK in a small series of seven eyes of six amblyopic children show that postoperative refraction has remained fairly stable throughout the follow-up period and that five children achieved an improvement in visual acuity.

The study involved children ranging from two to 12 years in age. In their treated eyes the mean preoperative spherical equivalent was -10 D and ranged from -5.00 D to -16.0 D and the mean preoperative visual acuity ranged from hand movements to 6/18.

After a mean follow-up of 9.5 years the mean spherical equivalent was -4.3 D, compared to -9.6 D preoperatively. In addition, visual acuity improved by a mean 2.5 Snellen lines in six eyes, although one eye remained amblyopic. Postoperative visual acuity ranged from 6/6 to 6/60. One EUROTIMES | Volume 17 | Issue 4

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Courtesy of William F Astle MD, FRCSC

of 6.5 years showed that the mean spherical equivalent was -1.73 D. Prior to surgery they had more than 3.0 D of anisometropic amblyopia and/or more than -5.0 D of bilateral myopia (Astle et al, J Cataract Refract Surge 2008; 34: 411-416).

Moreover, among 28 eyes in which visual acuity was measurable preoperatively, there was a mean improvement of 1.6 lines, with a range of zero to seven lines of improvement.

In addition, 19 (49 per cent), had measurable stereopsis after surgery, compared to only seven patients (18 per cent) preoperatively.

Furthermore, none of the children had a reduction in BCVA or binocular fusion postoperatively.

In addition, in their responses to a quality-of-life questionnaire, parents noted numerous improvements in the behaviour and general demeanour of the children following their treatment and over 90 per cent said they would recommend LASEK for children with similar problems, Dr Astle said.

He noted that although trace corneal haze occurred in nine patients, all cases resolved over time.

“In our initial studies we had three or four children who were a little over the -15 D range who got significant haze that we had to re-laser. But at about that time LASEK came on board and we added mitomycin to the mix. That combination of LASEK and mitomycin virtually eliminated that problem, so haze is never a significant issue anymore,” Dr Astle said.

He noted that an inherent difficulty with corneal ablative techniques in very young children is that they require the use of general anaesthesia. Therefore children cannot fixate during the procedure. However, Dr Astle said that the iris recognition capabilities of the Technolas laser he now uses could provide an acceptable result. Patients tended to have a satisfactory resolution of their anisometropic amblyopia if the refraction of their treated eye was within two or three dioptres of their fellow eye, he added.

Moreover, as the patients’ eyes grew, the normal myopic shift that occurs as a child grows generally occurred at the same rate in the two eyes, maintaining their refractive balance. He added that he currently corrects them by about a dioptre extra to compensate for the myopic shift of the children’s growing eyes. “You get the occasional outlier where you have to tweak it again but usually they'll shift at the same rate in both eyes,” he added.

Standard anaesthetic technique delivered in a standard way, airway management options usually include either a laryngeal mask, or a naso-pharyngeal airway

child gained no improvement because of non-compliance with postoperative patching.

“My findings were that I didn't have any complications and my youngest was aged two. Those that improved were the ones that I did early and could patch later. There were no flap complications and no signs of ectasia,” Dr O’Keefe told EuroTimes.

Another finding was that there were no complaints from the children regarding photic phenomena, despite the high amounts of aberrations the procedure produced, he said.

“We didn’t have wavefront-guided ablations or any of those things, so we induced a lot of higher order aberrations on these corneas. But none of these children complained about haloes or glare of any form so maybe they have some sort of adaptation but they don’t get any of the symptoms associated with higher order aberrations,” he said.

Phakic IOLs becoming more favoured option Dr O’Keefe told

EuroTimes that since conducting those cases he has converted from the corneal ablative approach to a lenticular approach using Artisan and Artiflex iris-clip IOLs, which he said have become the preferred option for most practitioners of paediatric refractive surgery in Europe. He noted that he has been using the lenses in children and has found that they appear to produce very predictable results.

“Implants have become the more common option for amblyopic anisometropia for a number of reasons.

First of all, there is quicker rehabilitation, second it can be done in the ordinary operating room and can be done by surgeons who don't have any expertise in using lasers or for cutting flaps or doing corneal refractive surgery, and of course it's also less expensive because you don't need all this equipment.“ An additional advantage of phakic IOLs is that they can be replaced if refraction changes significantly as the child grows.

Furthermore, it leaves the cornea largely untouched, leaving the option open for future corneal ablative procedures.

On the other hand, some have expressed concern that although the Artisan lens has a proven track record regarding safety in the adult population, the situation is less clear in children, given the short follow-up available to date and the greater number of years the implants would likely be in the child’s eye.

“These implants have been used for a greater period of time in Europe than in the US. However the 15-year experience in an adult eye is not comparable to the same 15 years in a child's eye. My particular concerns are low-grade iritis and pigment dispersion, along with gradual but inexorable endothelial cell loss. We may or may not find that in 15-20 years we are explanting phakic IOLs placed in children, and/or performing lamellar corneal

“

If by ‘failure’ it is meant that the parent comes back and says the child didn’t want to wear glasses, I would have that every day David B Granet MD

contacts

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Cover Story

paediatric ophthalmology

William F Astle – william.astle@albertahealthservices.ca Michael O’Keefe – mokeefe@materprivate.ie Sandra M Brown – sbrownmd@cabarruseye.com David B Granet – dgranet@ucsd.edu

“You have a child with autism, cerebral palsy, Down’s syndrome, or some other behavioural issue who for some reason will not wear glasses or cannot wear glasses. By doing refractive surgery on them you give them the opportunity to re-engage with the world and see clearly and interact”

Courtesy of William F Astle MD, FRCSC

David Granet MD

Paediatric anaesthesia under the laser

“

When you propose an operation with inherently unknown long-term complications, you have to be honest with parents and patients about how the surgery is going to change the child’s life for the better Sandra Brown MD

transplantation,” said Sandra Brown MD, Cabarrus Eye Centre, Concord, North Carolina, US. However, Dr O’Keefe said the benefits may justify the risks, particularly since in his experience to date the implants have been as free of complications in children as they have been in adults.

“My experience to date is that these implants work really well in children as well. We haven't seen pigment dispersion in adults or children in any shape or form and although we haven’t done endothelial cell counts we have no reason to believe the results will be different in children than adults. Another thing that critics of refractive surgery in children say is that children might displace their implant by rubbing their eyes, but again, I don't buy into that either,” he said. "I have shown significant improvement in all vision specific sub-scales of National Eye Institute VFQ-25 using foldable irisfixated intraocular lens implantation in a subset of paediatric patients with special refractive needs who were intolerant of conventional treatment (article published in Acta Ophthalmol February 2012)."

Patient selection still a matter of debate The current indications for

paediatric refractive surgery include anisometropic amblyopia, high bilateral high myopia and accommodative esotropia that has not responded to conventional treatment.

Those who perform such procedures say that eligibility for such procedures is often obvious at an early stage.

“The anisometropic amblyope, the classic one, is a child who starts at 20/400 and after patching treatment they get to 20/80 but no matter what you do it won't change. If you’ve done six months to a year of traditional EUROTIMES | Volume 17 | Issue 4

treatment and it's really not responding you can add this to the armamentarium,” Dr Astle said.

On the other hand, while there is a broad consensus that an essential eligibility criteria for paediatric refractive surgery in a given patient is the failure of conventional treatment, there appears to be less agreement about what actually constitutes treatment failure. And some have expressed concern that the availability of refractive surgery for children with amblyopia and high ametropia may cause the parents of affected children to regard it as an easy option.

“If by ‘failure’ it is meant that the parent comes back and says the child didn't want to wear glasses, I would have that every day. And if we told those families: 'by the way, if you fail wearing glasses, then we will laser the child,' how many of those families would've failed the glasses, knowing they had another option?” said David B Granet MD, UCSD Ratner Children's Eye Centre, La Jolla California, US. He noted that in a study he conducted a few years ago involving children with hyperopic anisometropia he was able to achieve satisfactory results in 97 per cent of cases. He noted however, that he had fewer qualms about recommending refractive surgery to children with refractive disorders who have neurobehavioral disorders.

“You have a child with autism, cerebral palsy, Down's syndrome, or some other behavioural issue who for some reason will not wear glasses or cannot wear glasses. By doing refractive surgery on them you give them the opportunity to re-engage with the world and see clearly and interact. To me that falls into the category of a blessing, it is a blessing to be able to do that for that child because those kids really need our help, and they really have no other choice,” Dr Granet said.

Dr Brown said that she has seen some interesting preliminary results in a study involving developmentally delayed children with bilateral high myopia who underwent phakic IOL implantation.

“The study was spearheaded by Evelyn Paysse MD and has a more rigorous design vis-à-vis measuring 'soft' outcomes like socialisation, mobility, and environmental awareness. Rather than showing considerable improvement in these paramaters, the early data showed a slower rate of decline compared to agematched normal children. I do not think

this surgery should be offered outside of an IRB-sanctioned investigation with a safety monitoring committee,” she added.

Dr Brown noted she had more reservations about performing corneal photoablative procedures in paediatric eyes. She said that such procedures would be best restricted to very cooperative patients who could undergo wavefront-customised treatment, and even then, only if testing with contact lenses could prove that definite gains in binocular vision were possible.

“Such gains would include better oculomotor alignment if strabismus is present, and markedly improved stereopsis.

Ideally the patient would reliably and convincingly report improvement in activities of daily living when wearing a contact lens as opposed to spectacles or no optical correction, although such self-reports must be interpreted with caution,” she said.

Dr Brown has published several articles in ophthalmology journals criticising paediatric refractive surgery as currently practised.

She said her principal objection has been that investigators have focussed mainly on refractive outcomes and visual acuity, but with, in her opinion, inadequate attention to the child’s binocular quality of life.

“When you propose an operation with inherently unknown long-term complications, you have to be honest with parents and patients about how the surgery is going to change the child's life for the better.

And the answer to this question needs to be concrete and relevant to the particular child in question,” she told EuroTimes. "It needs to positively affect the child's function with both eyes open."

Meanwhile, proponents of paediatric refractive surgery argue that the benefits to children are clear from the results thus far achieved. They warn, furthermore, that an overly cautious attitude to paediatric refractive surgery could result in a lot of children not receiving treatment at an age when it would be most effective.

“I think that the time to consider paediatric refractive surgery is now because there are a lot of people around the globe who are looking into this and we’re all getting the same results and it works extremely well.

I'm not suggesting that we laser every child who wears glasses, but for the ones who are falling through the cracks and struggling and not doing well it's the way to go and it's time to really consider it seriously because it really works,” Dr Astle said.

Symptomatic VMA A Disease That’s Gaining Traction

Symptomatic vitreomacular adhesion (VMA) is an increasingly recognized sight-threatening disease of the vitreoretinal interface 1

VMA: » May lead to symptoms such as metamorphopsia, decreased visual acuity, and central visual field defect2 » Can cause traction resulting in anatomical damage, which may lead to severe visual consequences, including3,4 • •

Macular hole3 Retinal tear/detachment4

RefeRences 1. Schneider EW, Johnson MW. Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review.

Clin Ophthalmol. 2011;5:1151-65. 2. Steidl SM, Hartnett ME. Clinical pathways in vitreoretinal disease. New York: Thieme Medical Publishers; 2003. Chapter 17; 263-86. 3. Gallemore RP, Jumper JM, McCuen BW 2nd, Jaffe GJ, Postel EA, Toth CA. Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina. 2000;20(2):115-20.

4. Mitry D, Fleck BW, Wright AF, Campbell H, Charteris DG. Pathogenesis of Rhegmatogenous Retinal Detachment: Predisposing Anatomy and Cell Biology. Retina. 2010 Nov–Dec;30(10):1561–72.

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Cover Newsmaker Story //Interview

SECTION WCPOS HEAD

David B Granet – dgranet@ucsd.edu

Section sub head

sharing ideas

The co-chair/founder of the World Congress of Paediatric Ophthalmology and Strabismus, David B Granet, encourages collaboration among specialties

S

ome international conferences err on the side of one part of the world thinking they know everything, telling other parts of the world this is how it should be done. Our idea with the upcoming WCPOS meeting in Milan, in contrast, is that expertise does not reside just in one region of the world.

Rather we need a conversation, a sharing of information. We are putting on the podium the best people from each part of the world. Part of the great success of our initial meeting in Barcelona was what you cannot capture at home. There was a great camaraderie, and sharing that happened in between the sessions, or after a session when a crowd would come up afterwards to the front after hearing about a new procedure or technique. Whether the information came from South America, or Europe, the Middle East or Asia, there was excitement about something never heard before. We saw equally smart people from around the world talking to each other, all with the goal of helping patients. People made lasting friendships that can develop into research projects. For example, I met a young man in Barcelona that ended up coming to my centre from Egypt, and spent two years here doing a fellowship.

There is no room for dogmatic thinking I think some of my US colleagues were quite surprised by what they learned at our first meeting. Things that we thought of as dogma in the US are really not in other parts of the world. For example, the idea that many Europeans were doing strabismus surgery with an operating microscope, was surprising to the Americans.

It is important to understand cultural issues We also have a lot to learn about cultural considerations of care. Some of the differences are shocking. A doctor from southern India stood up in Barcelona and said that in her region strabismus was considered a blessing and good luck. Parents don’t want to straighten the eyes because it’s a gift from God. I had never in my life heard that before. Cultural differences lead to differences in care. A recent Swiss study reported that children over the age of six with strabismus don’t get invited to birthday parties. In parts of Asia we know that strabismus can lead to ostracism. We need to understand how cultures differ, and look at the psychosocial impact of the care we provide. We are planning to do shared research to try and look at those issues in different parts of the world.

David B Granet

There are so many interesting differences, for example with strabismus surgery, how do you measure? Do you cut muscle? What kind of suture are you using? This all varies across the globe. This is seen across the board. And in the retina field, we’ve seen that screening for retinopathy of prematurity is not the same the world over. What about paediatric cataract – do you operate on both eyes simultaneously? When do you operate, and which lens should you use? In Europe it is standard practice to place an Artisan clip lens in an aphakic child. This lens was only recently approved in the US, and not for aphakia. The US FDA wants us to do a study on something that has been around for more than 20 years in Europe!

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Adults and children, who does what? In the US, paediatric and strabismus care have been a unified specialty for quite a while. However, this is not the case everywhere. In South America these have been considered separate specialties. Similarly, in England there were two separate societies. This is starting to change. We want to provide an opportunity to facilitate this.

In much of the world the general ophthalmologist includes paediatric patients in his/her practice. Some cataract and refractive surgeons may have upwards of 20 per cent paediatric patients.

There are so many differences between these patient groups that we have developed a programme that will update adult ophthalmologists on the latest developments in paediatrics. What do you do in a child

with a corneal opacity? Who takes care of that child? The cornea surgeon may be best trained to replace the cornea, but the paediatric ophthalmologist might be the best one to deal with the refractive errors and post-op exams. We have to partner and share information. It is like the old story of the three blind men and the elephant, one grabs the tail, one the trunk, one the leg, and they all describe a different animal. We’re doing that with children. The retina people for example, are OK with injecting Avastin into the eye because they are doing it all the time, but now this is being tested in ROP in preemies. Paediatric ophthalmologists are hesitant about putting an antiangiogenesis drug into a growing child, and want to know how this will affect brain growth and what will happen to eyes later on. We’ve added special sessions on retina and cornea for the Milan meeting so we can all exchange views on these topics.

Paediatric ophthalmology is rewarding It is an incredibly exciting and satisfying career choice. Yet there are paediatric fellowships available now that are not even getting filled.

The tide does seem to be turning, and we’re seeing more interest, with some medical students looking more at the intellectual challenge and favourable lifestyle profile associated with this specialty. You will see every possible form of disease: cornea, oculoplastics, cataracts, glaucoma, refractive, retina ROP and diabetes. You are a generalist and a specialist, and doing strabismus surgery on top of that. It is so rewarding because you never stand so tall as when you bend to help a child. You are having an incredible impact on these patients’ lives. With simple amblyopia therapy you will restore vision for 80 years.

Being a paediatric ophthalmologist is the most rewarding thing I can possibly imagine.

David B Granet MD, FACS, FAAP, FAAO, is the Anne Ratner chair of paediatric ophthalmology and director of the Anne F and Abraham Ratner Children’s Eye Centre located within the Shiley Eye Complex, University of California, San Diego, US.

RUSSIAN LANGUAGE EDITION NOW ONLINE

www.eucornea.org

3rd EuCORNEA CONGRESS 6-8 SEPTEMBER

www.euretina.org

12TH EURETINA Congress 6-9 SEPTEMBER

ION T A R T S REGI OPEN

www.wcpos.org

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

www.escrs.org

XXX Congress of the ESCRS 8-12 september

Special Focus

paediatric ophthalmology

contact

Helen A Mintz-Hittner – helen.a.mintz-hittner@uth.tmc.edu

AVASTIN FOR ROP

Timing of bevacizumab is a critical component of the therapy

by Sean Henahan in Orlando

A

study showing therapeutic value for the anti-VEGF agent bevacizumab (Avastin, Genentech) in infants with retinopathy of prematurity (ROP) is stirring hope, and controversy.

Helen A Mintz-Hittner MD, professor in the Department of Ophthalmology and Visual Sciences, University of Texas Health Science Center-Houston Medical School, Houston, Texas, discussed the latest results of the BEAT-ROP study during a session of the annual meeting of the American Academy of Ophthalmology.

“This research was published recently in a landmark article in the New England Journal of Medicine. To say that it has generated some controversy among ophthalmologists, paediatricians and neonatologists would be an understatement,” noted Ken Nischal, MBBS, director of Children’s Hospital of Pittsburgh, Pennsylvania, US, in his introduction of the keynote address.

The BEAT-ROP (Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity) study is an ongoing prospective, controlled, randomised, stratified, multicentre trial that was designed to assess intravitreal bevacizumab monotherapy for Zone I or Zone II posterior stage 3+ retinopathy of prematurity. Infants received either intravitreal bevacizumab (0.625mg in 0.025ml of solution) or conventional laser therapy, bilaterally.

The study enrolled 150 infants of whom 143 survived to 54 weeks’ post-menstrual age. Retinopathy of prematurity recurred in four infants in the bevacizumab group

“

Mortality comes up in editorials. It seems that a lot of people can count a lot better than they can read. I want to point out that three of the Avastin patients had non-Avastin related deaths

Helen A Mintz-Hittner MD EUROTIMES | Volume 17 | Issue 4

compared with 19 infants in the lasertherapy group, a highly statistically significant difference. A significant treatment effect was found for Zone I retinopathy of prematurity but not for Zone II disease.

“The Zone I results are the ones we consider to be significant. We think bevacizumab treatment should be considered for the treatment of visionthreatening ROP in zone I patients by the people doing this kind of work.

“Indeed, I think it is inappropriate not to at least explain this drug to parents. It is a game changer in Zone I cases – with life-long consequences to vision,” Dr MintzHittner commented.

Editorials and commentaries in various medical journals raised questions about the study design and findings, and the potential risks of using anti-VEGF agents in very small infants. Dr Mintz-Hittner addressed these issues in her presentation.

Written informed consent Because the use of bevacizumab as monotherapy for vision-threatening ROP is an off-label indication, it is essential to obtain written informed consent from the parent or guardian. Records must reflect that Avastin is not FDA approved for this patient group or this disease. Clinicians need to keep a patient log with the pharmacy source and log numbers recorded by trained personnel. The drug must be administered using a sterile technique by an ophthalmologist trained to give intravitreal injections specifically for ROP, she emphasised, adding: “This is not something to be undertaken lightly.”

Timing of bevacizumab is a critical component of the therapy. Given too early in phase 1, before 31 weeks post-menstrual age (in Stages 1 and 2), patients may develop a severe retinal dystrophy causing cessation of retinal development. Given too late, beyond phase 2, after 45 weeks' postmenstrual age, the drug may cause severe, rapid contraction of the membranes, producing an accelerated retinal detachment. The surgeon must be prepared to do a vitrectomy if administering the drug when severe tractional elements are present (in Stages 4 and 5), she explained.

“When the drug is given at just the right time, in the phase 2 of the

Avastin: 470 grams + 23 weeks at birth – pre injection – 2.5 months of age

Avastin: 490 grams + 24 weeks at birth – pre injection – 2.5 months of age

Avastin: formerly 470 grams + 23 weeks – now one year postinjection – 14 months of age

Avastin: formerly 490 grams + 24 weeks – now one year postinjection – 13 months of age

pathogenesis of ROP (best when Type 1-ETROP), it reduces venous dilatation, arterial tortuosity, and intravitreal neovascularisation, and allows continuation of the retinal avascularisation into the avascular retina.”

Dose is also very important. If too low a dose is administered, the result could be recurrence of intravitreal neovascularisation. Too high a dose will stop the growth of retinal vascularisation into the avascular retina. Patients in the BEAT-ROP protocol received half the adult dose of bevacizumab, 0.625mg in 0.025ml of solution.

Some commentators raised the issue of mortality in the BEAT-ROP study. Seven patients died before reaching the primary outcome of the study, 54 weeks’ postmenstrual age. Five of these had received intravitreal bevacizumab, and two had undergone laser treatment.

“Mortality comes up in editorials. It seems that a lot of people can count a lot better than they can read. I want to point out that three of the Avastin patients had non-Avastin related deaths. One was a do not resuscitate (DNR), which we did not know at the time of enrollment.

A few days into the study, the mother asked for the baby to be taken off the ventilator. Two other patients were the only ones who went home on oxygen. The parents discontinued the oxygen, turned off the monitors and left the room. I do not consider those drug-related deaths.

That leaves two deaths in each treatment group,” she said.

