Vol 17 - Issue 9

VOLUME 17 ISSUE 9 SEPTEMBER 2012

30

YEARS OF ESCRS

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ESCRS

EUROTIMES

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SEPTEMBER 2012 Volume 17 | Issue 9 This ISSUE...

Cover Story

Glaucoma

4 The History of ESCRS

50 Lowering IOP may be possible with high-intensity ultrasound

Cataract & Refractive 8 Experts discuss phakic IOL preferences 10 Intrastromal keratotomy for astigmatism 12 New IOL shows positive short-term results

5

24

13 Study results encouraging for new implant 14 Phakic IOL procedure successful 16 LRI for astigmatism correction 18 More presbyopia options now available

54 CATT and IVAN study results discussed

56 Future directions for RPE transplantation

24 Toric mIOLs showing good results in presbyopes

57 New laser effective for performing PRP 59 CATT study and public health policy

Ocular 60 New technology could find broad application in ophthalmic surgery

28 New form of surgery has many advantages

61 Adaptive optics system could increase office efficiency

30 Doctors discuss their experiences with IOL pre-warming

News

33 Latest developments in IOL designs

62 ESASO offers training for young ophthalmologists

Cornea

63 EUREQUO Goes Global 64 Eye Facts looks at effects of benzalkonium chloride

36 Corneal surgery and the femtosecond laser 37 Painless acanthamoeba can be resistant to therapy 38 Combined detection procedure may be more useful 41 Preoperative screening benefits highlighted

76

Retina

21 New technology could perform pain-free surgery

39 Less painful treatment for keratoconus

75

53 Device may work well in combined procedures

55 Finnish register looks at visual prognosis for diabetic patients

27 Spectacle independence with new IOL

61

52 Reducing complications in patients with pseudoexfoliation

19 Presbyopes can benefit from eyedrops

25 New technology helps improve surgery standards

57

51 Advances in imaging with high-resolution OCT

Features 67 Eye on History 68 Industry News 69 Ophthalmologica Highlights 70 JCRS Highlights

42 Four dry eye tests to watch

73 Book Review

43 Techniques used for corneal complications in refractive surgery

76 Resident’s Diary

44 Alternatives to penetrating keratoplasty 46 DSAEK grafts show good visual results

75 Eye on Travel 78 Practice Development 80 Calendar

47 New advances in ocular surface imaging 48 Dry eye screening device more affordable?

With this month’s issue... 17th ESCRS winter meeting preliminary programme & Providing Broad Spectrum Presbyopia Correction

editorial staff

ESCRS

EUROTIMES

™

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

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

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

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

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

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

ISSN 1393-8983

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2011 and 31 December 2011 is 32,332.

1

EUROTIMES

Editorial

ESCRS

2

EDITORIAL

Medical Editors

Volume 17 | Issue 9

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

AN HISTORIC OCCASION

Milan hosts four congresses with very exciting scientific programmes

by Roberto Bellucci MD

International Editorial Board

O

n behalf of ESCRS, I am delighted to welcome friends and colleagues from all over the world to Milan for what is truly an historic occasion. The first meeting of our society in Italy promises to be the largest European meeting in ophthalmology so far.

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

Outstanding scientific programmes are planned, with numerous lectures, presentations, courses, posters and videos. Leading experts will present the latest scientific knowledge in research and state-ofthe-art of ophthalmology.

ESCRS is very grateful to the Programme Committee for the many hours they have spent in putting together a programme that has something of interest for ophthalmologists from different countries and different backgrounds. One of the biggest challenges the committee faces is to make sure that we highlight the newest innovations and this year, as in previous years, they have done an excellent job in showcasing the hot topics.

I would also like to thank the judging panels who have given up their time to judge the Video Awards, the Poster Awards and the John Henahan writing prize for young ophthalmologists.

I do not have the space here to mention all of our distinguished speakers but let me give a special thanks to my good friend and colleague Prof Mats Lundstrom of Karlskrona, Sweden a long-time advocate of surgical outcome registries who will look at Quality Outcomes in Cataract Surgery: The Real Story, when he delivers the Ridley Medal Lecture at our Opening Ceremony.

My special thanks, on behalf of ESCRS, also go to the sponsors and exhibitors for their support. Without their contributions these four meetings would not have been possible.

In addition to the scientific programme in Milan, I hope our visitors get to enjoy the many delights on offer in our beautiful city.

Milan is an historic city, full of cultural and architectural wonders but it is also a vibrant 21st Century city full of life and passion with sport, fashion and music on offer for young and old alike.

Let us also not forget that this is the 30th ESCRS Congress. We have come a long way since the forerunner of ESCRS, the European Intra-Ocular Implant Council, held its first congress in The Hague, Netherlands in 1982. We have a proud history to remember and we are also excited about the new projects which the society is continuing to develop such as the Practice Development programme and iLearn. We are also building closer bonds with our younger colleagues in training through the Young Ophthalmologists’ Forum.

EUROTIMES | Volume 17 | Issue 9

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 Today, ESCRS is Europe's leading organisation for cataract and refractive surgeons and is at the forefront of developments in anterior segment surgery. The society currently has more than 4,000 members from over 100 different countries worldwide. The ESCRS offers a unique forum for discussion and learning which ensures that international expertise is shared by ophthalmologists all over Europe.

If you are not already a member, I would encourage you to visit the ESCRS booth and join the society. We have many exciting offerings to members and our staff in Milan will be very happy to talk to you about the services we are offering.

Let me again welcome you to Milan. Let us share our knowledge and experience at these four outstanding congresses. We will also have the opportunity to meet old friends and make new ones and many of these friendships will last for life.

Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY

• Roberto Bellucci MD, is chief of ophthalmology at the Hospital and University of Verona, and professor of anterior segment surgery, University of Verona, Italy. He is also secretary of ESCRS.

Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Cover Story

THE HISTORY OF ESCRS

A GREAT SUCCESS

The History of ESCRS will tell the story of the society from its foundation in 1982 to the present

The aim of our official history will be to tell the story of the society from the beginning...

Peter Barry, president of ESCRS

“

We have been talking about commissioning a history of the society for a long time and as we celebrate our 30th congress, it is fitting that we acknowledge the contributions of our great colleagues and friends

Emanuel Rosen, chairman of the ESCRS Publications Committee

EUROTIMES | Volume 17 | Issue 9

I

Archive As part of the project, ESCRS is also establishing an archive which will include programmes from past conferences, photos from private collections and from EuroTimes and other material. The book will draw on this material and on the personal recollections of the early founders and those who helped to develop the society in later years.

“This is a very important project,” said Emanuel Rosen, chairman of the ESCRS Publications Committee. “We have been talking about commissioning a history of the society for a long time and as we celebrate our 30th congress, it is fitting that we acknowledge the contributions of our great colleagues and friends.

Credit: Karl Jacobi

“

n 1982, the European Intra-Ocular Implant Council (EIIC) held its first meeting in The Hague, The Netherlands. Some 11 years later in 1993 in Innsbruck, Austria, the society held its first meeting as the European Society of Cataract and Refractive Surgeons (ESCRS).

This year’s congress in Milan is the XXX ESCRS Congress and will see the beginning of a number of important new initiatives to celebrate the achievements of the society.

Among these is the commissioning of The History of ESCRS which will be published in 2013.

“The ESCRS is an extraordinary success story,” said Peter Barry, president of ESCRS. “The aim of our official history will be to tell the story of the society from the beginning, drawing on the recollections of people such as Emanuel Rosen, Karl Jacobi, Ulf Stenevi, Paddy Condon and Philippe Sourdille. They were all innovators, fighting what was really an uphill battle to gain acceptance of the concept of intraocular lens implantation.

The reason for the establishment of the EIIC was that the people called together

by Binkhorst in The Hague were the very people who were the pioneers, or about to become the pioneers, of the whole complex procedure of intraocular lens implantation.

EIIC Copenhagen 1985: Back row (left-right): Peter Choyce, Karl Jacobi, Ken Miyake; Front row: Cornelius Binkhorst, Harold Ridley, Robert Drews

Credit: Emanuel Rosen

4

1987 EIIC, Jerusalem: Emanuel Rosen, Michael Blumenthal and Israeli Prime Minister Yitzhak Shamir

“Sadly, some of them are no longer with us, including Cornelius Binkhorst, Harold Ridley and Michael Blumenthal, but we are lucky to be able to draw on the recollections of many of our early members who have devoted most of their working lives to establishing ESCRS,” he said.

Harold Ridley The book will also put into context the struggles and challenges that the early pioneers faced. On a rotating basis every two years, the society honours Cornelius Binkhorst and Harold Ridley, whose memories live on through the Binkhorst and Ridley Medal Lectures which are among the highlights of each congress.

Ridley’s story has been told by the late Dr David Apple in his book Sir Harold Ridley and His Fight for Sight (Slack Incorporated 2006), but The History of ESCRS will attempt to put his contribution to the society into a broader context.

“Delivering the Ridley Lecture in Amsterdam the year of his death, 2001, was an emotional moment for me,” said Emanuel Rosen. “Ridley was feted around the world and had the satisfaction of knowing his work was really appreciated, which is not always the case with pioneers.”

Cornelius Binkhorst

Cornelius Binkhorst was the first president of the EIIC, an office he held from 1982 to 1986. In the early years, his name was synonymous with EIIC and as Dr Rosen has noted, Binkhorst was also one of the leading ophthalmological surgeons of his generation. “Even today, I still see patients I operated on in the early days of my career with implants of the Binkhorst variety which are still functioning,” said Dr Rosen.

Michael Blumenthal Michael Blumenthal helped to organise the EIIC meeting in Jerusalem, Israel, in 1987 and went on to serve as ESCRS president in 1996 and 1997. His memory is commemorated

by ESCRS through the annual Michael EUROTIMES | Volume 17 | Issue 9

Credit: EuroTimes

An international outlook As Philippe Sourdille points out, one of the strengths of the ESCRS has been that it has brought together eye surgeons from different countries and backgrounds to work for a common cause. “More than 20 years ago, the whole concept of Europe as a unified continent was not a unanimously accepted idea,” he said. “What was really present and tangible from the beginning of the ESCRS was a very enthusiastic European patriotism which made us work together,” he said. “Our common cause was the furtherance of scientific enquiry in a discipline that was dear to all of our hearts.”

The History of ESCRS will also acknowledge the key role that industry has played in the development of new technologies and techniques but it will also stress the importance of the independence of the society which at every congress endeavours to make sure that the scientific content of the presentations are robust and independent. “We have to ensure that our standard of independence is maintained.

We all recognise the symbiotic relationship that is necessary for functioning and the valuable contribution that industry has made to the society, but we are recognised as being independent such that scientific presentations at meetings are not commercially based,” said Dr Barry.

5

Mrs Elizabeth Ridley with Harold Ridley at the presentation of the first ESCRS Grand Medal of Merit by ESCRS president Thomas Neuhann, in Vienna, 1999

Blumenthal Award for the winner of the ESCRS Video Competition. Again Dr Rosen has remarked on his immense contribution to the society. “He was a wonderful surgeon and travelled all over the world to perform his form of cataract surgery,” said Dr Rosen.

“He had a great vision for the society and was a great enthusiast.”

Centralised secretariat The Dublin meeting in 1990, organised by Peter Barry and Paddy Condon, marked another major milestone in the history of the society. The conference was organised by a local Irish event management company, Agenda Communications, and was widely acknowledged to be one of the most successful EIIC meetings.

Dr Rosen, who served as EIIC/ESCRS president from 1987 to 1993, had been campaigning for a full-time secretariat for ESCRS. In 1993 in Innsbruck, Austria, Agenda Communications took over the running of all ESCRS congresses. The company now employs 28 full-time staff and is responsible for the organisation and running of the annual ESCRS congress and the society’s general activities.

JCRS and EuroTimes Another significant development following the establishment of the permanent secretariat was the amalgamation of the American peer-reviewed Journal of Cataract & Refractive Surgery and the European Journal of Implant and Refractive Surgery, which came together as The Journal of Cataract and Refractive Surgery (JCRS). Up to 1995, ESCRS had its own journal but the society felt it was not getting the recognition it deserved. That year, following discussions with the American Society of Cataract and Refractive Surgery (ASCRS), it was decided to merge the journals.

“The first joint issue was in 1996,” said Dr Rosen. “We had our tenth anniversary issue in 2006 and we are still getting stronger being ranked 8th in Journals of Clinical

Ophthalmology. I became co-editor with Stephen Obstbaum. We joined forces with the common aim of ensuring the Europeans had an equal share in content of the journal and the financial people on both sides got together to ensure the journal was properly managed by the two societies.”

The launch of JCRS also coincided with the publication in 1996 of the first issue of the society’s news magazine, EuroTimes.

EuroTimes, which now reaches over 32,000 ophthalmologists around the world, is published 10 times a year and carries reports from the major ophthalmological congresses all over the world and also updates on ESCRS activities.

New decade, new millennium The last 10 years, as The History of ESCRS will detail, have marked a dramatic increase in the level of the society’s activities with the launch of a number of new projects that have allowed the society to expand its educational services to members. These include the Endophthalmitis Study, ESCRS On Demand, the Young Ophthalmologists’ Programme, the Practice Development Programme, EUREQUO and iLearn. There has also been a decisive shift in the society’s orbit of influence with the membership of the established national societies in western Europe now being augmented with new members from the new European countries in eastern Europe. Recent Winter Meetings have been held in Istanbul, Budapest and Prague and the 2013 Winter Meeting will take place in Warsaw.

“From my perspective,” said Dr Rosen,” going back to the early days of 1982, the last 30 years have gone in a flash. We have moved from an embryo to a fully fledged important European ophthalmological organisation.

Research But while the society continues to grow, as Dr Sourdille points out, it must not lose sight of its primary role in education and research. Dr Sourdille

“

What was really present and tangible from the beginning of the ESCRS was a very enthusiastic European patriotism which made us work together

Philippe Sourdille, a founder of the ESCRS Clinical Research Committee and ESCRS president, 1994-1995

contacts

Cover Story

THE HISTORY OF ESCRS

Emanuel Rosen – erosen9850@aol.com Peter Barry – peterbarryfrcs@theeyeclinic.ie Philippe Sourdille – philippe.sourdille@wanadoo.fr

EIIC members and distinguished guests at the EIIC meeting in Dublin,1990. The then President of Ireland, Patrick Hillery, is second from right in the front row, accompanied by the Minister for Health, Rory O’Hanlon, front row far right

“The challenges facing the society over the next five to 10 years will be first of all survival given the economic difficulties that Europe finds itself in, given the progressive reduction in the funding of healthcare” Peter Barry, president of ESCRS

was a founder of the ESCRS Clinical Research Committee. “Innovation is at the heart of the ESCRS,” he said. “One of the main challenges that we have today, which is not unique to our society, is the fact that when we come to a meeting we have approximately 30 simultaneous events and we need to know how to make the best use of the time available to us. I think we can help delegates to filter information and to prioritise. We are subjected to such a huge amount of information through the Internet, journals, trade journals and there are some very exciting meetings, but we need to be there to help our members sort out the truly important information.”

The future While The History of ESCRS will look back on the past, it will also offer members of the society an opportunity to look forward to the future.

“The challenges facing the society over the next five to 10 years will be first of all survival given the economic difficulties that Europe finds itself in, given the progressive reduction in the funding of healthcare.

EYE CHAT Exclusive interviews Up to date information Problem solving

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Credit: EuroTimes

Credit: Emanuel Rosen

6

1995 dinner celebrating the combining of the European and American journals: Front row: Marilee Obstbaum, Lorraine Sinskey, Charlie Kelman; Back row: Dave Karcher, Steve Obstbaum, Michael Blumenthal, Bob Sinskey, Emanuel Rosen, Paddy Condon

Ophthalmology has to fight for its share of that budget; cataract surgery has to fight for its share of the budget within the different countries. I think that the ESCRS can play a major role in that because it’s scientific studies, such as EUREQUO, prove the benefits of our work to the health providers,” said Dr Barry.

Work in progress Finally, Dr Rosen says the story of the society is best told through its members. “This is very much a work in progress,” he said, “although we have a deadline to get the book to the publishers to ensure that we can distribute the book to members and delegates at the XXXI ESCRS Congress in Amsterdam. We are still looking for old programmes, photos and other memorabilia and we would like to talk to other members, particularly those who remember the very early years of the society. It goes without saying that we cannot include everything in the book, but we will strive as best we can to produce a publication that will tell our story in as comprehensive a way as possible,” he said.

ESCRS Presidents 1982-2012

1982-1986 1987-1993 1994-1995 1996-1997 1998-1999 2000-2001 2002-2003 2004-2005 2006-2007 2008-2009 2010-2011 2012

If you wish to contribute to The History of ESCRS please contact EuroTimes executive editor Colin Kerr at: colin@eurotimes.org.

DMEK – Challenges and rewards This month Dr Oliver Findl speaks with Friedrich E Kruse MD, University Hospital Erlangen, Bavaria, Germany, about the challenges of Descemet’s membrane endothelial keratoplasty (DMEK), and the potential therapeutic rewards.

podcast

www.eurotimes.org

Also available on iTunes

EUROTIMES | Volume 17 | Issue 9

C Binkhorst E Rosen P Sourdille M Blumenthal T Neuhann J Cunha-Vaz U Stenevi M J Tassignon I Pallikaris P Rosen J Güell P Barry

NEVANAC® IS NOW ALSO INDICATED FOR REDUCTION IN THE RISK OF POSTOPERATIVE MACULAR EDEMA ASSOCIATED WITH CATARACT SURGERY IN DIABETIC PATIENTS

1

EXPLORE THE DEPTHS OF NSAID EFFICACY

NEVANAC® 1mg/ml eye drops, suspension (nepafenac).

Prescribing information (Refer to full Summary of Product Characteristics (SmPC) before prescribing) Presentation: 1ml of suspension contains 1mg nepafenac, benzalkonium chloride 0.05mg.

Indication(s): Prevention and treatment of postoperative macular edema associated with cataract surgery in diabetic patients Posology and method of administration: Adults, including the elderly: For the prevention and treatment of pain and inflammation, 1 drop in the affected eye(s) 3 times daily beginning 1 day prior to cataract surgery, continued on the day of surgery and up to 21 days of the postoperative period, as directed by the clinician. An additional drop should be administered 30 to 120 minutes prior to surgery. For the reduction in the risk of macular edema associated with cataract surgery in diabetic patients, 1 drop in the affected eye(s) 3 times daily beginning 1 day prior to cataract surgery, continued on the day of surgery and up to 60 days of the postoperative period, as directed by the clinician. An additional drop should be administered 30 to 120 minutes prior to surgery.

Children and adolescents: Not recommended. Hepatic and renal impairment: No dose adjustment warranted. Contra-indications: Hypersensitivity to nepafenac, any of the excipients, or to other nonsteroidal anti-inflammatory drugs (NSAIDs); and in patients in whom attacks of asthma, urticaria, or acute rhinitis are precipitated by acetylsalicylic acid or other NSAIDs. Warning and precautions: Do not inject or swallow.

Instruct patients to avoid sunlight during treatment. Use of topical NSAIDs may result in keratitis, in some susceptible patients, continued use may be sight threatening. Topical NSAIDs may slow or delay healing.

Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems.

Topical NSAIDs should be used with caution in patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surfaces diseases, rheumatoid arthritis or repeat ocular surgeries within a short period of time. These patients may be at increased risk of corneal adverse reactions which may become sight threatening. Prolonged use of topical NSAIDs may increase patient risk for occurrence and severity of corneal adverse reactions. Ophthalmic NSAIDs may cause increased bleeding of ocular tissues (including hyphaemas) in conjunction with ocular surgery. Use NEVANAC with caution in patients with known bleeding tendencies or who are receiving other medicinal products which may prolong bleeding time. Concomitant use of prostaglandin analogues and NEVANAC is not recommended.

Benzalkonium chloride may cause keratopathy and irritation and is known to discolour soft contact lenses.

Contact lens wear is not recommended during the postoperative period following cataract surgery. Patients should be advised not to wear contact lenses during treatment with NEVANAC. Close monitoring is required with frequent or prolonged use. An acute ocular infection may be masked by the topical use of anti-inflammatory medicines. NSAIDs do not have any antimicrobial properties. In case of ocular infection, their use with anti-infectives should be undertaken with care. Cross-sensitivity: Potential exists for cross-sensitivity of nepafenac to acetylsalicylic acid, phenylacetic acid derivatives, and other NSAIDs. Interactions: In vitro studies have demonstrated a very low potential for interaction with other medicinal products and protein binding interactions. Pregnancy and lactation: Pregnancy: not recommended during pregnancy and in women of childbearing potential not using contraception. Lactation: Can be used during lactation. Effects on ability to drive and use machines: If blurred vision occurs wait until the vision clears before driving or using machinery. Undesirable effects: Common: Punctate keratitis. Frequency not known: Dizziness, impaired corneal healing, corneal scar, reduced visual acuity, eye irritation, eye swelling, blood pressure increased. Serious: Keratitis, choroidal effusion, corneal epithelium defect, corneal opacity. Prescribers should consult the SmPC in relation to other side effects. Overdose: No experience of overdose with ocular use. Application of >1 drop/eye is unlikely to lead to unwanted side-effects. Practically no risk of adverse effects due to accidental oral ingestion. Incompatibilities: Not applicable. Special precautions for storage: Do not store above 30° C. Legal Category: POM. Package Quantities and Basic NHS Costs: 5ml £16.73.

GMS Price: €8.89. MA Number(s): EU/1/07/433/001. Further information available from the MA Holder: Alcon Laboratories (UK) Limited, Pentagon Park, Boundary Way, Hernel Hempstead, Hertfordshire. HP2 7UD. Date of preparation: April 2012 (V5) Adverse events should be reported. Reporting forms and information can be found at www.mhra.goc.uk/yellowcard. Adverse events should also be reported to Alcon Medical Information.

Tel: 0871 376 1402. Email: gb.adr@alconlabs.com Reference: 1. Summary of product characteristics NEV: EUR: 07/12: HC

©2012 Novartis AG

Deep Performance

Update

Cataract & refractive

PHAKIC IOL DEBATE

More data is needed on the latest results

by Priscilla Lynch in Southport

T

he debate over iris/angle-supported phakic intraocular lenses (PIOLs) versus posterior chamber (PC) PIOLs is not as clear-cut as many believe and more data is needed on the latest results, delegates attending the XXXV United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) Annual Congress heard.

Presenting in favour of iris/anglesupported PIOLs, Jan Venter MD, London, said large-scale studies have shown these PIOLs have a far lower incidence of cataracts compared to PC PIOLs like the implantable Collamer lens (ICL).

“The average incidence of cataracts after surgery within 10 years is 25 per cent so that was my main concern with (ICL),” he stated (presented at DOC 2010, “The real incidence of cataracts with ICL”).

When choosing a PIOL surgeons have to consider the space available for the implanted PIOL, the structures in

immediate contact with the PIOL and the effect of age on dimensions of various involved structures and spaces; both the posterior chamber and anterior chamber, Dr Venter noted.

A major advantage of an iris/angle fixated lens is that it can be examined from end to end under the slit lamp throughout the patient’s life, while a lens inserted into the posterior chamber cannot. Discussing the structures in contact with iris/angle fixated PIOLs, he pointed out the posterior surface of the lens is concave and cannot touch the crystalline lens (0.5mm away), the maximum height optic in the centre is less than 1.0mm, while the haptic of the lens in the periphery is 0.18mm and there is a safe distance from the endothelium (at least 1.5mm). With an iris fixated lens, the vessels of the iris are not fenestrated, they are located in more cellular parts of the stroma and are invested in more cellular adventitia, plus the integrity of vascular supply is maintained, as shown in

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2012-03_EUROTIMES_120x120.indd 6 EUROTIMES | Volume 17 | Issue 9

fluorescein angiographic studies. “There is also no friction between the iris claw and anterior iris surface with an iris fixated lens, and post-mortem studies have shown no sign of inflammation,” he said adding that this can be an issue with PC PIOLs. Reporting the results of a meta-analysis of cataract development in 6,338 post PIOL surgery eyes (Chen LJ; Chang YJ; Kuo JC; Rajagopal R; Azar DT, J Cataract Refract Surg 2008 Jul;34(7):1181 200), Dr Venter said 4.35 per cent were noted to have new onset or pre-existing progressive cataracts. Of these, 1.29 per cent were in the anterior chamber, 1.11 per cent were in iris-fixated, while 9.60 per cent were posterior chamber lenses.