No ocular complications were observed in the study or in animal models or in human case reports. Nonetheless, it is essential that clinicians be looking for immediate traumatic events including: lens rupture, lens dislocation, retinal tears, and retinal detachment. They should also be vigilant for cataracts, and endophthalmitis, she stressed.

Courtesy of Helen A Mintz-Hittner MD

10

More studies needed “Systemic toxicity associated with intravitreal bevacizumab has not been demonstrated in pre-term infants with ROP. Nonetheless, we must have additional prospective studies. We need to have one or more large prospective studies to investigate the potential effects of anti-VEGF agents on the brain, lung and kidney,” she said.

She also cited a need for better pharmacokinetic studies, including studies of human plasma samples for at least 10 weeks following injections, although these may not reflect tissue levels because of natural organ development (eg, blood brain barrier). Future large, randomised clinical trials should also look for efficacy in patients with ROP in zone II, as well as for toxicity. There is also a need for a registry for those patients not treated in the context of a clinical trial that would track immediate complications, recurrence, long-term toxicity (ocular or systemic), and drug-related mortality.

The complete details of the BEAT-ROP study appeared in the New England Journal of Medicine, Mintz-Hittner et al., 2011 Feb 17;364(7):603-15.

11

Special Focus

paediatric ophthalmology

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

This is the moment we work for.

Paediatric LASIK

Safe and effective long-term results reported

by Dermot McGrath in Vienna

L

ong-term data suggest that LASIK may be employed safely and successfully in children with anisometropia and high myopia to treat or prevent amblyopia that is refractory to conventional treatments, according to a study presented here. “LASIK in children is very rare and still controversial, but it may be indicated in exceptional circumstances such as high myopia or high anisometropia where the patients are poorly compliant or have failed to respond to conventional amblyopia treatment,” Claire Hartnett MD told delegates attending the XXIX Congress of the ESCRS. Dr Hartnett’s case series included seven eyes of six children who underwent LASIK between 2000 and 2005 at the Children’s University Hospital, Dublin, Ireland. The patients’ ages ranged from 2.5 to 8.5 years with a mean of four years.

Five of the children presented with highly myopic anisometropic eyes and one child had bilateral high myopia. The mean spherical equivalent was -9 D and all patients had failed conventional amblyopia/ anisometropia treatment. All LASIK surgeries were performed under general anaesthesia with a flap size between 8.5mm to 9.5mm and an optical zone of 5.5mm to 6.0mm. In all patients the aim was to achieve a symmetrical refraction and to reduce the anisometropia, said Dr Hartnett.

Myopia reduction The results showed no intra- or postoperative complications with a mean follow-up of 9.5 years. Visual acuity improved in six out of seven eyes with a mean improvement of 2.5 Snellen lines. One patient had no change in visual acuity and remained amblyopic. All eyes achieved a reduction in myopia and an improvement in symmetrical refraction with a reduction in anisometropia.

The mean spherical equivalent went from -9.6 preoperatively to -3.0 D postoperatively after two years and -4.3 D at 9.5 years.

In terms of long-term outcomes, Dr Hartnett noted that myopic regression had not occurred at two years postoperatively but was found in five out of seven eyes at the end of the follow-up period. The mean myopic regression was -2.4 D in the treated eyes and -3.7 D in the fellow non-treated eyes.

There was no evidence of corneal ectasia or haze, epithelial ingrowth, flap complications or complaints of glare. The pachymetry results were satisfactory overall with a mean EUROTIMES | Volume 17 | Issue 4

central corneal thickness of 472 microns.

Summing up, Dr Hartnett said that the study was limited by the fact that it was a small case series, but said that to her knowledge this was the first report of longterm follow-up of LASIK in young children.

LASIK may also be successfully employed as an alternative treatment for non-compliant paediatric patients with esotropia, according to a separate study presented by Ahmed M Saeed MD, Benha University, Egypt.

Dr Saeed noted that accommodative esotropia is the most common type of strabismus with a very favourable prognosis if the appropriate treatment is initiated promptly. Traditional methods of treatment included spectacle or contact lens correction for the cycloplegic hyperopic refractive error.

“We found a considerable proportion of the spectacle-dependent children did not wear their glasses or did not return for follow-up visits. This non-compliance leads to loss of stereopsis and development of ammetropic and strabismic amblyopia which is difficult to correct later on,” he said.

Dr Saeed’s study included 20 eyes of 10 consecutive paediatric patients with accommodative esotropia. All patients were non-compliant with spectacles and had stable refraction for at least 12 months prior to the LASIK procedure. The mean patient age was seven years. All patients underwent bilateral LASIK under general anaesthesia using standard hyperopic nomograms on the Allegretto Wave (Alcon) excimer laser platform to fully correct their cycloplegic hyperopic refractive error.

All eyes were within 0.5 D to +1.5 D of emmetropia at the final evaluation, with a statistically significant improvement of the refractive error. Dr Saeed noted that all patients achieved orthophoria and no significant intraoperative or postoperative complications were recorded.

“While there are some obvious limitations to the study in terms of the small number of patients, short follow-up time and lack of a comparison group, LASIK does seem to be an effective and relatively safe method to treat accommodative esotropia in young children, although the role of careful patient selection must be emphasised,” he concluded.

contacts

Claire Hartnett – claire.hartnett@cuh.ie

Ahmed M Saeed – a_saeed775@

yahoo.com

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13

Special Focus

paediatric ophthalmology

RETINA SURGERY

Dublin conference discusses key problems and results of retinal surgery in children

by Priscilla Lynch in Dublin

S

cleral buckling is still the most common paediatric retinal surgical procedure, while vitrectomy should be left as the last option, reported researchers at the 13th International Paediatric Ophthalmology Meeting.

“The potential problems with retinal surgery in children are absolutely enormous.

First of all children often present late with detachment and they often have aggressive PVR,” said Dara Kilmartin MD, consultant vitreoretinal surgeon, Royal Victoria Eye & Ear Hospital, Dublin, Our Lady’s Children’s Hospital, Crumlin, Dublin. He added that the anatomical and functional success rate is poorer compared to adult surgery.

Dr Kilmartin’s presentation during the retina session at the meeting outlined the key problems and results of retinal surgery in children. To safely operate on young children a trained paediatric anaesthetist is essential, Dr Kilmartin emphasised, adding that the pars plana is not fully developed in infants until they are well over six months of age and it continues to develop up to six years.

Retinal tears “Posterior hyaloid separation is usually not possible and often dangerous with high risk of retinal tears so this should not be your surgical goal in most children,” he said.

Dr Kilmartin stressed that amblyopia management requires an aggressive team approach, with close co-ordination with paediatric ophthalmology colleagues. Patients should ideally be managed in a paediatric unit with assessment with the orthoptic team.

Internationally, retinopathy of prematurity (ROP), trauma, congenital abnormalities, and uveitis/infection are still the most common indicators for retinal surgery in infants and young children. However ROP-related detachments are rarely seen in Ireland, most likely due to a “very proactive” screening programme in Irish neonatal units and the low incidence of premature births, he said.

Scleral buckling is the most common retina procedure in children, particularly for dialysis and trauma-related detachments, as it is a very good, safe technique in children, according to Dr Kilmartin.

However, there are potential problems in this cohort as their eyes are still growing and the scleral buckle often needs division later.

“That can often be achieved by cutting the silicone band, which I use in all my scleral EUROTIMES | Volume 17 | Issue 4

buckle cases,” Dr Kilmartin explained.

“Up to 12 D anisometropia can be induced by buckling in an ROP eye and this will induce a massive degree of amblyopia and this will need to be cut within months of performing this procedure. A wider buckle is often needed, as later presentation is usually associated with PVR. You can cut the 40 band alone later leaving the silicone explant in place.”

Highlighting the risks with vitrectomy, he said it is not necessary and is dangerous to try and remove all vitreous or pre-retinal membranes from the inner retinal surface.

“Iatrogenic retinal breaks usually result in inoperable retinal detachment, even with PFL and oil, as you cannot completely dissect vitreous from inner retina.”

However, Dr Kilmartin acknowledged that the newer techniques in microincision vitrectomy mean it is now easier to safely shave much closer to the retina, but there is still some way to go in this area.

He presented a comparative study of two of his patient cohorts over succeeding time periods, which showed that uveitis has superseded trauma as the main indication in the latter group. He reiterated that modern vitreoretinal surgical techniques can help achieve retinal reattachment in most cases but multiple procedures are required frequently to attain this. “Microincision vitrectomy techniques are becoming more important particularly with core vitrectomy.

There is a new trial using microplasmin to enzymatically dissolve the vitreous.

The results of that study will allow safer vitrectomy”, he told EuroTimes.

Dr David Keegan, consultant vitreo-retinal surgeon, Mater Hospital, Dublin, gave the meeting a detailed presentation on the key causes of paediatric retinal detachment.

Infant retinal detachments comprise 10 per cent of all detachments though the annual incidence in the paediatric population is low (2.9 per 10,000) compared to adult incidence (10-20 per 10,000), while prevalence is also higher in male infants (3.7 male vs 1.6 female per 10,000), he noted. Tractional retinal detachments are the most common type seen in infants, with developmental conditions (eg, ROP, FEVR, or PHPV) and congenital disorders (eg, coloboma or incontinentia pigmenti) causing most paediatric retinal detachments.

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The Ziemer FEMTO LDV Z Models are CE marked and available for delivery. Product launch and availability for the United States pending FDA clearance. For some countries availability may be restricted due to local registration. The creation of a corneal pocket is part of a presbyopia intervention. Availability of related corneal inlays and implants according to policy of the individual manufacturers and regulatory status in the individual countries. Cataract procedures with the FEMTO LDV Z2, Z4 and Z6 models are not cleared in the United States and in all other countries. An upgrade possibility for these devices is planned once cataract options are available and cleared by the responsible regulatory bodies.

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14

Update

cataract & refractive

FEMTOSECOND LASER LASIK

Laser for flap creation affords numerous benefits, but also trades some old problems for new

by Cheryl Guttman Krader in Vienna

F

emtosecond laser for LASIK flap creation offers many advantages, but it does not overcome all of the issues associated with mechanical microkeratomes, said Joseph Colin MD, at the 2nd EuCornea Congress.

Dr Colin, chairman, Department of Ophthalmology, Bordeaux University Medical School, reviewed the differences in characteristics of flaps created using a femtosecond laser and mechanical microkeratome.

He concluded that while mechanical microkeratomes can create high-quality flaps, results from a number of studies establish the superiority of the laser for creating better quality flaps with more predictable thickness and smoother stromal beds. In addition, the femtosecond laser creates flaps with a more desirable, planar morphology compared with a mechanical microkeratome, which enables better positioning to reduce risks of epithelial ingrowth and striae formation.

The laser also offers greater customisation.

Hinge location can be varied, which can be helpful in some eyes, flap shape can be oval, which may decrease resection of corneal nerves, and side-cut angulation can be bevelin, which has the potential to improve flap stability and decrease epithelial ingrowth.

Benefits for improved flap geometry and for limiting many intraoperative flap complications of mechanical microkeratomes have contributed to the increased popularity of femtosecond laser LASIK. In addition, outcomes data show that relative to eyes with a mechanical microkeratome flap, femtosecond laser flap eyes have less loss of low contrast visual acuity, and, in most studies, less induced high order aberrations.

Better clinical outcomes have reduced enhancement rates and helped offset the cost of the laser, said Dr Colin.

“However, our experience and others’ show that there are still some safety issues.

As reported by Moshirfar et al, while

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http://m.eurotimes.org Our new mobile website is designed for tablets and smartphones and includes content from the print edition of the magazine.

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EUROTIMES | Volume 17 | Issue 4

“

In one study, the risk of clinically significant ingrowth was especially increased if the flap lift was after three or more years Joseph Colin MD

the femtosecond laser and mechanical microkeratomes differ in their complication profiles, with major epithelial defects and dislocated flaps more common using mechanical microkeratomes and the laser being associated with more diffuse lamellar keratitis (DLK), the total complication rate is similar. In addition, an advantage for reducing the incidence of epithelial ingrowth with the laser has not yet been corroborated by clinical evidence, and while thin-flap LASIK (sub-Bowman’s keratomileusis) helps preserve stroma and so may reduce the incidence of corneal ectasia, it seems to be associated with an increased incidence of interface haze.”

Dr Colin noted that a study by Michael Knorz MD, showed improved flap adhesion with femtosecond laser-created flaps having a bevel-in side cut. However, using the Ocular Response Analyzer (Reichert) to measure corneal biomechanical properties, Dr Colin and colleagues found no differences in corneal hysteresis or corneal resistance factor values between eyes with bevel-in femtosecond laser versus mechanical microkeratome flaps.

Thicker flap Intraoperative problems associated with the mechanical microkeratome that can still occur using the femtosecond laser include suction loss leading to an incomplete flap and creation of an irregular flap. However, with an incomplete laser flap, the procedure can usually be completed with a second laser pass at the same thickness level, and an irregular flap is very rare, occurring particularly in eyes with a previous corneal scar. Management for this complication involves creating a thicker flap at a later time using a mechanical microkeratome.

Joseph Colin – joseph.colin@chu-bordeaux.fr

DLK still occurs with the femtosecond laser and seems to be more common than with mechanical microkeratomes. However, according to two published studies, the risk of epithelial ingrowth is greater after an enhancement procedure (~2 per cent) and is extremely rare using the femtosecond laser in primary femtosecond laser LASIK (incidence zero per cent and 0.3 per cent).

“In one study, the risk of clinically significant ingrowth was especially increased if the flap lift was after three or more years.

So in this situation, surface ablation with or without mitomycin-C may be preferred for retreatment,” Dr Colin said.

Unique intraoperative issues accompanying use of the femtosecond laser include opaque bubble layer (OBL), anterior chamber bubbles, and epithelial breakthrough. OBL, a collection of gas bubbles in the intralamellar spaces above and below the resection plane, may make flap lifting more difficult, impede some excimer laser trackers, and possibly change the rate of tissue ablation, resulting in some induced astigmatism. Bubbles in the anterior chamber occur very rarely and also interfere with infrared pupil trackers. In these eyes, the surgery can proceed without active pupil tracking or after waiting a few hours for the bubbles to disappear.

Epithelial breakthrough, in which gas bubbles break through the epithelium within the flap margin prematurely, has an estimated incidence of 0.1 per cent and is most likely if the flap thickness is programmed to be 100 microns or less or in eyes with a focal break or scar in Bowman’s membrane. However, in most cases, the flap can still be lifted and the ablation performed safely.

Unique postoperative complications of femtosecond laser flap creation include transient light sensitivity (TLS), in which patients develop photophobia two to six weeks after an uneventful procedure, and rainbow glare, where patients perceive a spectrum of coloured bands radiating from a white light source in darkness.

“Rainbow glare is not serious, but it can cause complaints from patients who expect perfect results,” Dr Colin said.

Results of a retrospective safety analysis including 1200 consecutive eyes that underwent femtosecond laser LASIK at Bordeaux University show the rate of intraoperative and postoperative flap complications was similarly low (~0.7 per cent). Intraoperative complications included two cases each of anterior chamber gas bubbles interfering with laser pupil tracking and premature breakthrough of gas bubbles through the epithelium, three incomplete flaps due to suction loss, and one irregular flap in an eye with a previous corneal scar.

Six eyes developed DLK, which was stage three to four in two eyes, and there were three cases of TLS.

15

Update

cataract & refractive

INFORMED CONSENT

Interactive computer tutorial improves cataract patients’ understanding

C

ataract patients who took a seven-chapter interactive tutorial on the procedure were significantly better informed than controls educated with traditional methods, and the effect was especially pronounced in elderly patients, Christine Wollinger MD, of the Vienna Institute for Research in Ocular Surgery (VIROS), at Hanusch Hospital, Vienna, Austria, told the XXIX Congress of the ESCRS. The system proved easy to use even for computer illiterate patients, and helped identify topics patients didn’t understand well, making face-to-face discussions more efficient and effective. “By law, the duty to inform a patient has to be carried out face-to-face between the patient and physician. In practice however, printed forms are simply handed to the patient and only a brief discussion is performed, so the informed consent is often insufficient to satisfy the patient’s requirement for information. It is also legally questionable,” Dr Wollinger said.

Interactive program To address these shortcomings, Oliver Findl MD, MBA together with the company Eyeland developed a novel interactive program called CatInfo. It provides audio information via a headset and visually on a touch-screen monitor. The program leads the patient through what a cataract is, symptoms, treatment options, preassessment visit, day of surgery, risks and complications, and post-op treatment.

Patients can learn at their own pace.

At the end of each chapter, patients are asked if they would like to repeat, discuss the contents later or move on. Patient feedback is recorded and printed out. It serves as a guideline for patient counselling and the patient-surgeon interview. It also provides legal documentation of the patient’s understanding and the informed consent process.

Dr Wollinger and colleagues tested the program in a randomised, controlled, patient and observer-masked study involving 90 patients. Thirty control patients were shown a five-minute sham program about the hospital that included no information on cataracts. Sixty study patients were given the interactive program lasting about 15 minutes. All EUROTIMES | Volume 17 | Issue 4

Courtesy of Christine Wollinger MD

by Howard Larkin in Vienna

CatInfo program

patients then had a masked face-to-face discussion with the surgeon. Afterward, they were evaluated on their understanding with a multiple choice questionnaire. The 23-item questionnaire was developed based on focus groups of patients and ophthalmologists not involved in the study.

The study and control groups were closely matched demographically, and had similar computer experience, with about 70 per cent rarely or never using them, and about one-quarter using computers weekly or daily.

The study group scored significantly higher on the questionnaire, with a mean score of about 15 compared with about 12 for controls (p<0.05). Plotted against patient age, older study group patients scored as much as six points higher on average than similarly aged control subjects. Younger patients did only slightly better.

In addition to better informing patients about cataracts, the program made moreproductive use of patient waiting-room time, and allowed surgeons to focus on their questions in face-to-face interviews.

“It also provides legal documentation of informed consent,” Dr Wollinger said.

The group plans to roll out the system for daily use in clinic, build add-ons for co-morbidities such as myopia, diabetes and pseudoexfoliation, and translate the package into other languages.

contact Christine Wollinger – christinewollinger@hotmail.com

Update

cataract & refractive

contact

16

Clive Peckar – clivepeckar@yahoo.co.uk

VALUE OF WET LABS/VIDEO

Dramatic changes over 20 years but more discussion at meetings is vital

by Priscilla Lynch in Southport

Courtesy of Clive Peckar FRCS, FRCOphth

Stegmann Canal Expander™ (stent) being inserted into Schlemm’s Canal during canaloplasty surgery

1999-2011 ESCRS Annual Courses: Total 763

T

he development of wet labs and surgical video have been two of the most important advancements in ophthalmology surgical training in the last 20 years, the XXXV United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) Congress heard.

Clive Peckar FRCS, FRCOphth, consultant in private practice in Cheshire, UK, outlined the emergence and vital role of video and wet labs in ophthalmology during this year’s Pearce Medal Lecture.

Dr Peckar designed and established the Warrington Microsurgical Teaching Centre and is renowned for his contributions to ophthalmic surgical teaching and training through utilising video and microsurgical simulation.

His passion in promoting the importance of wet labs was clearly evident as he showed many useful and contextual video clips from the early days of surgical video recording up to the present.

Looking back at the introduction of IOLs in the UK in the early 1980s, Dr Peckar said UKISCRS discussions on

EUROTIMES | Volume 17 | Issue 4

new techniques were invaluable, but there were no videos of complications shown at that stage and questions arose as to whether this should change.

The routine recording of all microsurgical procedures took place by 1984 in Warrington, which Dr Peckar said enabled detailed analysis of technique, complications and unusual occurrences. One such new technique where video proved very useful in the 1980s was YAG laser capsulotomy.

It also became apparent in the mid-1980s that video was very useful, and far superior to photographs, for endothelial visualisation and quantification. The technique Endovid (Endothelial Specular Microscopy & Quantification Using Video) was subsequently developed, and then enhanced with a “zoom” version, which enabled the scanning of large areas of endothelium for focal pathology eg, Nd:YAG damage (using posterior corneal rings).

Endothelial specular microscopy has since become a routine part of screening in Warrington, explained Dr Peckar. It helps identify any specific risk to the cornea thus ensuring the patient can give fully informed consent.

It also prevents the surgeon having a “post-op corneal decompensation surprise” he elaborated. Furthermore, in those cases with compromised endothelium, surgeons can consider if surgery is necessary at that particular time.

Widespread acceptance In 1988, a UKISCRS symposium on current techniques in IOL surgery saw the introduction of video recorded surgical techniques and complications, which then became a regular feature of UKISCRS meetings.

“This was a watershed, as at this meeting we had intracapsular cataract extraction, extracapsular cataract extraction which was the norm at the time, and the beginning of phaco,” Dr Peckar commented.

Showing the audience a clip from the 1988 meeting, he said the video was important as many would not have seen it and realised the progress and potential of video and the importance of discussion sessions, especially on the management of certain conditions.

Maintaining his preference for videoing every surgery, Dr Pecker reiterated that good quality video allows selflearning and teaching, and is vital for learning to deal with complications and the unusual.

“If a complication develops, by studying the video you can, in virtually every case, see the cause of the problem, and that these ‘acts of God’ are not actual ‘acts of God’ at all, but acts of the surgeon,” he added.

The birth of wet labs Moving on to the development of wet labs and using porcine eyes in the UK, Dr Peckar said by the early 1990s it was universally agreed that the use of the labs provided the best method for trainee surgeons to safely simulate practice on patients.

While the need for regional/national wet lab training in the UK was recognised, no permanent trade-independent

Clive Peckar (accompanied by his partner Mia Gu) receiving The Pearce Medal from UKISCRS president Milind Pande

“I’m confident after 14 years’ experience that Schlemm’s canal surgery will continue to develop.

You should consider adding it to your armamentarium for openangle glaucoma” facilities existed and there was no funding for setting up surgical simulation laboratories in ophthalmology.

The cost of setting up a nine-station phaco wet lab at that time with new equipment was around £700,000, although with donated equipment the cost was less.

It was eventually agreed to set up the UK’s first fully equipped, permanent multi-station wet lab in Warrington. Following Dr Peckar’s efforts the Warrington Microsurgical Teaching Centre was opened in 1996.

Many new ophthalmological techniques have now been trialled through the lab, including viscocanalostomy in 1997. Following training with a wet lab, theoretical videos of previous surgical cases, and live surgery from an expert in the surgery, Dr Peckar carried out his first viscocanalostomy procedure. He told delegates that the experience totally convinced him of the value of combining live surgery, from an experienced surgeon, with theoretical videos and wet lab practice. He added that new surgical techniques are now becoming available in Schlemm’s canal surgery.

“I’m confident after 14 years’ experience that Schlemm’s canal surgery will continue to develop. You should consider adding it to your armamentarium for open-angle glaucoma,” Dr Peckar recommended.

Looking at the future of wet labs, he said while virtual reality simulators may help to develop many of the skills surgeons require, they do not impart the same “feel” as real instruments on real tissue.

Concluding, Dr Peckar said a key role of UKISCRS, which he joined 30 years ago, is to stimulate debate and that it must continue to do so.

“We need more people to contribute their experience for discussion. The discussion sections [of meetings] on the management of certain conditions are vital, which is why I showed the discussion session from 1988.

Those were really small meetings but had really intense discussion and I think UKISCRS’s role is to stimulate discussion, particularly for young surgeons and developing techniques,” he told EuroTimes.

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18

Update

cataract & refractive

ENDOPHTHALMITIS

Dr Barry reported that following glaucoma surgery the risk of endophthalmitis is higher

New challenge of anti-VEGF cases

by Priscilla Lynch in Southport

Peter Barry FRCS

W

hile endophthalmitis following cataract surgery is on the decline thanks to the growing use of intracameral antibiotics, infection associated with repeated anti-VEGF injections appears to be a growing problem, according to Peter Barry FRCS, St Vincent’s University Hospital and Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

Dr Barry outlined the latest research on the risk factors for developing endophthalmitis following cataract surgery, trauma, glaucoma surgery, sutureless vitrectomy and antiVEGF injections, to delegates at the United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) XXXV Congress in Southport, UK. He revealed a surprising risk factor identified by the ESCRS Endophthalmitis Study was the use of silicone IOLs, which led to a three-times greater risk of developing endophthalmitis as opposed to other IOLs, the vast majority being acrylic.

A large controlled study carried out in Sweden showed silicone IOLs had a greater risk than heparin surface-modified PMMA. If the cataract surgery is complicated

that too is a risk factor, Dr Barry noted. He cited the ESCRS study results showing a five-times greater risk if there were surgical complications. However, overall, the most important risk factor is the failure to use perioperative antibiotics, Dr Barry stressed.

“The ESCRS Endophthalmitis Study showed the range of endophthalmitis was between 0.05 per cent in those patients who were randomly allocated to receive intracameral cefuroxime 1.0mg in 0.1ml of normal saline into the anterior chamber at the end of the case versus an incidence of 0.35 per cent developing endophthalmitis in that group that did not receive any perioperative antibiotic, either topically or intracamerally. They all received povidone iodine because at the time of the study that was the only evidence-based, recognised prophylaxis,” he explained.

The endophthalmitis range of 0.35 per cent surprised the study organisers and was widely criticised, particularly in the US, as “extraordinarily high”.

“But if you compare that figure with the Swedish prospective study of 225,000 patients from Mats Lündstrom and the range of endophthalmitis in Sweden, it is

between 0.048 per cent in patients receiving cefuroxime which is the norm. But if you subtract that small group of patients from the Swedish register who did not receive intracameral cefuroxime for whatever reason, then the endophthalmitis rate was 0.35 per cent in that group which coincides precisely to the non-antibiotic group in the [ESCRS] Endophthalmitis Study.”

He added that the standard regime in the US, which is topical 4th generation fluoroquinolones commenced on the day of surgery, has been demonstrated in a large cohort study to have an endophthalmitis rate of 0.05 per cent, similar to the intracameral group of the ESCRS study.

Dr Barry reported that following glaucoma surgery the risk of endophthalmitis is higher with studies showing a 0.1 per cent rate for early onset and up to 0.7 per cent for late onset, increasingly quite dramatically with the utilisation of 5-fluorouracil.

He noted that after standard vitrectomy the incidence of vitrectomy is traditionally low. However, after the introduction of 23-gauge vitrectomy there was a scare in the earlier years. “In Japan, Kunimoto [Ophthalmology 2007] demonstrated a 12-times odds ratio with 25-gauge vitrectomy

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for endophthalmitis. Hu [Ophthalmology 2009] demonstrated no difference, and Baharani [Ophthalmology 2010] showed no difference between 20-, 23- and 25-gauge vitrectomy; 0.02 per cent, 0.03 per cent and 0.02 per cent, out of a series of 35,000 eyes in a multicentre study,” he reported. Dr Barry believes that this earlier high risk related probably to technique, and that nowadays surgeons do not think that sutureless vitrectomy has a meaningfully higher risk.

Anti-VEGF Nowadays probably the most important challenge, he said, is the risk of endophthalmitis from anti-VEGF injections, which have seen huge growth in recent years. The risk of endophthalmitis has been reported as between 0.022 per cent and 0.16 per cent, but there are particular issues with the injections in that there is a cumulative risk if the patients are receiving six or more injections in a given year, and are using an off-licensed product. “Particular attention should be given by retinal surgeons and physicians to the routine use of topical antibiotic drops for several weeks after the anti-VEGF injection as there is a risk. I think this will facilitate the development of resistant organisms in that patient’s conjunctival sac and expose them to a higher risk of endophthalmitis a couple of weeks later when they are faced with their next injection,” Dr Barry contended.

Summarising, Dr Barry said endophthalmitis following cataract surgery has been dramatically reduced by the adoption of intracameral antibiotics. In the US he believes intracameral injections are moving forward all the time though it is still an un-licensed procedure there.

Update

cataract & refractive

Visit Angiotech Booth 801 during ASCRS

ALZHEIMER’S patients

Surgery improves mood and sleep, but can increase agitation

The Surgeon’s Edge

by Howard Larkin in Vienna

T

reating Alzheimer’s patients for cataracts not only improves visual acuity, it may also improve sleep and reduce depression in many patients, and significantly improve cognitive function in patients with milder dementia, Brigitte Girard MD, Paris, France, told the XXIX Congress of the ESCRS. However, in her first-of-its-kind study of the neuropsychological impact of cataract surgery on Alzheimer’s patients, about one-quarter of the 38 patients followed displayed increased agitation and behavioural problems three months after surgery, with more severely demented patients apparently at higher risk. (The study has been called VIVA – la VIe par la Vue chez l’Alzheimer = Life by Sight in Alzheimer’s – LiSA.) “According to Neuropsychological Inventory (NPI) the benefit of cataract surgery is real for 25 per cent of patients and it improves conditions for 25 per cent of caregivers.

It improves sleep and depression in almost all subjects.

But beware of possible behaviour deterioration, with the caregiver burden increased,” said Dr Girard, who also presented her study at the annual meeting of the American Academy of Ophthalmology.

While the study was not designed to identify predictive factors, the data suggest patients scoring higher than 14 on Mini Mental Status, or MMS, tests before surgery do better, with a net increase in aggregate NPI and depression scores at three months, Dr Girard noted. Overall about one-third of patients improved social skills, most of whom were in the higher MMS group. These included one 99-year-old-woman who began seeing her son again after several years.

By contrast, for patients scoring 14 to 10 on MMS before surgery, net aggregate NPI and depression scores were worse after surgery. They were more likely to display agitation, delusional ideas and hallucinations, increase the burden on caregivers, and many showed declines in social function, Dr Girard said. “When you relieve them of the cataract, at the bottom they are in a good or bad mood, and some of them are very aggressive. If they can see they can move and it is really a problem sometimes.”

Local anaesthesia

This prospective interventional study was carried out at Tenon Hospital in Paris. In addition to standard visual tests, all patients were evaluated for neuropsychological function one month before and three months after surgery with the same psychologist administering NPI, Instrumental Activities of Daily Living (IADL) and depression questionnaires to all patients and caregivers. The main assessment criteria were behaviour improvement and relief of caregivers. Secondary assessment criteria were cognitive score (Adas cog) improvement, autonomy and mood disorders.

All patients had disabling cataracts and mild dementia, defined as an MMS score of 10 to 25. Mean age was 85 with nine patients over 90 years old, and 84 per cent were women.

Of 42 patients operated, 38 had complete follow-up data.

Intraocular lenses were placed in the posterior chamber in EUROTIMES | Volume 17 | Issue 4

Disposable Ophthalmic Products 36 patients and in the sulcus in five patients. One patient was not implanted due to lack of cooperation during surgery.

Only five patients required general anaesthesia, the other 37 received local or regional anaesthesia.

This surprised Dr Girard, who thought most patients would need general anaesthesia. However, anaesthesiologists were concerned over safety and how general anaesthesia might affect their brains. So Dr Girard used patient reaction to B-scan tests as a guide to their suitability for local anaesthesia. If they tolerated the probe touching the eye, they would probably tolerate surgery. Patients were mostly calm and cooperative during surgery, she reported. However, all surgeries were done in the hospital, with patients admitted the afternoon before for tests and discharged the morning after.

Visual results Surgery was difficult due to many hard cataracts and weak zonules, Dr Girard said. But results were excellent. Mean corrected distance vision improvement was 0.5 LogMAR from a pre-op mean of 0.55 LogMAR, or about 20/70, with 52 per cent achieving 20/25 at three months.

Vision did not improve in two patients, one who was not implanted due to agitation, and one suffering dry AMD behind a white cataract.

At three months, NPI behaviour scores improved for 47 per cent, were unchanged for 26 per cent and decreased for 17 per cent with 10 per cent damaged. Mean scores improved, but not significantly. Sleep and appetite improved, but agitation and motor behaviour also increased.

Burden on caregivers improved for 26 per cent, was unchanged for 40 per cent and decreased for 26 per cent.

Mean scores did not change significantly, but reduced caregiver burden correlated significantly with improved behaviour scores, p<0.001, and improved depression scores, p=0.02. Increased agitation in particular resulted in higher caregiver distress while improvements in sleep disturbances were associated with reduced stress.

Cognitive function improved for 32 per cent, was unchanged for 40 per cent and decreased for 22 per cent.

However, mean instrumental activities and autonomy increased significantly, p=0.05. Twenty-four gained three points or more, 50 per cent were unchanged and 26 per cent decreased. More improvements were made in the easy gesture category, which includes eating and self-care. Patients were mostly stable in instrumental activities such as using a telephone. In social activities, one-third improved, one-third were stable and one-third decreased.

Mean depression scores improved for 48 per cent of patients with MMS higher than 14 compared with 27 per cent for those with MMS scores 14 or lower. Similarly, 13 per cent of the milder group showed mood declines compared with 27 per cent for those with more severe dementia.

If it was only for depression improvement it’s worth removing cataract in Alzheimer’s patients, especially before dementia decreases too much MMS, concluded Dr Girard.

contact

Brigitte Girard – docteur.girard@orange.fr

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19

n a l i M

XXX Congress OF THE ESCRS 8-12 September

2012 Registration Open

Symposia Corneal Neovascularisation Chairpersons: R. Nuijts THE NETHERLANDS, H. Dua UK (EuCornea)

Saturday 8 September

Ridley Medal Lecture Femtosecond-assisted cataract surgery: Where are we now?

Chairpersons: P. Rosen UK, M. Piovella ITALY

Quality Outcomes in Cataract Surgery: The Real Story

Monday 10 September

Sunday 9 September

Cataract surgery and macular disease

Innovations in IOL power calculation

Chairpersons: P. Barry IRELAND, G. Richard GERMANY (EURETINA)

Chairpersons: T. Kohnen GERMANY, R. Mencucci ITALY

Saturday 8 September

Tuesday 11 September

Cataract and refractive surgery in children

I am a perfect cataract surgeon.

How can I become better?

Chairpersons: D. Epstein SWITZERLAND, K. Nischal UK (WCPOS)

Sunday 9 September

M. Lundstrรถm SWEDEN

Chairpersons: M. Lundstrรถm SWEDEN, R. Bellucci ITALY

Wednesday 12 September

for Preliminary Programme visit

www.escrs.org

Update

cataract & refractive

LIGHT ADJUSTABLE LENS OUTCOMES

Novel technology allows excellent refractive outcomes in challenging cases

by Cheryl Guttman Krader in Vienna

T

he Light Adjustable Lens (LAL, Calhoun Vision) is safe and effective in the treatment of virgin and complicated eyes, providing desired refractive results that remain stable during follow-up to one year, reported Tobias H Neuhann MD, at the XXIX Congress of the ESCRS. The study included 34 virgin eyes and 20 “complicated” eyes including 11 eyes with a history of myopic or hyperopic LASIK, two eyes with keratoconus and seven eyes with a mature or posterior pole cataract in which axial length could not be reliably measured.

About 80 per cent of eyes underwent two adjustments prior to lock-in of IOL power.

Thereafter, changes in spherical equivalence between serial visits were minimal and met the FDA criteria for refractive stability.

Good outcomes With data available from follow-up at 12 months for 39 eyes, including 12 complicated eyes, UCVA was 20/32 or better in all eyes and was 20/20 or better in the 11 post-LASIK eyes and five eyes with a posterior pole cataract. The achieved refraction was within 0.5 D of attempted in 95 per cent of eyes, and the outcomes were equally good in the virgin and complicated eyes, reported Dr Neuhann, medical director, Marienplatz Eye Clinic, Munich, Germany.

“Achieving accurate refractive outcomes after cataract surgery is challenging in eyes with a history of corneal refractive surgery, keratectasia, or when biometry measurements are otherwise unreliable.

Using the LAL in these difficult eyes can provide refractive outcomes matching those achieved in virgin eyes because LAL power adjustments are made based on the patient’s postoperative refraction and do not depend on preoperative measurements,” he said.

“In our series, the refractive outcomes with the LAL for both sphere and cylinder power are remarkable. This technology is as safe as today’s customised corneal laser refractive surgery, and although the digital light delivery system used with the LAL is expensive (~€120,000), considering the excellent and reliable patient outcomes, in my opinion it is currently a much better investment than a femtosecond laser for cataract surgery.”

For the study eyes, preoperative mean SE (subjective refraction) was −2.27 ± 4.69 D, sphere was −1.95 ± 4.69 D, and mean EUROTIMES | Volume 17 | Issue 4

cylinder was −0.65 ± 0.57 D. Among the 39 eyes seen at one year, mean SE was −0.51 ± 0.59 D, mean sphere was −0.43 ± 0.58 D, and mean cylinder was −0.17 ± 0.23 D. Scattergrams for both sphere and cylinder outcomes showed that all eyes were within 1.0 D of attempted correction. R2 for the regression line of attempted versus achieved refraction was 0.99 for spherical correction and 0.82 for astigmatism.

“Precise correction of astigmatism in the range of 0.5 to 2.0 D using a toric IOL is challenging in older patients because dry eye and small surface irregularities can make topography measurements unreliable. In fact, in ‘old’ corneas with less than 2.0 D of astigmatism, the results of two topographic measurements are rarely identical,” noted Dr Neuhann.

“Therefore, it was especially satisfying to be able to correct astigmatism so beautifully with the LAL in this series that included eyes with 1.5 to 2.0 D of astigmatism.”

The outcomes were also remarkable in the keratoconus patients. Dr Neuhann described one case involving a 49-year-old woman whose corneal thinning disease was not detected when she underwent cataract surgery with implantation of the LAL in her right eye. After surgery, she was +1.5 D off the attempted refraction and had irregular astigmatism. However, after LAL power adjustment based on her subjective refraction, she achieved 20/20 UCVA. “The second eye of this patient has more advanced keratoconus and has also undergone cataract surgery with LAL implantation, but the final refraction has not yet been reached,” Dr Neuhann said.

Of the two eyes with a final refraction not within 0.5 D of intended, one eye had an SE of -0.75 D and the other was -1.25 D. “The latter patient was not very compliant with postoperative instructions about wearing sunglasses, which is necessary to prevent changes to lens power from ambient ultraviolet light,” Dr Neuhann told EuroTimes.

Based on the outcomes with the LAL and its versatility, Dr Neuhann said he considers the LAL his “platinum” choice among premium IOLs. Per the manufacturer’s recommendations, spherical and toric power can each be modified by up to 2 D. However, clinical experience indicates the magnitude of possible power adjustment is even greater,

and individual high order aberrations can also be corrected, he noted.

“The LAL has greater potential for customised correction beyond how it is being used today, but one application that I have found very helpful is for providing a monovision trial,” Dr Neuhann told EuroTimes.

More versatile For monovision, Dr Neuhann targets a refraction of plano in the dominant eye and -1.75 D in the nondominant eye and allows a two-week trial to determine tolerability.

“Patients who choose pseudophakic monovision using a conventional monofocal IOL have no choice if they are unhappy but to adapt. With the LAL, there is a simple solution as I can easily ‘beam’ the myopic eye to emmetropia,” he said.

Dr Neuhann added that the LAL not only provides excellent unaided distance

“

Patients who choose pseudophakic monovision using a conventional monofocal IOL have no choice if they are unhappy but to adapt Tobias H Neuhann MD

vision, but patients also achieve J4 to J6 unaided reading vision with an emmetropic refraction, which is much better than with a standard or aspheric monofocal IOL. “As we will report, this benefit can be explained by depth of focus that is produced during the radiation process,” he said.

Do you have more photos like this?

ESCRS is setting up an archive.

Contact colin@eurotimes.org if you want to share your photos, old ESCRS programmes and other historic items with us.

21

Update

cataract & refractive

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22

Roberto Zaldivar – zaldivar@zaldivar.com Roger F Steinert – steinert@uci.edu

ASTIGMATISM MANAGEMENT

New tools raise the bar in astigmatism management

by Dermot McGrath in Vienna

Courtesy of Roberto Zaldivar MD

to see as much as 15 degrees of cyclotorsion, so patients will vary quite a bit,” he said.

For the marking of the eye, Dr Steinert said that there are a wide variety of instruments currently on the market such as the Mendez gauge, the Dell marker or the Steinert-Rumison marker, which do the job adequately. He advised surgeons using ink marks to select the 3 o’ clock and 9 o' clock positions rather than 6 and 12 o’ clock, because the latter positions require the surgeon to manipulate eyelids and may lead to greater inaccuracy.

Taken collectively, all of these factors lead to an increased chance of eventual toric IOL misalignment.

“The variables start to add up with the estimation of what is truly horizontal and vertical, the possible spread of the ink marks and problems of cyclotorsion. This is really what is driving the technological drive to see if we can come up with something better,” he said.

“

For better outcomes with toric IOL implantation we know that we need more accurate surgery and the latest generation of technologies will certainly help us to achieve that Roger F Steinert MD

N

ew technologies allied to improved surgical techniques are helping surgeons to deliver more predictable, accurate and reproducible outcomes in the treatment of astigmatism according to a number of studies presented here.

“For better outcomes with toric IOL implantation we know that we need more accurate surgery and the latest generation of

EUROTIMES | Volume 17 | Issue 4

technologies will certainly help us to achieve that,” Roger F Steinert MD told delegates attending the XXIX Congress of the ESCRS. Dr Steinert, the Irving H Leopold professor and chair of ophthalmology, professor of biomedical engineering and director of the Gavin Herbert Eye Institute at the University of California, noted the critical importance of accurate toric IOL alignment in treating astigmatic patients.

“If the alignment is off by just 15 degrees, we lose half of the IOL effect and 30 per cent misalignment means that we have lost all of the effect as well as picking up some higher order aberrations,” he said.

The traditional method of marking the eye for toric IOL implantation introduces a number of variables that undermine the likelihood of obtaining precise and reproducible outcomes, said Dr Steinert.

“Marking the limbus must be performed preoperatively with the patient in an upright position. Once the patient is draped, it can be hard to determine the coronal or horizontal plane. Cyclotorsion is another big problem and it is the rule, not the exception, in a supine patient. We did a study a few years ago and found that the mean deviation was four degrees, but that it was not unusual

New devices Dr Steinert said that new technology platforms such as the Osher Toric Alignment System (Haag-Streit Inc), the TrueVision 3D Visualization and Guidance System, Callisto (Carl Zeiss Meditec AG) and the ORA(WaveTec Vision) should all help to significantly reduce the risk of misalignment.

“The technology now coming onto the market is showing us some pathways for improvement but we need to continue to balance clinically significant improvements against cost, as there is capital outlay, user fee and time involved in these new devices as well,” he concluded.

The need to move from subjective refractive assessment to more objective measurements was also emphasised

by Roberto Zaldivar MD in a separate presentation.

Dr Zaldivar focused in particular on the benefits of using the OQAS (Optical Quality Analysis System, Visiometrics S.L, Spain), noting that the device offers an effective means to measure accurately and objectively patients’ quality of vision.