With regards to endothelial cell loss, he said there was very little difference between iris/angle PIOLs and PC PIOLs in followup review studies. A European multicentre study (Budo, 2000) showed 9.6 per cent loss at three years, while with PC IOLs at five years there was a 12.5 per cent loss (study

by Henry F Edelhauser). Dr Venter said he preferred using an iris/angle fixated lens as it has the longest history (dating back to 1986), ‘one size fits all’ in that you can do myopia, hyperopia and astigmatism, it is easy to re-position and is reversible, and also has excellent centration. “The iris claw lens has proven itself for a long time; it has been implanted in more than 240,000 eyes over 25 years. Other lenses must surmount many difficult problems before they can become a serious alternative,” he concluded.

The benefits of PC PIOLs Arguing in favour of PC PIOLs (specifically the ICL version) as the best choice, Bruce Allan MD, FRCS, Moorfields Eye Hospital, London, focused on patient quality of life.

“Quality-of-life instruments are not included often enough in trials on refractive surgery. Probably the only outcome that really matters is what the patient feels after treatment,” he told delegates.

Citing the results of a comparison study (Leong A, Rubin GS, Allan BD. Quality of life in high myopia: implantable Collamer lens implantation versus contact lens (CL) wear. Ophthalmology 2009;116(2):27580.), he confirmed the quality-of-life impact of refractive correction scores Don’t Miss Eye Facts, see page 64

01.08.2012 15:34:59

contacts

8

Bruce Allan – Bruce.allan@ucl.ac.uk Jan Venter – janventer@opticalexpress.com

“

The iris claw lens has proven itself for a long time; it has been implanted in more than 240,000 eyes over 25 years Jan Venter MD

were significantly higher (P<0.001) in ICL recipients (53.67+/-4.50) than in contact lens wearers (44.42+/-5.07). However, correcting high myopia, using whatever method, makes a huge difference to patients’ quality of life, he noted.

Promoting the value of systematic reviews, Dr Allan reminded delegates that studies in refractive surgery are dealing with a technology that is constantly in evolution, so they are always going to be behind. “Part of the point of doing a systematic review is to say where the holes in the evidence are,” he said.

The debate about LASIK versus PIOLs isn’t clear-cut and a major trial in the area is needed, Dr Allan suggested. He said that the choice now for a lot of surgeons is between the Cachet lens (an anterior chamber angle-supported, hydrophobic acrylic lens) and the ICL.The takehome message is that studies show the endothelial cell loss from ICL implantation is equivalent to phacoemulsification; about 10 per cent at four years in FDA studies, he stated. The cell loss rates that are published for the Cachet lens to date are relatively good, admitted Dr Allan, but he was sceptical that this will last. He reminded delegates that other anterior chamber lenses did well initially but were taken off the market after sudden crashes in endothelial cell count.

“For me that’s the clinching argument in terms of which PIOL to use,” he said.

Touching on the issue of cataract rates in this cohort, he contended that the problem can often be with the patient and the eye itself (older patients, higher myopia) rather than the actual lens and that newer versions of the ICL have been associated with much lower rates of cataract, with the V4c, featuring centreflow technology, offering particular promise. The V4c ICL aims to maintain normal aqueous circulation with no peripheral iridectomy and this may cut down the risk of cataract formation.

Concluding his arguments, Dr Allan said that an ICL doesn’t alter the appearance of the eye, has great refractive range and good safety results.

xxx Congress of the eSCrS, Milan

LooKing toWarDS the Future KC Solutions has the pleasure to invite you to the official presentation of the new products which will mark a new era for keratoconus treatment. This will take place on the 9th of September in Le Sale del Re (Gallería V. Emanuele, Milan) during the XXX ESCRS Congress. The event will include for the first time ever, a historical archive exhibition comprising pictures of Barraquer´s family.

For further information and bookings please come and visit our booth #312 in the convention centre (MiCo North Wing - Level 0).

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10

Update

Cataract & refractive

KERATOTOMY

A possibly safer alternative to conventional relaxing incisions

By Roibeard O’hEineachain in Prague

Arcuate cuts The study included 17 patients with naturally occurring astigmatism ranging from 0.75 D to 3.5 D and four patients with 1.25 D to 1.5 D of residual astigmatism following cataract surgery, he said. All underwent the creation of arcuate cuts placed completely within the corneal stroma on the steep axis using the femtosecond laser.

Immediately preceding the laser treatment, the steep axis using the Keratron Scout (Optikon), an intraoperative videokeratoscope was marked by the surgeon (GG) and an ultrasoundpachymetry centrally and in four quadrants was performed. Depending on the amount of astigmatism present in each eye, one of four different treatment patterns was selected, which varied in the zone diameter, side-cut angle and incision width, based on pachymetry. At a follow-up which extended a minimum of six months keratometric changes with the Pentacam® HR (Oculus) and the Keratron Scout were measured and wavefront aberrometry was collected with the WASCA Wavefront Analyser (Carl Zeiss Meditec).

Following surgery, all patients had a reduction of their astigmatism, which EUROTIMES | Volume 17 | Issue 9

Courtesy of Wolfgang Riha MD

P

erforming intrastromal arcuate keratotomy with an IntraLase femtosecond laser (iFS, AMO) is a safe and effective means of treating moderate amounts of astigmatism, reports Wolfgang Riha MD, for the research team which includes Theresa Rückl MD and Prof Günther Grabner MD, University Eye Clinic, Paracelsus Medical University, Salzburg.

“The iFS-laser allows the creation of precise, purely intrastromal incision patterns that are not readily achievable by standard diamond blade techniques.

Our preliminary outcomes indicate an excellent safety profile, the possibility of highly precise pattern placement, very rapid recovery and stability of vision,” Dr Riha said at the 16th ESCRS Winter Meeting.

In a study involving 21 eyes of 21 patients, intrastromal arcuate keratotomy with the IntraLase femtosecond laser (iFS, AMO) reduced corneal astigmatism by 0.25 D to 2.5 D in a manner highly dependent on the cut angle. In addition the cylinder reduction remained stable over the first six months of follow-up, Dr Riha noted.

Change of refractive and topographic astigmatism over time

remained extremely stable throughout follow-up. At six months the mean manifest refraction cylinder of 16 patients having had treatment with the same incision pattern was 0.33 D and their topographic cylinder was 0.63 D. Dr Riha said that they were able to place all incisions in their planned locations and no perforations occurred. Furthermore, the incisions were barely visible by slit-lamp examination from the first postoperative day, but were detectable by OCT (Visante®, Carl Zeiss Meditec). Endothelial cell count was unchanged from preoperative values, he added.

Encouraging safety results

Complications occurred in two patients, Dr Riha said. In one case there was a slight decentration, but the patient nonetheless achieved an uncorrected visual acuity of 20/20 in that eye. In another case there was a loss of suction, requiring a repeat treatment. At six months the patient had an uncorrected visual acuity of 20/50, which was better than the baseline value prior to planned phacoemulsification.

“The take-home message is that we have encouraging safety results. The intrastromal incisions probably have less of an antiastigmatic effect than standard arcuate incisions, but we think that it may be more stable in the long-term. In addition, we seem to have less sicca syndrome with this technique because it doesn’t harm the corneal nerves as much. The patient satisfaction was also very high, because of the short treatment time and low rate of complications,” Dr Riha summarised.

contact Wolfgang Riha – w.riha@salk.at

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12

Update

LOOK

Cataract & refractive

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EUROTIMES | Volume 17 | Issue 9

By Roibeard O’hEineachain in Prague

T

he OptiVis™ diffractive-refractive multifocal IOL (Aaren Scientific) can provide good spectacle independence with few visual disturbances and a good level of satisfaction that improves with time, the glare and haloes decrease after six months and satisfaction with vision during the night increases according to the results of a study presented by Magda Rau MD, Cham, Germany at the 16th Winter Meeting of the ESCRS. The prospective study involved 48 eyes of 24 cataract patients who underwent implantation of the OptiVis multifocal IOL during the period from October 2009 until May 2011. At six months’ follow-up, the uncorrected distance, near and intermediate visual acuity were 0.76, 0.76 and 0.7, even in the group of patients with the mean age of 70 years, respectively, and 57.1 per cent of patients reported complete independence from spectacles, she noted.

“Previous multifocal IOLs had no provision for intermediate vision. The OptiVis is the first lens of its kind in this respect,” she noted.

The OptiVis IOL is a hydrophilic acrylic IOL with a refractive-diffractive design. Its 6.0mm biconvex optic has a spherical anterior surface and a bi-sign aspheric multifocal posterior surface with a 2.8 D effective add at the spectacle plane. The IOL has a total diameter of 11.0mm and can be implanted through a sub-2.0mm incision.

Dr Rau noted that the central 1.5mm of the lens is a progressive refractive zone that provides depth of focus for far and intermediate foci. The mid-periphery from 1.5mm to 3.8mm is an apodised diffractive zone which has a near and distance focus. The peripheral portion of the optic is a non-prolate bi-sign aspheric zone, designed to improve image contrast for distance vision by making it less susceptible to the effects of tilt, decentration and variations in corneal asphericity than is the case with a prolate aspheric lens, she added.

In photopic conditions, when the pupil is constricted to 2.0mm, the OptiVis lens distributes light about equally to the near, intermediate and distant foci, with only two per cent of light outside its focal range, Dr Rau noted.

In scotopic conditions, when the pupil becomes dilated to 5.0mm, 68 per cent of light goes to the distance focus, 20 per cent to the near focus and six per cent to the intermediate focus, she said. “The apodisation increases the percentage of light from near to far as the pupil increases in size. In addition, the unique apodisation design of diffractive zone results in less than 4.2 per cent of light being out of focus. This reduces the multifocal optic’s negative impact on contrast sensitivity and haloes.”

Satisfactory vision The patients in the study had a mean age of 70.4 years and all had a strong desire to achieve spectacle independence and a willingness to accept a potential optical side effect and longer optical adaptation after surgery, she noted. In addition, all eyes had a mesopic pupil size of 4mm or less and had no more than 1.0 D of corneal astigmatism preoperatively. None of the patients had

“

Previous multifocal IOLs had no provision for intermediate vision. The OptiVis is the first lens of its kind in this respect Magda Rau MD any ocular or systemic co-morbidities that might affect their visual outcome.

Dr Rau noted that patients’ distance vision appeared to improve slightly while near visual acuity decreased between the third and sixth postoperative month. The mean uncorrected distance visual acuity was 0.68 at three months’ follow-up and 0.76 at six months’ follow-up, she said. The mean best corrected visual acuity for distance was 0.78 at three months and 8.0 at six months.

In addition, the mean uncorrected near visual acuity was 0.8 at three months and 0.76 at six months. Moreover, the mean uncorrected intermediate visual acuity was 0.69 at three months and 0.7 at six months, she added.

Patients underwent contrast sensitivity testing using a device called the functional visual analyser. The results of the testing indicated that, in patients aged 60 to 69 years, contrast sensitivity was slightly above the normal range at three cycles per degree, within normal range at six cycles per degree and below normal range at 12 cycles per degree in both daytime and night-time conditions. In patients aged 70 to 79 years, contrast sensitivity was within normal range at three cycles per degree but below the normal range at six and 12 cycles per degree.

Visual symptoms were mild when they occurred and appeared to diminish over time, Dr Rau said. For example, the proportion reporting haloes was 44.2 per cent at three months and only 22.2 per cent at six months.

Furthermore, in their responses to a satisfaction questionnaire, 57.1 per cent said they never wore glasses and the same proportion were completely satisfied with their vision without glasses at both day and night, she noted. The remaining 42.9 per cent of patients said they wore glasses sometimes and the same proportion said they were mostly satisfied with their vision without glasses during the day, she said.

Satisfaction with uncorrected night vision improved over time, she pointed out. That is, the proportion moderately and mostly satisfied rose from 14.2 per cent and 0.0 per cent, respectively, at three months, to 22 per cent and 11 per cent, respectively, at six months. Furthermore, only 10 per cent said they were only a little satisfied with their night vision without glasses at six months’ follow-up.

contact Magda Rau – rau@augenklinik-cham.de

contact

Detlef Holland – d.holland@augenklinik-bellevue.de

Update

Cataract & refractive

NEW TORIC IOL

Implant achieves good visual outcomes in highly astigmatic cataract patients

By Roibeard O’hEineachain in Prague

A

series of astigmatic cataract patients implanted with a new toric IOL called the Basis Z toric (FirstQ) have achieved encouraging one-year results, said Detlef Holland MD, Augenklinik Bellevue, Kiel, Germany, at the 16th ESCRS Winter Meeting. “The Basis Z toric IOL is easy to implant and shows a good centration within the capsular bag and the predictability of the postoperative refraction is good,” Dr Holland said.

The study involved 100 eyes of 50 patients with cataract and astigmatism. At a follow-up of one to 12 months following implantation

“

We will need a longer-term followup concerning its rotational stability and PCO Detlef Holland MD

of the Basis Z IOL, subjective astigmatism was -0.5 D, while mean postoperative sphere was -0.25 D. Furthermore, uncorrected visual acuity was 0.8 and best corrected acuity was 1.0.

The Basis Z toric IOL is a foldable IOL with z-haptics and is composed of hydrophilic acrylic material, he noted. It is available in spherical powers from zero to 30 D and in cylinder powers from 1.5 D to 9.0 D. It is also available in both clear and blueblocking versions, he said.

Haigis formula The patients in the study had a median age of 71 years and their

corneal astigmatism had a median value of -2.4 D and ranged from -1.03 D to -9.8 D. Dr Holland and his associates used corneal topography to exclude eyes with corneal pathologies. They performed biometry with the Zeiss IOLMaster with an online calculator program to calculate the cylinder power, using the Haigis formula.

Immediately prior to surgery, they marked the axis in each case with Gerten marker while the patient was in a sitting position. In all cases, patients underwent implantation of the Basis Z toric with a 2.4mm clear cornea incision and the Firstinjektor (FirstQ) lens injecting system.

The implanted lenses had a median sphere of 19.0 D and cylinder ranging from a median of +2.25 D, with a mean target refraction of -0.17 D spherical equivalent and -0.18 D cylinder.

Dr Holland noted that all IOLs could be implanted within the capsular bag with good centration, without complications and only a very negligible impact on corneal astigmatism. The IOLs’ rotation deviated by a mean of three degrees from the planned axis after six months.

In three of the earlier cases the IOL had to be repositioned due to rotation. However, since adopting the practice of using a 5.0mm rhexis, which fully overlaps the optic by at least 1.0mm, followed by slower removal of the viscoelastic, no rotations have occurred, he pointed out. He and his associates also always now take the precaution of implanting the lens with a capsular tension ring.

Dr Holland noted that at the time of his report he and his associates had implanted 306 of the new toric lenses. “We will need a longer-term follow-up concerning its rotational stability and PCO,” he concluded.

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Visit our ESCRS stand S149 EUROTIMES | Volume 17 | Issue 9

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14

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EUROTIMES | Volume 17 | Issue 9

Cataract & refractive

PHAKIC IOL

New ICL design streamlines implantation and may improve safety

By Roibeard O’hEineachain in Prague

A

new model of the Staar Surgical Visian ICL™ produced good short-term results in a small series of myopic patients, reported Erik Mertens MD, FEBOphth, Medipolis Eye Centre, Antwerp, Belgium, at the 16th Winter Meeting of the ESCRS. The new lens has a small hole in the centre of its optic to allow the passage of aqueous and eliminate the need for iridectomy in patients receiving the lens.

“We all know that when we perform an iridectomy it is bothersome for the patient.

Furthermore, iridectomies can result in pigment dispersion in the eye and bleeding, which are two things you want to avoid during surgery. The new version of the lens makes the implantation procedure more like a LASIK procedure,” said Dr Mertens.

He said that in 48 eyes of 24 patients who underwent implantation of the lens, uncorrected distance visual acuity and best corrected distance visual acuity was 1.1 and all eyes were within 0.5 D of emmetropia at one month’s follow-up. Moreover, there was no postoperative elevation of IOP in any eyes and the holes in the implant did not appear to produce any perceptible effect on vision. Preoperatively the patients’ spherical refraction had a mean value of -6.0 D, and ranged from -3.5 D to -8.75 D. In addition, none of the eyes had more than 0.75 D of cylinder, their mean anterior chamber depth was 3.28mm, and their mean IOP was 15.0 mmHg, with values ranging from 10.0 mmHg to 20.0 mmHg. At one month’s follow-up, all eyes were within half a dioptre of the intended refraction and 80 per cent of eyes gained one line or more of best-corrected visual acuity. The efficacy index of the lens was 1.17 and its safety index was 1.07. In addition, IOP values remained low with a mean value of 11.0 mmHg and a range from 9.0 mmHg to 14 mmHg, Dr Mertens said.

The new Visian 4C posterior chamber phakic IOL is identical to the previous 4B model of the ICL except for a small hole, or aquaport, 360 microns in diameter in the centre of the optic, Dr Mertens noted.

Like the 4B model, the new version of the ICL is a foldable phakic IOL composed of a collagen polymer material and has a plate haptic that rests in the ciliary sulcus, he said.

“The aquaport is designed to restore a more natural aqueous flow around the

natural crystalline lens and through the port in the ICL. In this way it eliminates the need for iridectomies or iridotomies,” Dr Mertens said.

He noted that, out of concern, that the hole might induce photic phenomena like glare and haloes under night driving and similar conditions; his first two patients implanted with the lens received the new 4C version in one eye and the older 4B version without the aquaport in the other eye, but were not told which eye had which type of IOL. Postoperatively, they could not tell which eye had the new ICL design, Dr Mertens said.

Viscoelastic material An additional advantage of the new lens is that it makes it much easier to remove viscoelastic material following implantation, Dr Mertens said.

He noted that he uses methylcellulose in all of his ICL implantation procedures, and he provided a video demonstration of the technique he uses to remove it at the conclusion of surgery.

“I will direct my irrigation port through the aquaport giving it a push; it pushes the methylcellulose out from the posterior surface of the ICL. So people using hyaluronic acid, where it is extremely important to remove all of it, can do a better job and it is much easier to push that from behind the ICL into the anterior chamber where it can be easily aspirated,” he said.

Dr Mertens said that when he assesses eyes for the sizing of the ICL he measures the sulcus-to-sulcus diameter with a Quantel or Sonomed UBM device, which provides an average of 10 measurements, and he then compares them to white-to-white measurements obtained with the Orbscan.

In addition, he always makes sure that there is a vault of at least 200 microns between the posterior surface of the IOL’s optic and the crystalline lens. That way, even if the vault varies by 100.0 microns as a result of accommodation and other factors, eyes with the implant will still remain within the safety zone.

“In our experience to date with the new ICL with an aquaport we haven't seen any IOP elevation and have had very good predictability and our patients have reported no side effects,” he concluded.

contact Erik L Mertens – e.mertens@medipolis.be

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Update

ESCRS 2012 MILANO

Cataract & refractive

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Merging the refractive and cataract worlds Moderator - Dr Sheraz Daya (UK) SCORE - A New Approach to Keratoconus Analysis with the Orbscan® IIz Dr Damien Gatinel (France) Clinical Experience with SUPRACOR™ - Hyperopic and Myopic results Prof Michael O'Keefe (Ireland) Initial Experience and Learnings with the VICTUS® Femtosecond Laser Prof Chris Lohmann (Germany) The Versatility of the VICTUS® Femtosecond Laser Platform Dr Erik Mertens (Belgium) High Volume Use of the VICTUS® Femtosecond Laser Platform for Laser Refractive Cataract Surgery Dr Pavel Stodulka (Czech Republic)

VICTUS is not cleared for sale in the United States. VICTUS has CE marking. Indications may vary by country.

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astigmatism

Inexpensive astigmatism correction technique remains a good option

by Roibeard O’hEineachain in Prague

T

he anti-astigmatic effect of limbal relaxing incisions (LRIs) appears to remain stable over the medium term, according to a study by Rongxuan Lim, who is a resident, and Luca Ilari FRCS, at the Princess Royal University Hospital, South London Healthcare Trust, NHS, UK. In their study involving 22 eyes of 17 patients who underwent LRIs to treat a mean preoperative keratometric astigmatism of 2.26 D (min 1.2 D, max 3.6 D), the mean postoperative astigmatism was 1.31 D (min 0.3 D, max 4 D) at two weeks' follow-up, 1.24 D (min 0.2 D, max 3.9 D) at six weeks' follow-up, and 1.23 D (min 0.4, max 4.7 D) at an average of 3.41 years' follow-up.

“LRIs remain an attractive option for reducing astigmatism, given their stability over time,” Dr Lim said at the 16th ESCRS Winter Meeting in Prague.

The patients in the study underwent the LRIs between November 2006 and November 2008. Their age at the time of surgery ranged from 49.8 years to 86.9 years, and their mean age was 77.9 years.

All had at least 2.58 years of follow-up. The average length of follow-up was 3.41 years and the longest follow-up of 4.24 years.

At the patients’ most recent assessment, Dr Ilari and Dr Lim measured their corneal astigmatism and topography using the Pentacam and compared their findings with data that had been collected preoperatively, two weeks and six weeks postoperatively. They performed their statistical analysis using the Wilcoxon twotailed matched-pair test.

They noted that there was no statistically significant difference between the average keratometric astigmatism at two weeks' and six weeks' follow-up (p=0.28), nor between those values at six weeks and at a mean of 3.41 years follow-up (p=0.94).

On the other hand, the surgically induced astigmatism, was significantly less at six weeks' follow-up than it was at two weeks' follow-up (p=0.0004). However, the surgically induced astigmatism at six weeks was statistically similar (p=0.28) to that at a mean of 3.41 years of follow-up.

Don’t Miss Industry News, see page 68 EUROTIMES | Volume 17 | Issue 9

“

LRIs remain an attractive option for reducing astigmatism, given their stability over time Rongxuan Lim

In addition, when they divided the overall group into those having with-therule astigmatism and those having againstthe-rule astigmatism, both groups showed a similar pattern of astigmatic stability as the main group.

Dr Lim noted that, according to a recent survey, toric intraocular lenses and LRIs are the most popular forms of astigmatism correction. LRIs have the advantage of being cheaper and usable with any design of intraocular lens. However, they require some additional instruments and have a reputation for being less predictable than toric IOLs. Moreover, they carry a risk of infection and perforations and can exacerbate postoperative dry eye symptoms.

She added that although a few small studies have shown that the astigmatic correction LRIs provide is stable for up to a year, the data is sparse for results beyond that length of time.

“In our study, the astigmatic effects of limbal relaxing incisions remain stable from six weeks postoperatively to an average follow-up of 3.41 years.

Thus, limbal relaxing incisions remain a competitive option for reducing astigmatism,” she said.

contacts Rongxuan Lim – rongxuan.lim@chch.oxon.org Luca Ilari – lilariuk@yahoo.co.uk

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contacts

Cataract & refractive

PRESBYOPIA

104: 366-401). By contrast, a US prospective study involving 60 patients found a slight improvement in stereopsis six months after surgery, he reported.

Corneal inlays, laser surgery and IOLs all show promise

by Howard Larkin in Orlando

W

ith the baby boom generation approaching retirement, presbyopia correction may be the fastest growing refractive surgery market. Many workable approaches are now available.

Which one is best depends on the specific needs and characteristics of individual patients, according to presenters at the annual meeting of the American Academy of Ophthalmology.

Diffractive inlay

In a study of 32 eyes in its fourth year of follow-up, the AcuFocus Kamra ACI 7000 diffractive corneal inlay has proven an effective and safe presbyopia treatment, providing J1 or better near visual acuity in half of patients and J3 or better in nearly all patients with minimal loss of distance acuity, said Günther Grabner MD of the Paracelsus Medical University of Salzburg, Austria.

The inlay is a 5.0 micron thick circle of polyvinylidene fluoride 3.8mm in diameter with a 1.6mm central aperture. It is implanted under a flap or in a tunnel in the cornea centred over the visual axis of the non-dominant eye to create a pinhole effect that increases depth of focus. In Dr Grabner’s study, 30 eyes improved near visual acuity by up to 6 log-scaled lines. At 48 months, the average gain from J7/8 before surgery was 4.6 lines, with intermediate vision improving from a mean of 20/40 to 20/25.

The Kamra inlay also improves on the performance of monovision, said Vance Thompson MD of Sioux Falls South Dakota, US. Monovision LASIK with plano in the dominant eye and -1.25 in the other eye show significantly reduced distance visual acuity and contrast sensitivity, as well as reduced stereoacuity, with the impact rising with the add power in the non-dominant eye (Durrie. Trans Am Ophthalmol Soc 2006;

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Refractive inlay Refractive inlays also show great promise for exceeding the performance of monovision. Tests of the Flexivue Microlens 3.2mm yield near vision near 20/20 while maintaining contrast sensitivity, distance acuity and stereopsis.

The lens has a central zone without power and a peripheral add from 1.5 to 3.5 D. With a small pupil, the near add covers the optical zone for close work, but allows good vision with a wider pupil.

The ReVision Optics Presbylens is a 2.0mm hydrogel inlay that changes the contour of the central cornea, creating an add without side effects such as glare and haloes. It is entering Phase III clinical trials in the US. Inlays of all types are also longer lasting than presbyopic LASIK and are removable, Dr Thompson noted.