“This device introduces a new concept that we call super refraction. Most ophthalmologists consider normal vision as 20/20 but we know now that all 20/20 visual acuities are not the same. When an optical system is subject to diffraction plus

“

Most ophthalmologists consider normal vision as 20/20 but we know now that all 20/20 visual acuities are not the same Roberto Zaldivar MD

aberrations plus scattering, all of these affect optical quality. The OQAS helps us to explain why some 20/20 patients see better than others,” he said.

Based on research by Pablo Artal PhD and Jaume Pujol PhD, the OQAS system consists of laser diagnostic sensory equipment, a computer workstation and custom-designed software. The device uses a double-pass technique to analyse the size and shape of a punctual light source imaged on the retina after passing twice through the ocular media.

The analysis of the light provides users with the point spread function (PSF), optical scattering index (OSI), the modulation transfer function (MTF) of the eye, as well as tear film quality.

The PSF, OSI, and MTF and tear film analysis are highly accurate measures of image quality, which provide an objective assessment of the presence of visual aberrations and light scattering, said Dr Zaldivar.

“The OQAS allows for objective measurement and has a clear advantage over traditional aberrometers in that it can measure higher order aberrations and scatter. Using this approach, we obtain better results in post-LASIK eyes, irregular corneas, corneas with rings, and normal eyes as well,” he said.

Summing up, Dr Zaldivar said that the OQAS devices gives surgeons an exciting tool for improving refractive and surgical results.

“It is mandatory to keep improving our preoperative information in order to obtain better visual quality for our patients postoperatively. With this system, I think we are finally moving to an exciting new era of objective refraction,” he concluded.

contacts

John Hovanesian – jhovanesian@harvardeye.com Stephen S Lane – sslane@associatedeyecare.com John Kanellopoulos – ajk@laservision.gr Matteo Piovella – piovella@piovella.com

Update

cataract & refractive

HYDROGEL BANDAGES

Bandages stay put, speed visual recovery and may reduce infection risk

by Howard Larkin in Vienna

EUROTIMES | Volume 17 | Issue 4

At the slit lamp we saw greater corneal clarity with the hydrogel bandage John A Hovanesian MD

H

“

I don’t think the absolute difference in refractive cylinder is as important as the stability of the refractive cylinder

Courtesy of Matteo Piovella MD

John Kanellopoulos MD

OcuSeal application on the corneal incision

Courtesy of John Kanellopoulos MD

ydrogel bandages for clear corneal incisions are more likely to stay in place than collagen shields, improve early visual outcomes, and may reduce induced astigmatism, according to speakers at the XXIX Congress of the ESCRS. They may also reduce endophthalmitis risk.

Hydrogel bandages are a liquid polymer placed on the eye, where they polymerize into an adherent gel that biodegrades in a few days. Previous research shows they control microleaks after corneal incisions better than stromal hydration alone (Calladine et al. J Cataract Refractive Surg 2010; 35:1839-1848) and greatly increase the burst pressure of incisions in cadaver eyes (Maddula S et al.

Presentation, ASCRS, 2010).

In a prospective randomised trial involving 420 eyes at 17 sites comparing the ReSure (Ocular Thearpeutix) hydrogel bandage with the Soft Shield Collagen Corneal Shield (Oasis), 79 per cent of 290 hydrogel bandages remained in place 24 hours after cataract surgery compared with 27 per cent of 98 collagen shields, a statistically significant difference (p<0.001), said John A Hovanesian MD of UCLA, California, US. The bandage group also showed significantly less stromal edema and mean best corrected visual acuity at 20/29 compared with 20/40 for the shield group one day after surgery (p<0.0001). “At the slit lamp we saw greater corneal clarity with the hydrogel bandage,” said Dr Hovanesian.

He hypothesised that better-sealed hydrogel wounds had less leakage and hypotony, leading to less corneal edema, although 24-hour IOP findings were similar in the two groups.

Stephen Lane MD, Minneapolis, US, reported similar results in a 30-eye study he conducted. Of 23 patients with hydrogel bandages, 86 per cent were in place at 24 hours compared with 43 per cent of seven collagen shields (P=0.038) and produced better visual results.

“We would recommend the product in lieu of or in addition to sutures in premium IOLs, where maintaining stability of the capsular bag is key, and in high risk cases.”

John Kanellopoulos MD of Athens, Greece, and NYU Medical School, US, reported less induced astigmatism with hydrogel lenses. In a study of 166 clear

“

OS: one month post-op without ReSure

Same patient, OD: one month post-op with ReSure.

Although the refractive cylinder is not much different, there is clear irregular astigmatism present in the non-ReSure case that may significantly contribute to difficult visual function especially if a toric and/or multifocal IOL was used

corneal incision cataract cases randomly assigned to the ReSure bandage or closure with stromal hydration alone, topographic cylinder values for the hydrogel group were 0.45 compared with 1.2 D for controls at one-week post-surgery; 0.35 and 0.8 at one

month; and 0.37 and 0.75 at three months respectively, all statistically significant findings. Mean refractive cylinder vectors and corrected and uncorrected visual acuity were also better in the hydrogel bandage group.

“Specifically statistical tests and the results between ReSure and the standard procedure are statistically significantly different at seven days (p=0.03), but not at one month (p=0.50) and three months(p=0.20). This is based on 166 eyes with data at all three time points,” Dr Kanellopoulos said.

“I don’t think the absolute difference in refractive cylinder is as important as the stability of the refractive cylinder. The standard procedure demonstrates a larger change in the one week to one month period than the ReSure procedure, and this ‘procedure by time’ effect is statistically significantly different (p=0.04). That, to me, is one of the potential values of ReSure – reaching astigmatic refractive stability faster.

In plain clinical terms and in an era when Femto cataract surgery, toric and multifocal IOLs cater mainly to a better refractive result, the use of ReSure will provide more stable astigmatic behaviour in the first postoperative month,” he said.

“ReSure may be a value adjunct in clear corneal cataract surgery in reducing astigmatic change,” Dr Kanellopoulos said.

It may also reduce risk of endophthalmitis by reducing early wound ingress after surgery, though no large trial has demonstrated this.

Matteo Piovella MD, Monza, Italy, reported that another hydrogel bandage, OcuSeal (Beaver Visitec International) reduced foreign body sensation, with only 15 per cent of 98 OcuSeal patients reporting it at 24 hours compared with 70 per cent for controls without the bandage. He also pointed out that hydrogel bandages may help prevent endophthalmitis. “But even if it does not prevent these horrible infections, at least they will help me serve patients by giving them greater comfort after surgery.”

23

contact

Update

cataract & refractive

FS CATARACT SURGERY

Why lasers designed for corneal flaps don’t cut it for cataracts

by Howard Larkin in Vienna

“W

hy do I need another €500,000 femtosecond laser for cataract surgery when I already have one for LASIK flaps?” It’s a question physicist Holger Lubatschowski PhD hears often from ophthalmic surgeons.

The answer stems from different and somewhat incompatible technical requirements for corneal procedures compared with those deeper in the eye, said Dr Lubatschowski, founder and CEO of Rowiak GmbH, Hannover, Germany, and consultant to Ziemer Group, Port, Switzerland.

“In principle we could combine them doing their jobs rather poorly. But with new systems and designs we could do both very well,” he told the XXIX Congress of the ESCRS.

Precision vs. volume

Current corneal and cataract lasers share many operating principles and parameters, Dr Lubatschowski noted. Both rely on photodisruption to cleave tissue without thermal damage to surrounding tissues.

Both use lasers of about 1,000 nm wavelength because they are economical to produce and penetrate clearer ocular tissues well. And both are capable of pulse duration in the femtosecond range with nanojoule to microjoule energy.

Corneal and cataract laser systems are also similar in patient application. Both require fixation of the eye, and the patient is either moved in and out on a movable bed, or the laser mirror arm is moved to the patients’ eye.

“The applications are not only similar, they are identical,” Dr Lubatschowski said.

Where they differ is in depth and ablation precision requirements. For corneal flaps, intrastromal refractive procedures or lamellar transplant cuts, the laser must operate over an area of up to 10mm wide, ablating tissue in essentially a single planar cut within less than 1.0mm of the corneal surface. The laser cut must be very smooth to avoid inducing “rainbows” or other corneal aberrations, particularly after refractive surgery.

Courtesy of Holger Lubatschowski PhD

24

Beam characteristics for corneal and cataract surgery

“In my opinion OCT is the most powerful technology for this application. It quite easily delivers the 3-D data to access the lens and capsule” Cataract surgery, on the other hand, requires multiple ablation planes to disrupt a much larger tissue volume, measuring about 7.0mm diameter by 4.0mm deep and located about 5.0mm to 10.0mm below the corneal surface. The cuts do not have to be as smooth since the ablated lens tissue is removed, but the cutting must be quick.

Achieving these divergent clinical objectives requires lasers of different power and, perhaps more important, different numerical apertures result in different cavitation profiles in tissue, Dr Lubatschowski said. Numerical aperture is a function of the width and focal length of the laser beam. Cavitation is a function of numerical aperture and laser energy.

For a given focal length, a wider lens creates a higher numerical aperture, which results in a wide cone of energy producing a very small focal spot. A numerical aperture of around 0.2 is

Don’t miss Bio-ophthalmology, see page 41 EUROTIMES | Volume 17 | Issue 4

typically used in corneal lasers. This creates a wide cone of energy focusing into a very small focal spot. With low pulse energy, say some hundreds of nanojoules in a 200 femtosecond pulse, this creates a nearly spherical cavitation bubble in the 10 micron range that does not disrupt surrounding tissue.

This level of precision is required for corneal surgery because a three-micron irregularity produces about one micron of wavefront error, but it cannot be achieved in the crystalline lens, Dr Lubatschowski said.

“For corneal applications we have a high focus quality, but because of the high aperture we have more aberrations when there are more refractive surfaces, which limits focus quality deeper in the eye. Moreover, we have scattering loss in the crystalline lens. Both aberrations and scattering loss inhibit the laserpulse to reach the threshold for disruption.”

Holger Lubatschowski – h.lubatschowski@rowiak.de

By contrast, a numerical aperture closer to 0.1 is typical in cataract lasers. This creates a narrower cone of energy that produces a more elongated focal spot. At higher energy levels, say 1.35 microjoules in a 200 femtosecond pulse, this results in a more or less elliptical cavitation profile in the 100 x 20 micron range that also disrupts surrounding tissue.

“To target volume you need higher pulse energy and smaller numerical aperture with a weaker focus,” Dr Lubatschowski explained.

The more-parallel, higher energy beam produced by a lower numerical aperture aberrates less as it moves across several refractive surfaces and through layers of tissue with different refractive indices, including cloudy lens material. This allows the beam to retain enough energy to achieve photodisruption deep in the eye, but also inherently reduces focus quality below that required for corneal treatment, he added.

Navigation required For cataract surgery, the laser also must operate at a greater range of depths with slightly different anatomy for each patient, Dr Lubatschowski said. For any patient, there is a different depth of anterior chamber and size of crystalline lens. Thus, cataract lasers tend to employ more complex mechanisms to adjust the focal spot to the target.

With corneal lasers, the laser is docked directly to the tissue target, applying a flat cut or another distinct geometrical pattern into the cornea and making imaging during surgery less necessary. However, the greater distance of the lens capsule from the corneal surface, where the laser is docked, to the target in the capsular bag is variable depending on patient anatomy.

As a result, real time imaging is required to keep cataract lasers on target, Dr Lubatschowski noted.

“In my opinion OCT is the most powerful technology for this application. It quite easily delivers the 3-D data to access the lens and capsule.”

The imaging system and laser share a common optical system to ensure they are in synch, which further complicates design to accommodate multiple wavelengths.

Dr Lubatschowski noted that cataract laser is in its early stages of development, and he believes technical challenges can be overcome to produce lasers that will do a good job of both corneal and cataract work. These might include lasers operating at 1,400 to 1,700 nanometer wavelengths capable of penetrating sclera, though producing these wavelengths is currently prohibitively expensive, he said.

217P Advert Eurotimes 120x300:TPV

21/2/12

18:11

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25

Update

CORNEA

Outstanding refractive results for your patients throughout their vision lifecycle

New method

Technique could reduce treatment time and patient discomfort for corneal cross-linking

by Howard Larkin in Orlando

I

ontophoretic delivery of riboflavin could greatly reduce the administration time, and may even eliminate the need to remove the epithelium for patients undergoing corneal cross-linking treatment, reported George O Waring MD, assistant professor of ophthalmology and director of refractive surgery at the Medical University of South Carolina, medical director of the Magill Vision Center, at the annual meeting of the American Academy of Ophthalmology.

“There is a lot of debate about the best way to deliver riboflavin; with the epithelium removed as in the cross-linking procedure originally described, or with the use of bioenhancers for transepithelial delivery, or even mechanical disturbance for transepithelial delivery. What we are looking at is an active delivery method with iontophoresis, which is the use of an electric field to move ions,” Dr Waring said.

Iontophoresis is over a century old, and was described as a method for transdermal delivery of strychnine in an animal model in 1905. It has been used in dermatology for delivery of analgesics, and there is a phase III trial for using it to deliver steroids through the sclera. Ion movement is determined by the strength of the current applied, concentration of the drug or other substance to be moved, and the presence of competing ions, such as in tears.

Dr Waring believes that riboflavin is especially suited to iontophoretic delivery because it is low in molecular weight, it’s prodrug is negatively charged at physiological pH levels and is highly water soluble.

He described a pilot preclinical translational study where a variable current generator could vary the current time and intensity. Tests were conducted on a dozen New Zealand rabbits, with three each in a control group with no riboflavin, but five minutes of iontophoresis in one eye with a saline solution; a group receiving a transepithelial formulation of riboflavin for 15 minutes without iontophoresis; and groups receiving riboflavin for five

“

There is a lot of debate about the best way to deliver riboflavin; with the epithelium removed as in the cross-linking procedure originally described, or with the use of bioenhancers for transepithelial delivery, or even mechanical disturbance for transepithelial delivery George O Waring MD

and three minutes with current applied.

Corneas were then analysed for the presence of riboflavin 15 minutes post application.

Stromal riboflavin concentrations were highest in the five-minute iontophoresis eyes, and the three-minute was still significantly higher when compared with the passive transepithelial formulation with 15-minute imbibition time.

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“Iontophoresis moved riboflavin into the cornea more rapidly than conventional application,” Dr Waring said.

Tissue concentrations rose proportional to treatment time but further clinical study is needed to confirm this, he added.

Clinical trials of a new riboflavin solution designed for iontophoresis in 10 sites with 50 eyes began in January.

SUPRACOR is CE marked. SUPRACOR for myopic, emmetropic, and post-LASIK patients is currently in clinical evaluation.

SUPRACOR is NOT approved for use in the US. Technolas Excimer 217P is NOT approved for use in the US. Some of the products and/or specific features as well as the procedures featured in this document may not be approved in your country and thus may not be available there. Design and specifications are subject to change without prior notice as a result of ongoing technical development. Please contact our regional representative regarding individual availability in your respective market.

The trademarks (™ and ®) and logos used in this document are the property of Technolas Perfect Vision GmbH or the respective owner.

Design by kbcomunicacion. Ref. TPV-014/02-2012 ©2012 Technolas Perfect Vision GmbH. All rights reserved.

contact George Waring – gwaring@revisioneyes.com

Don’t miss ORBIS update, see page 38 EUROTIMES | Volume 17 | Issue 4

TECHNOLAS Excimer 217P

Technolas Perfect Vision GmbH Messerschmittstr. 1 + 3, 80992 München, Germany www.TechnolasPV.com

26

Update

cornea

OOKP REPORT

Data highlight efficacy along with complications

by Cheryl Guttman Krader in Vienna

Young Ophthalmologists’ Resource Centre Visit our website http://youngophthalmologist.escrs.org

to find out more about the new ESCRS Observership Programme.



The ESCRS has developed a grant programme to support European trainee ophthalmologists who wish to observe clinical practice in a hospital or university setting.



The society is currently seeking interest from centres willing to offer observerships of one-to-two weeks’ duration in cataract and/or refractive surgery.



Those centres wishing to participate will be added to a database of centres available on this website.

EUROTIMES | Volume 17 | Issue 4

S

ome keratoprosthesis surgeons consider the modified osteoodonto-keratoprosthesis (mOOKP) an option for visual rehabilitation in only the most challenging KPro candidates – those with extremely dry eyes and the worst ocular surface disease.

However, for Konrad Hille MD, the mOOKP is the procedure of choice as long as the patient has a suitable tooth for fabricating the device.

Speaking at the 2nd EuCornea Congress, Dr Hille defended what he acknowledged was likely a provocative viewpoint by presenting outcomes from his personal series of 33 patients. Noting that he was assigned to speak about “Demystification of the OOKP”, Dr Hille said he was perplexed at first by this title and uncertain about what should be the content of his talk.

Superior device “I see nothing mystifying about the OOKP. The procedure can be performed successfully by a skilled surgeon, anatomical success data from Falcinelli show it is superior to other keratoprostheses with survival in some cases reaching nearly 30 years, and patients who undergo the procedure unanimously agree that it was worth exchanging a tooth for an eye,” he noted. Dr Hille also noted the result of Falcinelli’s Kaplan-Meier curve with anatomical success of about 90 per cent over 20 years (88 per cent).

“Perhaps the best way to demystify the procedure is to show how it works in my hands,” said Dr Hille, Josephs-Hospital Eye Department at Ortenauklinikum, Offenburg, Germany.

His series of 33 patients had a median age of 53 years (range, 18 to 70) and median follow-up of eight years (range to 15 years). Nearly half had severe dry eye, most often associated with pemphigoid, and preoperative visual acuity was less than 0.05 in the better eye.

Visual acuity improved to 0.9 or better in 10 (31 per cent) eyes. While it remained 0.05 or less in 13 per cent of eyes, the latter cases were patients with poor visual potential secondary to retinal or optic disc disease. There were some patients who had loss of visual acuity over time. These events were due to diabetes in two eyes, and glaucoma in two eyes. There were two cases of anatomic loss, one due to an

“This technology allows us for the first time to reproducibly and accurately measure laminar volume in vivo and compare serial scans to detect thinning Fook Chang Lam MD

iatrogenic surgical error, and the other after development of a corneal melt.

Complications included mucosal necrosis (42 per cent) and bone absorption (six per cent). There was a relatively low rate of retroprosthetic membranes (six per cent).

Discussing OOKP complications, Fook Chang Lam MD, reviewed findings of research being conducted at the Sussex Eye Hospital, National OOKP Referral Centre, Brighton, UK, that are providing insights on laminar resorption/extrusion and glaucoma. He reported highlights from histological studies performed in 12 specimens, including eight laminae from cases of OOKP reversal or replacement, two specimens from eviscerated eyes, and two from whole donor eyes of patients who died with functioning OOKPs. Dr Lam noted the histological observations confirm previous information about the role of chronic inflammation in laminar resorption. Interestingly, however, in one of the functional OOKPs obtained after the patient’s death, the alveolar dental ligament was intact, but there were subepithelial colonies of bacteria and yeast-like organisms accompanied by chronic inflammation. Evidence of bone remodelling and bone reformation was also found despite absence of damage to the alveolar dental ligament.

Other findings from the histological evaluations have relevance to the development of glaucoma. Despite total iridodialysis, iris remnants in one eye had led to formation of peripheral anterior synechiae that closed off the trabecular meshwork. In another eye with an intact alveolar-dental ligament, there was

stratified squamous epithelium lining the corneal defect, Descemet’s membrane, ciliary body and angle, leading to trabecular meshwork collapse. Evidence of chronic inflammation and giant cell formation as a reaction to absorbable sutures was also present in this patient who was apparently well.

Discussing clinical management of OOKP complications, Dr Lam reported on the introduction of multi-detector CT with volumetric analysis for evaluating laminar resorption. “This technology allows us for the first time to reproducibly and accurately measure laminar volume in vivo and compare serial scans to detect thinning. We believe it has important applications clinically and for research,” he said, illustrating its clinical use with the case of a patient who was shown to achieve stabilisation of laminar volume loss after starting treatment with a bisphosphonate.

Major challenge Dr Lam also reviewed outcomes in a consecutive series of 48 patients followed for six months to 13 years to highlight that management of glaucoma continues to be a major challenge in OOKP patients. In this cohort, glaucoma was present prior to OOKP surgery in 27 per cent of eyes and at last follow-up in 52 per cent. Due to poor ocular penetration of topical medications, all of the patients were on oral medications for IOP-lowering, predominantly acetazolamide SR. Ten patients had undergone cyclodiode or endocyclodiode laser treatment intra- or postoperatively, and more recently rectus disinsertion and reinsertion surgery has been attempted, noted Dr Lam. “Most patients still require tube surgery for management of progressive glaucoma, but results with tube surgery have been discouraging.”

Of five patients who had tube surgery, one had spontaneous tube extrusion, one developed endophthalmitis after orbital cellulitis, and the tube was rendered nonfunctional in two patients as the pseudocapsule around the plate blocked aqueous flow.

“In the future we will probably place tubes at an earlier stage or even preplace them at the time of the OOKP surgery. We are considering endoscopic vitrectomy to improve the success of tube surgery and reduce the likelihood of retinal detachment in the future. However, there are other risks to consider with use of this approach,” Dr Lam said.

contacts Konrad Hille – konrad-hille@web.de Fook Chang Lam – fook_chang@hotmail.com

27

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cornea

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European Society of and and European Society ofCornea Cornea Ocular Surface Disease Specialists Ocular Surface Disease Specialists

DALK SURGERY

Advances in surgical tools and techniques fostering increase in lamellar surgery

by Dermot McGrath in Vienna

N

ew indications for deep anterior lamellar keratoplasty (DALK) are enlarging the scope of surgeons’ ability to perform corneal transplantations without the risk of rejection, Donald Tan MD told delegates attending the 2nd EuCornea Congress.