Presbyopic LASIK Despite some issues with glare and haloes, presbyopic LASIK remains an attractive alternative for younger presbyopes, those under age 56, said Gustavo E Tamayo MD, Bogota, Colombia. In a retrospective study of 121 eyes in 66 patients undergoing presbyopic LASIK, he found that 100 per cent of myopes and emmetropes, and 78 per cent of hyperopes achieved 20/25 or better uncorrected near visual acuity, and 100 per cent of all patients achieved 20/25 or better best corrected binocular vision after presbyopic LASIK treatment.

The procedure works much like multifocal intraocular lenses, Dr Tamayo said. A “knee” contour is ablated in the cornea, creating a central zone of negative spherical aberration and a peripheral zone of positive spherical aberration, increasing depth of focus. The procedure works well, with 92.6 per cent of patients reporting they do not use glasses at any time. The basic procedure is well known and reversible with a CustomVue treatment, he noted.

Multifocal IOLs While multifocal IOLs are not as popular as corneal approaches for patients with clear lenses, they remain a top choice for presbyopia correction for cataract patients. However, they inherently suffer from loss of contrast sensitivity associated with up to 20 per cent light loss, due to splitting of incoming light, and in many cases lack intermediate correction, said Matteo Piovella MD of Monza, Milan, Italy.

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Günther Grabner – G.Grabner@salk.at Vance Thompson – Vance.Thompson@SanfordHealth.org Gustavo Tamayo – gtvotmy@telecorp.net Matteo Piovella – piovella@piovella.com David Hardten – drhardten@mneye.com George Beiko – georgebeiko@hotmail.com

in the intermediate range, but shift the light split from near to far, potentially leaving not enough light at near with a 5.0mm pupil. Apodised diffractive lenses may also be far-dominant, shifting from 40 per cent near at a 2.0mm pupil to 10 per cent at 5.0mm. Theoretically, non-pupil-dependent diffractive designs preserve near vision at larger pupil size, but this may produce haloes, and they still lose 20 per cent of light at all distances.

Nonetheless, about 90 per cent of patients achieve 20/25 or better distance with 20/32 or better near vision with these lenses. An advanced multifocal design from OptiVis minimises light loss and improves intermediate vision with a mix of diffractive, refractive and aspheric zones, he noted. Also new Zeiss AT LISA trifocal improves better light distribution to achieve an increase of depth of focus.

Many workable approaches are now available. Which one is best depends on the specific needs and characteristics of individual patients Accommodating IOLs Several lenses have been designed to provide accommodation by moving in the capsular bag. According to a study by George Beiko MD of the University of Toronto, Canada, presented by David R Hardten MD of Minneapolis, US, comparing the single optic Crystalens HD implanted bilaterally in 10 patients with the dual optic Synchrony lens in 11 patients, the dual optic design is superior. The Synchrony group achieved mean 20/20 vision at near, intermediate and far while the Crystalens was 20/20 at distance, 20/25 intermediate and 20/40 near. While the single optic results are better than bilateral plano monofocal lenses, they are about the same as mini monovision with monofocals and the Tetraflex single optic accommodating lens.

Objective data as measured by wavefront, does not support mean accommodation in any single optic accommodating IOL group, Dr Beiko reported. However, the dual optic design provides better near visual acuity and does show evidence of movement in the bag.

A.R.C. Laser certifies that the product complies to 21 CFR 1040.10 and 1040.11 EN 13485/ 2003 - 93/42 EWG

Update

A.R.C. Laser certifies that the product complies to 21 CFR 1040.10 and 1040.11 EN 13485/ 2003 - 93/42 EWG

18

19

Update

Cataract & refractive

EYEDROPS

Monocular topical miotics may improve near vision without distant vision loss

By Howard Larkin in Chicago

M

ean near visual acuity improved by 6.3 Jaeger lines in presbyopic patients receiving carbachol 2.25 and 3.0 per cent in the non-dominant eye, Stephen C Kaufman MD, PhD, told the innovators session at the annual ASCRS symposium. The pilot test suggests that drug treatment may be viable for presbyopia in some patients.

“The pharmacologic treatment of presbyopia with one drop a day in the nondominant eye permits acceptable reading vision for many presbyopes. It does not blur distance vision as does typical monovision therapy, and the perception of normal brightness in the untreated eye eliminates symptoms of dimming from the smaller pupil of the treated eye,” Dr Kaufman said. The treatment may also enhance near vision for monofocal IOL and contact lens patients.

However, topical miotic treatment carries a small risk of retinal detachment in patients with retinal pathology, Dr Kaufman noted. Other local risks include ocular inflammation, iris cysts and frontal headaches, while systemic side effects could include cardiovascular and digestive problems. A dilated fundus exam should be conducted before treatment to reduce risks.

Pinhole effect Rather than tackle presbyopia with multifocal or accommodating lenses, pharmacologic treatment relies on the pinhole effect – increasing depth of focus by reducing aperture, Dr Kaufman said. The principle is being successfully applied in corneal inlays implanted in the non-dominant eye to enhance near vision, he noted.

To achieve a similar effect with reasonable patient effort, a pharmacologic agent must create significant and long-lasting pupil constriction. So Dr Kaufman, at the University of Minnesota, Minneapolis, US, and his colleagues, Alessandro Meduri, Italy, and Salomon Esquenazi, US, tested several widely available topical miotics alone and in combination. These were the cholinergic agonists pilocarpine and carbachol and the alpha 2 agonist brimonidine.

Pilocarpine, pilocarpine with brimonidine, carbachol, and carbachol with brimonidine in various doses were tested against a placebo in a masked trial involving 12 patients in carbachol and 12 in pilocarpine groups. Each combination was EUROTIMES | Volume 17 | Issue 9

“

The pharmacologic treatment of presbyopia with one drop a day in the nondominant eye permits acceptable reading vision for many presbyopes

Stephen C Kaufman MD, PhD tested in each patient with a washout time in between.

Pre-treatment near and distance visual acuity were compared with post-treatment values at one, two, four and eight hours after drops. Adverse symptoms and subject satisfaction were assessed. The goal was to determine if a parasypathomimetic and brimonidine are synergistic, and if a single dose in the non-dominant eye would provide reading vision without symptoms of dimness or blurring of distance vision.

In the pilocarpine groups, the optimal dose was one per cent, which yielded a mean near vision improvement of J-2.3 alone, and J-3.0 combined with brimonidine. The optimal dose of carbachol was 2.25 and 3.0 per cent, yielding a J-6.3 improvement alone and in combination with brimonidine, though the higher concentration of carbachol and the combined treatment lasted longer.

“We were very surprised,” Dr Kaufman said. Mild drop-associated discomfort was noted in 10 per cent to 30 per cent of all groups, including placebo.

Beyond medically significant side effects, treatment considerations include the cosmetic appearance of a constricted pupil, degraded effect due to corneal or lenticular opacities, and reduced effect in combination with non-steroidal anti-inflammatory drugs, Dr Kaufman said.

Still, 90 per cent of test subjects said they would use the drug therapy if it were available. Dr Kaufman pointed out that these drugs are already used by subspecialists in limited circumstances, and there is great potential for broader use.

“I think it’s exciting. Think about it.”

contact Stephen C Kaufman – SCK@UMN.edu ad-EUR-1-2 hoch-1202v2-pva RZ.indd 1

29.02.12 13:43

evolve. get expert advice and grow your practice

PRACTICE DEVELOPMENT WEEKEND ROYAL COLLEGE OF SURGEONS DUBLIN, IRELAND FRIDAY 5 – SUNDAY 7 OCTOBER 2012

meet the experts

FRIDAY 5 OCTOBER

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Norah Casey

Kris Morrill

Arthur Cummings

Norah Casey is owner and CEO of Harmonia, Ireland’s largest magazine publishing company, printing over four million magazines annually for the Irish, British and US market.

Kris Morrill focuses on the commercialisation of innovative technology and on working with physicians to broaden their commercial skills.

Key areas of interest are refractive surgery, IOL power calculation and keratoconus. He has always worked in private practice and is interested in the business of ophthalmology.

Keith Willey He leads managing the growing business and new technology ventures courses. His work focuses on entrepreneurship, venture capital, managing growth, technology ventures and organisation development

Register online: http://pddublin.escrs.org DELEGATE FEE (INCLUDING GALA DINNER IN MERRION HOTEL, DUBLIN) €350

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Kris Morrill, Medeuronet, France Arthur Cummings, Wellington Eye Clinic, Ireland FRIDAY 5 OCTOBER

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Motivating and Rewarding your Staff in a Challenging Environment Norah Casey, CEO of Harmonia and panelist on Ireland’s Dragons Den SATURDAY 6 OCTOBER

Practice Development Masterclass Strategies and Tactics for a Successful Practice Keith Willey, London Business School, UK SUNDAY 7 OCTOBER

Social Media in Action Rod Solar, LiveseySolar Practice Builders, UK

21

Update

Cataract & refractive

The moment IOL power calculation becomes second nature.

This is the moment we work for.

painless SURGERY

Non-invasive in situ vision correction seen by adjusting refractive index in corneas and IOLs

by Howard Larkin in Chicago

H

igh-repetition femtosecond lasers can now be used to alter the refractive index of living corneas and crystalline lenses in an animal model, and in hydrogel ocular implant materials. If stable, the technology could enable non-invasive vision correction in both phakic and pseudophakic eyes, Scott M MacRae MD told the innovator’s session at the annual ASCRS symposium.

Unlike femto laser lens or flap cuts, these refractive index changes are accomplished by working below the threshold of tissue damage, said Dr MacRae, who is testing the technology developed by Wayne Knox PhD and Krystel Huxlin PhD at the University of Rochester, New York, US. In this new modality, the femtosecond laser does not need to disrupt the epithelium and leaves no microscopic or immuno-histochemical evidence of cell damage in living cat corneas.

As a result, refractive surgery could be performed without pain or the risk of dry eye, or the need for postoperative antibiotics or shields, Dr MacRae said.

“Using this technique, we hope to achieve custom vision correction of -3.0 to +3.0 D sphere or astigmatism on corneas, lenses and hydrogel implants.”

High-speed, low power Called femtosecond Intra-tissue Refractive Index Shaping (IRIS), the system uses localised energy deposition from laser pulses to create a change in refraction by increasing the refractive index in patterns that can treat myopia, hyperopia or astigmatism.

This can be done within hydrogel materials, corneas and crystalline lenses, Dr MacRae said. IRIS is docked to the eye using a suction ring and liquid interface similar to those on existing flap cutting and cataract systems.

However, IRIS works at a much higher repetition rate of 82 MHz, compared with 5 kHz to 5 MHz for corneal flap cutters. IRIS pulses are also shorter, at 30 to 100 femtoseconds compared to 200 femtoseconds to 2 picoseconds, and lower power, at 1 to 12 nJ compared to 150 to 6,000 nJ. This yields a total power per pulse about 100 times less than with flap cutters, imparting much less heat energy per pulse.

As a result, refractive index changes can be made in corneas and lenses EUROTIMES | Volume 17 | Issue 9

“

Using this technique, we hope to achieve custom vision correction of -3.0 to +3.0 D sphere or astigmatism on corneas, lenses and hydrogel implants Scott M MacRae MD

without disrupting corneal epithelium, endothelium, stroma or lens tissue, Dr MacRae noted. In cat corneas and lenses, refractive index changes of up to +0.037 have been obtained to date, which when enacted over a large region and in multiple layers, can attain power changes of several dioptres.

In hydrogel lenses, the effect is even greater, with refractive index increasing by up to +0.05 in each lasered layer. After treatment the material remains optically clear with virtually minimal light scatter, he added.

Potential treatment options include writing corrections directly in the cornea and/or crystalline lens; implanting an IOL and then adjusting the lens power by writing directly in the IOL; or implanting a lens and writing corrections in the cornea.

Unresolved issues However, several issues remain to be resolved, Dr MacRae said. Stability in vivo is one. So far, lines inscribed in cat eyes have remained stable for three months. In hydrogel, the refractive change appears to be permanent and lasts more than 2.5 years. Tissue response may also be an issue as total treatment power approaches that of flap cutters.

Dr MacRae expects these issues will be successfully resolved. “The field is moving fast and it is very exciting.”

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Update

Cataract & refractive

contact

Gerd Auffarth – gerd.auffarth@med.uni-heidelberg.de

TORIC mIOLS

Informed consent should familiarise patients with the issues they might face with mIOLs

by Howard Larkin in Orlando

T

oric multifocal intraocular lenses (mIOLs) now available in Europe are not only safe and stable, they improve both distance and near vision in patients with presbyopia and corneal astigmatism greater than 1.0 to 1.5 D, Gerd U Auffarth MD, University of Heidelberg, Germany, told an ESCRSsponsored symposium at the American Academy of Ophthalmology annual meeting.

Some patients who want the benefits of multifocality are less-than-ideal candidates due to high corneal astigmatism that can interfere with lens function, he noted.

Toric mIOLs are an option for these patients, but their stability also makes them attractive for those with moderate astigmatism. “There are patients with moderate astigmatism, 1.0 to 2.0 D, who can be difficult to deal with. You can try incisional techniques, but they may only be temporary. With multifocal toric lenses we

can correct it completely regardless of the amount of torus.”

Dr Auffarth noted that toric mIOLs are available in refractive models, such as the Rayner M-Flex-T, and diffractive designs, such as the Carl Zeiss Meditec Acri.Lisa MIOL-Toric and the Alcon AcrySof IQ Toric ReSTOR, which are among the most widely used in Europe. In addition, Oculentis makes the Mplus Toric, a segmented multifocal lens that confines the near add optic to less than half the lens, and the Rayner Sulcoflex Multifocal Toric, which can be added to a pseudophakic eye to provide multifocality and compensate for residual astigmatism.

Most are based on established proven monofocal designs that ophthalmic surgeons are familiar with and are easy to implant. For example, the Rayner M-Flex T is based on the C-Flex hydrophilic acrylic platform. Research in which Dr

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Registration: www.cxl-congress.org EUROTIMES | Volume 17 | Issue 9

Courtesy of Gerd U Auffarth MD

24

Rayner Mflex T

Auffarth participated has shown that the design’s 360-degree sharp edge resists PCO. Significantly, its haptic design also ensures accurate centration as the capsular bag contracts over time and resists rotation, which is essential to keep a toric IOL on axis.

The Alcon ReSTOR platform is also known for its good fit in the eye and minimal rotation, he said.

Dr Auffarth reported good results with the Rayner M-Flex T that he implanted in 10 eyes of six patients. Mean age was 47.4, ranging from 17 to 60 years old; six eyes were refractive lens exchange and four were cataract eyes. Two patients with anisometropia and amblyopia received a toric multifocal in one eye and a standard multifocal in the other. Preoperative mean sphere was -0.03 +/- 7.25 D, ranging from -10.0 to +9.0; mean cylinder -2.65 +/- 0.97 D ranging from -1.5 to -4.75, and best corrected distance vision was 0.19 logMAR, or about 20/30. Mean sphere of the implanted lenses was 20.95 +/-10.61; cylinder 2.95 +/- 0.93; and near add 3.20 +/- 0.42.

At follow-up four to 11 months after surgery, median sphere was 0.00 ranging from -0.25 to +2.00; cylinder -0.5 ranging from -2.50 to 0.00; and spherical equivalent median 0.00 ranging from -0.50 to +0.75.

This translated to median uncorrected distance visual acuity of 0.15 logMAR, or about 20/28, ranging from 20/16 to 20/50, and median corrected distance vision of about 20/25 ranging from about 20/12 to 20/50. Uncorrected near vision median was 20/40 ranging from 20/50 to 20/25; and median near add was 0.00, ranging up to +1.50, producing corrected near vision results ranging from 20/20 to 20/40.

Anisometropia and amblyopia

One patient with anisometropia preoperatively had 0.75 sphere in one eye and +6.0 with -4.75 D astigmatism in the other, producing 20/20 and 20/30 best corrected vision. Dr Auffarth implanted a standard multifocal in the stronger eye, resulting in 20/20 uncorrected near and

distance, and a toric multifocal in the other, resulting in 20/25 distance and 20/40 near uncorrected. He cautioned, however, that multifocal lenses will not work for patients with severe amblyopia.

Dr Auffarth also reported good results with the Oculentis toric multifocal. In a 52-year-old female with zonular cataracts, hyperopia of +3.25 D and -1.25 astigmatism in the right eye and +4.25 and -1.75 in the left, and best corrected visual acuity of about 20/32 in both eyes, he observed uncorrected distance acuity of 20/32 and near acuity of about 20/32 and 20/25 one day after surgery.

In five patients he saw median uncorrected distance vision of about 20/25, ranging from 20/20 to 20/32; and uncorrected near vision of about 20/25 ranging from 20/20 to 20/32.

He noted that because the Oculentis add zone covers only about half the lens optic, the lens is always implanted straight up and down, and must be ordered with the cylinder on the proper axis. “Most multifocal lenses are available in custom mode. They are individualised lenses and can be ordered, in extreme cases, up to 10 or 12 D cylinder.”

He said, however, that while standard power toric multifocals generally are reasonably priced, a custom lens may cost up to €2,000. One popular multifocal toric lens that is not available in custom powers is the Alcon ReSTOR, Dr Auffarth said.

“You can get very nice results with the Alcon toric multifocal. But it comes in fixed cylinder powers so you have to look at the incision size.”

The Alcon lens power calculator helps choose an appropriate power and axis.

In six patients examined three months after surgery, he saw median uncorrected distance vision of 20/40 ranging from 20/20 to 20/50, and median uncorrected near vision of 20/32 ranging from 20/25 to 20/63.

“Toric multifocal lenses are not for everyday cases,” Dr Auffarth said.

He emphasised the need for careful biometry and corneal topography to rule out corneal pathology, and rigorous informed consent to familiarise patients with the issues they might face with multifocal lenses.

Update

Cataract & refractive

MEASURING VISION

New technology brings new standards of accuracy in diagnosis to refractive surgery

by Roibeard O’hEineachain in Prague

Relationship with patient Dr Brogelli noted that it is during diagnostic procedures that the refractive surgeon establishes the relationship with the patients. It is the findings of the diagnostic procedures that determine what the surgeon should tell the patient to expect.

It is therefore essential that the diagnosis be carried out in the most accurate and efficient manner possible using the most up-to-date equipment, which itself must be measured against the diagnostic instrumentation that has proved tried and true in the past, she said.

EUROTIMES | Volume 17 | Issue 9

Self-defenSe Safety Doesn’t Happen By Accident Introducing The Safety Knife Series* From Surgistar

Courtesy of Silvia Brogelli MD

A

s the diagnostic technology to measure vision evolves, a careful audit of the utility of each type of examination can help in determining which ones are still clinically useful and which have become outmoded, said Silvia Brogelli MD, Centro Oculistico Barbantini, Lucca, Tuscany, Italy.

“Clinicians do not always know when it is time to change their way of operating in the diagnostic and in the surgical domains.

Everything may seem to be all right in their everyday practice but internal audit can determine whether that is actually true,” she told the 16th ESCRS Winter Meeting.

She and Francesco Fortunato, orthoptist, performed a review of the medical records of 3,500 patients in whom she, Marco Fantozzi and the other surgeons of their team had carried out IntraLASIK procedures since the beginning of 2009 to the end of 2011.

IntraLASIK had two phases: 1) creation of a flap by Femtosecond Laser iFS 150 kHz IntraLase; 2) Photoablation by Excimer Laser Schwind Amaris. The results of the review showed a definite change in the technology used in the decision-making process. What had increased most was the use of OCT instruments for anterior segment imaging and, conversely, what had decreased most was the use of non-OCT corneal diagnostic imaging technology such as ultrasound, she said.

“We found that the continuous upgrading of hardware and software of the computerassisted instruments devoted to refractive surgery was accompanied by some changing in diagnostic procedures, although accuracy and reproducibility were always of a high level,” she explained.

viSit uS at eSCRS - Booth n240

Cornea of a patient Dr Brogelli operated on, the first slit lamp control after IntraLASIK

“No test is immortal. But no revolutionary innovation may be introduced without the help of a pre-existing clinical experience,” Dr Brogelli said.

She added that the primary diagnostic procedure of refractive surgery candidates is, in effect, a visual optics laboratory applied to a specific clinical case. Visual optics is a clinical discipline that studies refraction in the context of optics ocular physiology and visual psychophysics.

However, the evolving nature of visual diagnostic technology means that standardisation of diagnostic techniques has become very difficult.

Upgrading instruments Optical instruments used to change very slowly, taking multiple generations, even centuries to be replaced, she noted. However, the continuous upgrading of hardware and software of modern computer-assisted instruments devoted to refractive surgery is accompanied by frequent changes in preliminary diagnostic protocols, better accuracy of results of measures is counterbalanced by variations in the sequence of examinations performed at different clinical centres in the same period of time and also by the same centre in different years, she said “New instruments are continually presented by some very well known companies but the ultimate choice about the surgical procedure and the instruments used must be that of the single surgical team, who must decide what is successful and what is not in their own hands,” she added.

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7/24/12 10:03 AM

25

17th ESCRS Winter Meeting Warsaw, Poland 15 – 17 February 2013

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS

www.escrs.org

27

Update

Cataract & refractive

Corneal Transplant

SPECTACLE free

Apodised diffractive IOL yields high levels of patient satisfaction

by Roibeard O’hEineachain in Prague

T

EUROTIMES | Volume 17 | Issue 9

“

The Diffractiva-aA provides excellent uncorrected distance and near visual acuity...

For Conventional and Ultra-thin Lamellar Grafts

Alois Dexl MD

Busin Inserting Forceps, 23G

Courtesy of Alois Dexl MD

he new Diffractiva®-aA (HumanOptics, Erlangen, Germany) multifocal intraocular lens (mIOL) can provide a very high degree of spectacle independence and a good quality of vision, according to the results of a study presented at the 16th ESCRS Winter Meeting.

“The Diffractiva-aA provides excellent uncorrected distance and near visual acuity and good uncorrected intermediate visual acuity, in addition to very good contrast sensitivity with a low incidence of haloes and glare,” said Alois Dexl MD, Department of Ophthalmology, Paracelsus Medical University Salzburg, Austria.

The prospective two-centre study involved 48 eyes of 24 cataract patients who underwent bilateral implantation of this new multifocal lens. The patients in the study had a mean age of 70.8 years, ranged from 57 to 87 years. All had less than 1.5 D of corneal astigmatism and had no other ocular pathologies.

The Diffractiva-aA mIOL is a one-piece hydrophilic acrylic multifocal lens. It has a diffractive aspheric aberration-free anterior surface with a 3.5 D near add and a spherical posterior surface. In addition, the implant’s optic has a 360-degree square edge to prevent PCO. After a mean follow-up of 8.1 months (range six to eight months) the postoperative mean spherical equivalent was 0.12 D. Sixty per cent of patients were within 0.25 D of emmetropia and all were within 0.75 D, Dr Dexl said.

In addition, the mean uncorrected distance visual acuity was 0.93, when tested monocularly, and 1.0 when tested binocularly. Furthermore, binocular uncorrected distance visual acuity was 20/20 or better in 83 per cent of eyes and 20/25 or better in all eyes. At a testing distance of around 40cm the patients’ mean uncorrected near visual acuity was 0.86, when tested monocularly, and 0.93, when tested binocularly. Moreover, binocular uncorrected near visual acuity was 20/20 or better in 88 per cent of eyes and 20/25 or better in all eyes.

Furthermore, the mean uncorrected intermediate visual acuity was 0.76, when tested monocularly, and 0.90, when tested binocularly. Binocular uncorrected intermediate distance visual acuity at one metre was 20/20 or better in 54 per cent of

Mini Busin Spatula

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Binocular uncorrected visual acuity six months postoperatively

eyes, 20/25 or better in 83 per cent of eyes, and 20/40 or better in all eyes.

Moreover, in response to a questionnaire, 96 per cent of patients said they either did not see or were not disturbed by glare around lights at night. Four per cent said they were moderately disturbed by such dysphotopsias.

In addition, 58 per cent said they did not see or were not disturbed by haloes around lights at night, 25 per cent said they found the phenomenon slightly disturbing, 12.5 per cent said they found it moderately disturbing.

The only patient who was disturbed “a lot” by haloes noticed an improvement of the symptoms with time. Furthermore, contrast sensitivity values under photopic and mesopic conditions were within normal range for patients 60 years of age and older.

Regarding spectacle independence, 92 per cent of patients said they never had to wear glasses for any distance and the remaining eight per cent (two patients) said they wore them only very rarely, half for reading small print (one patient) and half for watching the television (one patient). Moreover, all patients said they were satisfied with the lens including 92 per cent who were very satisfied, Dr Dexl added.

contact

Alois K Dexl – a.dexl@salk.at

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28

Update

Cataract & refractive

FEMTO SURGERY

Cataract surgery assisted by laser requires change in mentality and operating technique

by Priscilla Lynch in Dublin

F

The power of one

The one FeMTo plaTForM for cornea, presbyopia and cataract.