“DALK surgery can be used to treat a wide variety of corneal, refractive, ocular surface and anterior segment conditions and corneal surgeons today should avail themselves of this option where appropriate,” said Dr Tan, director of the Singapore National Eye Centre and professor of ophthalmology at the National University of Singapore.

He stressed that advances in surgical tools and techniques are fostering an increase in lamellar surgery and a marked reduction in penetrating keratoplasty (PKP) procedures in some institutions who perform highvolume lamellar surgery.

“The trend is towards increased anterior lamellar keratoplasty and endothelial keratoplasty in Singapore. Of all grafts performed at our centre in 2010, 61 per cent were lamellar keratoplasties, with anterior lamellar grafts accounting for 24 per cent and endothelial keratoplasty 36 per cent.”

The principal reason for the shift lies in the data for graft rejection, said Dr Tan. In the Singapore corneal transplant study, which looked at 901 PKPs performed from 1991 to 2003, 60 per cent of the graft failures were due to either endothelial rejection or late endothelial decompensation.

By contrast, a significant improvement in graft survival was found for DALK and Descemet’s stripping automated endothelial keratoplasty (DSAEK) outcomes, he said.

Current indications for DSAEK include conditions such as bullous keratopathy, re-grafts and Fuch’s dystrophy, while the main indications for DALK are keratoconus, post-infectious or traumatic stromal scars, post-refractive surgery ectasia or scarring, active infectious keratitis unresponsive to medical treatment, and as an adjunct to ocular surface transplantation.

Looking at some of these indications in more detail, Dr Tan said that a recent study comparing visual outcomes in DALK and PKP for keratoconus showed better outcomes and less complications for DALK procedures. “Endothelial cell loss was reduced in the DALK group and there were EUROTIMES | Volume 17 | Issue 4

3rd EuCornea Congress

“

The trend is towards increased anterior lamellar keratoplasty and endothelial keratoplasty in Singapore Donald Tan

no rejections compared to a 35 per cent incidence of rejection episodes in the PKP. DALK patients also experienced less raised IOP, and reduced rates of glaucoma and cataract as well because we are using far less topical steroids for these patients,” he said.

In terms of new and emerging indications for DALK, Dr Tan highlighted scenarios such as therapeutic DALK for infectious keratitis, refractive surgery stromal disasters, DALK combined with ocular surface transplantation, keratoconus with previous hydrops, and anterior lamellar keratoplasty over failed PKPs due to stromal disease.

In a recent case series, eight eyes of eight patients successfully underwent DALK over a previous PKP for a variety of optical, therapeutic, and tectonic indications, where endothelial function from the PKP remained healthy, said Dr Tan. He added that while DALK is usually contraindicated in cases of previous hydrops because of the risk of Descemet’s membrane rupture at the hydrops scar, improved manual lamellar dissection techniques means that manual DALK is possible for such cases with the possibility of obtaining good vision as an alternative to PKP. Dr Tan also noted that refractive surgery disasters such as complete flap necrosis, ectasia or infections are also possible indications for treatment using automated lamellar therapeutic keratoplasty (ALTK).

For medically unresponsive infectious keratitis, therapeutic DALK may be considered instead of therapeutic PKP, said Dr Tan, as the procedure yields better overall graft survival.

Dr Tan reiterated that DALK is now rightly seen as a viable alternative to PKP with equivalent or better visual results.

contact

Donald Tan - donald.tan.t.h@snec.com.sg

MILAN 6 - 8 September 2012 www.eucornea.org

registration open Programme Overview Available online

28

Update Single-Use Instruments

cornea

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EUROTIMES | Volume 17 | Issue 4

Targeting lymph and blood vessel growth may help, but translational studies needed

by Howard Larkin in Vienna

A

growing body of research suggests that targeting existing blood and lymph vessels and the growth factors that promote them could improve survival rates for corneal grafts, Claus Cursiefen MD, of the University of Cologne, Germany, told the second annual EuCornea Congress. However, large-scale translational studies are needed to confirm the efficacy and safety of several drugs and procedures that show great promise in early human and animal trials.

For corneas with immature blood and lymph vessels, antiVEGF compounds, such as bevacizumab and VEGF trap, as well as a novel Insulin Receptor Substrate-1 inhibitor, which blocks both blood and lymph vessel formation, have been shown to regress neovascularisation in humans and animals, and reduce graft rejection rates in animals.

For established blood vessels that are less sensitive to antiVEGF compounds, a combination of fine-needle cautery to physically occlude blood vessels before transplantation combined with topical and subconjunctival bevacizumab before and after surgery can regress blood vessels and improve visual acuity after corneal transplants (Koenig Y & Cursiefen C., Cornea; in press).

However, this combined approach has not been shown to improve graft survival, Prof Cursiefen pointed out.

Questions also remain about the efficacy of primary prevention of corneal neovascularisation in promoting corneal graft survival, the impact of different hemangiogenic and lymphangiogenic inhibitors on corneal disease in genetically diverse subjects, and the risk of side effects.

Basic science “We all know that numerous studies show that blood vessels in the cornea increase the rejection of corneal grafts,” Prof Cursiefen said. He pointed to a metaanalysis of studies involving more than 24,000 patients that shows the risk of graft rejection increases with the number of cornea quadrants affected (Bachmann, Taylor, Cursiefen, Ophthalmology 2010; 117:1300-5). Neovascularisation is a risk factor for rejection whether it occurs before or after the transplant (Vinh et al, Am J Ophthalmol 2006; 141:260-266).

Several studies also suggest that lymph vessels play a major role in graft rejection. One mouse study found that “high-risk” cornea beds that had visible blood vessels but were alymphatic had a similar graft survival rate to avascular corneas. But corneas with both blood and lymph vessels failed at a much higher rate (Dietrich et al. J Immunol 2010; 184:535-9). Pre-existing lymph vessels are also important for induction of the immune response that leads to failure, (Cursiefen et al. Invest Ophthalmol Vis Sci 2004; 45:2666-73).

“There is abundant evidence of the role of lymphangiogenesis in graft rejection. So how can we make our patients benefit?” Prof Cursiefen asked.

Recommendations An expert roundtable including Prof Cursiefen published a consensus statement on the use of anti-angiogenic therapy in the management of corneal diseases associated with neovascularisation (BJO Online

First June 28, 2011; 10.1136/bjo.2011.204701). He presented several options. “The best thing is to prevent angiogenesis in the first place, for example in infectious keratitis,” said Prof Cursiefen, calling this strategy primary prevention.

Because blood and lymph vessels in this scenario are very immature, they are sensitive to steroids, anti-VEGF and anti-IRS-1 medications. These compounds are also effective in blocking neovascularisation after transplantation (Regenfuss et al. Lymphat Res Biol 2008; 6:191-201).

Steroids are anti-inflammatory and can also inhibit lymphatic vessels, but their effectiveness varies widely from agent to agent, with prednisolone a top choice after transplant, Prof Cursiefen said.

Among anti-VEGF compounds, bevacizumab regresses post-keratoplasty neovascularisation and can block progressive neovascularisation (Koenig et al. Graefes Arch Clin Exp Ophthalmol 2009; 247:1375-82), but carries a risk of side effects, such as neurotrophic keratopathy and ulceration. Transient topical bevacizumab for tertiary prevention after transplantation is in trials, and controlled phase I/II trials are needed for other applications, he said.

A new compound, GS-101 (Aganirsen), an antisense oligonucleotide that blocks IRS-1, inhibiting both VEGF and IL1 production, regressed corneal neovascularisation in a phase II trial (Cursiefen et al. Ophthalmology 2009; 116:16307). A phase III trial is under way and Prof Cursiefen hopes to have results this year. Targeting IRS-1 also inhibits inflammatory lymphangiogenesis in vivo (Hos D & Cursiefen C. Invest Ophthalmol Vis Sci, in press).

In vivo studies also suggest GS-101 may be more reliable than steroids in suppressing lymphangiogenesis, which can be difficult to detect (Hos D & Cursiefen C. Invest Ophthalmol Vis Sci in press). However, another study has found that mice with different genetic types have very different responses to the same anti-lymphangiogenic treatment (Regenfuss B et al. Am J Pathol 2010; 177:501-10).

The same could be true in humans, and trials will be needed to determine it, Prof Cursiefen said.

Prof Cursiefen noted that lymph vessels can be visualised by staining, but they may not be detected with current clinical procedures and equipment. In-vivo confocal microscopy can help “but it is not fail-proof in the clinic.”

Often, though, corneal blood vessels are well established by the time keratoplasty is indicated. Regressing them improves outcomes, but mature vessels that are surrounded by pericytes are less sensitive to anti-VEGF compounds.

Prof Cursiefen recommends fine needle cautery to occlude them followed by subconjunctival and topically as eye drops bevacizumab to dampen the inflammatory response caused by the cautery and prevent recurrence. This is known as secondary prevention. He has had good results with this approach, but cautions against high concentrations or too-frequent applications of bevacizumab to avoid complications.

contacts

Claus Cursiefen - claus.cursiefen@uk-koeln.de

29

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VERSATILITY

Corneal surgeons find the femtosecond laser to be a laser for all seasons

by Roibeard O’hEineachain in Vienna

T

he femtosecond laser is fast becoming the Swiss-army knife of the corneal surgeon, opening up new possibilities in an everbroadening range of indications, said Sonia H Yoo MD, Bascom Palmer Institute, University of Miami Miller School of Medicine, Miami, Florida. “Femtosecond laser technology is a corneal surgeon’s dream and it is an evolving technology with limitless potential,” Dr Yoo said at the XXIX Congress of the ESCRS. The femtosecond laser was originally marketed roughly a decade ago as a replacement for the microkeratome in LASIK surgery. Corneal surgeons soon began to investigate the femtosecond laser’s use in other forms of corneal surgery. She noted that, since first acquiring a femtosecond laser in 2004, she and her associates have been exploring its potential in the treatment of special refractive cases.

One example of an additional use for the laser is to facilitate the re-lifting of LASIK flaps in eyes undergoing retreatments several years after the initial procedure, Dr Yoo noted. To that end, she and her associates use a technique that involves the creation of sidecuts within the side-cuts of the original LASIK flaps. The precision of the femtosecond laser enables the surgeon incise the cornea just to the depth of the original cut.

Another application of the femtosecond laser in corneal surgery is the creation of channels for placement of intrastromal ring segment. The femtosecond laser provides a precise control of the depth of channel placement and the size optical zone. That, in turn, permits a more accurate titration of the stromal ring segments’ refractive effect.

Dr Yoo noted that she has also achieved very good results with the femtosecond laser in the performance of astigmatic keratotomy in the treatment of post-keratoplasty astigmatism. In one such case she was able to reduce cylinder from -11.0 D to 0.5 D. She and her associates have also been working to further refine the technique by adopting a sub-Bowman’s approach, to reduce under- and over-corrections and reduce epithelial ingrowth and the dry eye that results from cutting across corneal nerves. She described the case of a patient who had 1.75 D of astigmatism after undergoing implantation of a multifocal IOL. Following a sub-Bowman’s arcuate incision with a femtosecond laser, the patient had a

EUROTIMES | Volume 17 | Issue 4

manifest cylinder of 0.5 D and an improved uncorrected visual acuity. Moreover, postoperative OCT imaging showed clearly that the incisions were below Bowman’s membrane, she said.

Keratoplasty The femtosecond laser is also useful in both penetrating and nonpenetrating keratoplasty procedures. For example, in penetrating keratoplasty, the femtosecond laser makes it easy to create side-cuts of the button and host cornea that can be optimised for the treatment of anterior cornea, as in the case of corneal scarring, or for the posterior cornea as in the case of endothelial disease. In the former case, a mushroom cut would preserve as much endothelium as possible, and in the latter case a top hat pattern would preserve as much of the anterior corneal surface as possible.

“I hope that in my career I will no longer be suturing penetrating keratoplasty grafts.

My hope and my dream is that we will be able to combine this technology that maximises surface area and optimises fit between the donor and the recipient and couple it with bioadhesives so that we can simply glue or adhere this lenticule into place without the need for sutures,” Dr Yoo commented.

She noted that femtosecond laser-assisted anterior lamellar grafts are possible in eyes with corneal scars where the scar is limited to the anterior half of the cornea and there is adequate posterior thickness.

The microkeratome remains the best tool in deep anterior lamellar keratoplasty for the preparation of both the donor tissue and the patient’s cornea. That is because DALK performed with a microkeratome results in a smoother stroma-to stroma interface.

However, it may be that future improved versions of the femtosecond laser or some other laser technology may be able to create interlamellar cuts as smooth as or smoother than those of a microkeratome, she noted.

Microkeratomes also produce better results than femtosecond lasers in the preparation of graft tissue for DSAEK procedures. However, the lasers are very useful in the creation of a Descemetorhexis in the recipient’s eye, greatly facilitating the surgery, Dr Yoo said.

“The femtosecond laser has changed how corneal and cataract surgery are performed and will continue to do so in the future.”

contact

Sonia H Yoo MD - syoo@med.miami.edu

Win The John Henahan Prize 2012

30

a €1,000 travel bursary to the XXX ESCRS Congress

EuroTimes Writing Competition Call for Entries

The Trials and Tribulations of a Young Ophthalmologist

See www.escrs.org for details EUROTIMES | Volume 17 | Issue 4

Update

cornea

KERATOCONUS

Clues sought using advanced imaging and genomic analysis techniques

by Cheryl Guttman Krader in Vienna

T

he pathophysiology of keratoconus remains a mystery, but increased understanding may be on the horizon thanks to efforts of dedicated researchers and analytic advances in genomic medicine, said François Malecaze MD, at the 2nd EuCornea Congress.

“New molecular techniques are allowing new strategies for studying corneal dystrophies, and hopefully they will bring us closer to unraveling the cause of keratoconus,” said Dr Malecaze, professor of ophthalmology, University Hospital of Purpan, Toulouse, France.

Providing an update on keratoconus pathophysiology, Dr Malecaze noted that the development of keratoconus is thought to require the combination of genetic predisposition and environmental factors.

However, there are different theories over whether the primary defect in keratoconus is biomechanical or biological.

According to the biomechanical theory, the characteristic corneal deformation of keratoconus is the result of abnormal distribution and orientation of collagen fibrils with loss of cohesion between collagen fibrils and non-collagenous matrix that allows interlamellar and interfibrillar slippage. Evidence to support this concept derives from studies by Meek and colleagues who used X-ray diffraction techniques to investigate the ultrastructure of the cornea.

In addition, using second-harmonic imaging microscopy, Morishige et al. showed structural abnormalities in the organisation of the anterior corneal collagen lamella in eyes with keratoconus that are consistent with characteristic changes in collagen organisation and biomechanical properties.

They also reported that relative to normal controls, keratoconic eyes had fewer fibres inserting into Bowman’s membrane, shortening of the lamellae that were present, and decreased interweaving of the lamina in the anterior part of the cornea.

Studies investigating possible biological defects in eyes with keratoconus show no significant differences in the composition or amount of stromal collagen in eyes compared with normal controls, and findings from studies investigating the concept that keratoconus develops as a result of increased matrix metalloproteinase activity leading to excessive collagen degradation are contradictory.

“

This research represents the first genome-wide transcriptome analysis of keratoconic corneas...

François Malecaze MD

“Although it has been shown that the balance of enzymes in keratoconic corneas favours protein degradation, with an increase in matrix metalloproteinase-1 and decrease in tissue inhibitor of metalloprotease-1 (TIMP-1), the enzyme alterations did not co-localise with the lesional area of the cornea,” Dr Malecaze said.

It has also been proposed that the biological defect of keratoconus involves accumulation of abnormal proteoglycans and chondroitin sulfates, and various investigators have reported altered expression or structure of proteoglycans in eyes with keratoconus. However, these changes are thought to be secondary to the disease and not etiologic.

Genetics Researchers investigating genetic associations for keratoconus have identified candidate regions in some chromosomes, although to date, individual genes have not been identified. However, rapid progress is expected in this area as researchers apply new methods of genetic analysis, Dr Malecaze said.

In a recently published paper, Dr Malecaze and colleagues reported on their findings from transcriptome and network biology analyses conducted to differentiate patterns of gene expression between normal corneas and those with keratoconus.

“This research represents the first genome-wide transcriptome analysis of keratoconic corneas, and the findings suggest that keratoconus may be secondary to an alteration of the pathway regulating the balance between cellular differentiation and proliferation,” he said.

contact

François Malecaze - malecaze.fr@chu-toulouse.fr

ESCRS GLAUCOMA DAY Friday 7 September 2012 Milan, Italy

Registration: 2200 Chairpersons Carlo Traverso (ITALY) and Keith Barton (UK)

Scientific programme organised by

www.escrs.org

32

Update

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EUROTIMES | Volume 17 | Issue 4

Best procedure?

Initial trabeculectomy failure is often directly related to postoperative wound healing response

by Dermot McGrath in Paris

G

laucoma surgeons are often faced with the question of the best procedure to perform when the initial trabeculectomy has failed.

Should they repeat the trabeculectomy or opt instead to place a tube shunt?

Two leading glaucoma specialists, Robert D Fechtner MD and Richard K Parrish MD, presented arguments in favour of each approach at a head-to-head debate at the World Glaucoma Congress.

Acknowledging that the “best advice is not to have the first trabeculectomy fail”, Dr Fechtner, professor of ophthalmology at the Institute of Ophthalmology and Visual Science, New Jersey Medical School, said that when failure does occur the surgeon should keep his options open and not routinely dismiss the possibility of a second trabeculectomy. “Tubes and shunts are not without their own problems. Why do a repeat trabeculectomy? Because it is a simple, efficient, and effective procedure that can be successful with careful patient selection,” he said.

A key consideration is to obtain an understanding of why the initial trabeculectomy surgery failed, said Dr Fechtner. “The reality is that you cannot answer what procedure to do next if you do not understand the procedure that was done previously. Trabeculectomies fail for a number of reasons, perhaps because of poor patient selection, by operating on patients who should not have had a trabeculectomy in the first place, and also because of intraoperative complications with the conjunctiva, the sclera, the vitreous, and with bleeding,” he said.

Above all, initial trabeculectomy failure is often directly related to postoperative wound healing response, said Dr Fechtner.

Dr Fechtner said that the evidence from the scientific literature is far from conclusive concerning repeat glaucoma surgery.

“There are limited head-to-head comparisons with modern surgical techniques and many of the studies have inappropriate patient populations for us to truly gauge whether trabeculectomy or tube might be the best option,” he said.

Referring to the Trabeculectomy versus Tube (TVT) study, Dr Fechtner said that while the results have clarified some questions relating to surgical treatment, many others remain unanswered.

Summing up, Dr Fechtner said surgeons could and should consider repeat trabeculectomy if they adhere to rigorous patient selection.

Making the case for tube shunt surgery as the appropriate second procedure following initial trabeculectomy failure, Dr Parrish MD, professor of ophthalmology at the Bascom Palmer Eye Institute, Miami, Florida, US, said his argument was based on an evidencebased review of the medical literature and recent clinical trial data.

He cited the Cochrane Collaboration

by Don Minckler et al, a meta-analysis of 15 trials involving 1,153 participants with varied diagnoses of glaucoma, which found insufficient evidence to conclude that clinical outcomes of trabeculectomy differ substantially from those of aqueous shunts in similar patients with complicated glaucomas. The review also said that there was insufficient evidence to conclude that any specific aqueous shunt is superior to the others currently in widespread use.

An ophthalmology technology assessment published in Ophthalmology in 2008 concluded that aqueous shunts seem to have benefits in terms of IOP control and duration of benefit comparable with those of trabeculectomy in the management of complex glaucoma in aphakic or pseudophakic eyes after prior failed trabeculectomies, said Dr Parrish.

The five-year follow-up data from the TVT study also showed that tube shunt surgery has a higher success rate than trabeculectomy with mitomycin C. Moreover, a higher rate of reoperation was observed after trabeculectomy with mitomycin compared with tube shunt surgery.

Of those patients who failed their initial surgery, whether primary trabeculectomy or drainage implant, the choice made by the surgeon for subsequent treatment tells its own story, said Dr Parrish. “The surgeons voted with their decision making. Of the 18 failures in the trabeculectomy group, 15 of those patients underwent subsequent tube shunt surgery. Of the eight failures in the tube group, four had another tube shunt procedure and four had transscleral cyclophotocoagulation,” he said.

contacts Robert D Fechtner - fechtnrd@umdnj.edu Richard K Parrish - rparrish@med.miami.edu

contact

Ike Ahmed - ike.ahmed@utoronto.ca

Update

glaucoma

MIGS LOOKS PROMISING

Micro-Invasive Glaucoma Surgery (MIGS) may be good choice for mild-to-moderate disease

by Pippa Wysong in Toronto

“

MIGS is an alternative for that big space that’s empty right now which is mild-to-moderate glaucoma Ike Ahmed MD

MIGS procedures are all ab interno and each device enhances flow through one of three routes: Schlemm’s canal, uveal sclera outflow, or enhancing subconjunctival flow.

There have been substantial advances in the development of MIGS just in the past few years because of improved technology and better understanding of surgical intervention in terms of physiology, Dr Ahmed said.

At this point five devices have been developed, though only two are on the market internationally: the iStent (Glaukos) and the Trabectome (NeoMedix). Both devices enhance flow via Schlemm's canal, albeit in slightly differently ways, and the number of stents in an eye could vary.