Presenting the unparalleled Ziemer FEMTO LDV Z Models – a technical revolution in ocular surgery. No laser is more Precise, more powerful or more progressive when it comes to meeting all your procedural needs in a single platform. With Ziemer’s FEMTO LDV Z Models, now you can operate with a modular femtosecond system that is easy to configure, designed to grow with your practice – cornea and presbyopia today, cataract tomorrow. www.ziemergroup.com

The Ziemer FEMTO LDV Z Models are FDA cleared and CE marked and available for immediate delivery. For some countries, availability may be restricted due to local regulatory requirements; please contact Ziemer for details. 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.

eurotimes_sep2012_FEMTO_LDV_Z_Models_Ad_120x300mm.indd EUROTIMES | Volume 17 | Issue 9

1

24.07.12 13:23

emtosecond laser-assisted cataract surgery helps provide more predictable outcomes and reduces the amount of manual steps the surgeon has to carry out, Lucio Buratto MD told the Joint Irish and UKISCRS Refractive Surgery Meeting in Dublin.

Dr Buratto, Milan, Italy, spoke to the meeting about his experiences with this relatively new form of surgery. Looking back to 1978, Dr Buratto said the question at the time was: "Is phacoemulsification the future of cataract surgery?" Or was it simply a more complex surgery from the technological, organisational and cost points of view?

“Over the last 30 years, more than 50 million eyes have been subjected to phaco surgery so the answer was yes,” he said.

Ophthalmic surgeons are now faced with a similar question in 2012 about whether femtosecond laser is the future of cataract surgery, or is it simply the installation of a more sophisticated, expensive instrument in the operating room?

“I don’t know the answer for sure but in my opinion the answer is yes, laser is the future for cataract surgery, for certain stages,” he told the meeting.

Explaining the role of the femtosecond laser in cataract surgery he stressed that the femtosecond laser does not aim to replace phacoemulsification or remove the cataract with a laser phaco. Instead, femtosecond laser aims to replace some of the manual procedures that are dependent on the surgeon’s skill with some procedures that are controlled by a computer, he elaborated.

Today the femtosecond laser can perform a capsulotomy, fragmentation of the nucleus, corneal incisions and, if needed, relaxing incisions. Looking at the technology itself, he said there are currently four companies providing femtosecond laser technology, three American and one European.

Dr Buratto gave a positive report on the LenSx Alcon machine having now treated over 400 eyes with the device.

Looking at the benefits of femtosecond laser in performing a capsulotomy, Dr Buratto said it is very precise in terms of diameter, position and centring. It also gives a perfectly circular shape.

Overall, he said there are many key benefits of using the femtosecond laser in cataract surgery. These include less intraocular manipulation, lower stress on

the incision, fewer instruments enter the eye and less intraocular ‘work’. There is also lower use of intraocular liquids and a reduction in surgical time (but perhaps an extension of overall time, especially during the learning curve). “The main incision can be programmed very precisely in width, shape position and depth. A good incision means better standardisation of the refractive result, a better ratio between the phaco tip and the incision, and better closure of the incision at the end of surgery,” Dr Buratto reported.

Optimum refractive results The optimal results in the correction of refractive defects on the cornea with laser surgery (femto and excimer) depend on reduced surgeon involvement, said Dr Buratto. He said the surgeon controls the femtosecond laser and the lamellar cut for LASIK is completely automated. The surgeon follows with the excimer laser and the refractive treatment is completely automated.

“Yesterday LASIK was a surgical procedure performed by the surgeon, while today LASIK is a surgical procedure performed predominantly by the laser machine! Likewise, yesterday phaco was a surgical procedure performed by the surgeon while today we have a partial reduction of the surgeon’s involvement and a new surgical assistant appears: the laser technician.

However, phacoemulsification is still required,” he said.

Briefly discussing the indications for femtosecond laser-assisted cataract surgery, he said a fully dilated pupil is needed (≥ 6.0mm) as is a relatively clear cornea.

This form of surgery is not without difficulties, Dr Buratto said. Docking may be uncomfortable in small eyes and conjunctival redness may occur. Capsulotomy diameter can only be set to the extent the pupil dilates.

When the laser is delivered too close to the iris it can stimulate miosis.

One must also exercise caution when learning the laser technique and may need to make slight adjustments to phaco technique intraoperatively.

Overall however, Dr Buratto maintained the advantages far outweigh the negatives.

contact

Lucio Buratto – office@buratto.com

Cataract Surgery Will Change in a Femtosecond.

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Delivering the accuracy of a femtosecond laser to Refractive Cataract Surgery, the LenSx® Laser is designed to predictably perform many of the most challenging aspects of traditional cataract surgery. Creating highly reproducible capsulotomy, lens fragmentation and all corneal incisions with image-guided surgeon control, Alcon’s LenSx® Laser is Putting the Future in Motion.

To learn more about LenSx® Laser technology for Laser Refractive Cataract Surgery, visit lensxlasers.com.

© 2011 Novartis

12/11

LSX11500S0V-D EU

30

Update

Cataract & refractive

IOL PRE-WARMING

IOL pre-warming may be easy fix for safe injection of high-power IOLs

1

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3

4

5

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1. Microcrack of the optic surface of a 26.0 D IOL, stored at room temperature prior to injection; 2. Microcrack and microscratches of the optic surface of a 27.0 D IOL, stored at room temperature prior to injection; 3. Microscratches and debris of the optic surface of a 28.5 D IOL, stored at room temperature prior to injection; 4. No abnormalities of the optic surface were found of a 29.5 D IOL, stored at room temperature prior to injection; 5. No abnormalities of the optic surface were found of a 26.0 D IOL, warmed prior to injection; 6. Microcrack and microscratches of the optic surface of a 27.0 D IOL, warmed prior to injection; 7. No abnormalities of the optic surface were found of a 28.5 D IOL, warmed prior to injection; 8. No abnormalities of the optic surface were found of a 29.5 D IOL, warmed prior to injection

P

re-injection IOL warming may be a simple solution for enabling high-power foldable lenses to be safely delivered using a cartridge injector system designed for microincision cataract surgery, according to research presented by investigators from New York University School of Medicine at the annual meeting of the Association for Research in Vision and Ophthalmology.

Jonathan B Kahn MD and Jack M Dodick MD, reported the findings from a small feasibility study in which they evaluated the IOL optic for surface damage after lens delivery using the Monarch III handpiece and D cartridge (Alcon Laboratories), designed for use with a 2.2mm incision.

Pre-warming lens They assessed four pairs of single-piece acrylic multifocal IOLs (AcrySof IQ ReSTOR SN6AD3, Alcon) with powers of 26.0, 27.0, 28.5, and 29.5 D. One lens of each pair was pre-warmed in a 45º C water bath for 10 minutes and the other lens was injected after being taken from storage at 23º C. The temperature for pre-warming represents the manufacturer’s recommended maximum temperature for lens storage.

The cartridges were filled with viscoelastic prior to IOL loading, and the lenses were rinsed thoroughly with balanced salt solution after they were delivered.

Photomicrographs taken from light microscopy inspection revealed abnormalities of the optic surface on four IOLs, of which three were in the control group (26.0, 27.0 and 28.5 D) and one was pre-warmed (27.0 D). The findings included debris, microscratches, and/or microcracks.

“Phacoemulsification has advanced from a larger incision procedure to microincision surgery using a 2.2mm incision, and IOL delivery systems have been introduced that can preserve the advantage of the microincision.

EUROTIMES | Volume 17 | Issue 9

However, according to the manufacturer, use of the D cartridge should be limited to single-piece AcrySof IOLs with powers up to 27.0 D,” said Dr Dodick.

“We are encouraged by the findings from this study and hope to continue our research with a larger investigation in order to determine more definitively if IOL pre-warming can allow the advantages of small cartridges for high powered lenses. There is value for any incremental advance in cataract surgery, and we think lens warming may offer an incremental improvement in insertion technique.”

Dr Kahn, senior resident, Department of Ophthalmology, New York University School of Medicine, noted that the multifocal IOLs were used in this study because they were provided as samples by the manufacturer. However, in addition to investigating larger numbers of IOLs, a future study might also be done with monofocal IOLs. Dr Dodick said he came up with the idea of lens prewarming by extrapolating from his experience using warming as a technique to facilitate IOL folding.

“When IOLs were being inserted using folders, a lens that was fairly rigid at room temperature would develop a gummy bear-like consistency and become more pliable and easier to fold if it was warmed by placing it on top of the steriliser,” he explained.

Dr Dodick reasoned that if a potential for optic surface damage was related to contact between the lens and the cartridge, the risk could be mitigated by warming the lens to modify its pliability.

contacts Jack Dodick – jackdodick@aol.com Jonathan B Kahn – jonathankahn@alumni.upenn.edu

Courtesy of Jonathan B Kahn MD and Jack M Dodick MD

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33

Update

Cataract & refractive

NEW IOL DESIGNS

Still no perfect IOL but the latest developments are bringing notable improvements

by Priscilla Lynch in Dublin

I

OL designs are continuing to improve with exciting developments in improving accommodation but there is still no ‘perfect’ lens available to surgeons, Rajesh Aggarwal MD, FRCOphth told the joint Irish and UKISCRS refractive surgery meeting.

Dr Aggarwal, consultant ophthalmic surgeon, Southend University Hospital, UK discussed the latest developments in the IOL market. “Ideally as we all know the ideal lens is the crystalline lens of a 21-year-old.

At present we have nothing that can come anywhere near it.”

However, he acknowledged there is a lot of innovation going on in IOL designs. The crystalline lens is now much better understood, as are the theories of accommodation, which Dr Aggarwal said is helping with new designs. Surgical techniques are also continuing to improve.

“In future for example with femtolaser, things are going to get even more predictable and that’s allowing for new development and better IOL designs.”

The four key issues new IOLs are trying to address are astigmatism, presbyopia, capsular bag transparency and higher order aberrations Dr Aggarwal said if there is rotational instability of the IOL, then a surgeon can almost forget trying to correct astigmatism with IOLs. Thankfully the newer toric IOLs are very stable and do not show the rotation that the previous IOLs used to, he noted.

To tackle astigmatism Dr Aggarwal said most would agree that it is possible to reduce surgically induced astigmatism by keeping the incision below 2.0mm for implantable IOLs. Another interesting development is the attempt to manipulate higher order aberrations to actually mimic accommodation he said.

Presbyopia is one of the biggest drivers of IOL design improvement, and the current premium multifocal IOLs give very good near and distance vision, but poor intermediate vision, he reported. This is now being addressed by trifocal IOLs. There are also issues with dysphotopsia, especially night vision, and reduced contrast sensitivity.

The accommodative IOLs do not have issues with dysphotopsia at night or contrast, but near vision and the accommodative range is poor, according to Dr Aggarwal.

EUROTIMES | Volume 17 | Issue 9

Multifocals Dr Aggarwal said that the four most commonly used multifocal IOLs all have particular positive attributes, but indicated a preference overall for the MPlus (Topcon) lens, partly due to its better night vision results. “The other intriguing advance has been the tri-focal lens. When first this was mentioned to me I thought here we go, we are going to get more problems and I was a bit reluctant… but to my surprise it (Fine Vision Trifocal IOL) has become my standard of multifocal lens now.”

He said this lens gives very good distance, reading and intermediate vision.

Summarising, Dr Aggarwal said the newer multifocal IOLs have a better range of focus, reduced light loss, better contrast sensitivity profile, reduced dysphotopsia and better patient acceptance “But they are still not perfect and they never will be perfect in my opinion because you are introducing abnormalities by having more than one focus within that lens, so I think the way forward has to be accommodative lenses – if we can get them to accommodate.”

Accommodative lenses There remains a question as to whether the current accommodative lenses are truly accommodative or if it is pseudo accommodation, Dr Aggarwal remarked, saying that in his opinion single accommodative lenses do not accommodate well. He said dual optic accommodative IOLs give good results but have issues with delivering emmetropia.

Research has shown that high accommodative amplitudes can be achieved by lens curvature changes and experiments with new lenses using that approach are yielding good results.

He also briefly discussed LiquiLens and Fluid Vision lens, which he said show some progress, while he expressed excitement at the development of light adjustable lenses and the SmartIOL. Concluding, Dr Aggarwal said patient needs are key to choosing the right lens but the newer lenses coming on stream will mean more flexibility, and better results and choice.

contact Rajesh Aggarwal – rajesh@r-aggarwal.co.uk

Saturday, 8 September

Latest Trends in Surgical and Medical Retina Red Rooms 1 and 2 - Milan Conference Centre 10:00 - 11:00 (refreshments will be provided) Moderator: Albert J. Augustin, Germany Faculty: Dr. Carl Claes, Belgium Dr. Stanislao Rizzo, Italy Dr. Adnan Tufail, UK Hear from distinguished faculty as they present the latest trends and technology in vitreoretinal equipment and disposables, as well as the latest developments in the pharmaceutical treatment of retinal disorders.

http://www.euretina.org/milan2012/satellites.asp

Sunday, 9 September Innovations in Cataract and Refractive Surgery Auditorium di Milano 18:15 - 19:00 – Registration 19:00 - 20:00 – Symposium 20:00 - 21:00 – Reception Transportation provided from MiCo to the Auditorium di Milano.

Moderators: Dr. Rudy Nuijts, Netherlands Prof. Dr. Theo Seiler, Switzerland Faculty: Dr. Francesco Carones, Italy Dr. Robert Cionni, USA Prof. Dr. Michael C. Knorz, Germany

Sunday, 9 September

Learn from top industry opinion leaders as they share their experiences with the newest Alcon cataract and refractive technologies featuring the AcrySof® IQ ReSTOR® family of Multifocal and Multifocal Toric IOLs as well as the WaveLight® Refractive Suite and LenSx® Laser systems.

Space 1 – Milan Conference Centre

Monday, 10 September

New Value Proposition in Cataract and Refractive Surgery: Femtosecond Laser and Advanced Technology IOLs 13:00 - 14:00 (lunch boxes will be provided) Moderator: Dr. Robert Cionni, USA Faculty: Dr. Philippe Crozafon, France Dr. Kjell G. Gundersen, Norway Prof. Dr. Michael C. Knorz, Germany Prof. John Kanellopoulos, Greece Discover what’s new in cataract and refractive surgery featuring femtosecond laser cataract surgery using the LenSx® Laser as well as the AcrySof® IQ ReSTOR® family of Multifocal and Multifocal Toric IOLs.

Sunday, 9 September

Advancements in the Diagnosis and Treatment of Dry Eye

Improving Predictability and Outcomes: Innovations in Glaucoma and Cataract Surgery Space 1 – Milan Conference Centre 13:00 - 14:00 (lunch boxes will be provided) Moderator: Dr. Khiun Tjia, Netherlands Faculty: Dr. Christer Johansson, Sweden Prof. Marco Nardi, Italy Dr. Gangolf Sauder, Germany Prof. Daniele Tognetto, Italy Join experts in cataract and glaucoma surgery as they share their experience and techniques using the latest Alcon® technologies featuring the INFINITI® Vision System with OZil® Intelligent Phaco (IP), INTREPID® AutoSert® IOL Injector and the EX-PRESS® Glaucoma Filtration Device in a combined cataract/glaucoma surgery.

Space 2 – Milan Conference Centre 13:00 - 14:00 (lunch boxes will be provided) Moderator: Dr. James P. McCulley, USA Faculty: Dr. Stephen S. Lane, USA Dr. Stefano Barabino, Italy Join experts in the field as they discuss the differential diagnosis, treatment, and therapeutic options in the Management of Dry Eye and associated Ocular Surface Disease.

Meet the Experts Do not miss the Meet the Experts forum, where you can hear presentations showcasing the latest technologies in ophthalmology. Visit Alcon booth #S134.

This event is for healthcare professionals only. Please present your EURETINA/ESCRS badge for entry into the meeting.

For important safety information about the Alcon products discussed in these programs, please visit Alcon booth #N227 at EURETINA or Alcon booth #S134 at ESCRS. © 2012 Novartis

EUROTIMES

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8-12 September, 2012 | Milan, Italy Join us for these important symposia during the 12th EURETINA Congress and the XXX Congress of the ESCRS in Milan.

Saturday, 8 September

Surgical Faculty

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Live Surgery:

Advancements in Surgical Techniques and Technologies Gold Hall – Milan Conference Centre 18:00 - 18:30 – Registration and light refreshments 18:30 - 20:30 – Live Surgery Telecast in High Definition from the Azienda Ospedaliera Fatebenefratelli e Oftalmico

Dr. Lucio Buratto Host Surgeon Italy

Dr. Donald N. Serafano Moderator USA

Prof. Dr. Michael C. Knorz Germany

Mr. David Allen United Kingdom

Dr. Antonio Scialdone Italy

Dr. Francesco Carones Italy

Dr. Mehmet Söyler Turkey

Dr. Richard Mackool USA

Host Surgeon: Dr. Lucio Buratto, Italy Moderator: Dr. Donald N. Serafano, USA Register now to learn from world-acclaimed surgeons demonstrating their techniques using the latest Alcon® technologies in cataract surgery.

Featured technologies include: - The Alcon® LenSx® Laser - INFINITI® Vision System with OZil® IP Intelligent Phaco (IP) - INTREPID® AutoSert® IOL Injector - AcrySof® IQ ReSTOR® family of Multifocal and Multifocal Toric IOLs

Dr. Rudy Nuijts Netherlands

Dr. Robert H. Osher USA

Register Now! http://www.escrs.org/alconsatellites

36

Update

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EUROTIMES | Volume 17 | Issue 9

CORNEA

high accuracy

Femtosecond laser shows great versatility in its first decade of use in corneal surgery

by Roibeard O’hEineachain in Prague

A

s femtosecond laser technology evolves, so do the ways in which the lasers are used in corneal surgery, according to George Kymionis MD, University of Crete, Heraklion, Crete, Greece.

“Every day we discover a new application of this technology in corneal surgery.

Femtosecond lasers significantly improve the efficacy and safety of corneal surgery,” he told the 16th ESCRS Winter Meeting.

Since the earliest models came onto the market in 2001, the femtosecond laser has provided an improvement in the safety of LASIK procedures, he said. By enabling the more accurate creation of LASIK flaps, the laser reduces the complications that can arise when the flap is too thick or too thin, he noted. Over the years, the femtosecond laser has rapidly expanded its profile from being a high-tech microkeratome to becoming a precision scalpel, which can in many cases outperform the traditional tools used in corneal surgery, he said.

Some of the surgical tasks for which it has proved its utility include the creation of tunnels in the corneal stroma for the placement of intracorneal ring segments, creating pockets for placement of intracorneal inlays, and performing astigmatic keratotomies, Dr Kymionis said.

Expertise enhanced Dr Kymionis noted that femtosecond laser technology affords a level of accuracy that is in some cases unattainable by even the most experienced surgeon using conventional tools and manual techniques. The way it provides such accuracy is through the delivery of very high amounts of energy in very short pulses, he added.

To illustrate his point he described several short cases where the femtosecond laser had achieved an accuracy far surpassing that which had previously been possible.

One case was a patient undergoing implantation of intracorneal ring segments.

He programmed the femtosecond laser to create tunnels for the ring segments at a depth of 400 microns. Postoperative anterior segment OCT showed that the tunnels were at a depth of 417 microns.

“I don’t think even the best surgeon can achieve this kind of result with a mechanical device, and accuracy in the depth of INTACS implantation means better results.”

Custom-fit keratoplasty One of the most exciting uses of the femtosecond laser is in the creation of perfectly matching donor buttons and recipient corneas in lamellar and penetrating keratoplasty procedures, Dr Kymionis said.

“The potential advantages of this technology in keratoplasty is the earlier wound healing, faster visual rehabilitation and the ability to customise the patterns of corneal transplantation according to the recipient disease.”

In penetrating keratoplasty procedures, the precision side-cuts which the femtosecond laser provides can help reduce the amount of tissue removed from the recipient’s cornea. For example, using a “mushroom” side-cut profile in eyes with anterior corneal scarring will preserve more of the recipient’s endothelium, and using the “top hat” side-cut profile in eyes with endothelial disease will preserve more of the recipient’s stroma.

In a separate presentation by Dr Kymionis, a case study was presented which showed how the femtosecond laser can be used to help improve the delivery of antimicrobial agents to diseased corneas.

This case involved a 71-year-old woman who presented with red eye, mucopurulent discharge, photophobia, blurred vision and pain. She was referred because of recurrent episodes of keratitis and corneal abscess non-responsive to antibiotic therapy and surface keratectomy. Her corrected distant visual acuity in the affected eye was finger counting. Slit-lamp examination revealed corneal infiltrate, severe neovascularisation, corneal oedema with Descemet’s membrane folds and anterior chamber reaction.

Dr Kymionis and his associates therefore decided to try using the femtosecond laser to create a channel through which to deliver antifungal therapy directly into the region of the corneal abscess.

The investigators saw an improvement in the clinical condition of the eye at slit lamp examination by the fifth day of followup. At six months follow-up the patients’ eye remains in a stable condition with a corrected distance visual acuity of 20/100.

contact George Kymionis – kymionis@med.uoc.gr

37

Update

CORNEA

THERE’S O N LY ONE

ACANTHAMOEBA

Case study shows unusual acanthamoeba infection highly resistant to usual treatments

by Roibeard O’hEineachain in Prague

P

ainless acanthamoeba keratitis can bring about a rapid loss of vision and can prove very resistant to therapy, according to Emiliano Ghinelli MD, who presented a case study at the Cornea Day session of the 16th ESCRS Winter Meeting.

The case involved a young man who wore contact lenses and whose visual acuity suddenly decreased to counting fingers over the course of a few days. The affected eye had minimal anterior epithelial debris, very mild limbus inflammation, no Tyndall effect, and no pain, said Dr Ghinelli MD, Ospedale Civile di Volta Mantovana, Volta Montavana, Italy.

“We didn't know it was acanthamoeba at first, but since this case we have collected reports of similar cases. This guy was really young and he was a pizza maker so this gave him a history of thermal exposure. It was a very sudden onset he went to counting fingers in just a few days,” he said The early management of the case consisted of topical wide spectrum antibiotics, topical non-steroidal anti-inflammatory drugs, topical cycloplaegics, topical antiamoebic drugs. Dr Ghinelli and his associates also performed a double-layer amniotic membrane transplant on the ocular surface In addition, they took bacterial and fungal cultures from the eye and performed PCR testing on scraped epithelial debris to check for the possible presence of herpes simplex virus and acanthamoeba.

During the first 10 days after the amniotic membrane transplant, the eye seemed to respond pretty well, becoming less inflamed and stabilising in terms of most disease parameters, Dr Ghinelli said. However, after that period the eye returned to the condition it was at presentation, he added.

Dr Ghinelli and his associates then performed a conjunctival graft, which quickly became perforated, necessitating the performance of a penetrating graft.

Despite the presence of major anterior chamber inflammation and major anterior uveitis, and a procedure which involved the removal of fibrin from the angle and some additional difficult manoeuvres, the eye looked fairly good during the first three postoperative months, Dr Ghinelli said.

“We’re creating a database of all the painless cases of acanthamoeba keratitis that resemble this case, and incredibly, there are an increasing number of cases of acanthamoeba in our area that all look like this” However, graft rejection occurred at the third month of follow-up, followed by corneal melting a month later. He added that they have since washed out the conjunctiva of any of the toxicity from the anti-amoebic agents and are administering wide spectrum antibiotics, systemic steroids, and systemic voriconazole.

They are also contemplating performing a penetrating keratoplasty with the PCR-testing of the rejected graft. They may also perform collagen cross-linking as an antimicrobial treatment while continuing with the systemic steroid and voriconazole regimen.

He noted that some authors have reported good results with systemic voriconazole in the treatment of chronic stromal acanthamoeba keratitis. The concentrations used in those reports is 200mg once or twice daily for three months, always monitoring kidney and liver function.

“We’re creating a database of all the painless cases of acanthamoeba keratitis that resemble this case, and incredibly, there are an increasing number of cases of acanthamoeba in our area that all look like this,” Dr Ghinelli added.

contact Emiliano Ghinelli – info@emilianoghinelli.com

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Don’t Miss EUREQUO update, see page 63 EUROTIMES | Volume 17 | Issue 9

MK-966 Rev A_There's Only One.indd 1

5/30/12 8:54 PM

contacts

Update

CORNEA

EARLY DETECTION

Does additional data from Scheimpflug outweigh proven Placido algorithms?

by Howard Larkin in Orlando

I

dentifying forme fruste keratoconus is essential to avoid ectasia after laser refractive surgery. But which is more effective – Scheimpflug corneal tomography, with its ability to image the posterior cornea and measure corneal thickness, or Placido topography, with its proven diagnostic algorithms and greater sensitivity to minute anterior corneal curvature abnormalities?

Strong cases can be made for either, though combining topographic and pachymetric data may be more useful, according to presenters at Refractive Surgery Day at the annual meeting of the American Academy of Ophthalmology.

Arguing for the superiority of Scheimpflug tomography, Michael W Belin MD, of the University of Arizona, Tucson, US, acknowledged that computer-based keratoscopes using Placido technology introduced by Stephen D Klyce PhD in 1984 were a monumental advance in corneal imaging. But he noted Placido imaging provides data only on the anterior corneal surface. While it can detect very subtle changes in corneal steepening, keratoconus also involves corneal thinning which may not be evident on the anterior surface.

“It’s time we look below the surface to see the true extent of the pathology,” Dr Belin said.

Scheimpflug tomography does this by providing not only a complete white-to-white elevation map of the anterior corneal surface, but also of the posterior corneal surface, as well as a pachymetric map of the entire cornea and a 3-D image of the anterior chamber. This allows diagnosis of subclinical keratoconus, which Dr Belin defines as a patient with normal or near normal corrected visual acuity, normal slit lamp findings and normal anterior contour, but abnormal posterior surface and abnormal pachymetric progression.

Courtesy of Michael W Belin MD

38

Patient with normal anterior curvature and a normal ultrasound pachymetry of 527. If all you are using are Placido topography and ultrasound pachymetry, this patient would be screened as ‘normal’

Dr Belin suggested that the term “subclinical keratoconus” may be more useful than “forme fruste” because it clearly distinguishes patients with actual keratoconus from keratoconus suspects. He defines suspects as those with normal corrected visual acuity and slit lamp combined with asymmetric anterior curvature that is orthogonal in the principal meridians, normal or borderline posterior surface, and borderline pachymetric progression.

The utility of posterior corneal surface mapping in detecting subclinical keratoconus was demonstrated by a 2010 study that used Scheimpflug tomography to examine 25 fellow eyes found to be topographically normal using Placido imaging in patients with so-called unilateral keratoconus.

From the Archive Retinal pigment epithelial tears reported after anti-VEGF treatment

By Cheryl Guttman in Fort Lauderdale

E

nthusiasm for the potential therapeutic benefits of anti-VEGF agents in the management of exudative age-related macular degeneration should be tempered with caution, following reports of treatment-associated retinal pigment epithelial (RPE) tears, say researchers.

Several research groups reported cases of RPE tears in patients treated with intravitreal bevacizumab (Avastin) or ranibizumab (Lucentis) at the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO).

Sunir J Garg MD and colleagues presented findings from a retrospective review of eyes treated with intravitreal bevacizumab for exudative AMD. They found 16 cases of retinal tears of which 15 occurred in eyes previously naive to any treatment for exudative AMD. * From EuroTimes Volume 12 Issue 9 September 2007

EUROTIMES | Volume 17 | Issue 9

Michael Belin – MWBelin@aol.com Stephen Klyce – sklyce@klyce.com

When analysed using the Belin/Ambrosio deviation index, 24 of the 25 eyes, or 96 per cent, showed tomographic abnormalities (Ambrosio R Jr et al. 2010 AAO/ISRS).

“These were not suspects; these patients had keratoconus.”

Diagnosing early keratoconus requires looking for what changes first, Dr Belin argued. His research suggests this is often the posterior surface, elevation at the thinnest point, pachymetric progression graphs and relational thickness, with anterior curvature changes often a late finding (Belin MW et al. Am J Ophthalmol 2011; 152(2): 157-162).

“Often, normal anterior curvature combines with abnormal posterior curvature,” Dr Belin said. And Scheimpflug tomography is clearly better able to detect it than Placido, he concluded.

Placido offers proven sensitivity Arguing that Placido topography is more accurate for spotting forme fruste keratoconus, Dr Klyce, of the Mount Sinai School of Medicine, New York City, US, disputed that the first signs of keratoconus appear at the posterior corneal surface.

“This is patently false. Typically, corneas that develop ectasia don’t have abnormal posterior surfaces preoperatively. Check it in your own records.”

Rather, the most reliable sign of early keratoconus is localised steepening of the anterior corneal surface, Dr Klyce said. And because Placido topography is based on analysing displacement of reflected mires, which amplify any surface irregularities, it is 20 times more sensitive to curvature changes than elevation maps produced by corneal tomography. When properly used with modern, evidence-based algorithms, it is much more reliable in detecting and correctly interpreting minute surface changes, he said.

Dr Klyce addressed several potential criticisms of Placido imaging. The central “hole” of about 0.4mm in the Placido image does not necessarily result in an unmeasured area, in part because the patient’s eye moves during the procedure.

If there is any doubt, a couple of additional photos can eliminate any blind spots.

Dr Klyce discounted the potential for false positives due to asymmetric bow tie patterns produced by misaligning the Placido discs off the visual axis.

“Two decades ago we developed algorithms to detect this. This issue currently is not valid in topography.”

If anything, the low precision of tomography is more likely to produce a misleading anterior curvature map. He showed several samples to demonstrate this.

The possibility that highly aberrated or post-transplant corneas might break-up the reflected mires enough to make a map impossible also is not a problem, Dr Klyce said.

“If we are looking for very subtle changes in corneal topography, an almost smooth surface with a little inferior steepening, this is not an issue.”

Dr Klyce also pointed out that Placido tomography is a mature diagnostic technology proven over decades, and even has standards documented by the American National Standards Institute and the International Standards Organization. He allowed that Placido imaging does not supply pachymetry readings, and that slit data is combined to provide it on some current systems. And pachymetry is an essential part of the screening procedure for refractive surgical candidates. But because of its superior sensitivity and established record “there is no better alternative for the accurate detection of forme fruste keratoconus than Placido disk topography.”

39

Update

CORNEA

cross-linking

Epithelium-conserving collagen cross-linking technique better for patients’ recovery

REACHING NEW HEIGHTS IN CORNEAL CROSS-LINKING

by Roibeard O’hEineachain in Dublin

A

Courtesy of Sheraz Daya MD, FACP, FACS, FRCS(Ed)

new technique for facilitating the passage of riboflavin into the cornea through the epithelium in collagen cross-linking procedures appears to be effective in the treatment of keratoconus and causes less pain and allows faster recovery than the conventional epithelial debridement approach, Patrick Condon FRCS, Waterford, Ireland, told a conference of the Irish College of Ophthalmologists.

The new approach to the application of riboflavin to the cornea is called the epithelial disruption technique.

It involves first making numerous small perforations in the epithelium with a device designed by Sheraz Daya MD, FACP, FACS, FRCS(Ed). That allows the riboflavin to penetrate into the cornea at a very high dosage, Dr Condon said.

After applying the riboflavin for 45 minutes, he and his associates check at the slit lamp to make sure that the penetration of the agent is complete, he said. They then expose the cornea to ultraviolet light with a variable aperture for up to 30 minutes and then place a bandage contact lens on the cornea which is removed after 48 hours, Dr Condon noted.

“In summary, we feel that the epithelial disruption technique is an effective technique for crosslinking, gives a faster recovery, less pain, less discomfort...”

Patrick Condon FRCS

“Riboflavin is a large molecule which doesn't penetrate the epithelium very well, so the traditional method of performing corneal collagen cross-linking has been to remove the epithelium completely. To reduce the amount of pain that patients experience, Roberto Pinelli in Italy has devised a transepithelial approach using mixtures of different kinds of riboflavin to enhance the passage of riboflavin into the cornea. However, Dr Daya and I have been using an epithelial disruption technique for several years,” Dr Condon said.

He presented a retrospective study with up to four years of follow-up involving 111 consecutive eyes of 72 keratoconus patients who underwent collagen cross-linking with the epithelial disruption technique. The patients included those treated by Dr Condon and his associates in Waterford and those treated by Dr Daya’s team at the Centre for Sight in London over a four-year period.

He noted that there was a general improvement in uncorrected and best-corrected visual acuity and astigmatism, and there were no instances of persistent epithelial defects, infectious keratitis or sterile infiltrates. In addition, although patients reported pain, it was significantly less than that associated with removal of epithelium, Dr Condon said.

Furthermore, the mean spherical equivalent refraction improved from a preoperative value of around -4.0 D to -2.0 D at a year’s follow-up, indicating a flattening of the cornea postoperatively. Similarly, the mean refractive astigmatism improved from -4.0 D preoperatively to -3.0 D during the first postoperative year.

He noted that a common side effect of the treatment is a line of anterior corneal haze, visible under the slit-lamp and

by OCT imaging, which persists for about a month or two postoperatively. In this particular series it occurred in 61 per cent of eyes, he added.

“In summary, we feel that the epithelial disruption technique is an effective technique for cross-linking, gives a faster recovery, less pain, less discomfort, and there is not much of a change in the mean K or steep K readings after two years. There is a tendency to improve in both the uncorrected and the best corrected visual acuity and we feel that further long-term analysis is required,” Dr Condon concluded.

contacts Patrick Condon – pcond@eircom.net Sheraz Daya – sdaya@centreforsight.com

EUROTIMES | Volume 17 | Issue 9

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Update

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CORNEA

SURGISTAR CORNEAL PRODUCTS

SCREENING

Hyperosmolarity in pre-op dry eye LASIK patients results in reduced UCVA

by Cheryl Guttman Krader in Fort Lauderdale

EUROTIMES | Volume 17 | Issue 9

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reoperative measurement of tear film hyperosmolarity appears to be a useful tool for identifying individuals at risk for a suboptimal visual outcome after LASIK and who might especially benefit from intensive therapy for dry eye disease, said David C Eldridge OD, at the 2012 annual meeting of the Association for Research in Vision and Ophthalmology.

Dr Eldridge, vice-president of clinical affairs, TearLab Corporation, reported findings from a post hoc analysis of data collected in a prospective, multicentre study in which 128 patients (256 eyes) undergoing bilateral-sequential VisX® wavefront-guided LASIK with Intralase® flaps were randomised to three days of preoperative QID use of an ocular lubricant (Blink® Tears, AMO) or no pre-treatment.

Eight highly experienced LASIK surgeons performed the procedures using the same technology, but their own standard medication regimen. However, all patients used the ocular lubricant QID for one month after surgery. All surgeons were masked to the osmolarity measurement throughout the three-month period.

To determine if tear osmolarity measured before starting any ocular lubricant treatment using a point-of-care osmometer (TearLab Osmolarity System) predicted postoperative visual acuity outcomes, patients were divided into hyperosmolar (≥308 mOsml/L; n = 48) and normal (<308 mOsml/L; n = 81) groups. The results showed the normal osmolarity group had a statistically significant better outcome.

At three months after surgery, mean UCVA in the right and left eyes of hyperosmolar patients was 20/26 and 20/28, respectively, compared with 20/19 for both eyes in patients with normal osmolarity.

Mean BCVA in the hyperosmolarity patients was about 20/19 for both eyes and not significantly different from the mean BCVA in the normal group, he reported.

“The importance of maximising tear film stability preoperatively to improve outcomes after laser vision correction surgery has been realised for some time. It is particularly important in patients undergoing a customised ablation to assure capture of an accurate wavefront that will guide the laser ablation. Preferably, we would be able to identify at-risk hyperosmolar

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David C Eldridge OD patients preoperatively and target them with interventions for modifying their risk factor rather than using a shotgun approach that treats all patients with the same standard regimen. Our findings suggest that surgeons should measure tear osmolarity before surgery to identify patients with dry eye disease.”

Dr Eldridge added that data collected in the study are also consistent with information reported in the 2007 Report of the International Dry Eye Workshop showing that tear film osmolarity has a higher positive predictive value for detecting dry eye disease than any other conventionally used diagnostic tests.

Ocular surface staining was also performed preoperatively, but was a very insensitive indicator of dry eye as the average score in hyperosmolar patients was just 0.2 on a scale of zero to four, he explained.

UCVA data were also measured at one month after surgery, when required four times/day postoperative ocular lubricant use had just ended, and the means were 20/20 in both eyes of hyperosmolar patients and 20/20 and 20/19 for the patients with normal preoperative tear osmolarity.

“The divergence in visual acuity outcomes between the normal and hyperosmolar patients in the interval from one to three months suggests that in selected at-risk (hyperosmolar) patients, it may be important to maintain dry eye therapy for an extended period of time,” Dr Eldridge said.

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Update

CORNEA

DRY-EYE TESTS

The Surgeon’s Edge

Disposable Ophthalmic Products

Four diagnostic technologies to watch in the next five years

by Howard Larkin in Chicago

R

ecent technologies make possible precise measurement of many clinical characteristics of dry eye, moving closer to objective diagnosis of this ocular condition. Presenters at the 2012 ASCRS Cornea Society Cornea Day highlighted four that they believe could become primary diagnostic tests within five years.

Ocular surface interferometer According to the International Workshop on Meibomian Gland Dysfunction (MGD), MGD may be the leading cause of dry eye disease throughout the world (Nichols et al. Invest Ophthalmol Vis Sci 2011; 52(4):1922-1929), said Richard S Davidson MD, of the University of Colorado, US. A study in press of one clinic found that 86 per cent of dry-eye cases involved lipid deficiency compared with 14 per cent aqueous deficiency, he added. Decreased lipid secretions associated with MGD increase tear evaporation by four to 16 times, leading to decreased aqueous layer thickness, unstable tear film and dry eye symptoms, Dr Davidson noted. But in up to half of cases, MGD is not obvious from visual examination, though expressing the glands often can reveal non-obvious MGD, which may appear as thick, non-liquid lipid secretions.

The ocular surface interferometer provides a means to precisely measure tear film thickness and quantify lipid levels in the tear film. This enables not only objective initial diagnosis of MGD, but also tracking progression and treatment response, Dr Davidson said. Using images collected in a non-contact 20-second scan, the device calculates interferometric colour unit statistics on a frameby-frame basis, processing about one billion data points.

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Osmolarity test Hyperosmolarity, which often results from excessive tear evaporation disrupting normal ion concentrations, is a common finding across all forms of dry eye diseases, said Reza Dana MD, MPH, MSc, of Harvard Medical School, Boston, US. Increased osmolarity also has been shown to cause ocular surface epithelial cell death by initiating apoptosis cascade, cause inflammation and up-regulate inflammatory cytokines.

Osmolarity can easily be measured using the hand-held TearLab device, which collects a minute quantity of tear from the ocular surface and instantly tests it, and is much less cumbersome than traditional corneal staining or Schirmer strip tests, Dr Dana said.

In tests, osmolarity also correlates more closely with dry eye severity than staining or Schirmer tests, with an R² coefficient of 0.5538 for osmolarity compared with 0.4339 for staining and 0.1698 for Schirmer (Sullivan B et al. IOVS 2010). However, a retrospective study of 378 subjects at Harvard showed that osmolarity did not correlate well with corneal staining or symptom change in response to therapy, and osmolarity was highly variable whether symptoms improved or worsened, Dr Dana said.

“Tear film osmolarity is an easy-to-use, standardised test that can be very helpful in the diagnosis of dry eye disease, especially in the mild-to-moderate range. It has, however,

some limitations in predicting changes in symptoms and corneal staining in response to therapy,” Dr Dana said.

MMP-9 inflammatory marker Because it detects an important chemical marker of inflammation in distressed epithelial cells, whether inflammation is visible or not, a test for metalloproteinase 9, or MMP-9, may help objectively identify dry eyes, said Stephen Kaufman MD, PhD, of the University of Minnesota, Minneapolis, US. “It is a tool to help diagnose dry eye disease in patients who do not demonstrate the classic clinical findings of the condition.”

Many studies have described the association of MMP-9 with dry eye, Dr Kaufman noted. A new clinical device from Rapid Pathogen Screening that draws a small quantity of tear fluid allows detection of this compound, which is expressed in the presence of ocular inflammation. A company test showed the system has 92 per cent specificity and 87 per cent sensitivity, much higher than existing diagnostic tests. The test is positive when it detects more than 40 ng/mL MMP-9 in tear fluid. This makes it sensitive enough to detect MMP-9 even in dilute tears. However, in early dry eye the test may not be positive if no inflammation has developed.

Elevated MMP-9 levels indicate a patient may respond to anti-inflammatory treatments, such as corticosteroids, cyclosporine and doxycycline, Dr Kaufman said. The device also could be useful in assessing dry eye treatment.

High-resolution OCT Because the eye is available for inspection, imaging the ocular surface may be the easiest way to make a diagnosis, said Victor L Perez MD, of the University of Miami School of Medicine. He presented an ultra-high resolution optical coherence device operating at 840 nm central wavelength capable of 3.0 micron resolution at 24 frames per second. This allows quantitative and qualitative assessment of epithelium thickness, and tear film integrity and break-up. Dr Perez and colleagues observed that the corneal epithelium is bumpy, and has coined a term called the epithelial irregularity factor (EIF), which is defined as the standard deviation of epithelial thickness in the central 3.0mm of the cornea. Preliminary data suggests the EIF correlates with subjective dry eye symptoms (r=0.88), and with corneal fluorescein staining (r=0.55).

Once we optimise and validate the measure we hope the EIF may help identify dry eye patients. We also have noted in very preliminary data that EIF values decline in response to treatment, he noted, leading to the possibility that the EIF may be used to monitor patient response to therapy.

“EIF could be a novel qualitative and quantitative criterion for diagnosing and follow-up of dry eye,” Dr Perez said. He predicted that in five years it could be an objective indicator of the clinical symptoms of dry eye patients.

contacts Richard Davidson – richard.davidson@ucdenver.edu Reza Dana – reza_dana@meei.harvard.edu Stephen Kaufman – sck@umn.edu Victor Perez – vperez4@med.miami.edu

43

Update

CORNEA

YOU CAN HAVE...

corneal COMPLICATIONS

When keratoplasty is necessary, match the graft to the patient

by Roibeard O’hEineachain in Prague

T

he best type of keratoplasty to use for treating an eye with corneal complications following refractive surgery depends on the type of complication, said Jose Güell MD, Autonoma University of Barcelona, Barcelona, Spain, in a keynote lecture at the 16th ESCRS Winter Meeting’s cornea day.

“The logical approach, when you must consider keratoplasty, is to take out only the layers there that are diseased,” he added.

The techniques a corneal surgeon might use in such cases range from a simple epitheliectomy – with or without the use of amniotic membrane – to a deep anterior lamellar keratoplasty (DALK) or a full thickness keratoplasty procedure. In some cases where the only damage is to the endothelium, a posterior lamellar keratoplasty procedure may be indicated, he said. However, the efficacy of each technique is not entirely clear since the amount of published studies on the topic is sparse, he added.

Both corneal and lenticular refractive surgery approaches have the potential to cause damage to the cornea.

Complications of corneal refractive surgery that require keratoplasty can include flap complications, corneal scars and ectasia. The main complication of intraocular surgery is persistent endothelial cell loss, such as can occur with anterior chamber phakik IOLs. Dr Güell noted that there are only a few refractive surgery complications where he would currently recommend superficial anterior lamellar keratoplasty. They include those cases where there is an anterior opacity with a low degree of topographic irregularity, since using a microkeratome for such procedures will not correct any such irregularities but mimic the irregular surface. Another indication for a superficial approach is any abnormality restricted to the LASIK flap, in which case he would recommend a lenticule substitution, he said.

He noted that in a series of 12 eyes of 10 patients in whom he performed superior anterior lamellar keratoplasty with a microkeratome to treat complications after corneal refractive surgery, there was a mean reduction in best corrected visual acuity in about 50 per cent of the cases, although in 85 per cent of the cases uncorrected visual acuity improved.

The post-keratoplasty complications included one case of epithelial rejection, which resolved with topical steroids, and one case of lamellar keratitis which resolved with topical steroids and antibiotics. “We had a number of cases with the residual hyperopia and astigmatism resulting in a low best spectacle corrected visual acuity. That is possibly because using this technique will leave some degree of anterior lamellar irregular corneal irregularity,” he added.

DALK most widely applicable Dr Güell noted that DALK is his preferred technique for the majority of cases of corneal refractive surgery complications that require keratoplasty.

“Dissection at Descemet’s or 75 microns pre-Descemet’s EUROTIMES | Volume 17 | Issue 9

“

The logical approach, when you must consider keratoplasty, is to take out only the layers there that are diseased Jose Güell MD

is my procedure of choice when keratoplasty is indicated and the endothelium is healthy, because we preserve the endothelium and visual quality and acuity are the same as with penetrating keratoplasty [PKP]. The endothelial cell loss is also much less with DALK as is the number of rejection episodes,” he said.

The main contraindications to DALK are eyes where the health of the endothelium is in doubt and eyes with very thin, previously perforated corneas. The most common complications after DALK are perioperative perforation – with reported incidences ranging from zero to 17 per cent – and the formation of a double anterior chamber between the Descemet’s membrane and the endothelium after the surgery.

“Sometimes you're not aware of the perforation until the part Descemet’s dissection is being performed, but we all need to be aware that in very thin postoperative corneas the rate of perforations is higher. The result is that sometimes we will have a double anterior chamber, although most of the cases are solved with time and/or the injection of air/gas in the anterior chamber.

He added that injecting viscoelastic material directly rather than air beneath the stroma when performing the dissection with the “big-bubble” technique can reduce the chance of perforation and anterior chamber perforation because it is a slower and more easily controlled process. It also provides superior visualisation of the process, he said.

Dr Güell recommended restricting the use of PKP to those refractive surgery patients whose complications damage the stroma and also damage or obscure the endothelium to a point where its status cannot be confirmed.

Finally, Dr Güell noted that endothelial complications of refractive surgery have become more common in recent years because of problems with some models of anterior chamber phakic IOLs (angle supported). In such cases he said that he prefers DMEK rather than DSAEK in order to provide optimum visual outcome. In patients older than 55 years, simultaneous refractive lens exchange can enhance patient satisfaction in such cases, he added.

contact Jose Güell – guell@imo.es

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44

Update

CORNEA

new advances

Pros and cons of tissue targeted corneal replacement versus full thickness keratoplasty

by Priscilla Lynch in Dublin

T

argeted tissue replacement has come of age and deep anterior lamellar keratoplasty (DALK) is slowly becoming a preferred procedure for some corneal surgeons, according to George J Florakis MD, clinical professor of ophthalmology, Columbia University, New York.

Speaking at the joint Irish and UKISCRS refractive surgery meeting, Dr Florakis discussed the pros and cons of tissue targeted corneal replacement versus full thickness keratoplasty, and traced the development of the latest procedures.

Corneal transplants He noted that corneal transplants are still the most common corneal operation. In the US alone 38,000 are carried out annually, despite the decrease in recent years due to improvements in cataract surgery.

“For several decades full thickness corneal transplantation has been the treatment of choice for decreased vision due to various corneal pathologies but that is changing and more and more patients are getting targeted tissue replacements.”

At the 2010 Paton Society Luncheon, about 200 corneal surgeons unofficially surveyed reported that full penetrating keratoplasties (PKPs) had dropped to 30 per cent or 40 per cent of their transplants – in some cases less than 10 per cent, he said.

The indications for corneal transplantation are changing. In the 1980s, 80 per cent of corneal transplants were for pseudophakic bullous keratopathy, while nowadays, Fuchs' dystrophy and keratoconus have risen in terms of the percentage of transplants done, partly because the threshold for doing a transplant has now lowered, Dr Florakis commented.

Another major development has been the advancement of eye banks.

Discussing the latest tissue targeted techniques, Dr Florakis said the goal of endothelial keratoplasty is the preservation of normal stroma and the surface, resulting in quicker rehabilitation, less astigmatism and fewer suture-related problems, and less rejection. With DALK the goal is to leave a healthy Descemet’s membrane and the endothelium intact and only replace the stroma (as well as Bowman’s and epithelium), eliminating endothelial rejection. Lamellar keratoplasty selectively EUROTIMES | Volume 17 | Issue 9

replaces abnormal corneal tissue while preserving normal host tissue.

In endothelial keratoplasty the posterior corneal layers are replaced, therefore eliminating the problems of PKP (corneal sutures, corneal surface incisions, (fewer) rejections, wound instability, etc). It also offers a faster recovery time.

Deep Lamellar Endothelial Keratoplasty (DLEK) replaces the endothelium through a limbal, scleral pocket incision that leaves the surface of the recipient cornea untouched.

It initially seemed like a great procedure, said Dr Florakis. However, despite training, not many surgeons carry out the procedure and it has been mostly abandoned. “There are a couple of reasons for that. First of all there were some interface irregularities.

Secondly it is very technically difficult, with a significant learning curve,” he said.

The next major advance, which he claimed propelled endothelial keratoplasty, was Descemet’s stripping automated endothelial keratoplasty (DSAEK).