Studies show on average, patients end up with an IOP of about 15mmHg on after MIGS. “MIGS is not a procedure to lower IOP to 10 or so, nor is it a procedure for very advanced disease where patients need single-digit IOPs,” Dr Ahmed said. Patients who get the implants can achieve IOPs in the mid-to-low teens. “It would be great if we could get them down to 12 or so with

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no medications, but there is a limit in terms of what MIGS can do based on normal physiology,” he said.

Improving compliance However, if a medication is added, sometimes even lower levels can be attained. Generally, successful outcome for MIGS is determined by the ability to reduce the number of a patient’s medications. Many glaucoma patients take multiple types of drops throughout the day, and compliance is often poor. If the number of medications can be reduced, the better the compliance may be with the remaining eye drops they may need.

Another reason MIGS is performed along with phaco is that phaco is often associated with lowering of IOP. There can be some advantages with phaco and MIGS working together, he said. Studies to date show MIGS to be a very safe procedure, though issues can arise that accompany any implantable device. Some of those problems can include fibrosis around the device, or internal lumen blockage from fibrin, blood or pigment.

“These are all issues with the healing process of the eye and need to be combated as devices evolve in their development.

Also, as surgeons we need good technique and [need to] be as atraumatic as possible.

Certain patients might fail or will have limited success because of those reasons,” Dr Ahmed said.

As one of the few Canadian glaucoma surgeons to perform MIGS, Dr Ahmed sees the approach as something that doesn’t have to be limited to sub-specialists. General ophthalmologists could perform the procedures. No special equipment is needed aside from a gonioscopy lens and surgical microscope.

EUROTIMES

ESCRS

M

icro-Invasive Glaucoma Surgery (MIGS) is a promising approach for patients whose disease isn’t severe enough to require trabeculectomy, but for whom drops aren’t quite doing the job either.

This was one of the key messages from Ike Ahmed MD, an assistant professor of ophthalmology at the University of Toronto.

He is one of Canada’s leading authorities on glaucoma and spoke at the recent annual Walter Wright Day – Update in Ophthalmology in Toronto, Canada.

“We have a gap between medications and trabeculectomy. MIGS is an alternative for that big space that’s empty right now which is mild-to-moderate glaucoma,” he told EuroTimes in an interview.

However, at this point, MIGS is most commonly used for mild-to-moderate glaucoma in patients who undergo cataract removal rather than being used for glaucoma on its own.

MIGS entails implanting a small device designed to reduce intraocular pressure by enhancing aqueous flow. It spares the conjunctiva, does not destroy surrounding tissues, and preserves the trabecular meshwork. Compared to traditional surgery it is a much safer option with rapid recovery.

Because it is a surgical approach, it comes with surgical risks, albeit small – and the risk-benefit profile hasn’t been fully evaluated, Dr Ahmed said. But in glaucoma patients undergoing phaco, the incision is already there and consequently MIGS performed in that environment shouldn’t represent an increased risk for that population.

A review of glaucoma procedures and devices was published recently in Ophthalmology (July 2011). In “Novel Glaucoma Procedures, a report by the American Academy of Ophthalmology”, authors reported on devices and procedures that are either approved for use in the US or are in phase-III clinical trials, and included the iStent and Trabectome. The authors noted these show promise as alternative treatments for lowering IOP in open-angle glaucoma, but said there is not yet enough information on how devices compared to each other in terms of efficacy.

Nor is it known yet how they compare to other procedures such as trabeculectomy.

Randomised controlled trials are needed.

Additional MIGS devices in the pipeline are Cypass (Transcend), Hydrus (Ivantis) and the Aquesys. The Hydrus is a Schlemm’s canal device, with the Cypass enhancing flow through the suprachoroidal space, while the Aquesys is intended to work via the subconjunctival space.

MIGS has the potential to change the algorithm ophthalmologists use when treating glaucoma patients, Dr Ahmed said.

Right now, less invasive approaches for milder glaucoma cases start with one and then multiple medications, followed by SLT. Later, with disease progression, patients may undergo trabeculectomy. Some patients undergo either a second trabeculectomy or a drainage tube implant.

In future, that algorithm could change to starting with one medication or SLT. Patients who need a lower target pressure or whose disease progress could then be treated with one MIGS device and then even another if needed. Perhaps conventional outflow may be targeted first, with movement to alternative outflow pathways as needed. After that, either the ExPress device (Alcon) could be offered, or trabeculectomy or a tube.

Overall, MIGS could allow for less invasive and less traumatic procedures overall, and help preserve natural ocular physiology. But right now, their use is primarily for those in-between glaucoma patients who undergo phaco.

India www.eurotimesindia.org EUROTIMES | Volume 17 | Issue 4

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contacts

34

Update

retina

ANTI-VEGF INJECTIONS

Specialists may not always be available to patients in rural communities

by Pippa Wysong in Toronto

J

ust how qualified are general ophthalmologists in making the decisions to give patients ranibizumab (Lucentis, Genentech) injections?

In Canada, this is an issue because many patients live in rural communities and don’t have access to centres where specialists are located. The topic was discussed at the recent 51st Walter Wright Annual Ophthalmology and Vision Sciences Symposium in Toronto.

According to David Lane MD, a general ophthalmologist in the rural community of Lindsay, Ontario, the key issue is access to care. Retinal specialists tend to be located in urban centres, and are usually the ones who do Lucentis injections there. But in small, outlying communities, general ophthalmologists take on much of the load.

Alan R Berger BSc, MDCM, FRCSC, Dip ABO, a vitreoretinal specialist and ophthalmologist-in-chief at St Michael’s Hospital, a university of Toronto teaching hospital, argues that while general ophthalmologists are capable of giving the injections, they are not as well trained to make the needed clinical decisions, especially in confusing or complex cases.

Lucentis is approved for coverage for the treatment of AMD under Canada’s public healthcare system in most of the country’s 10 provinces. Bevacizumab (Avastin, Genentech) is not reimbursed in most provinces and must still be paid for out-ofpocket by patients.

“

Access to care is inextricably linked to quality of care.

You can’t separate the two. If you don’t have access to the care, your quality of care will be poor David Lane MD

A large part of Canada’s population resides in small communities where it takes at least a couple of hours to drive to urban centres. Many Canadians live in even more remote communities where access to even a general ophthalmologist is not easy, and may even require flying to regional hospitals for visits. For many patients, especially older, sicker patients, regular visits to a specialist centre is difficult, stressful, and often impossible.

“Access to care is inextricably linked to quality of care. You can’t separate the two.

If you don’t have access to the care, your quality of care will be poor,” Dr Lane said.

He notes general ophthalmologists are not only capable of performing intravitreal injections, but should be able to read an OCT, and can recognise macular degeneration.

The question of clinical judgement could be an issue. If a general ophthalmologist who’s been in practice for 10 or more years has only a small amount of experience with retinal pathology, and has limited experience with OCT, that could be a concern. “If you don’t feel comfortable with intravitreal injections, don’t do them,” he said.

Dr Lane argues that ophthalmologists working in rural communities are preventing more vision loss than doing potential harm. “I see at least one patient every day who would lose vision if I didn’t inject,” he said. In four years, this means about 1,200 people would permanently lose vision due to poor access to care.

To illustrate his point, he offered a hypothetical situation: Assume a generalist gives 50 patients injections each week.

Assume too that their clinical judgement is so poor that 10 per cent of the time they perform injections that never should been done. This would equal five inappropriate injections per week. This equals 250 injections per year. If the rate of complications is one in 1,000, it would take four years for one patient to potentially lose vision because of the injections.

“This means 1,200 people would lose vision in four years due to poor access to care versus potentially one patient due to

Don’t miss Resident’s Diary, see page 42 EUROTIMES | Volume 17 | Issue 4

“

My ideal scenario is that the retinal specialist either makes or confirms the proper diagnosis and discusses the treatment options and initiates treatment

Alan R Berger BSc, MDCM, FRCSC, Dip ABO

poor clinical judgment. It is clear where the risks lie, poor access to care,” he said.

However, general ophthalmologists who want to start doing Lucentis injections shouldn’t go into it cold. He suggests teaming up with a retinal specialist and working some sort of a co-management model as a way to learn more about AMD. He looks at this as a learning model.

The other side The concept of co-management is something Dr Berger strongly supports, but considers it more of a standard of practice rather than simply a learning model.

He described several difficult and complex cases where the incorrect diagnosis of macular degeneration was made by the general ophthalmologist and Lucentis injection treatment was started.

In one case, the patient went on to develop endophthalmitis after 11 months of Lucentis injections. While OCT studies had initially been performed, no fluorescein angiogram was done initially and the incorrect diagnosis made.

“The patient didn’t need Lucentis treatment. She had adult vitelliform macular degeneration which is most commonly a stable disease that doesn’t progress,” Dr Berger said.

In another case, a general ophthalmologist diagnosed wet AMD

David Lane - lane1@cogeco.ca Alan R Berger - Bergera@smh.ca

in both eyes and suggested Lucentis injections. However, it turned out the patient didn’t have AMD, but rather idiopathic juxtafoveal retinal telangiectasia.

This is an uncommon retinal vascular condition rarely associated with choroidal neovascularisation.

“Most retinal specialists undergo 12 to 24 months of intense retinal fellowship treatment training, and most see over 250 patients per week, specifically with retinal diseases,” he said.

The field of retinal disease, diagnostics and therapeutics has exponentially expanded. It’s difficult for even a full-time retinal specialist to keep up, he noted.

“Can the general ophthalmologist, who sees retina patients maybe 20 per cent of the time, possibly keep current and still do a good job? It’s not to say they can’t do Lucentis injections, but the diagnosis and follow-up decision process can be tricky,” Dr Berger said.

The number of Lucentis injections increased from 60,000 to 120,000 between 2008 and 2010 in Ontario alone. In two Canadian provinces, intravitreal injections are paid for by the provincial health service only if retinal specialists do the injections. If general ophthalmologists do the injections, patients have to pay for the injections out-of-pocket.

Dr Lane argues the situation in those provinces is “a disaster”. Special clinics were supposed to be set up where specialists would visit periodically, but never materialised. If specialists do fly in to do injections, they aren’t there for follow-up or to deal with complications.

Rural patients are now paying to have the injections by their local general ophthalmologist, which is unfair.

Is there a compromise? For people in rural communities, Dr Berger supports the idea of close, continuous co-management.

“My ideal scenario is that the retinal specialist either makes or confirms the proper diagnosis and discusses the treatment options and initiates treatment,” he said. Periodic consultation with the retinal specialist is a good idea.

“I think it’s optimal for the patient in terms of accuracy of diagnosis, accuracy of knowing whether they need further treatment. It’s also good support for the general ophthalmologist,” he said. And if the patient lives in a remote area, then the retinal specialist can still help co-manage via telemedicine.

35

Update

retina

RETINOPATHY

Grading system for proliferative diabetic retinopathy provides useful guide to treatment

by Roibeard O’hEineachain in London

A

t the 11th annual EURETINA meeting in London, UK, Borja Corcostegui MD, Spain outlined a grading system for proliferative diabetic retinopathy based on the amount of vitreoretinal attachments and its relationship to the likely prognosis of the disease.

Delivering the EURETINA lecture, he said the goals of surgery in proliferative diabetic retinopathy are to remove the posterior hyaloid membrane and vitreous attachment in order to clear the opacity and traction.

In eyes with type zero proliferative diabetic retinopathy there is a total posterior vitreous detachment. The main indication for surgery in such cases would be a vitreous haemorrhage, in which case a core vitrectomy should be performed to clear the opacity.

In Type 1 disease there are at most just a few focal vitreoretinal attachments located at the optic disc or at the vascular arcades, he noted. The results of surgery in both Type 0 and Type 1 disease is generally pretty good with a low likelihood of retinal detachments or epiretinal membranes, he added.

However, the incidence of post-surgical complications increases to around five per cent in eyes with Type 2 proliferative diabetic retinopathy, Dr Corcostegui said. The diagnostic features of that stage of disease include a broad vitreoretinal attachment of at least two disc diameters.

There may or may not be an underlying traction or combined traction under a rhegmatogenous retinal detachment.

In Type 3 disease the vitreous is attached at the disc along the vascular arcade and over the macula but is detached between the arcades and the vitreous base attachments in the macula. In this group of patients the rate of complications is about seven per cent.

In a patient with Grade 4 disease the vitreous is attached to disc out to the vascular arcade and the only area of vitreous detachment is over the macula. In such cases the risk of epiretinal membrane and retinal detachment reaches eight per

Don’t miss Book Review, see page 45 EUROTIMES | Volume 17 | Issue 4

“

I think the size of the instrumentation is less important. What is most important is to leave the retina completely free of traction Borja Corcostegui MD

cent to 10 per cent. In Type 5 disease there is a total vitreous attachment and the risk of the complications rises to 12 per cent to 15 per cent.

Dr Corcostegui said that in eyes with Type 2 to Type 5 disease he generally injects an anti-VEGF agent four to seven days prior to performing surgery, to dampen down the neovascularisation and reduce bleeding.

He then proceeds to remove the proliferative tissue using one of three techniques. In the simpler cases he will use the vitreous cutter on its own, in the more difficult cases he will use bimanual dissection with vitreous cutter and forceps or bimanual dissection with vitreous cutter and scissors. All cases can be assisted with viscodissection.

He noted that in most cases patients are unlikely to require more than three sclerotomies. He added that modern vitreoretinal surgical technology has several advantages including more efficient vitreous cutters with faster duty cycles which can be used in cannulas from 20 gauge to 27 gauge.

“But the most important thing is to not break the retina and to remove the proliferative tissue. I think the size of the instrumentation is less important. What is most important is to leave the retina completely free of traction,” he said.

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36

Update

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retina

Vitrectomy in DME

Surgical procedure can reduce macular swelling but produces mixed results on visual acuity

by Roibeard O’hEineachain in London

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itrectomy can help normalise the anatomical appearance of the macula in eyes with chronic diffuse diabetic macular oedema (DME) or diabetic macular oedema with vitreomacular traction, but the procedure does not generally bring about improvements in visual acuity, said William F Mieler MD, University of Illinois, Chicago.

“Vitrectomy surgery for chronic diabetic macular oedema can be successful, though the patient needs to understand the potential visual limitations,” he told the 11th EURETINA Congress.

He noted that by the time a patient with DME has been referred for surgery, they will have undergone treatment with a range of therapies, including focal laser photocoagulation, which can itself have damaging effects, as well as treatment with topical agents, intravitreal corticosteroids and/ or anti-VEGF agents.

“Many of these eyes have extensive chronic oedema prior to surgery that has not responded as hoped for to extensive therapy, so in many cases we cannot achieve any visual recovery,” Dr Mieler said.

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EUROTIMES | Volume 17 | Issue 4

The principal indications for surgery are taut posterior hyaloid syndrome and diffuse DME that has not responded to conventional therapy with laser or pharmacological approaches, alone or in combination.

However, the published literature’s support for surgery in such cases is somewhat equivocal, he noted.

In eyes with taut posterior hyaloid membrane syndrome, the area of the vitreous attached to the macula contracts in a way similar to an epiretinal membrane. The oedema that occurs is generally unresponsive to laser treatment.

However, starting from a study published nearly 20 years ago, there have been reports that vitrectomy can result in improved visual function in such eyes, the theory being that it relieves traction on the macula from the contracted vitreous and thereby also reduces the oedema (Lewis et al. Ophthalmology (1992); 99(5): 753-759).

In a more recent study conducted on behalf of the Diabetic Clinical research Network (DRCR.net) vitrectomy produced mixed results in 87 patients with taut posterior hyaloid membrane syndrome (Haller et al,

Ophthalmology2010;117: 1087-1093), Dr Mieler said. That is, although there was 50 per cent reduction in thickening in 68 per cent of patients and 38 per cent of patients had an improvement of at least 10 letters in bestcorrected visual acuity, visual acuity fell by 10 or more letters in 22 per cent of patients.

The study’s authors estimated that, based on their findings, between 28 per cent and 49 per cent of eyes with DME and vitreomacular traction will have some degree of visual improvement, while 13 per cent to 31 per cent will have a reduction in vision.

Vitrectomy’s benefits Apart from its more direct effects on retinal thickness and visual acuity, there is a lot of evidence in the published literature to suggest that vitrectomy may have other effects that improve the general health of the retina.

For example, research has shown that the inner segment/outer segment photoreceptor line appears improved on OCT following vitrectomy. (Sakamoto et al. Graefes Arch Clin Exp Ophthalmol. 2009; 247(10):1325-30). It may therefore be that removal of adherent vitreous facilitates enhanced diffusion of nutrients and other metabolic factors from the vitreous to the inner retina.

In another study, eyes with macular oedema had a normalisation in their macular microcirculation following pars plana microcirculation, if the procedure also resulted in a resolution of the central macular thickness on OCT (Park et al. Graefes Arch Clin Exp Ophthalmol. 200; 247:1009-17).

A report from Japan showed that patients who had undergone pars plana vitrectomy reported an enhanced quality of life in their responses to the VFQ-25 questionnaire (Emi et al, Nihon Ganka Gakkai Zasshi 2008; 112(2):141-7).

“The majority of cases of diffuse DME can be successfully managed through focal photocoagulation and/or pharmacologic therapy. But when those treatments fail, pars plana vitrectomy can be beneficial in many cases. There is almost always improvement on OCT and many cases have visual improvement as well,” Dr Mieler concluded.

contact William F Mieler - wmieler@uic.edu

37

Update

Ocular ‘FOR ADVANCED DMEK SURGERY I FOCUS ON D.O.R.C. INSTRUMENTS’

PHOTORECEPTOR

STANDARDIZED ‘NO TOUCH’ DESCEMET MEMbRANE ENDOTHElIAl KERATOplASTY TECHNIQUE

Biological clocks can play extraordinary role in physiological behaviour

by Priscilla Lynch in Southport

T

world that lacks both vision and a proper sense of time, clinical guidelines should incorporate this information, he contended.

“If you have no eyes your ability to coordinate internal time is lost completely.”

The discovery of a third photoreceptor system within the eye based on melanopsin photosensitive retinal ganglion cells (pRGCs) unlocked the key to understanding the regulation of the body clock, and many other responses to light including pupil constriction, alertness, hormone release, and even our subconscious awareness of light.

“We found a mouse could be visually blind but not blind to these non-visual responses to light,” Prof Foster noted.

Thus, he recommended that a ‘blind’ individual who exhibits a bright-lightdependent pupil constriction should be encouraged where possible to expose their eyes to sufficient daytime light or even use light boxes to maintain normal circadian entrainment and sleep/wake timing.

Patients with diseases of the inner retina that result in RGC death such as glaucoma are at particular risk of body clock issues and sleep disruption and should receive targeted treatment, including potentially melatonin, to address this, he suggested.

Meanwhile, Prof Foster said that because so much of our physiology and behaviour is being affected by these new receptors, the clinical diagnosis of complete blindness should assess the state of both the rod/cone and pRGC photoreceptive systems.

Role of the eyes The eye and the retina play a vital role in regulating the body clock system. As eye loss places patients into a

Russell Foster - Russell.foster@eye.ox.ac.uk

EUROTIMES | Volume 17 | Issue 4

Courtesy of Russel Foster BSc, PhD, FRS

he contribution of the third class ocular photoreceptors (non rod or cone) to a range of light detection tasks, as well as its role in circadian rhythms, should now be factored into all assessments of clinical blindness, the XXXV United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) Congress heard.

One of the highlights of the event was the Choyce Medal Lecture given by Russell Foster BSc, PhD, FRS, professor of circadian neuroscience, and chair of the Nuffield Laboratory of Ophthalmology, University of Oxford, whose research over 10 years led to the discovery of a third class of ocular photoreceptor in 1999.

Prof Foster discussed the link between eyes, light and the regulation of body clocks, and the importance of circadian rhythms in the healthy functioning of humans. “The body clock is constantly adjusting physiology and behaviour across the 24-hour day, anticipating and finetuning physiology to the varying demands of activity and sleep. Blood pressure, temperature and metabolic rate all rise before we wake, and fall in anticipation of sleep. Even our pain sensitivity varies across the day. Furthermore, there is a 49 per cent higher chance of having a stroke between 6am and midday, while overall there is a 29 per cent greater chance of dying during this period. We are very different creatures at midnight compared to midday. For example, even accounting for fatigue, the human ability to process information at 4am or 5am is worse than the drop in brain performance we experience when we have consumed sufficient alcohol to make us legally drunk,” Prof Foster commented.

He stressed the impact of sleep and body clock disruption on health. Disrupted sleep can have effects that range across activation of the stress axis, immune suppression, metabolic abnormalities and greater risk of heart disease. Prof Foster said that because the eyes are so vital in regulating the 24-hour body clock, ophthalmologists have an important role to play in advising patients about the relationship between light and the body clock.

Three photosensitive retinal ganglion cells (pRGCs) labelled green in the mouse retina. Red nuclei are of normal retinal ganglion cells

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

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

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

“

David Granet

Ken Nischal Scan this QR code to gain access to EuroTimes podcasts

The ESCRS, working with ORBIS, is helping to fund sub-speciality teaching in Ethiopia

by Colin Kerr

WCPOS Challenges In Paediatric Ophthalmology The 2nd World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) promises to be even more exciting than the first.

In this month’s Eye Chat, WCPOS co-chairs Dr David Granet and Dr Ken Nischal, give a preview of the congress which will be held in Milan from 7-9 September, 2012.

Listen to our podcasts at

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EUROTIMES | Volume 17 | Issue 4

TRAINING DAYS

A

total of €33,500 was donated by the ESCRS to the ORBIS and Oxfam charities in 2011.

Funds were initially raised from delegates when registering for the 15th ESCRS Winter Meeting in Istanbul, Turkey and the XXIX ESCRS Congress in Vienna, Austria.

Additional funds were raised from a raffle at the Vienna Congress. The ESCRS Board also pledged to donate €25,000 from the society’s funds. The amount donated to each charity in 2011 was €16,750 and new fundraising activities are already being planned for 2012.

As part of this project, money donated by the society to ORBIS is helping to fund paediatric training for Dr Mulusew Asferaw, an ophthalmologist working in the Department of Ophthalmology, University of Gondar, Ethiopia.

“Before I joined this department,” Dr Asferaw told EuroTimes, “I had worked as a general medical practitioner in Debretabor and Bahirdar hospitals. After a couple of years of practice in the Eye Department of Gondar University Hospital, I joined Addis Ababa University for my four years postgraduate study in ophthalmology,” he said “Immediately after completion of my residency programme, I resumed my work in the Department of Ophthalmology with the position of assistant professor. Because of my interest in paediatric ophthalmology I started practising in the child eye care service in Gondar University Hospital and currently I am in charge of the Paediatric Ophthalmology Unit. The most commonly seen childhood eye diseases include paediatric cataract, refractive errors, strabismus and eye infections,” said Dr Asferaw.

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38

Dr Asferaw during the follow-up of a case

The first part of Dr Asferaw’s sub-speciality training took place in November 2011 when an ORBIS volunteer, Dr Donal Brosnahan, an Irish ophthalmologist, carried out a 10-day training programme at Menelik Hospital in Addis Ababa that was attended by Dr Asferaw. This was paid for out of the ESCRS funding.

“After this training,” said Dr Asferaw, “my expertise in paediatric eye surgery has markedly improved and the number of paediatric patients examined at the Outpatient Department and those receiving eye surgeries has significantly increased. This has prevented us referring paediatric patients to eye care centres in the capital city in search of better eye care services,” he said.

Dr Asferaw points out that the impact of childhood blindness in Ethiopia is such that children who became blind in early childhood will suffer many years of blindness.

“This creates a burden to the members of the family and has an adverse economic impact in the country,” he said. “If we are able to detect childhood eye disorders early and give appropriate and timely intervention, we can avoid unnecessary childhood blindness, enhancing the growth and development of the next generation. It is because of this objective that I choose to study paediatric ophthalmology,” he said.

For more information visit www.escrs.org/charitable-donations

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contact Allan Thompson - athompson@orbis.org.uk

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Register Now www.ASCRS.org ASCRS Symposium on Cataract, IOL and Refractive Surgery

April 20–24, 2012

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ASOA Congress on Ophthalmic Practice Management

April 20–24, 2012

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

Technicians & Nurses Program

April 21–23, 2012

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Update

BIO-OPHTHALMOLOGY

GENE DELIVERY ADVANCE

More efficient technologies may expand list of treatable retinopathies

by Dr Gearóid Tuohy

EUROTIMES | Volume 17 | Issue 4

Courtesy of Foundation Fighting Blindness (FFB). www.fightblindness.org

R

esearchers have reported that a self-complimentary adenoassociated virus (AAV) vector with a specific capsid alteration can increase the efficiency of a gene therapy for Leber congenital amaurosis.

The research, led by Dr Cristy Ku and Prof Visvanathan Ramamurthy at the RC Byrd Health Sciences Centre of the University of West Virginia, US, represented the first-ever demonstration in a rapid retinal degeneration model using a self complimentary AAV with mutations of surface-exposed tyrosine residues on the viral capsid.

If successful in larger studies, the technology may have significant implications for broadening the spectrum of patients treatable with ocular gene therapy tools.

Leber congenital amaurosis (LCA) is well characterised as an early onset severe form of inherited retinopathy, representing about five per cent of inherited retinal degenerations. The disease may be caused by mutations in any one of up to 15 different genes, mostly expressed in photoreceptors or the retinal pigment epithelium (RPE).

Recently, researchers have demonstrated proof-of-concept using a gene replacement strategy to treat one form of LCA. Clinical trials involving the replacement of RPE65, delivered with viral vectors, have shown visual improvements in a number of patients. However, with 15 other genes potentially causing the disease, many patients will require delivery of a different gene or some other modification that addresses the particular genetic lesion.

The current studies, which appear in Human Molecular Genetics, [2011, Vol. 20, No. 23, pp 4569-4581] focused on a severe form of LCA caused by mutations in a gene called aryl hydrocarbon receptor interacting protein like 1, or “Aipl1” for short.

Patients with Aipl1 gene mutations account for about five to seven per cent of LCA; the mutation may also arise in juvenile retinitis pigmentosa and conerod dystrophy. Aipl1 patients possess a significantly reduced visual acuity by the age of 10 years, often ranging from 20/200 to no light perception. In such instances, time is of the essence, and therapeutic success in part may become a function of

Lancelot, a Briard dog model of RPE65-/- LCA, was the first large animal used to demonstrate a gene replacement strategy to restore visual function in 2001

delivering the therapy before all recipient photoreceptors have degenerated.

Delivering the right genes to the right cells at the right time are challenges that must be overcome in any gene therapy strategy; the key tool in addressing these challenges is the delivery system. While there are limited types of delivery system to choose from, viral vectors, and in particular adeno-associated virus in retinal medicine, has become the tool of choice. In recent years, there have been significant advances made in the development of viral vector technology and, two advances in particular, have provided considerable optimism in the application of these tools to clinical medicine. Firstly, the development of self-complimentary vectors has provided double-stranded gene vectors that are more stable and eliminate the step of second strand synthesis.

As a consequence, transduction efficiencies of self-complementary vectors have increased and an earlier onset of expression of the delivered gene has been achieved. Secondly, experimentation with the surface exposed tyrosine residues on the viral capsid have led to more accurate targeting of specific cell types and have reduced the ubiquitination of viral particles due to decreased capsid tyrosine phosphorylation.

Combining both these developments – self-complimentary vectors and tyrosine residue alterations – the West Virginia research group used a murine model with no Aipl1 into which a single sub-retinal injection at post-natal day two or postnatal day 10 was performed. The injection contained the self-complementary “AAVY733F-RKp-hAipl1” – a viral vector with capsid modifications housing a replacement

Ailp1 gene driven by a rhodopsin kinase promoter.

Analysis of the results demonstrated that vision had been restored, including improvements in the ERG a-wave and an increase of up to 45 per cent in the number of photoreceptor cell nuclei. Most importantly, behavioural analysis provided convincing data when single stranded AAV (ssAAV, unmodified) was compared to selfcomplimentary AAV (scAAV, with tyrosine modifications).

An adapted maze test was used to time reaction speeds under a variety of lighting conditions. Normal subjects with functional Aipl1 had a reaction time of 4.38±0.45 seconds while subjects with no functioning Aipl1 scored a reaction speed of 25.20±6.52 seconds. Following injections at post-natal day 10, subjects without any Aipl1 that received an ssAAV had a reaction time of 24.00±3.51 seconds (similar to no treatment at all) while similar subjects injected with scAAV had a reaction time of 6.69±1.30 seconds – a dramatic difference. The definitive result clearly indicated that, 10 days after birth, use of the scAAV carrying Aipl1 restored certain visual abilities to levels generally found in normal wild-type subjects.

According to the authors of the study, their results represent the first demonstration of the use of a selfcomplimentary AAV vector with tyrosine modifications in a rapid retinal degeneration.

Combining these advances with increasingly efficient gene packaging may significantly alter the range of retinal degenerations capable of treatment. While RPE65 delivery represented the first clinical success, technologies such as those developed by the US-based researchers may now expand the list of retinopathies that may benefit, most especially to the benefit of rapidly degenerating disorders where time is of the essence and delivery of the gene at the critical time can potentially make an enormous difference to the medical outcome.

“There is an impetus to broaden gene therapy clinical trials to treat a wider severity spectrum of inherited retinal dystrophies,” Prof Ramamurthy commented. “Recent clinical studies report cases of adolescent and adult patients with genetic defects associated with rapid retinal degeneration, who show varying extents of ONL (outer nuclear layer) preservation and inner and outer segment integrity as observed with optical coherence tomography (OCT). These studies show that patients with genetic defects associated with rapid retinal degeneration may potentially benefit from AAV-mediated gene replacement therapy”.

41

Feature

RESIDENT’S DIARY

the eye test

Study method exercises body and mind

by Leigh Spielberg MD

T

he Residents’ Lounge in the Rotterdam Eye Hospital usually has a rather carefree vibe. Conversation bounces from discussions of last weekend’s activities to the spectacular cases that presented the night before in the emergency room. And the conversation is always interesting. One resident recently married a Brazilian lawyer he met while in Vienna. Another resident (me) just welcomed the arrival of his first child. How’s that for early-morning conversation? To be sure, the carefree vibe is punctuated by some requisite whining. After all, it’s raining outside, the sun has yet to rise and the caffeine has yet to reach our blood streams, but we’re generally pretty happy to be there in the morning and to get started early.

A few weeks ago, we 20 residents arrived in the clinic just before 8am, as we always do. One or two arrived by train, two or three on foot and, this being Holland, the rest by bicycle. We swarmed into the Residents’ Lounge and gathered around the espresso machine. But on this particular day, the mood was different. We were all tense, agitated, excited, like greyhounds at the starting gate. There, above the espresso machine’s distinctive droning hum, we looked at each other and hoped it would be relatively painless and over soon.

The yearly ophthalmology exams were about to begin and the pressure was on. The exam proctor entered to tell us it was time to start. We filed out of the Residents’ Lounge and into the hospital’s conference room. At 8 o’clock sharp, the exams were distributed and we were off.

All ophthalmology residents throughout The Netherlands take these exams simultaneously, and passing four sets of them is required before graduation. This year was my first time, and I realised that they were the first exams that I’d ever taken in which the material would be relevant for the rest of my career. Sure, information that I had studied in medical school has been secondarily useful during my ophthalmology residency. Medical retina is impossible to practise without understanding diabetes as a systemic disease. But I found myself, a year into my residency, studying the actual presentations of uveitis, the diagnostics of glaucoma and the techniques of cataract surgery, the updated versions of which I’ll still be applying 30 years from now.

EUROTIMES | Volume 17 | Issue 4

No longer did I have the medical school feeling of, “I’m going to try to learn this really well so I’ll get good enough grades to be able to get into ophthalmology and actually learn what I want to learn.” This was it! Learn it and remember it! Make it a part of yourself.

Learning curve Fortunately, learning during residency is very different than it is during medical school. It’s more interesting, less painful and more all-enveloping. During the week, it’s a full-day experience, broken up into tolerable chunks. Half the day is spent in the clinic learning from patients, colleagues and attendings. The other half of the day is spent learning from case studies, journal articles and, via textbooks, renowned experts. Clinical experience and book learning eventually blend into a relatively seamless entity. It isn’t quite effortless, but it’s no longer the sort of isolated martyrdom that sometimes characterised the hours, days, weeks spent memorising pulmonary physiology and renal pathology.

Nevertheless, the familiar feelings came surging forward while I was studying, wild oscillations between the excitement of learning and the dread of exams looming ahead, interspersed with totally irrational ideas (“I wish the white dot syndromes didn’t exist because I don’t understand them!”). But this time, I was learning for my patients and myself rather than for my professors and my résumé. Back in medical school, did I ever really want to know exactly what a gastric chief cell does? No, not really. Do I now want to be able to tell the difference between sterile and infectious endophthalmitis? Yes, for sure.

The questions were drawn from the textbooks we were told to study, but I felt I could answer about one fifth of the questions just purely based on what I had seen in the clinic, and for another fifth, practical experience helped me eliminate at least the more incongruous answer possibilities. For the other 60 per cent, my brain was on its own and was going to have to recall what it had come across in the books.

Or, more accurately, what it came across in the fields, which is where I did most of my real learning. I have developed an unusual studying method. Borne of necessity during otherwise lost hours of commuting to rotations in far-flung hospitals during medical school, I started distilling the information I needed to know into

Credit: Eoin Covney

42

questions and answers and recording the results on a tiny digital voice recorder. I read the textbooks and then recorded the important facts, which I could listen to later.

My commutes thus became intense study sessions in which the soundtrack was a stern “me” asking myself what I needed to know.

Now that I’m living and working in Holland, I have no real commute, but instead endless flat terrain behind my house and bike paths connecting every point on the map.

So, while my colleagues were inside sweating it out with their books, I was outside, cramming it in on my bicycle. I found I could cover the important points of a book from the AAO series in a long day in the saddle, cruising from Rotterdam to the Hague and back. Sometimes I didn’t know which I was exercising more, my mind or my body.

The idea was to get out of my comfort zone. I felt I could answer basic questions about glaucoma while sitting at a desk with my head in the books, but could I do the same in the middle of an iconic, wide-open Dutch field dotted with cows and windmills?

Could I prove to myself that I had made this information my own? Because that’s what it comes down to in the end, making the ophthalmic knowledge one’s own.

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

Review

JCRS Highlights

JCRS Symposium CONTROVERSIES IN CATARACT AND REFRACTIVE SURGERY Monday, April 23, 2012 1:00–2:30 PM Chairs: William J. Dupps Jr, MD, PhD, Nick Mamalis, MD

LASIK Enhancements: To Lift or Not to Lift?

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

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

EUROTIMES | Volume 17 | Issue 4

Journal of Cataract and Refractive Surgery

Cosmetic iris implants Iris prosthetic devices offer significant benefit in patients with iris defects with subsequent glare and light sensitivity. These devices are properly made and properly placed devices and have been shown to have excellent results. The same cannot be said for cosmetic iris implants, unapproved devices for which patients are travelling to Panama to change the colour of the iris, typically to blue. Researchers at the New York Eye and Ear Infirmary report a case series highlighting some of the serious problems associated with the implants. The report covers 14 eyes of seven patients who received the NewColorIris cosmetic iris implants. Nine eyes presented with decreased visual acuity, seven had elevated IOP, five had corneal oedema, and five had anterior uveitis. All 14 eyes had explantation of the iris prosthesis. Intraoperative complications included suprachoroidal haemorrhage during explantation in one eye. Postoperative complications included corneal oedema, cataract, and increased IOP/glaucoma. In an accompanying editorial, Dr Nick Mamalis calls for both patients and physicians to seriously reconsider the use of this cosmetic iris implant device in healthy phakic eyes. n A

Hoguet et al., JCRS, “Serious ocular complications of cosmetic iris implants in 14 eyes”, Volume 38, Issue 3, 387-393.

N Mamalis, “Cosmetic iris implants”, Volume 38, Issue 3, 383.

Multifocal IOLs for AMD patients Strategies for treating cataract in patients with age-related macular degeneration (AMD) include implantation of intraocular telescopic lenses and implantation of lowpower IOLs that provide telescopic vision when combined with spectacles. A new approach using multifocal IOLs with myopic postoperative targets could offer a new option. Surgeons evaluated this approach in 20 eyes of 13 AMD patients. They implanted the AcrySof ReSTOR SN60D3 multifocal IOL, targeting an SE of -2.0 D, which yielded +5.2 D near addition. At six months the uncorrected near visual acuity improved in 18 eyes and was unchanged in two eyes. The corrected distance visual acuity improved in 14 eyes, was unchanged in four eyes, and decreased (≤3 lines) in two eyes. Patients reported improvements in vision, mental health symptoms due to vision, and limitations with peripheral vision.

The researchers believe the preliminary results in this study suggest this multifocal– magnification strategy holds promise for visual rehabilitation of AMD patients with cataract. They note that it may be useful in guiding researchers and manufacturers in the

design of high-magnification IOLs for AMD patients. n JL

Gayton et al., JCRS, “Implantation of multifocal intraocular lenses using a magnification strategy in cataractous eyes with age-related macular degeneration”, Volume 38, Issue 3, 415-418.

Cross-linking plus phakic IOL Correcting refractive errors with phakic IOLs in cases of progressive keratoconus has hitherto not been considered a good idea because the refractive correction and uncorrected distance visual acuity achieved would not be maintained over the long term. However, with the advent of corneal collagen cross-linking for the treatment of keratoconus, researchers are reconsidering this dogma. Guell and colleagues report medium-term outcomes in 17 eyes of nine keratoconus patients who underwent cross-linking, and then, once the cornea stabilised, also underwent toric Artiflex/ Artisan phakic IOL implantation for cataract.

With a median follow-up of three years, 14 eyes (82 per cent) were within ±0.50 D of the attempted SE correction and 13 eyes (76 per cent) were within ±1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow-up was 0.17 ± 0.45 D (range -0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94 per cent). No eye lost lines of CDVA. No significant decrease in central endothelial cell count occurred (P>.05).

The researchers believe this combination approach can effectively and safely correct myopic astigmatism in selected patients with progressive mild to moderate keratoconus. n JL

Güell, et al., JCRS, “Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus”, Volume 38, Issue 3, 475-484.

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

45

Feature

BOOK REVIEW

EasyGas

®

THE FIRST READY-TO-USE GAS TAMPONADE IN GEUDER QUALITY.

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EUROTIMES | Volume 17 | Issue 4

SAFELY DOSED, EASILY APPLIED, PRECISELY TAMPONADED.

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BOOKS EDITOR Leigh Spielberg PUBLICATION Surgical Techniques in Ophthalmology Pediatric Ophthalmic Surgery

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- Color-coding of the three gases for clear and safe choice - Sterile, pre-filled system for quick and easy preparation - Dosage manual on each syringe for precise mixture ratio

EDITORS IN CHIEF Ashok Garg, Jorge L Alio 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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Dr M Edward Wilson states in the forward to this book: “Children are not small adults.”

He understands that paediatric ocular surgeons operate in an entirely different domain than general ophthalmologists.

After all, Dr Wilson notes, the “postoperative period may last a half century or longer.” These are sobering words for those who might consider themselves unprepared, but they are also encouraging for those surgeons looking for another excellent reason to spend some more time reading up on the latest developments in the field of paediatric ophthalmic surgery.

Drs Ashok Garg and Jorge Alió have brought together a large group of subspecialists to write “Paediatric Ophthalmic Surgery” for the Surgical Techniques in Ophthalmology series published by Jaypee Brothers Medical Publishers.

This book is a detailed surgical instruction manual and atlas that covers everything from standard procedures like strabismus correction and cataract surgery to more complex glaucoma surgery, laserassisted lacrimal bypass surgery, and paediatric keratoplasty.

Although children are not simply miniature versions of adults, the techniques employed in the treatment of their ocular pathology increasingly borrow from those developed for adults. Indeed, removable piggyback IOLs, toric bag-inthe-lens implantation, multifocal IOLs, and paediatric refractive surgery are all discussed.

The atlas is divided into two sections: the first 500 pages are devoted to the anterior segment, including strabismus surgery, orbital and eyelid procedures; the last 100 pages cover the surgical treatment of posterior segment disease such as paediatric retinal detachment and retinal tumors. Very little space is “wasted” on the theoretical background, on the assumption that readers who are interested in the details of surgical technique already have a solid understanding of the etiology, pathophysiology and natural history of the disease they are seeking to treat. However, a discussion of the potential complications and their management follows each outline of surgical technique. This is very welcome, as we are all interested in reading not only how the experts’ surgical precision allows them to avoid problems, but also how they solve the problems that inevitably arise from time to time, even in their hands.

A fun addition is the inclusion of “tips” chapters, which provide the sort of surgical pearls that a mentor might suggest while assisting a fellow in the operating room.

These are very specific and practical, aiming not to teach a surgical method but to help

aim for an easier, less traumatic surgery.

In Chapter 13, “Tips and Pearls for Achieving Good Optical Results when Managing Cataract in a Child,” details are covered that everyone wants to know but might have been afraid to ask. Which contact lenses are best for aphakic children, and why? What are other surgeons using?

What are the precise indications for use of an IOL? And the contra-indications?

What might have been interesting to include in this volume is information on the preoperative preparation of the paediatric patient, as well as the ins and outs of paediatric anaesthesia. After all, general anaesthesia is required for nearly all paediatric ophthalmic procedures, and although surgeons will usually not be administering the anaesthesia, they are well served by having some insight into how it works and what to discuss with the anaesthesiologist and anaesthetic nurse before, during and after surgery.

This book is ideal for paediatric ophthalmology fellows, who have, in one single volume, detailed instruction for each operation they might be asked to perform.

Ophthalmology residents might also want to read specific chapters to prepare for upcoming time in the operating room.

Operations are far more interesting to watch when you know the indications and have memorised the steps ahead of time. Paediatric ophthalmologists might be interested in learning the variations in technique – “How do others do it?” – of the operations they perform. And, of course, general ophthalmologists are likely to benefit from keeping abreast of recent developments in this rapidly evolving surgical sub-specialty.

EASY ,

A different domain

23.02.12 12:54

Laurens Bouckaert - Laurens.bouckaert@ thrombogenics.com

Feature

OUTLOOK ON INDUSTRY

REVOLUTION IN TREATMENT

Ocriplasmin, a potential pharmacological agent for symptomatic vitreomacular adhesion including macular hole

by Howard Larkin

S

ome 30 years ago, Désiré Collen MD, PhD, of Katholieke Universiteit Leuven, Belgium, revolutionised cardiovascular and stroke care with tissue plasminogen activator, the first major clot breaking medicine. “Until that drug became available, most people died of heart attacks,” says Patrik De Haes MD, chief executive officer of ThromboGenics NV, which Dr Collen founded in Leuven.

Today, ThromboGenics may be at the brink of a similar revolution in vitreoretinal treatment with Ocriplasmin. Following successful Phase III clinical trials, the firm submitted applications to the European Medicines Agency and the US Food and Drug Administration (FDA) for treating symptomatic vitreomacular adhesion (VMA), including macular hole. If approved, it will be the first pharmacological treatment available for this indication, which the firm estimates may affect as many as 500,000 patients annually in the US and Europe.