“This eliminated all the manual procedures and that’s when endothelial keratoplasty really took off,” he said, adding that DSAEK is much faster to perform than PKP and especially DLEK. “Not only that, the recovery time is even shorter. So as opposed to a year or so for visual recovery after a transplant from PKP, or six months for DLEK, it is down to two or three months for a DSAEK procedure.”

The benefits of DSAEKs are similar to that of DLEK but also include faster visual recovery. “I’m going to venture to say that endothelial keratoplasty is now the standard of care for endothelial dysfunction,” he said.

Returning to DALK, he said as well as having less risk of rejection, it theoretically increases the donor pool as good donor endothelium is not required and longer preservation intervals are possible. So what is holding it back? Initially results were perhaps poorer than a traditional PK, it is more technically difficult, takes longer and is therefore most costly, and visual outcomes can sometimes be poor and if it is not successful, it is donor wasteful, he said.

“However, it has many advantages over PKP and as time goes on it will be accepted more,” he concluded.

contact George J Florakis – gjf2@columbia.edu

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46

Update

CORNEA

DSAEK GRAFTS

Vision improves quite quickly after DSAEK with notable improvement after one month

Courtesy of William Power MD, FRCOphth

by Priscilla Lynch in Dublin

D

SAEK (Descemet’s stripping automated endothelial keratoplasty) grafts are demonstrating good visual results and long-term survival rates despite high endothelial cell count loss, according to William Power MD, FRCOphth, Royal Victoria Eye and Ear Hospital (RVEEH), Dublin.

DSAEK has been performed for more than five years, meaning surgeons have access to medium-term outcomes data.

It is a superior option to penetrating keratoplasty (PKP), he told the Joint Irish and UKISCRS refractive surgery meeting.

Listing the advantages of using DSAEK, Dr Power said it provides stable refraction and a quick visual rehabilitation, intact innervation, a stronger wound, retention of corneal integrity, no suture-related complications and less problems with ocular surface healing. Additionally, two grafts can be obtained from one donor cornea.

Vision improves quite quickly after DSAEK with notable improvement after one month Dr Power said, quoting a study of 16 of his original DSAEK patients with four-tofive-years of follow-up.

“After three months most patients are experiencing a significant improvement so you are getting a very quick recovery in terms of vision. Between one and three months most patients achieve their new level of vision and maintain a fairly stable level following that. This is a huge advantage to the patient,” he explained, adding these results are very different from what is usually seen with PKP. Dr Power highlighted potential severe complications of PKP such as suture EUROTIMES | Volume 17 | Issue 9

Four clear DSEK grafts with very differing cell counts. Top left cell count 1750 cells/mm2, top right 1370 cells/mm2, bottom right 985 cells/ mm2, bottom left 590 cells/mm2

problems, endophthalmitis and expulsive haemorrhage. “Certainly every two to three years in our institution we would see a ruptured graft from some sort of accidental trauma. And of course these things are avoided by DSAEK.” He said while the disadvantages of DSAEK “aren’t major” there is an increased primary failure, “which can be very frustrating especially after what seemed like a very smooth procedure”. There can also be issues with donor dislocation, interface haze and of course there remains question marks over long-term graft survival.

Without doubt there is significant cell loss in the initial period following DSAEK, ranging from 25 per cent to 45 per cent in our study. “Thus a very important point is that you give the patients as many cells as you can,” Dr Power said.

For example, using a 9.0mm graft compared to an 8.0mm one means there is a 27 per cent increase in total cell count delivered to the patient, he said.

“What has surprised a lot of people is that so many of the grafts are clear but if we do cell counts it seems to be quite low. We may be able to keep these grafts clear with a smaller number of healthy cells in the presence of a more normal intact Descemet’s membrane. Cell loss is highest in the first three to six months but it plateaus out then. The key is to minimise the cell loss in the operative period and if you can do that then the long-term survival of grafts should be good,” Dr Power told EuroTimes.

contact William Power – ivisionltd@gmail.com

47

Update

CORNEA

New imaging techniques shed light on ocular surface pathology

by Dermot McGrath in Abu Dhabi

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The HRT Rostock Cornea Module gives us high-resolution, fully digital images of the entire ocular surface

Corneal Topography

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Courtesy of Christophe Baudouin MD, PhD

Christophe Baudouin MD, PhD

con ato Ker ection Det

EUROTIMES | Volume 17 | Issue 9

at

A

dvances in imaging technology are opening up whole new perspectives for clinicians in terms of identifying and tracking pathologies of the ocular surface, according to Christophe Baudouin MD, PhD. “The latest generation in vivo confocal microscopy provides a non-invasive means of studying the ocular surface at the cellular level. With this technology, normal or metaplastic epithelial cells, inflammatory infiltrates or goblet cells can be identified without requiring more invasive techniques for cell collection. Such in vivo imaging gives us a promising way to investigate ocular surface involvement in complex diseases and may provide new insights into corneal and conjunctival disorders in the future,” he told delegates attending the World Ophthalmology Congress.

Dr Baudouin, professor and chairman of ophthalmology at the Quinze-Vingts National Ophthalmology Hospital, Paris, noted that while confocal microscopy is not a new technique and has been used for corneal examinations since the early 1990s, the real breakthrough has been in terms of the resolution and quality of images achieved with the latest-generation Heidelberg Retina Tomograph (HRT) Rostock Cornea Module.

“The earlier systems were expensive and were difficult to handle and use. The resolution was quite poor so they were only useful for more superficial or peripheral structures. By contrast the HRT Rostock Cornea Module gives us high-resolution, fully digital images of the entire ocular surface. The technique is also painless and minimally invasive,” he said.

Dr Baudouin said that the HRT has a wide range of potentially useful applications to view corneal structure and pathology. As well as helping to differentiate bacterial, viral, parasitic and fungal infections, it can also be used to help image LASIK flaps, filtering blebs and to count endothelial cells for postsurgical follow-up.

To illustrate its utility in a clinical setting, Dr Baudouin discussed a number of case studies where the HRT helped to make a differential diagnosis or to assess the effectiveness of particular treatments.

“It is very useful in inflammatory conditions of the ocular surface because it can give us information that was only available before using corneal biopsy, which

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may be difficult to obtain in ocular surface disease,” he said.

In studies carried out by Dr Baudouin, confocal microscopy images of the corneal epithelium revealed significant changes in dry eye syndrome, limbal stem cell deficiency and chronic inflammatory impairment.

The images also enabled clinicians to follow different cases of acute alterations of corneal epithelium.

Looking to the future, Dr Baudouin said that further improvements can be expected in the resolution and quality of in vivo images obtained by the next generation of confocal microscopes. However, he noted that while the technical advances are all very well and good, they must also be accompanied by parallel progress in terms of image interpretation if clinicians are to be able to fully exploit the potential of this technology to help their patients.

“We will need to be able to understand and interpret the new information we are obtaining from these images and this process will take some time,” he said.

Dr Baudouin has no financial interest in the technology mentioned in his presentation.

contact Christophe Baudouin – baudouin@quinze-vingts.fr

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CORNEA

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newly developed non-invasive mobile meibography device performs similarly to an existing non-contact meibography system for imaging meibomian glands, but is more versatile and affordable for clinical use, said Reiko Arita MD, PhD, at the annual meeting of the Association for Research in Vision and Ophthalmology.

In 2008, Dr Arita, Department of Ophthalmology, University of Tokyo School of Medicine, Japan, and colleagues reported on their development of a non-invasive meibography system that used an infrared CCD video camera and an infrared filter equipped with a slit lamp (BG-4M, Topcon).

While the invention was an advance over conventional meibography in allowing in-office assessment of meibomian gland morphology, as a next step, Dr Arita and co-workers aimed to develop a portable device that could be used to examine patients of all ages, including infants, and in inpatients as well as outpatients.

The mobile device they created is referred to as the “meibom pen” because of its penshaped appearance. It measures 29mm wide by 150mm long, weighs 120gm, and is powered by two “AA” batteries. It has an infrared LED 940nm light source, a highly sensitive (400nm-1200nm) complementary metal oxide semiconductor image camera, and can be connected to any commercially available monitor using a video jack. Images are digitally recorded and captured using a footswitch; still photos are obtained by pressing on the left pedal and videos can be recorded by stepping on the right pedal.

In order to assess the performance of the meibom pen, a study was conducted comparing the quality and quantity of its images with those obtained using the original non-contact meibography system. The study included 20 normal eyes of healthy subjects, 17 contact lens wearers with dryness, 14 patients with allergic conjunctivitis, and 23 patients with meibomian gland dysfunction.

The images were processed using noise reduction, edge detection and binarization by enhancing the white and black portions and analysed for structural findings and the meibomian gland area.

The qualitative findings were similar with both devices and consistent with those from previous studies using the non-contact meibography system. With both devices, the

The meibom pen

Courtesy of Reiko Arita MD, PhD

For cataract and other ophthalmic surgeries

The upper meibomian glands. A 28-year-old man wears DSCL for 14 years with allergic conjunctivas. Dark area means the lost area of meibomian glands. Distortion and the shortening of meibomian glands were also observed

meibomian glands in the healthy volunteers appeared as hyperilluminated, long straight and grape-like clusters of individual acini.

In 11 of 17 eyes of the contact lens wearers, images from both technologies showed shortening of the meibomian glands, and with both devices, duct distortions were evident in six of 14 eyes of patients with allergic conjunctivitis. With both systems meibomian gland dropout, dilation and shortening was observed in all eyes of patients with meibomian gland dysfunction.

In all four subgroups as well, quantitatively analysed meibomian gland area was similar with the two techniques for both the upper and lower eyelids.

“Meibomian gland dysfunction is recognised as a major cause of dry eye syndrome and the availability of the noncontact meibography system has been a breakthrough in diagnosing dry eye,” said Dr Arita. “The new meibom pen may look like a toy, but our study shows that it performs just as well as the non-contact meibography system. We expect this mobile pen-shaped meibography system will be widely adopted and that its use will contribute to elucidate the pathologic mechanisms of meibomian gland disease.”

contact Reiko Arita – ritoh@za2.so-net.ne.jp

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50

Update

GLAUCOMA

ULTRASOUND

High-intensity ultrasound device shows promise for effective cyclodestruction

by Dermot McGrath in Abu Dhabi

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new device that uses highintensity ultrasound for targeted cyclodestruction of the ciliary body shows promise as a safe and effective means of lowering intraocular pressure (IOP) in refractory glaucoma, according to a study presented at the World Ophthalmology Congress.

“This technique, known as UC3, which stands for ultrasound circular cyclocoagulation, seems to be an effective and well-tolerated method to reduce IOP in patients with refractory glaucoma, although naturally we need longer follow-up to confirm these promising initial results,” said Philippe Denis MD, Hôpital de la Croix Rousse, Lyon, France.

Prof Denis noted that the conventional clinical treatment for advanced refractory glaucoma using diode laser trans-scleral cyclophotocoagulation works by partially destroying ciliary body processes and reducing production of aqueous humour and IOP. “The currently used techniques for cyclodestruction are effective in terms of lowering IOP, but they are also associated with a high risk of complications including hypotony, inflammation and irreversible visual loss,” he said.

The first commercial FDA-approved high-intensity focused ultrasound (HIFU) system (Sonocare) has been used since the 1980s to treat refractory glaucoma,

said Dr Denis, but the device’s popularity has been hindered by its bulky design, the complexity and duration of the procedure and complications associated with its use.

To overcome these drawbacks, the EyeOP1 device (EyeTechCare) uses miniature piezoelectric transducers for noninvasive treatment that can be administered on an outpatient basis under local anaesthesia, said Prof Denis.

The EyeOP1 system contains a command module that enables the ophthalmologist to set parameters for the procedure and to control the procedure throughout the treatment period. The command module is connected to the therapy device which is a sterile disposable part placed on the patient’s eye.

The major feature of UC3 treatment is the fact that it is circular and extremely accurate, said Prof Denis. The practitioner can administer treatment to the whole periphery of the globe of the eye in a single procedure, therefore avoiding the many applications that are usually needed. The system can also produce partial coagulation of the ciliary body by perfectly controlling the process, positioning the device simply, accurately and reproducibly.

“The machine features a powerful ultrasound generator with six cylindrical transducers in order to produce six lesions with accurate positioning on the target

and focalised on a linear segment. The transducers deliver energy to the eye with a specifically made aspiration system. Due to the high transducer operating frequency of 21 MHz, we obtain a highly focused, reproducible coagulation which preserves tissue barriers and reduces postoperative inflammation,” he said.

Preclinical studies of the device in albino rabbits observed no issues in terms of safety, said Prof Denis. “There were no problems in terms of local tolerance, no conjunctival burns, no scleral perforation, no cataract, and we obtained very nice IOP reduction of up to 55 per cent in some cases. And this effect was durable after three months.”

Positive results Results from the first pilot study evaluating the safety and efficacy of the device in patients with refractory glaucoma were similarly positive, said Prof Denis. In the prospective, non-comparative, interventional clinical study, 12 eyes of 12 patients with glaucoma and uncontrolled IOP were treated using the EyeOP1 device.

Patients were divided into two groups: group one in which patients received a three second spot duration, and group two in which the spot duration was four seconds.

In group one, IOP was reduced from a mean preoperative value of 35.6 mmHg to a mean postoperative value of 27.9 mmHg at day one, 29.6 mmHg at one week, 27.3 mmHg at one month and 27.0 mmHg at six months. In group two, IOP was reduced from a mean preoperative value of 39.1 mmHg to 26.9 mmHg at day one, 23.0 mmHg at one week, 24.2 mmHg at one month and 25.4 mmHg at six months.

“These patients had very high mean preoperative IOP and we observed that IOP reduction was up to 33 per cent from baseline IOP in group one and up to 45 per cent from baseline in group two,” he said.

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Philippe Denis – philippe.denis@chu-lyon.fr

“

There were no problems in terms of local tolerance, no conjunctival burns, no scleral perforation, no cataract, and we obtained very nice IOP reduction of up to 55 per cent in some cases Philippe Denis MD

No major intraoperative or postoperative complications occurred, said Dr Denis.

Superficial punctate keratitis was reported in three patients and central superficial corneal ulceration in one patient, but these were all treated successfully and all of these patients presented with a preoperative pathological condition of the cornea.

Prof Denis also noted that UBM imagery demonstrated localised and reproducible cystic involution of the ciliary body in eight of the 12 eyes, with no damage to the surrounding ocular tissues and a suprachoroidal fluid space in six of the 12 eyes.

Summing up, Prof Denis said that ultrasound circular cyclo-coagulation is an effective and well tolerated method to reduce IOP in patients with refractory glaucoma. “We now want to extend these results to less advanced glaucoma cases and to that end we have just begun a multicentre clinical trial in nine centres in France, and a European multicentre study is scheduled to begin in the fourth quarter of 2012,” he concluded.

51

Update

Fechtner

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Main outflow route Dr Castillejos noted that the trabecular pathway represents the main outflow route of the eye, accounting for 50 per cent to 90 per cent of the total aqueous humour flow depending on the age of the individual.

“The main site of resistance in this pressure-dependent pathway is found between the juxta-canalicular meshwork and the inner wall of Schlemm’s Canal. The question of whether the changes in Schlemm’s Canal morphology related to glaucoma differ from those solely occurring from ageing is a long-standing controversy,” he said.

Dr Castillejos added that most of the data currently available on the anatomy and physiology of the outflow pathways is based on animal models or mathematical calculations. “The anatomy and physiology of the collector channels and the intrascleral vascular plexus remain incompletely understood, partly because we do not have a reliable imaging method able to accurately evaluate this portion of the eye. Recent evidence from animal models suggests the possibility of other areas of resistance along this pathway,” he said.

Dr Castillejos said that much of the research of his group has been derived from an enhanced imaging technique based on spectral domain anterior segment OCT. He described a technique to improve OCT imaging of the microstructures comprising the outflow pathways during his training years at the New York Eye and Ear Infirmary.

“The OCT Enhanced Imaging Method (EIM) approach is used to capture high-resolution images of Schlemm’s Canal and collector channel junctions. The selected eye is imaged in adduction fixating on a target located at 15cm with the temporal limbus positioned perpendicular to the OCT beam. We then perform radial and tangential scans of EUROTIMES | Volume 17 | Issue 9

Courtesy of Alfredo R Castillejos MD

mages of the anatomy of trabecular pathway structures including Schlemm’s Canal can now be visualised and objectively measured using high- resolution spectral domain OCT, a technique which may help to shed light on the role of the aqueous outflow system in primary open angle glaucoma (POAG), according to Alfredo R Castillejos MD. Addressing delegates attending the World Ophthalmology Congress, Dr Castillejos, associate professor of ophthalmology at Nuestra Senora de la Luz Hospital in Mexico City and director of the Pan-American Eye Centre, Mexico City, said that advances in imaging technology are bringing researchers closer to answering some fundamental questions concerning aqueous outflow of the human eye.

“Many of these are key questions that have remained unanswered for almost 100 years. At this point in time we actually do not know how the aqueous humour drains, nor do we know what routes the aqueous humour follows in normal and pathological conditions. We also have much to learn about the morphological and physiological changes that occur with age as well as the anatomical changes related to POAG,” he said.

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the same collector channel and Schlemm’s Canal junctions after which an automated software is used to reconstruct the images of the structures along their entire course,” he said.

“We know that there is variability in the dimensions of the trabecular pathway structures even in age-matched subjects with normal eyes and normal IOP. However, it is not known if individuals with a functioning, yet smaller Schlemm’s Canal, may reach the endpoint in which trabecular flow is severely restricted in a shorter period of time as compared with those with normal or above normal-sized structures,” he said.

In terms of the risk factors for POAG, Dr Castillejos said his team carried out a study to establish whether reduced Schlemm’s Canal dimensions might be associated with decreased aqueous outflow. “In the near future, we will be able to evaluate and detect specific sites of aqueous outflow resistance and hopefully we will be able to perform individualised glaucoma surgery by selecting the most beneficial procedure for each patient,” he said.

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ood preparation, with the necessary tools at hand, is key to reducing the risk of complications during cataract surgery in patients with pseudoexfoliation, said Raimo Uusitalo MD, Finland.

“It has been reported that pseudoexfoliation increases the complication rate following cataract surgery by three to tenfold. But it has also been reported that with proper care and management this increase in complications is much reduced,” Dr Uusitalo told the 16th ESCRS Winter Meeting.

Pseudoexfoliation is an age-related disease characterised by the production of extracellular material from in the eye’s anterior segment, he noted. The prevalence of the condition varies from country to country and from region to region, from 0.5 per cent to nearly 40 per cent.

In Finland, the incidence of pseudoexfoliation among patients presenting for cataract surgery is about 25 per cent to 35 per cent, depending on the region, he added. The problems that pseudoexfoliation can bring to patients undergoing cataract surgery include a high postoperative spike in intraocular pressure, an unstable anterior chamber, weakened zonules, a disrupted endothelial function and macular oedema, Dr Uusitalo said.

The most obvious clinical sign of pseudoexfoliation is the presence of pseudoexfoliative material on the anterior capsule and the iris margin. In addition, the iris often becomes translucent at its margins. The pseudoexfoliative material will be present in less plainly visible places.

However, the amount of pseudoexfoliative material deposition is not in itself predictive of the amount of additional difficulty that a cataract procedure will involve, Dr Uusitalo said.

The presence of capsular glaucoma, on the other hand, is an almost sure sign that the patient will be more prone to postoperative IOP spikes and cystoid macular oedema. Preoperative broad fluctuations of IOP in general can presage poor postoperative pressure control.

Stabilising IOP as much as possible may reduce such complications, he said.

Pseudoexfoliation affects the iris in a number of ways, he said. For instance, the iris bleeds more easily because of increased

vascularisation, and the pseudoexfoliation material obstructs the mydriasis of the iris, making the dilatation of the pupil more difficult. Nonetheless, surgeons should take all measures necessary to achieve adequate pupil dilatation in order to allow for a fairly wide capsulorrhexis.

Dr Uusitalo noted that his usual practice is to first enlarge the pupil as much as possible with maximal medical intervention, with preoperative application of topical phenylephrine and lidocaine. If pupil dilatation is still insufficient he then moves on to the injection of a cohesive OVD and then to iris retractors and lastly to the performance of a sphincterotomy.

“I think it’s crucial to make the capsulorrhexis a bit larger than normal, 5.5 even to 6.0mm always making sure to keep the capsulorrhexis a bit smaller than the diameter of the IOL’s optic,” Dr Uusitalo added.

Zonules that are already loose preoperatively are another source of trouble in eyes with pseudoexfoliation, he noted.

Dr Uusitalo said that a weakened zonule makes an implanted IOL more prone to decentration, which usually occurs soon after surgery but can sometimes occur years later. He added that to avoid unnecessary risks he generally does not perform bilateral cataract surgery in patients with pseudoexfoliation.

Treatment decisions The presence of pseudoexfoliation can have a bearing on many aspects of phacoemulsification procedure. He noted, for example, that he prefers to use a bimanual technique in such eyes because it seems to result in a more stable anterior chamber and less stress on intraocular structures.

He added that in eyes with weak zonules he finds that lifting the nucleus up with an OVD and then performing the chopping can improve the safety of the procedure.

Capsular tension rings and iris retractors can be useful in cases where the capsular complex has become too unstable, he said.

“All in all, I think that pseudoexfoliation is like snow in winter. You get more of it up north, but if you see it and equip yourself accordingly, you do just fine,” he concluded.

contact Raimo Uusitalo – raimo.uusitalo@kolumbus.fi

Update

LOWERING IOP

“

A

EUROTIMES | Volume 17 | Issue 9

wound leak, flat anterior chamber, haemorrhage, hyphaema, and infection occur at a rate of between 50 per cent to 57 per cent in these two studies. In all, visually significant complications occurred at a rate of between 15 and 27 per cent,” he said.

Focusing on the Trabectome, Dr Rhee explained that it was developed by George Baerveldt MD at the University of California and received FDA approval in 2004. The handpiece of the device incorporates a variable power bipolar microsurgical pulse with simultaneous irrigation and aspiration, which allows for ablation and removal of the trabecular meshwork, unroofing Schlemm’s canal and exposing the natural drainage pathway of the eye to aqueous humour.

“What we are doing is ablating the tissue to create a direct communication between the anterior chamber and collecting channels. It is performed through a temporal clear corneal incision, and we ablate between 60 and 150 degrees of nasal trabecular meshwork,” he said.

Douglas J Rhee MD

Intraoperative and intraocular image of the Trabectome device after ablation of the trabecular meshwork

the sample attrition is well beyond what we would expect from a usual study,” he said.

Another study published in January 2012 by Jea et al. comparing ab interno trabeculectomy with conventional trabeculectomy found a much lower success rate for Trabectome compared to conventional trabeculectomy. The trabeculectomy success rate was 85 per cent at one year and 76 per cent at two years, compared to 46 per cent at one year and 22 per cent at two years for the Trabectome.

Dr Rhee said that the findings did not invalidate the hypothesis of Chandler and Grant, that the trabecular meshwork is directly implicated in POAG. “If we look at the initial one-month,

Lowering IOP In terms of clinical performance, Dr Rhee said that the device has limited effectiveness at lowering IOP. “Don Minckler MD published his first series of 37 patients in 2005 and he reported a reduction in mean pressure from approximately 28 mmHg preoperatively down to about 16 mmHg at six months' follow-up,” he said.

A further study by Minckler et al. which looked at 738 patients treated with Trabectome only and 366 patients with combined Trabectome-phacoemulsification surgeries reported a decrease in IOP among Trabectome-only cases with or without medications of 40 per cent at 24 months and 32 per cent at 60 months. Failure, defined as additional glaucoma surgery, was reported in 100 of 738 Trabectome-only cases (14 per cent), which is a relatively low failure rate, noted Dr Rhee.

While the success rates reported in the study are impressive at first glance, Dr Rhee said that closer inspection of the data raises some important concerns. “In general when you are doing a clinical study you do not want to lose more than 10 per cent to 15 per cent of the sample per year. In this study, we see the Trabectome group of 738 A.R.C. Laser GmbH patients reduced to 260 at six months, 102 Bessemerstraße 14 D-90411 Nürnberg at 12 months and just 46 at 24 months, so Germany

three-month, six-month data, the Trabectome success rate is excellent, so there is every reason to believe that the trabecular meshwork is the site of resistance.

However, the reason the procedure is failing is probably due to wound healing issues,” he said.

Dr Rhee added that initial data from a study presented at ARVO in 2010 indicated that phacoemulsification in combination with Trabectome offered a similar IOP-lowering effect and decrease in anti-glaucoma medication use as phacoemulsification combined with trabeculectomy. The failure rate of both groups was also similar.