The FDA indicated its intent to grant Ocriplasmin priority review status, so ThromboGenics expects approval in the US later this year. If the EMA grants marketing authorisation, the firm anticipates an early 2013 rollout in the major EU markets, says Dr De Haes. There is an ongoing phase II study of Ocriplasmin for wet age-related macular degeneration and further trials are planned in diabetic retinopathy. VMAs have been suggested to play a role in many retinal diseases.

Minimally invasive therapy While liquefaction and separation of the vitreous from the retina is part of the normal ageing process, sometimes the separation is incomplete and the vitreous continues to adhere strongly to the macula. As the vitreous continues its collapse and pulls on the retina, the resulting traction can lead to symptoms including metamorphosia, decreased visual acuity and central vision defects, says Steve Pakola MD, ThromboGenics’ chief medical officer.

Symptomatic VMA can resolve on its own if the adhesion separates. If it doesn’t, prolonged traction may progress, further impairing vision and possibly leading to macular holes and permanent retinal damage. But the only treatment option today is vitrectomy, which carries its own significant treatment burden and risk of EUROTIMES | Volume 17 | Issue 4

VMA is an increasingly recognised sight-threatening disease in which the adhesion between the vitreous and the macula does not weaken sufficiently to allow for separation of vitreous1

Persistent VMA can cause traction resulting in anatomical damage at the vitreoretinal interface, often referred to as VMT2-4

complications. As a result, many patients with vision loss are left untreated, Dr Pakola notes. “You wait until the benefits clearly outweigh the risks.”

As a well-tolerated, minimally-invasive treatment option, Ocriplasmin shifts the riskbenefit balance, allowing not only treatment of patients with significant visual loss or macular hole, but also early cases before they progress, Dr Pakola says. The compound is a truncated form of human plasmin produced by recombinant DNA technology. Injected into the eye, Ocriplasmin targets laminin, fibronectin and collagen, which induces both vitreous liquefaction and separation of the

vitreous at the vitreoretinal interface.

The resolution of VMA and closure of full thickness macular holes can be quick which can lead to significant visual acuity.

In Phase III clinical trials, ~30 per cent of 188 patients with vitreomacular traction treated with a single injection of Ocriplasmin experienced VMA resolution at 28 days after treatment, compared with just 7.7 per cent of patients receiving a placebo injection (p<0.001), according to data presented at the 2011 American Academy of Ophthalmology meeting by Pravin U Dugel MD of the University of Southern California, Los Angeles, US. Similarly, ~40 per cent of 106

contact

46

patients with full thickness macular hole, had hole closure at 28 days compared with 10.6 per cent of placebo patients (p<0.001).

The response rates to a single injection of Ocriplasmin were even higher (~58 per cent) for macular holes smaller than 250 microns compared with 16.0 per cent for the placebogroup (p<0.001) More importantly, all of the Ocriplasmin treated full thickness macular hole patients maintained their hole closure at six months, Dr Dugel reported. These patients also noticed a significant improvement in their visual acuity, with the percentage gaining three lines or more increasing from 2.3 per cent at day seven post injection to 51.2 per cent at six months. Dr Dugel noted that the study lasted only six months, but if it continued he believes the gains would likely continue for a year or more, a result he has observed with his own patients.

There was no notable difference in the incidence of serious adverse events between Ocriplasmin-treated and placebotreated patients. Most of the adverse events noticed were limited to the first seven days after treatment and were mostly transient resolving within weeks after the injection, Dr Dugel said. There were no retinal tears and one case (0.4 per cent) of retinal detachment noted at day 28 in the Ocriplasmin group.

Ocriplasmin’s success has prompted ThromboGenics to switch its research and development focus to ophthalmology. “We are committed to addressing unmet needs in ophthalmology,” Dr De Haes says.

ThromboGenics is focused on commercialising Ocriplasmin on its own.

Retinal diseases are treated by a small group of specialists consisting of ~4,000 physicians in the US and Europe, Dr De Haes says.

“As a small company with good funding we can build a manageable team to fully support the launch of the product on our own. We continue to invest into commercial organisation and have brought on board an experienced group of executives in 2011 to build and lead our commercial efforts,” Dr De Haes concluded.

Picture references: 1. Schneider EW, Johnson MW. Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review. Clin Ophthalmol. 2011;5:1151-1165.

2. Gallemore RP, Jumper JM, McCuen BW II, Jaffe GJ, Postel EA, Toth CA. Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina.

2000;20:115-120.

3. Mitry D, Fleck BW, Wright AF, Campbell H, Charteris DG. Pathogenesis of rhegmatogenous retinal detachment: predisposing anatomy and cell biology. Retina. 2010;30:1561-1572.

4. VMT image used with permission of Ferdinando Bottoni, MD, FEBO. Eye Clinic, Department of Clinical Science “Luigi Sacco”, Sacco Hospital, University of Milan, Milan, Italy.

47

Review

OPHTHALMOLOGICA

New strategies for retinal hypoxia A review of the scientific literature suggests that eyes with retinal neovascularisation could benefit from strategies that enhance the retina’s natural adaptive responses to hypoxia. The authors of the review note that there are powerful oxygen sensing mechanisms in the retina that rapidly detect alterations in intracellular oxygen tension and respond with adaptive changes that redress the balance between oxygen supply and demand. Those responses include rapid changes in blood flow, protective metabolic adaptations and angiogenesis. Current angiostatic regimens target aberrant angiogenesis but fail to address the underlying hypoxia. The authors suggest that future strategies should focus on improving the retina’s endogenous compensatory responses including neuroprotective mechanisms and appropriate vascular remodelling (Lange et al, Ophthalmologica 2012 ; DOI:10.1159/000331418).

Bevacizumab effective against macular oedema Intravitreal ranibizumab appears to be an effective treatment for macular oedema secondary to retinal vein occlusion, according to the results of a prospective trial. The study involved 40 consecutive eyes of 41 patients with branch or central retinal vein occlusion. All received three initial intravitreal injections of 0.5mg ranibizumab at monthly intervals, with further retreatment based on visual acuity changes and OCT findings. In patients with branch retinal vein occlusion, the mean logMAR BCVA improved significantly from the baseline value 0.76 to 0.19 at 12 months’ follow-up (± 0.18 (p = 0.000). There was also an improvement in mean logMAR BCVA at 12 months among eyes with central retinal vein occlusion, from 0.84 to 0.39, although it did not reach statistical significance.

(Kim et al, Ophthalmologica 2012; DOI:10.1159/000334906).

HD-OCT RNFL measurements highly reproducible Cirrus™ high-definition (HD) OCT (Zeiss) provides peripapillary RNFL thickness EUROTIMES | Volume 17 | Issue 4

measurements that are highly reproducible and repeatable both between different sessions and between different operators, according to an observational study. The study involved two experienced examiners who each assessed 68 eyes of 68 healthy volunteers in two different sessions. The average RNFL thickness ranged from 90.97 µm to 91.46 µm and from 91.34 µm to 91.78 µm, for the first and the second operator, respectively. Intra-session repeatability as tested by coefficient of repeatability was next to the device resolution, with very similar results between the two operators. However, when analysing quadrant and clock hour sector RNFL thickness measurements, both repeatability and reproducibility tend to decrease.

(Carpineto et al, Ophthalmologica 2012; DOI: 10.1159/000334967).

Differing roles of inflammatory factors A new study indicates that treatments that regulate inflammatory factors might be more beneficial in eyes with major branch retinal vein occlusion (BRVO) than in eyes with macular BRVO. The study involved 40 patients with macular oedema due to major branch retinal vein occlusion (BRVO) or macular BRVO who were treated by pars plana vitrectomy. Measurement of their vitreous fluid levels of inflammatory factors showed that eyes with major BRVO had higher concentrations of the inflammatory factors VEGF and sICAM-1, compared with eyes with macular BRVO, but eyes with macular BRVO had higher levels of the antiinflammatory factor PEDF, compared to eyes with major BRVO. (Noma et al, Ophthalmologica 2012; DOI:10.1159/000335047).

José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA ad-EUR-1-2 hoch-1202v2-pva RZ.indd 1

29.02.12 13:43

Feature

eye on travel

ESSENTIAL MILAN

Don’t forget to mark the Duomo, Brera and Navigli on your ‘must see’ list

by Maryalicia Post

Piazza Del Duomo Milan’s freshly scrubbed cathedral, the Duomo, is one sight no visitor is going to miss. Standing at the very centre of the city in its own piazza, it is Milan’s heart and soul. The cathedral’s facade, in the words of Mark Twain, seems a “delusion of frostwork,” while the interior is a stone forest of columns pierced with rosy light from the stained glass windows.

It is the world’s largest Gothic cathedral, big enough to hold 40,000 people; not surprisingly, it took nearly 500 years to complete.

Go up on the roof, too, for a close-up look at the thousands of spires and statues that surmount the cathedral. And don’t forget your camera! To access the roof, leave the cathedral by the main door and turn left. The inconspicuous doorway leading both to the stairs (201 steps) and the lift is around the corner tucked into a flank of the building.

Buy your ticket – €6 for the stairs or €10 for the lift – across the street from the entrance at Info Point, Via dell 'Arcivescovado, 1. Roof visits open from 09:00 daily. Closing times vary, but from late March to late October, the last ticket is sold at 21:15.

Round off your exploration with an excursion under the Duomo, to the 4th Century Baptistery. It was first discovered in 1940 when a bomb shelter was being dug under the cathedral. Subsequent excavations for the Metro uncovered more of the site, including the remains of the Basilica of Santa Tecla and 1st century Roman baths.

Tickets are available from the booth inside the cathedral, at the back. Metro: Duomo.

The Arengario, the pseudo-classical building on the right of the Piazza del Duomo was the municipal headquarters from which Italy’s Fascist dictator, Benito Mussolini, addressed the crowds on the piazza below. It was constructed in 1935.

The site had previously been reserved for a second Triumphal Arch to balance the entrance to the shopping mall, the Galleria, opposite. In 2011, after 10 years of restoration, the Arengario re-opened as the “Museum of the 1900s.” Displaying over 400 works of 20th century art, it provides a rare overview of “Futurism,” an Italian/Fascist social and artistic movement that died out with the end of WW II. There are wonderful views of the Piazza from the Arengario, EUROTIMES | Volume 17 | Issue 4

A courtyard in the Navigli district

particularly from the Giacamo Arengario restaurant. Open for lunch and dinner, reservations essential. Via G. Marconi, 1 corner of Piazza del Duomo. Telephone: 02 72093814.

The Royal Palace, once the home of the Visconti and Sforza families, and later of the Spanish and Austrian governors, is set back in its own courtyard to the right of the Cathedral. Damaged by fire after bombing in WWII, the Royal Palace was a neglected treasure until the year 2000, when a definitive restoration was begun.

Enough has already been accomplished to give visitors an idea of the glory of court life when the city played a major role in the affairs of Europe. The palace hosts temporary shows and exhibitions.

Brera

Few artists could afford to live in the Brera district now, though it’s still called Milan’s “bohemian” quarter. Today, it is a popular haunt for strolling, dining and browsing in up-market boutiques. Narrow streets give the area its atmosphere; unusual shops ensure there’s always something to see. Call in at Fabriano, for quality writing accessories, paper, cards, and gift ideas, or browse through Cavalli e Nastri’s trove of vintage designer clothing, bags, hats and jewellery. A magnet for art lovers is the Pinacoteca di Brera, the National Art Gallery, housed in a magnificent old convent. The Botanical Gardens, an enclosed oasis behind the Pinacoteca,

A cobbled street in the Brera district

opened to the public in 1998. Open from 9:00 to 12:00 and from 13:00 to 16:00. A wide variety of restaurants and bistros enliven Brera’s winding streets and Happy Hour is celebrated here with gusto. Every month, on the 3rd Saturday, there’s the traditional Antique Market. Fabriano, Via Ponte Vetero 17. Closest Metro stop, Lanza; Cavalli e Nastri, Via Brera 2, Metro Montenapoleone. Both stops serve the Pinacoteca di Brera, Via Brera 28. Open Tuesday-Sunday 8:30-19:15. The Brera is a 10-minute walk from the Duomo.

Navigli/Ticinese Though its vibrant Happy Hour is the main draw of Milan’s Navigli area, its unsophisticated, almost rural character is worth sampling even without the “eat all you want for the price of one drink” evening scene. There are courtyards that look as if they come from the 18th century, an old washhouse on the edge of a stream, artists’ workshops, two canals and the quasi-abandoned Darsena lake. (Tip: bring mosquito repellent.) East of the canals, deeper into the working class Ticinese area, you’ll find interesting old buildings, cafes and small restaurants. Many of the original factory worker families still live here – despite the area’s growing appeal to middle class and professional people.

Metro: Porta Genova. From the Duomo, a walk to Ticinese takes about 30 minutes.

A Brera facade

Milan’s Metro is clean and easy to use but crowded at peak hours of 7:00-9:00 and 17:00-20:00. Tickets are available from bars, tobacconists, stationers, newspaper stands, or station vending machines.

For full information and a route map, visit: www.atm-mi.it

The following congresses will be held in Milan in September 2012: 3rd EuCornea Congress (6-8 Sept); 2nd World Congress of Paediatric Ophthalmology and Strabismus (7-9 Sept); 12th EURETINA Congress (6-9 Sept); XXX Congress of the ESCRS (8-12 Sept).

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Feature

industry news

Recent developments in the vision care industry

Cataract Pre-OP Display

In collaboration with Prof Naoyuki Maeda, Osaka University Graduate School of Medicine, Japan, OCULUS has developed a display for a comprehensive evaluation of the anterior eye segment before cataract surgery. “The Cataract Pre-OP display contains all necessary parameters to select, calculate and position premium IOLs,” said an OCULUS spokeswoman. “This new display supports distinguishing whether a spheric, aspheric, multifocal or toric IOL might be the best solution for the patient.

Only the necessary parameters are displayed which are colour coded and described in detail to assure an intuitive use.This new display is part of the cataract package and free of charge to existing users,” she said. www.oculus.de

Eye expander

NIDEK CEM-530 specular microscope

CEM-530 specular microscope

NIDEK has launched the CEM-530 specular microscope. “In addition to conventional central and peripheral specular microscopy, the CEM-530 includes a unique function to capture paracentral images,” said a company spokesman. “The paracentral images are captured at eight points, 5º visual angle within a 0.25mm x 0.55mm field and enable enhanced assessment surrounding the central image,” he said.

16 images are captured and automatically sorted based on quality and the ability to be analysed. The optimal image for analysis is indicated with orange highlight. Once the image is selected, complete analysis is automatically performed in two seconds with the CEM-530.

The analysis screen allows visualisation of the endothelial cells in four modes, trace, photo, area, and apex, which helps the clinician to verify analysis values with the correspondent cell images. The 3-D auto tracking, auto shot, and tiltable touch screen provide ease of use, allowing faster and more accurate measurement.The CEM-530 utilises a LED light source for flash, which reduces power consumption, lasts longer, and saves on operational costs. www.nidek.com

OASIS Medical, Inc. has announced the introduction of the OASIS® Iris Expander.

The company say the 7.0mm diameter polypropylene ring expands and maintains access and visibility throughout the surgical procedure. The disposable device is indicated in cases where Miosis and Intraoperative Floppy Iris Syndrome is present. www.oasismedical.com

OASIS® Iris Expander

The new 25-gauge cannula from Geuder

Pelayes/Singh cannula

In cooperation with Dr David Pelayes of Argentina and Dr Arun Singh of US, Geuder has developed a new 25-gauge cannula for Fine Needle Aspiration Biopsy (FNAB) of uveal melanoma. A company spokeswoman said a particular feature of the product, in comparison to former standard cannulas, is the surface millimetre markings which facilitate the precise depth penetration into the uveal melanoma. “Besides, the short bevel of the cannula allows full entry of the needle tip into the tumour, so due to the superior cellularity of the biopsy aspirates the diagnostic yield is higher,” she said. www.geuder.com EUROTIMES | Volume 17 | Issue 4

Fundus imaging

Heidelberg Engineering SPECTRALIS® MultiColor Scanning Laser Imaging

Heidelberg Engineering says the recently launched MultiColorTM Scanning Laser Imaging is a new dimension in multimodality fundus imaging with the SPECTRALIS® product family.

The new imaging modality was unveiled at the World Ophthalmology Congress 2012 in Abu Dhabi. MultiColor imaging uses multiple laser colours simultaneously to selectively capture and display diagnostic information originating from different retinal structures within a single examination. www.heidelbergengineering.com

YOUR ADVERTISEMENT COULD BE HERE REACHING 32,332* READERS

ESCRS

EUROTIMES

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

* Average net circulation for audit period 1 January 2011 to 31 December 2011. See www.abc.org.uk

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Reference

Calendar of events

Dates for your Diary

April

April

May

May

27th APAO Congress

International Symposium on Glaucoma – New Insights and Updates

ARVO Annual Meeting

10th SOI International Meeting

2012

2012

13-16 busan, korea

www.apaobusan2012.com

ASCRS•ASAO Symposium and Congress 20-24 chicago, il, usa www.ascrs.org

2012

21 belgrade, serbia

www.glaucoma–belgrade2012.org

118th SFO Congress 27-30 paris, france

2012

6-10 fort lauderdale, FL, USA www.arvo.org

UKISCRS Cornea & Cataract Day 2012

23-26 milan, italy www.sedesoi.com

14 Liverpool, UK www.ukiscrs.org.uk

www.sfo.asso.fr

June

June

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

25th International Congress of German Ophthalmic Surgeons

June

2012

2012

13-16 Istanbul, TURKEY www.afroasian2012.org

June

2012

14-17 Nurnberg, germany www.doc-nuernberg.de

10th EGS Congress

17-22 Copenhagen, Denmark

2012

9th Congress of Slovenian Society of Ophthalmology 32nd Symposium of Ophthalmologists of Slovenia and Croatia 28-30 Portoroz, SLOVENIA www.zos2012.si

9th Congress of SEEOS 34th Symposium of Alpe Adria Countries 28-30 Portoroz, SLOVENIA www.zos2012.si

Aegean Cornea XI

29-1july Crete, GREECE

www.eugs.org

www.aegeancornea.gr

July

September

September

September

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

3rd EuCornea Congress

2nd World Congress of Paediatric Ophthalmology and Strabismus

12th EURETINA Congress

2012

2012

6-8 MILAN, ITALY www.eucornea.org

2012

7-9 MILAN, ITALY www.wcpos.org

22-27 berlin,germany

2012

6-9 MILAN, ITALY www.euretina.org

XXX Congress of the ESCRS 8-12 MILAN, ITALY

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

www.escrs.org

September

October

October

November

UKISCRS – XXXVI Annual Congress

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

Modern Technologies in Cataract and Refractive Surgery – 2012

AAO•APAO Joint Meeting

www.congresos-rohr.com/alaccsar2012

www.mntk.ru

2012

27-28 brighton, uk www.ukiscrs.org.uk

2012

4-6 Buenos Aires, ARGENTINA

2012

2012

10-13 chicago, il, usa www.aao.org

25-27 Moscow, RUSSIA

8th International Symposium on Uveitis 19-22 Halkidiki, GREECE www.ISU2012.org

Advertising Directory: Abbot Medical Optics: Page: 3; Alcon: Page: OBC; Angiotech: Page: 19; Benz Research and Development: Page: 17; Carl Zeiss Meditec: Page: 11; Chroma-Pharma: Page: 47; D.O.R.C. International BV: Page: 37; Geuder: Page: 45; Haag Streit: Page: 32; Moria: Page: 28; Medicel AG: Page: 18; NIDEK: Pages: 15, 29; Oculus: Page: 36; Oertli Instruments AG: Page: IFC; Schwind: Page: IBC; Tecnolas: Page: 5; ThromboGenics: Page: 5; Ziemer: Page: 13;

The perfect addition.

PresbyMAX® µ-Monovision.

Rejuvenation treatment for the eyes.

The new generati

on:

PresbyMAX® µ-M onovision.

Redefining vision .

• Uniquely comprehensive treatment range • Three-dimensional visions • Excellent visual acuity in all distances • Rapid and high patient satisfaction • Safety factor Presby Reversal

The latest technique for treating presbyopia with SCHWIND AMARIS® laser systems.

PresbyMAX µ-Monovision is unique of its kind: a procedure which uses bi-aspheric, multifocal ablation profiles to allow the optimum relationship between near and distance vision.

PresbyMAX µ-Monovision multifocally focuses the dominant eye slightly more on distance and directs the non-dominant eye slightly more towards near vision.

PresbyMAX µ-Monovision provides faster visual recovery at all visual distances and is better tolerated in uncorrected conditions. Patients with presbyopia who value distance vision can see the world through younger eyes, thanks to PresbyMAX µ-Monovision.

SCHWIND eye-tech-solutions GmbH & Co. KG Mainparkstrasse 6-10 · D-63801 Kleinostheim · fon: +49(0)60 27 / 508 - 0 · email: info@eye-tech.net · www.eye-tech-solutions.com

Visual Performance.

AcrySof ® IQ – The monofocal IOL proven to deliver excellent visual performance.1

Give your patients more time to react with the performance of AcrySof ® IQ IOL.2

CONFIDENCE

1. Results of a controlled, randomized, double-masked, multicenter, contralateral implant clinical study of the AcrySof® IQ IOL versus a spherical control lens (AcrySof® Single-Piece IOL Model SA60AT). See AcrySof® IQ IOL Directions for Use. 2. Gray R, et al. Reduced effect of glare disability on driving performance in patients with blue light-filtering intraocular lenses. J Cataract Refract Surg. 2011 Jan;37(1):38-44. © 2012 Novartis

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