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Our own clinical experience and the available studies suggest that the Trabectome is an elegant and safe anterior segment procedure for POAG

Trabectome may work best in combined phacoemulsification procedures b interno trabeculectomy performed with the Trabectome (NeoMedix Corp) appears to offer a safe and straightforward method of lowering intraocular pressure (IOP) in primary open-angle glaucoma (POAG) compared to conventional trabeculectomy, Douglas J Rhee MD told delegates attending the World Ophthalmology Congress.

“Our own clinical experience and the available studies suggest that the Trabectome is an elegant and safe anterior segment procedure for POAG. However, it does have limited effectiveness as an individual procedure, so the ideal clinical scenario might be to use it combined with cataract surgery,” he added.

Dr Rhee, associate professor, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, US, said that the basic concept of the Trabectome is to ablate and remove a strip of trabecular meshwork in order to re-establish access to the eye’s natural drainage pathway.

He noted that targeting the trabecular meshwork makes perfect sense bearing in mind the pathophysiology of POAG. “It has been known since the time of Chandler and Grant in 1958 that the cause of the elevated IOP that we see in POAG is at the level of the trabecular meshwork and it is not a problem of aqueous, hypersecretion or altered uveoscleral outflow. Traditional procedures such as trabeculectomy and tube shunt surgery both rely on creating a transscleral pathway by making a full thickness hole through the sclera, resulting in a direct communication between the anterior chamber and subconjunctival space to create a filtration bleb,” he said.

While targeting the trabecular meshwork is not a new concept, the difference with the Trabectome lies in its minimally invasive approach and reduced complication rate, said Dr Rhee. “We have some very good data from randomised controlled clinical trials concerning the complication rates with conventional trabeculectomy.

The Collaborative Initial Glaucoma Treatment Study (CIGTS) and Tube Versus Trabeculectomy (TVT) Study reported intraoperative complications at a rate of about 10 per cent. During the perioperative period complications such as hypotony,

53

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54

Update

RETINA

CATT and IVAN results

New RCT data show similar functional outcomes with all regimens, but prompts further study of possible safety difference

by Cheryl Guttman in Fort Lauderdale

A

special session held during the 2012 annual meeting of the Association for Research in Vision and Ophthalmology featured investigators reporting outcomes from two years of follow-up in the Comparison of Age-related Macular Degeneration Treatments Trials (CATT) and from an interim analysis after one year in the two-year Inhibition of VEGF in Age-related Choroidal Neovascularisation (IVAN) study.

Findings from both studies showed visual acuity outcomes in patients with exudative AMD are similar whether they receive intravitreal anti-VEGF treatment with ranibizumab (Lucentis, Genentech) or bevacizumab (Avastin, Genentech).

In CATT and in an analysis pooling data from both studies, the rate of serious systemic adverse events was higher for bevacizumab than ranibizumab. However, the interpretation of the latter difference is uncertain for now as is the clinical relevance of small, but statistically significant differences identified between drugs and dosing regimens in various functional and morphological endpoints.

Daniel F Martin MD, study chair for CATT and chairman, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, US, noted the new data will help clinicians and their patients make informed treatment decisions. He said that based on the outcomes of CATT, clinicians can proceed with confidence using either anti-VEGF agent. Deciding between the monthly dosing and as needed regimens may involve more of a discussion, he told EuroTimes.

Dr Martin explained, “There was more gain in visual acuity with monthly administration, but the difference was small, only 2.4 letters, and required giving 10 more injections over the course of two years. Furthermore, looking at broader metrics of visual acuity, there was not much difference between dosing groups. However, it’s clear from the two-year outcomes that if the decision is made to use the monthly regimen, it needs to be continuous.”

Dr Martin was referring to the aspect of the study designed to determine the impact of switching to as-needed treatment after one year of regular monthly injections.

Investigation of this issue was based on the idea that CNV histology may have been EUROTIMES | Volume 17 | Issue 9

altered after 12 months of continuous VEGF suppression.

“However, we found that the lesions are not dormant. Patients switched to a prn regimen after one year of continuous treatment had visual and anatomical results that were similar to the patients receiving prn treatment all along,” Dr Martin said.

Usha Chakravarthy MD, PhD, chief investigator, IVAN, and professor of ophthalmology and vision sciences, Queen’s University of Belfast, Ireland, told EuroTimes that, interestingly, in the IVAN trial there was no difference in visual acuity at one year between the continuous and prn dosing regimens. “Furthermore, the equivalence of the prn regimen, which required three monthly injections, and continuous dosing regimens was achieved with a very similar number of injections in the first year as observed in the CATT trial,” she said.

Morphological differences In analyses of morphological endpoints for CATT, the percentage of patients with no fluid on OCT was higher with monthly dosing and highest with monthly ranibizumab, but monthly dosing was also associated with a higher rate of geographic atrophy development and the rate was highest with monthly ranibizumab.

In IVAN, there were no between-drug differences in the morphological measures assessed, but compared with continuously treated eyes, eyes treated as needed for reactivation had a greater total lesion thickness and a higher proportion showed leakage on fluorescein angiogram.

“CATT and IVAN have provided a wealth of knowledge on the complex relationships between function and morphology in patients with exudative AMD. However,

“

Concern remains with respect to the serious systemic adverse events, and we are looking in greater detail into the possible mechanisms that might explain the difference

Usha Chakravarthy MD, PhD the clinical importance of the regimenrelated morphological differences observed in IVAN at one year is unclear given the negligible differences between groups in visual function,” said Dr Chakravarthy.

One year earlier, results from the primary endpoint analysis after one year in CATT showed a statistically significant higher risk (1.3-fold) of serious adverse events among patients treated with bevacizumab compared with ranibizumab. The difference persisted at two years, but there was no statistically significant difference between drugs in rates of death or arteriothrombotic events (ATEs).

In IVAN at one year, there was no statistically significant difference between drugs in the proportion of patients having serious systemic adverse events, albeit such events were higher among bevacizumabtreated patients. However, there was a statistically significant difference between drugs in the rate of arteriothrombotic events or heart failure (ATEs), with an excess of ATEs among ranibizumab-treated patients.

Dr Chakravarthy said the safety findings

CATT initially randomised 1,185 patients enrolled at 43 US centres into one of four treatment groups to receive ranibizumab 0.5mg or bevacizumab 1.25 monthly or prn.

A total of 1,107 patients were followed through year two, but at one year, which was the primary endpoint, patients in the monthly groups were re-randomised to continue monthly treatment or switch to prn.

The IVAN study randomised 610 patients at 23 sites in England and Northern Ireland and also compared ranibizumab 0.5mg and bevacizumab 1.25mg monthly or as needed.

Patients assigned to prn treatment received three monthly injections initially and whenever re-treatment became indicated based on structured criteria. In CATT, initial treatment and re-treatment for prn patients was with a single injection.

Usha Chakravarthy – u.chakravarthy@qub.ac.uk Daniel F Martin – martind5@ccf.org

are generally reassuring, and noted that in an analysis combining the one-year data for IVAN and CATT, the signal observed in IVAN for ATEs disappeared because it was in opposite directions for IVAN and CATT. However, the signal for more SAEs with bevacizumab persisted in the combined analysis because it was in the same direction in both trials (even though not statistically significant in the IVAN trial separately).

“Concern remains with respect to the serious systemic adverse events, and we are looking in greater detail into the possible mechanisms that might explain the difference,” she said.

The CATT investigators also undertook further analyses to try to understand if the higher risk of serious systemic adverse events with bevacizumab is true. Curiously, there was a higher risk with prn versus monthly treatment, and dissecting deeper into the data, they found most of the excess events associated with bevacizumab were not previously reported in oncological trials where patients had systemic bevacizumab exposure. “The differences between drugs in CATT are very nonspecific and diffuse.

They may be due to chance, perhaps there is some unidentified imbalance between groups at baseline that we did not adjust for, or the difference could be something meaningful. We are still trying to sort that out,” said Dr Martin.

Dr Chakravarthy began her presentation by noting that determining the relative effects of the two drugs and two regimens is important in the context that bevacizumab is much cheaper than ranibizumab and because fewer treatments with prn treatment is safer and helps keep costs down, particularly when using ranibizumab.

Cost analyses she presented, which included costs for medication, administration, monitoring and the costs of serious expected adverse events (hospitalisations and treatment of these events), showed a range from £9656 per patient per year for ranibizumab monthly to £1509 for as needed bevacizumab.

These estimates were calculated explicitly in the context of the economic evaluation and did not include value-added tax, Dr Chakravarthy noted.

Dr Martin also reported cost data, noting cost was a pre-specified secondary outcome for CATT but never drove the study, and he put the per-patient difference into a larger perspective.

“Extrapolating to the 220,000 AMD patients treated annually, there is a US$ 5bn difference between ranibizumab monthly and either bevacizumab group and a difference of $3bn comparing prn ranibizumab and the bevacizumab regimens,” he said.

Update

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RETINA

®

DIABETES

Findings from a 30-year Finnish study contain mixed news

by Cheryl Guttman Krader in Fort Lauderdale

A

EUROTIMES | Volume 17 | Issue 9

“

This study showed that visual impairment due to PDR was less severe in the past 20 years than it was in the 1980s

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Courtesy of Hannu Uusitalo MD, PhD

n analysis of 30 years of data from the Finnish Register of Visual Impairment indicates the visual prognosis of diabetic patients has improved over time. However, some of the positive trends observed between the first and second decades of the study seem to have levelled off more recently, perhaps as a result of the worsening epidemiology of diabetes itself, said Hannu Uusitalo MD, PhD, at the annual meeting of the Association for Research in Vision and Ophthalmology.

The Finnish Register of Visual Impairment is a government-funded national register organised by the National Institute of Health and Welfare in Finland and maintained by the Finnish Federation of the Visually Impaired. By law, healthcare providers must submit information about any patient who fulfils the WHO criteria for visual impairment (ie, corrected visual acuity permanently <0.3 in the better eye or diameter of the visual field <20 deg).

Between 1980 and 2010, 4,087 patients were entered into the registry with diabetic retinopathy (DR) listed as their primary cause for visual impairment. In order to assess changes over time in visual impairment due to DR, the patients were further divided as to whether the cause of their visual impairment was proliferative or non-proliferative disease (PDR or NPDR) and into three time cohorts by decade.

Patient age at time of notification of visual impairment, impairment severity based on the proportion of individuals who met the WHO definition for blindness at registry entry, and mean age of death were analysed for each decade for each diagnostic group.

For the PDR subgroup, the median age at the time of notification of visual impairment was 39 years for patients entered into the registry during the 1980s, 62 years for the 1990s cohort, and 59 years for those entered during the first decade of the 21st century.

During these three time periods, the median age of death was 42, 72, and 68 years respectively, while the proportion of blind persons decreased continuously, albeit most dramatically between the first and second decades, from 42 per cent to 22 per cent and then to 15 per cent over the last 10 years, Dr Uusitalo reported.

For the NPDR subgroup, there was little change across the three time cohorts in the

Diabetes PDR notification age

median age at the time of notification of visual impairment (71, 73, and 73 years) or in the age at death (76, 79, and 78 years).

The proportion of blind persons also was relatively unchanged between the 1980s and 1990s (10 per cent and nine per cent), but decreased to four per cent in the most recent cohort.

“This study showed that visual impairment due to PDR was less severe in the past 20 years than it was in the 1980s. However, the end of the favourable developments in notification age of visual impairment and age of death that occurred early is probably due to an unfavourable development in the incidence of diabetes itself,” said Dr Uusitalo, professor of ophthalmology, University of Tampere, Finland, and chief medical officer, Finnish Registry of Visual Impairment.

Dr Uusitalo noted that Finland ranks number one in the world for incidence of Type 1 diabetes and the incidence of Type 2 diabetes is also relatively high.

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Hannu Uusitalo – hannu.uusitalo@uta.fi Eurotimes_half-pg_0712.indd 1

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56

Update

RETINA

advancement

RPE transplantation research focuses on goal of developing a safe and successful procedure

by Cheryl Guttman Krader in Fort Lauderdale

P

rogress in retinal pigment epithelium (RPE) transplantation has so far occurred in very small steps, observes Susanne Binder MD. Nevertheless, investigators remain optimistic that steady incremental advances may someday allow RPE transplantation to become a widely performed method for rehabilitating vision in patients with agerelated macular degeneration (AMD) and other retinal degenerative diseases.

Speaking at the 2012 annual meeting of the Association for Research in Vision and Ophthalmology, Dr Binder discussed the current state of RPE transplantation and future directions by reviewing where the field has been and the challenges that investigators are attempting to overcome.

She noted that RPE transplantation was first done in a human in 1991. To date, more than 600 cases have been performed.

“Clinical investigation of RPE transplantation began after extensive experimental research established that transplanted RPE cells could rescue photoreceptors, and proof of principle was first provided in 2003 when Machemer and Steinberg showed that transfer of autologous adult human RPE from the extrafoveal region by 360 degree retinal translocation could restore foveal function,” said Dr Binder, professor and chair, department of ophthalmology, The Ludwig Boltzmann

EUROTIMES | Volume 17 | Issue 9

Institute for Retinology and Biomicroscopic Lasersurgery, Rudolf Foundation Clinic, Vienna, Austria.

Research over the past two decades has focused on optimising the RPE cell source, the condition of the recipient site, and the transplantation technique.

Cell source issues Dr Binder noted that her group became interested in using autologous RPE cell suspensions based on histopathologic evidence from animal studies showing the successful integration of cultured RPE cell suspensions in the subretinal space. However, while data from a consecutive series of patients showed subretinal membrane excision with simultaneous transplantation of an autologous RPE suspension was associated with a low complication rate, reduction in recurrent neovascularisation, improvements in subclinical tests, and improvement or stabilisation of vision, the use of aged cells and their placement in the “hostile” environment of an aged and defective Bruch’s membrane (BM) were limiting factors in achieving better outcomes.

As an alternative, Dr Binder’s group and others investigated use of a full thickness RPE-BM-choroid patch. However, their experience showed that visual acuity outcomes were no better than when transplanting the RPE cell suspension

and proliferative vitreoretinopathy (PVR) developed at a rate of up to 45 per cent.

Experiments have also been done using human foetal RPE cells. However, they are not considered a practical source for developing an RPE transplant paradigm considering that these cells show morphologic changes after just a few passages, have potential immunogenicity and are in limited supply.

Embryonic stem cells can undergo largescale expansion and are pathogen-free.

Human embryonic stem cell-derived RPE (hES-RPE) cells have been shown to be genetically similar to in situ RPE as well as to have better survival than aged adult RPE and iris pigment epithelial (IPE) cells when transplanted onto aged and diseased BM in laboratory experiments.

Dr Binder noted that human pluripotent stem cells are thought to hold the greatest promise for the future. RPE cells derived from this source have been shown to be morphologically similar to native RPE cells, to express markers of developing and mature RPE cells, and are able to phagocytose photoreceptor outer segments.

Manipulating cells Future success will also depend on identifying strategies for improving transplanted cell adhesion to BM and maintaining graft survival long-term.

Experimentally, success has been achieved using bovine corneal endothelial cells as a matrix for foetal RPE or mitomycin-C treated fibroblasts as a feeder layer.

“Reprogramming” of the RPE cells, either to rejuvenate aged cells in order to improve their likelihood of survival or to promote their expression of cytokines and trophic factors beneficial for the retina and choroid is also being investigated by various groups.

Dr Binder noted she and her colleagues are involved in this type of research with studies aiming to rejuvenate RPE cells

Susanne Binder – susanne.binder@wienkav.at

with epidermal growth factor and insulin growth factor and investigating a pigment epithelium derived cell-based gene therapy approach using autologous RPE or IPE cells.

Research is also under way aimed at improving the recipient site through the development of a prosthetic BM. The purpose of this artificial basal lamina would be to serve as a scaffold to guide the repair and restoration of function to the damaged tissue while maintaining a clinically functional epithelial phenotype, Dr Binder explained.

Various polymers have also been investigated for use as a prosthetic BM, including natural compounds such as collagen, gelatin and fibrinogen crosslinked in the presence of thrombin. These polymers are biocompatible and mimic the extracellular matrix of BM. However, their absorption is unpredictable and use of these natural substances is also accompanied by concerns relating to possible disease transmission and allergenicity.

Synthetic polymers offer the potential to overcome the latter limitations, and Dr Binder noted that her group has been working with electrospun polyamide nanofibres. In a recently published paper, they reported outcomes from an experiment in rabbit eyes where a foetal human RPE cell/polyester implant was embedded in a thermosensitive gelatin and introduced into the subretinal space using a specialised instrument.

"Cell-derived therapies are more difficult to perform than expected and progress happens in many small steps. This is related on one side to the difficulties we face during experiments but also to a lack of interest from the industry, because this kind of treatment will be less profitable than simple application of drugs. However, finally it is the way to go for curing so-far untreatable diseases," Dr Binder concluded.

Update

Reichert is Tonometry. ®

RETINA

novel laser

New generation laser platform shows promise for improved safety and efficiency

by Cheryl Guttman Krader in Fort Lauderdale

EUROTIMES | Volume 17 | Issue 9

Courtesy of Ken Lin MD, PhD

U

sers of a novel navigated 532nm retinal laser system with integrated imaging (Navilas, OD-OS GmbH, Teltow, Germany) report it is an effective tool for performing panretinal photocoagulation (PRP) to treat high-risk proliferative diabetic retinopathy, and one that appears to have advantages for improving patient comfort as well as treatment efficiency and safety.

Ken Lin MD, PhD, and Stephanie Lu MD from the Gavin Herbert Eye Institute at the University of California, Irvine, discussed the laser and their experiences during the 2012 meeting of the Association for Research in Vision and Ophthalmology (ARVO).

They explained that the laser system was designed to treat macular diseases especially diabetic macular oedema in the posterior pole using real-time eye tracking and registration of the diagnostic fluorescein angiography with the treatment plan onto the live fundus imaging. With no need of a contact lens, it offers better comfort to the patient and the physician. Recently, the system has added novel optics to enable PRP treatments in the periphery of the retina.

By changing the objective in the optical head and placing a contact lens, the Navilas system enables uniform spot size delivery for PRP. The PRP lens has a 63 x 50 degree static field of view. By moving the joystick laterally and vertically, it is possible to visualise the full posterior pole. There is no need of tilting the lens and therefore astigmatic changes of the image are minimised. As another feature, the platform offers an infrared imaging mode (in addition to live colour fundus imaging, red-free, and fluorescein angiography) that enables greater visibility and PRP in eyes with a mild degree of vitreous haemorrhage.

Dr Lin reported a PRP series comprised of 30 consecutive eyes of 24 patients. Treatment was performed using a 30 ms pulse duration, 300 micron spot size, 253 mW mean power intensity, with 11.5 J applied power, and was delivered to two to four quadrants using a pattern scanning mode. Each eye received an average of 1,532 spots, and eyes treated in all four quadrants received an average of 2,006 spots. Images taken post-treatment demonstrated consistent laser uptake across all quadrants, they reported.

When patients who had previously undergone PRP were asked to rate their

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Montage fundus image showing post-Navilas PRP treatment with uniform laser uptake. Average power used was 177mW with duration of 30ms and 300 micron spot size. The procedure took less than eight minutes

current experience, they unanimously reported having less pain and greater comfort during the session using the navigated laser.

There were no complications during the procedure or the available follow-up.

Mean visual acuity was stable from baseline to three months (20/70 and 20/63) as was central macular thickness (279 and 274 microns). Regression of neovascularisation occurred in all eyes by the three-month follow-up. “This system is a smart laser that makes PRP safer, faster and more accurate,” said Dr Lin, noting that to his knowledge, this is the first report of PRP performed with the navigated laser system in a reasonably large series of eyes.

Dr Lu told EuroTimes she has been using the navigated laser for PRP as well as for focal laser treatment for over a year and has been very pleased with her experience.

“While the pattern scanning laser (Pascal, Topcon Medical Laser Systems, Inc. Santa Clara, California, USA) also accelerates treatment time for PRP, all of the delivered laser spots using the navigated laser are true focused spots with uniform laser uptake across the quadrants,” said Dr Lu. She added that its benefit for increasing treatment precision and accuracy when performing focal laser photocoagulation for diabetic macular oedema has resulted in a decrease in retreatment rates.

contacts Ken Lin – kiln@post.harvard.edu Stephanie Lu – sylu@uci.edu

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meet

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Update

RETINA

Reichert is Corneal Biomechanics. ®

STUDY IN PRACTICE

CATT study can play important role in public health policy

by Dermot McGrath in Abu Dhabi

W

hile the Comparison of AMD Treatment Trial (CATT Study) results reassured some clinicians of the non-inferiority of bevacizumab (Avastin) compared to ranibizumab (Lucentis) in the treatment of exudative age-related macular degeneration (AMD), the study also provided important insights into other aspects relating to the clinical management of the disease, according to a presentation here.

“Although the most important finding of the CATT study was proving that bevacizumab is as effective as ranibizumab in preserving and improving visual acuity in wet AMD, the study also gave important pointers for dosing schedule and follow-up,” Gabriel Goscas MD told delegates attending the World Ophthalmology Congress. “There is a consensus now for a monthly follow-up that looks at systemic as well as ophthalmic factors. Furthermore, each intravitreal treatment decision must be based on the performed examination and we also know now that an induction phase is not necessary,” he said.

Dr Coscas, Emeritus Professor and chairman of ophthalmology at the University of Paris XII, France, said that the CATT study merited its designation as a landmark clinical trial.

“It was presented at all the major meetings and the results were widely disseminated to all the media. The significance of the trial lies in the fact that this was the first study organised for the comparison of two major drugs and was sponsored by ophthalmologists and research institutes in the United States rather than the pharmaceutical industry,” he said.

Differences in cost The cost implications of the CATT trial also loom large in any evaluation of the study’s impact, said Dr Coscas, bearing in mind that Lucentis is about 40 times more expensive than Avastin and reimbursement rules differ from country to country.

“We are all aware of the differences in costs for the wider community between the two drugs,” he said.

This is where randomised clinical trials such as the CATT study can really play an important role in influencing public health policy, said Dr Coscas.

EUROTIMES | Volume 17 | Issue 9

“We must make our opinions known to the health authorities and we must enable them to guide their decisions on a medical basis. As ophthalmologists, comparative studies of efficacy and safety are essential.

With the growing body of data from all phase one, two and three clinical trials, the health authorities will be in a better position to make a decision based on the scientific evidence rather than just price and according to the rules of the different countries,” he said.

Dr Coscas noted that ranibizumab has a robust safety and efficacy profile for ophthalmic use based on randomised clinical trials such as the MARINA and ANCHOR trials. Bevacizumab, by contrast, has been widely used off-label for ophthalmic use, but prior to CATT had no clinical trial data to support its use as a potential AMD treatment.

In terms of optimal dosing strategies, Dr Coscas said that attempts to treat less than monthly have been shown to be inferior to monthly treatments in the PEER, EXCITE and SUSTAIN trials, but there remains a strong interest in reducing the frequency of injections and controls for follow-up.

Caution needed Turning to the safety data, Dr Coscas said that no statistically significant differences in ocular and systemic safety were found between the two drugs in the CATT trial. Nevertheless, he said that longer follow-up was needed to know more about possible systemic side effects of Avastin, and he advised particular caution in treating patients with myocardial infarction, cardiovascular disease and gastrointestinal haemorrhages.

Dr Coscas said that the CATT study also revealed some surprises. Firstly, the absence of an induction phase in the Avastin patients treated on an as-needed basis did not worsen the group results. Furthermore, ranibizumab seemed to be more efficient in drying and thinning retinas without impacting on the final visual acuity results.

Summing up, Dr Coscas said that it will be interesting to see if the second-year data confirms the initial results of the CATT trial and perhaps answers some other key questions relating to anti-VEGF therapies.

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Gabriel Coscas – gabriel.coscas@libertysurf.fr Eurotimes_half-pg_0712.indd 3

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i TELL ME AND I’LL FORGET;

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

Update

OCULAR

NITINOL SUTURES

Injectable shape-memory clip is stronger, faster than manual filament and knots

by Howard Larkin in Chicago

UNDER

STAND - Old Chinese Proverb

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A

The nitinol suture has shape memory characteristics and thus can be straightened to fit in the injector.

Once it is injected it will return to its predetermined shape

n injectable metal clip may reduce time spent constructing intraocular sutures by up to 20 times, greatly simplifying procedures including pupilloplasty, iris fixation of intraocular lenses, encircling band fixation, and anchoring glaucoma drainage devices, Michael Erlanger MD told the innovators session of the ASCRS annual symposium.

The circular, shape-memory titaniumnickel alloy 0.007-inch nitinol (nickel titanium alloy) suture wire is five times stronger than prolene and 38 times stronger than nylon. Proven in neurosurgery and cardiac stent applications, it is highly biocompatible and can be delivered onehanded through needles as small as 30 gauge for intraocular procedures. And unlike filament sutures, the wire clip can be bent and returned to its original shape, said Dr Erlanger, who is developing the technology at the University of Colorado, Denver, US, and has a patent pending on the injectable Nitinol suture with Jeffrey Olson MD. “This is very useful when you are working in the eye. You don’t have to use ocular gymnastics to get in a Seipser suture,” Dr Erlanger said.

In animal tests, pupilloplasty was performed 16 times faster with the nitinol suture than with a modified Seipser slip knot, and the need for limbal-to-limbal passes was eliminated, making the procedure less technically challenging. Similarly, IOL iris fixation times were reduced 20-fold.

Biocompatible When properly prepared, the titanium-nickel nitinol alloy is highly resistant to corrosion, Dr Erlanger noted. The compound has been used extensively in cardiovascular stents as well as orthopaedic and dental devices.

While nitinol can be formed into any shape, for intraocular use a circular double coiled clip may be most useful. Dr Erlanger EUROTIMES | Volume 17 | Issue 9

“

You don’t have to use ocular gymnastics to get in a Seipser suture Michael Erlanger MD

has tested it in 0.5mm and 1.0mm suture sizes. He has developed an injector based on a syringe. Nitinol’s memory characteristics allow the suture to be straightened and injected through a straight or curved needle.

It resumes its circular shape as it leaves the injector, allowing it to be anchored in tissue as it comes out. The suture can be manipulated with forceps after injection. Pre-set sutures can be sprung open to grasp haptics, glaucoma shunts, rings or other devices.

In a three-month biocompatibility study involving five Yucatan mini pigs, five eyes receiving nitinol sutures and five receiving modified Seipser knots showed no significant differences in corneal specular cell counts, corneal thickness measured by OCT, corneal histology staining, or retinal histology measured by cell counts of the ganglion cell, inner nuclear and outer nuclear layers, Dr Erlanger reported (Inv Ophthalmol Vis Sci 2011). However, mean surgical time for the nitinol eyes was one minute 18 seconds compared with 19 minutes 38 seconds for the modified Seipser knot eyes (p<0.005).

Other successful tests include anchoring an Ahmed glaucoma drainage shunt, Retisert fixation, installation of encircling bands and IOL fixation, Dr Erlanger said. He believes this technology will find broad application in ophthalmic surgery.

contact Michael Erlanger – michael.erlanger@ucdenver.edu

Update

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#S107 H T O O V IS IT B E S C R S AT

OCULAR

ADAPTIVE OPTICS

Advanced binocular system automatically refracts with no moving parts Courtesy of Gholam A Peyman MD

by Howard Larkin in Chicago

A

A drawing of the three fluidic lenses stacked behind each other, two cylindrical (left) and one spherical (right)

n advanced “see-through” automated adaptive optics phoropter could greatly simplify patient refraction, reducing the need for highly trained personnel and increasing office efficiency, Gholam A Peyman MD told the Innovators Session of the ASCRS annual symposium.

The new phoropter eliminates the need to flip lenses, making it possible to operate the unit automatically or for the patient to manually adjust it. Not only is it objective, easier and quicker to use, it also refracts to within 0.1 D compared with ¼ D steps in manual phoropters, Dr Peyman said.

“Our objective was to develop an automated see-through adaptive optics phoropter for correction of refractive errors while the patient is looking at far or near.”

contact

Gholam Peyman– gpeyman1@yahoo.com

▲

EUROTIMES | Volume 17 | Issue 9

Thinner To make the system thinner and lighter, Dr Peyman and associates incorporated an array of diffractive liquid crystal lenses and a holographic optical element to replace the standard telescope, and a diffractive-refractive achromatic lens to replace the spherical lens. The diffractive optic breaks up incoming light into numerous waves and then recombines them into new waves. Electrical charges on liquid crystal differentially arrange the crystals to produce a new spherical wave. To control for chromatic aberration, they combined a refractive fluidic lens with a diffractive liquid crystal lens to cancel each other’s chromatic aberrations.

The holographic optical element creates a 3-D virtual image, which enables the system to simulate depth. It is monochromatic, which is a disadvantage, but it also has several advantages, Dr Peyman noted. A single holographic element can create a wavefront of any shape, and it is virtually distortion-free, focusing to the diffraction limit with submicron accuracy. It also allows close to 100 per cent diffraction efficiency with minimal light absorption. It has large apertures, allowing wide field of view. It is lightweight, easily replicated and inexpensive.

The third-generation binocular system allows practical, rapid vision tests in both eyes simultaneously, Dr Peyman said.

Dr Peyman owns a patent and shares two pending applications with his colleagues from the university of Arizona.

▲ ▲

Three lenses, no moving parts

The binocular system developed at the University of Arizona, Tucson, US, in collaboration with Drs Savidis, Schweugerling and Peyghambarian, uses computer-controlled adaptive fluidic lenses coupled with a refractive or holographic relay telescope and a see-through ShackHartmann sensor, allowing refraction of both eyes simultaneously, Dr Peyman said. It replaces the multiple glass lenses of traditional phoropters with three fluidic lenses; one spherical and two cylindrical.

The lenses are composed of a deformable silicone membrane and a lens fluid chamber.

Increasing or decreasing the fluid in the spherical changes power from -20.0 to +20.00 D in 0.1 D steps.

Cylinder lenses power ranges from 0.0 to 8.0 in 0.1 D steps. Combining the two lenses at a 45-degree orientation creates a universal astigmatic lens capable of creating a universal cylinder at any axis. This eliminates the need to move any lens in the system.

Instead, the lens power is controlled by a

computer, which determines how much fluid is pumped into each of the three lenses in a closed loop interaction. Incoming light is reflected into the eye and then back into the telescopic or holographic refractive system, which adjusts for sphere and astigmatism using the Shack-Hartmann sensor.

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62

News

ESASO

FELLOWSHIPS

ESASO offers training from today’s leaders for the benefit of future leaders and their patients

E

SASO has campuses in Lugano, Singapore and Ankara where leaders in international ophthalmology train young ophthalmologists who want to improve their skills. Over 400 participants have attended ESASO modules and well over 100 ophthalmic leaders have been teaching them with the intention of making them the future leaders in their specialties.

ESASO’s post-graduate programme consists of five one-week modules covering retina, cornea and refractive surgery, glaucoma, oculoplastics, strabismus and paediatric ophthalmology. Forty surgeons have completed their five modules and graduated, or will graduate this year, as Specialist Superiors in Ophthalmology but for some this is not enough “Young ophthalmologists who want to pursue international careers should apply for the master programme – the ESASO Fellowship”, said Prof Stanley Chang from Columbia University and chair of the Fellowship Committee. “The unique part about ESASO is the international Fellowship and the network that the participants and alumni can build up,” said Prof Chang.

Evaluation process At the end of June, the Fellowship Committee met with the applicants to hold interviews in Barcelona. According to Maurizio BattagliaParodi, general secretary of the Fellowship Committee, the evaluation process is very thorough. “Besides the qualifications and recommendations required, potential candidates have to state the reasons why they are seeking an international fellowship,” he said. “On the other hand, ESASO guarantees the high quality of its master programme with guidelines for the three-step education programme,” said Dr Battaglia-Parodi.

Prof Chang said that this year five applications arrived from ESASO alumni.

Two surgical, one medical retina and one research fellowship were available at the University Hospitals in Vienna, Munich, Milan and New York.

After completing the interviews the Fellowship Committee selected two Fellows for the coming year. Mohammed Zubair Yameen Arain from Pakistan will start his Research Fellowship at the University of Colombia. Dr Arain wants to develop a research programme in degenerative 08_1207_06 ESASO_Anz_EUT_120x300_RZ.indd EUROTIMES | Volume 17 | Issue 9

1

6.7.2012 9:28:40 Uhr

“

ESASO guarantees the high quality of its master programme Maurizio Battaglia-Parodi

myopia. The second Fellow is Janhvi Mehta, India who wishes to improve her surgical skills to develop her own practice. She will complete her practical Fellowship at the University Hospital in Vienna.

Maurizio Postorino, Italy, who was selected for a Fellowship last year is completing his retina Fellowship at the IMO in Barcelona. He said he was very impressed with the organisation of the Fellowship and the high standard of teaching. “Having the possibility of observing the different tutors including Drs Corcóstegui, Mateo, GarcíaArumí and Navarro and their techniques is an excellent 360° training programme,” he said. “I am also very impressed by IMO’s research motivation, clinical sessions and constant updating of the whole medical team,” said Dr Postorino. * To find out more about ESASO visit www.esaso.org.

ESASO Fellowship Committee Members Stanley Chang (committee chair), director at University of Colombia, US. Borja Corcὁstegui, president of IMO, Barcelona, Spain.

Leonidas Zografos, medical director at Jules Gonin Eye Hospital, Lausanne, Switzerland.

Ursula Schmidt-Erfurth, director at Medical University, Vienna, Austria.

Christoph Scholda, Medical University, Vienna, Austria.

Nicholas Evans, Royal Eye Infirmary in Plymouth, Great Britain.

Giuseppe Guarnaccia, executive director ESASO, Lugano, Switzerland.

Maurizio Battaglia-Parodi (committee secretary), San Rafaele, Milan, Italy.

contact Gabriella Skala – gabriella.skala@esaso.org

63

News

EUREQUO

GLOBAL reach

Today, almost one million cataract surgeries have been recorded in the system

by Colin Kerr

E

UREQUO Goes Global is an exciting new initiative from ESCRS which will give cataract and refractive surgeons all over the world the opportunity to record, monitor and compare their results.

The European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) started as an initiative co-financed by the European Union, under the Executive Agency for Health and Consumers and the ESCRS. Eleven national societies across Europe participated as associated partners in the project.

The aims of the project were to improve treatment and standards of care for cataract and refractive surgery, make a significant impact on the exchange of best practice in relation to patient safety and to develop evidence-based guidelines for cataract and refractive surgery across Europe.

During the project, surgeons and clinics from 16 countries reported data to the EUREQUO database. After three and a half years, more than 800,000 cataract extractions have been reported to the database.

Benchmarking and clinical improvement work has been done by clinics and clinical guidelines for cataract surgery based on the database have been published in the June issue of JCRS.

Improving outcomes EUREQUO provides a means to audit surgical results and encourages surgeons to make adjustments to their techniques and improve their outcomes.

Today, almost one million cataract surgeries have been recorded in the system.

This number is expected to increase substantially with EUREQUO Goes Global by giving the opportunity to all ESCRS members to access the system free of charge.

The system can be reached via the EUREQUO web portal for manual input of data at https://eurequo.net. The user can choose between cataract and refractive

After three and a half years, more than 800,000 cataract extractions have been reported to the database

EUROTIMES | Volume 17 | Issue 9

surgery and in both systems there is one form for preoperative and surgical data and another form for follow-up data.

Surgeons or clinics sign up for participation via the EUREQUO website (www.eurequo.org) and you can get a username and a password for log in.

Individual patient data is anonymous in the registry but each participating centre guarantees a possibility to trace the registered surgical procedure to the relevant medical record in the centre. This is for making an audit process possible. Data can also be entered into the database from existing national registries or electronic medical record (EMR) systems by an interface.

The output statistics are either frequency tables or graphs. Both systems give one preoperative and surgical report and one follow-up report. It is also possible to export own data from the system as an Excel file.

Each centre/surgeon can only get access to own data and aggregated data for a country (any participating country) and the whole database. This means that output data for a centre/surgeon is anonymous to everyone else. The output tables and graphs are standard reports with the possibility of making selections on gender, age, time period, type of operation, co-morbidity and complex surgery. This covers most of the wishes about output from the system. For more sophisticated statistical procedures export of data as an Excel file will enable the centre/surgeon to make their own customised output reports and advanced statistics.

If you wish to have access to the system, visit the website at: www.eurequo.org.

contact Mats Lundstrom â&#x20AC;&#x201C; mats.lundstrom@ karlskrona.mail.telia.com ad ET versario 1-2hoch ENG 1202v5 pva RZ.indd 1

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News

EYE FACTS

Susanne Gardner – susanne.gardner@gmail.com

DOES BAK MATTER?

Is there any effect from benzalkonium chloride in the aqueous humour after topical drops?

Courtesy of Susanne Gardner PhD

64

by Susanne Gardner PhD

A

ntimicrobial effects from commercially available antibiotic drops come not only from the active antibiotic component but also from additives such as benzalkonium chloride (BAK), included in formulations as a “preservative.” These preservatives serve to maintain the "sterility" of multi-dose eye drop bottles, exerting their effect over hours of contact time within the container. To pass FDA standards, the agent must be able to reduce bacterial counts as specified in standardised testing.

Clinicians often ask about what practical antimicrobial effects we can expect from the BAK component of antibiotic solutions in the treatment or prevention of eye infections, particularly as BAK is associated with ocular irritation and potential effects on corneal wound healing. In our two previous articles, we outlined comparative antimicrobial delivery from topical eye

drops to the tears and aqueous humour (AH). Here we will complete this discussion by including the antimicrobial contribution of BAK, under practical clinical circumstances, to the tears and AH. Two studies reported that the BAK containing Zymar® product (gatifloxacin 0.3 per cent + BAK 0.005 per cent) killed bacteria faster in vitro than did Vigamox® (moxifloxacin 0.5 per cent; no BAK).1,2 The BAK component of Zymar was thought to speed bacterial kill rates and even increase efficacy against MRSA strains that might be resistant to gatifloxacin alone. Hyon and associates2 also tested BAK 0.005 per cent separately, finding that bacterial killing of staphylococcal species required one hour of exposure time to the BAK. Despite the finding that BAK increased bacterial kill rates, these results drew attention to the fact that even the full strength commercial antibiotic drops often

Ophthalmic Women Leaders leadership

I

advancement

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community

Ophthalmic Women Leaders (OWL) is the preeminent nonprofit organization for the professional development and advancement of women in the eye care industry.

Consider OWL membership OWL offers members many career enhancing benefits including webinars, mentoring/coaching programs, networking opportunities, special events, and more.

For details and to become a member, visit www.owlsite.org.

Join us in Milan on Sept.10 OWL members are invited to get together for a fun, informal “OWL Roost” at ESCRS on Monday, September 10.

For event details, visit www.owlsite.org.

EUROTIMES | Volume 17 | Issue 9

BAK tear levels after a drop

required a "drug-bug" contact time of more than 15 minutes, in vitro, to reliably kill common ocular pathogens such as S. aureus and S. epidermidis, with most MRSA remaining viable after a full hour's contact time when BAK was not present.

These findings were notable because they highlighted a time factor requirement for BAK bacterial killing to occur. Yet, the time frames and drug concentrations tested were still not consistent with reallife clinical circumstances surrounding drop administration to the eye. Despite this, speculation remained about potential bacterial killing effects of BAK within shorter periods of time than those tested (5-15 minutes).

Another study3 then examined bactericidal effects of BAK along with diminishing concentrations of fluoroquinolone antibiotics. Rapid bacterial killing from BAK alone was observed within 5-15 minutes, but only with higher concentrations of BAK (ie: above 50mg/L [50 μg/ml] or 0.005 per cent), but not at lower concentrations such as 8-32 μg/ ml. However, Freidlander and associates4 had previously shown that after a drop of Zymar,® BAK tear concentrations fell to 6.4μg/ml by 30 seconds after instillation, and to 3.2 μg/ml by one minute after a drop. At these concentrations, the study

by Haas and associates3 indicates that very little bactericidal activity in the tear3 film can be anticipated from the BAK component alone, within time frames and concentrations resembling drop administration to the eye.

BAK and the aqueous humour

Given that a bactericidal effect in tears from the BAK component of eye drops is unlikely, is there any effect from BAK in the AH after topical drops?

After drop administration to normal eyes, BAK is detected in corneal tissue, mostly epithelium, and conjunctiva.

However, when AH is sampled to determine drug penetration, appreciable amounts of BAK are not found. On the surface of the eye, this agent serves to increase corneal permeability, but its own molecular penetration into the

anterior chamber is poor. Safely tolerated concentrations of BAK in eye drops are well defined and usually below 0.05 per cent.

Therefore, in analyses of eye drops that do, or do not, contain BAK, in vitro findings cannot be extrapolated to the AH, for example, because this chemical moiety does not pass through the normal cornea along with the active antibiotic ingredient, and so cannot exert a synergistic or additive effect with the antibiotic in the AH. In summary, BAK is a useful and effective antimicrobial when used as a preservative in multiple dose eye drop bottles. It also serves to enhance corneal permeability for many topical agents.

However, literature reports that describe an additive or synergistic effect for BAK in topical antibiotic formulations did so in the context of the laboratory setting, where BAK concentrations and duration of exposure to microbes did not mimic real-life conditions on the surface of the eye. Furthermore, no appreciable diffusion of BAK occurs through a normal cornea to the AH, so that an antimicrobial additive or synergistic effect there should not be anticipated. While in selected instances, some microbial strains may prove susceptible to brief time/ concentration profiles of BAK from eye drops, the current literature suggests that such expectations may be unrealistic under clinical conditions, and certainly not for prophylaxis where the AH or anterior chamber of the eye play an important role.

References 1. Callegan MC, Novosad BD, Ramadan RT, et al. Rate of bacterial eradication by ophthalmic solutions of fourthgeneration fluoroquinolones. Adv Ther 2009;26:447-454.

2. Hyon JU, Eser I, O'Brien TP. Kill rates of preserved and preservative-free topical 8-methoxy fluoroquinolones against various strains of Staphylococcus. J Cat Refract Surg 2009;35:1609-1613.

3. Haas W, Pillar CM, Hesje CK, et al. In vitro time-kill experiments with besifloxacin, moxifloxacin and gatifloxacin in the absence and presence of benzalkonium chloride. J Antimicrob Chemother 2011;66:840-844.

4. Freidlander MH, Breshears D, Amoozgar B et al. The dilution of benzalkonium chloride (BAK) in the tear film. Advances in Therapy 2006;23:835-841.

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Registration opens August 2012

Saturday, November 10—Monday, November 12

Saturday, November 10 Hyatt McCormick Place

Complex Cataracts, The Simple Truths IV Sponsored by MST

7:00 – 7:30am Registration 7:30 – 8:30am Program

Monday, November 12 Hyatt McCormick Place

Pursuing the Next Level of Outcomes in Customized Laser Refractive and Cataract Surgery 6:30 – 7:00am Registration 7:00 – 8:00am Program

Make the most of your time while in Chicago and attend these EyeWorld programs for an educational opportunity to network with your colleagues.

www.EyeWorld.org

Feature

EYE ON HISTORY

ANTONIO SCARPA

Scarpa's medical achievements

The brilliant Italian anatomist had few friends but his achievements continue to inspire

by Andrzej Grzybowski MD, PhD

A

ntonio Scarpa was born on 9 May 1752 into an impoverished family in Motta di Livenza, near Venice.

At the age of 15, he started his medical studies at the University of Padua, under Leopoldo Caldani (1725-1813) and Giovanni Morgagni (1682-1771). His academic performance impressed Morgagni, who invited him to work as his assistant and personal secretary. In 1770, at the age of 18, he graduated this medical school and obtained his doctorate. Within the next two years he wrote an important treatise titled De structura fenestrae rotundae auris (Mutinae, 1772), in which he firstly described the structure and functions of the inner ear.

In 1772, he was offered a professorship in anatomy and theoretical surgery at the University of Modena, where he spent the next 10 years.

In 1783 Scarpa joined the medical faculty at Pavia, where he became chair of anatomy in 1785, and head of the Surgical Clinic in 1787. He ordered a new anatomical theatre, which was opened in 1785 as an architectural jewel. His teaching model was based on anatomical dissection and surgery performed before students. In

the time when the cadaver ‘trade’ was the only way to possess corpses in many other universities, Scarpa suggested to the authorities that bodies of the deceased from the state hospital were to be transferred to the medical school. In 1813 Scarpa retired because of his vision problems. However, he continued to preserve his influence and power as director of medical faculty.

During his long stay in Pavia, Scarpa achieved a prominent and powerful position at the University as a long-time chair of both Surgery and Anatomy Department, rector of the university and a permanent director of the Faculty of Medicine; he controlled nearly every aspect of the faculty’s life and often behaved in a despotic and absolute manner.

Achille Monti described Scarpa based on the stories of his grandparents, who were medical students in Pavia between 1825 and 1836: “That grand old man with a serious face and a magnetic stare, who was familiar with no one, who taught and conversed in Latin with confidence, eloquence and an imperious tone and manner, who worked rapidly, regardless of patients’ cries, who enjoyed slicing up the corpses of illustrious colleagues such as Spallanzani, Brunacci and

t State-of-the-Ar

Antonio Scarpa (1752-1832)

Brugnatelli, who appeared as impenetrable as the sphinx, as cold as death, and as merciless as fate.”

On the other hand, Scarpa managed to obtain the greatest development of the University of Pavia and succeeded in reforming anatomy and surgery at the University to the most advanced scientific research level.

He had only a few friends, including Alessandro Volta (1745-1827) but his enemies were numerous. At the end of his life, he was alone and blind living in his palatial villa outside the city walls (today named “via Scarpa”), where he died. After burial ceremonies his body was disinterred and became the subject of dissection. His urogenital apparatus, both forefingers and first pahalanxes of thumbs and head were removed and placed in an anatomy museum for years. At present they are exhibited at the Museum of History of the University of Pavia.

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EUROTIMES | Volume 17 | Issue 9

The list of anatomical eponyms related to his name includes Scarpa’s fascia, Scarpa’s fluid, Scarpa’s sheath and Scarpa’s triangle.

His legacy includes works in otolaryngology, orthopedics, ophthalmology, neuroanatomy and surgery. Scarpa’ anatomical research was closely related with physiology, pathology and surgery, which was quite rare at his time and made him both an ingenious researcher and a very skilled and effective surgeon.

His textbook, The Principal Diseases of the Eye (Saggio di osservazioni e d’esperienze sulle principali malattie degli occhi. Pavia: Baldassare Comino, 1801) was one of the most popular ophthalmology books in the 19th century.

Scarpa was not an ophthalmologist, and as an anatomist and surgeon was rather critical of those arguing in favor of eye surgery not belonging to general surgery.

In the introduction of his book he declared: “professed oculists whom have entirely devoted themselves to this department [ophthalmology], and from whom great and important improvements might justly have been expected, have only contributed new theories, which, for the most part, have been disproved by a minute anatomical investigation of the eye, or have merely furnished histories of cures little less than miraculous”.

Andrzej Grzybowski MD, PhD, professor of ophthalmology, Poznan City Hospital, Poznan, Poland; Dept. of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland Acknowledgements: Prof Alberto Calligaro and Prof Paolo Mazzarello, director of the Museum of History of the University of Pavia for his help in supplying images related to Scarpa.

67

68

Feature

industry news

Recent developments in the vision care industry

Product innovations

Kowa Optimed will be launching its latest product innovations at the XXX ESCRS congress in Milan, Italy including its nextgeneration perimeter, and demonstrating the world’s first 2D/3D Non-Mydriatic fundus camera.

Located at stand S145, the European team will be on hand to introduce its latest product innovations as well as demonstrate the established Kowa products such as the nonmyd7 fundus camera; it’s portable product range and software analysis programs. n www.kowa.eu

New funding Oculus Keratograph 5M

Topography and dry eye screening

Oculus says that the introduction of the new Keratograph 5M is a revolution in topography and screening for dry eye disorders. “The high-resolution colour camera and integrated magnification changer open up entirely new perspectives in professional tear film analysis,” said a company spokeswoman. “A complete range of diagnostic possibilities are based on the new colour camera. For the first time it is possible to record bulbar and limbal redness and classify the results automatically and objectively. Due to the magnification changer, the Keratograph 5M allows a larger distance to the patient’s eye to perform meibography and examine the upper eyelid as comfortably as the lower eyelid,” she said n www.oculus.de

WaveTec Vision®, which recently introduced the ORA System™, a diagnostic device that brings revolutionary precision to cataract surgery, has recently closed a new round of financing, securing an additional $16.5m.

This latest round was led by a new investor, Burrill & Company. All of the company’s previous investors also participated in this round of financing, including Versant Ventures, Accuitive Medical Ventures, De Novo Ventures and Gund Investment Corporation “The participation of a new lead investor further validates the scientific and clinical potential of the ORA System,” said Tom Frinzi, WaveTec president and CEO. “This new capital enables us to further expand our commercial efforts as well as continue product refinement,” he said n www.wavetecvision.com

80th anniversary

This month Topcon Corporation will celebrate its 80th anniversary.

Topcon Medical Systems’ (TMS) president Sam Ogino said: “For 80 years, Topcon has strived to deliver cutting-edge ophthalmic technology and this significant milestone deserves celebration. Our customers and distributors are the driving force behind all that we do and I look forward to marking this occasion with them.”

To celebrate the anniversary, Topcon will hold a Global Distributors Meeting in Tokyo in November. The company’s top distributors from around the world will be invited to attend. n www.topcon.com

Priority review

The US Food and Drug Administration (FDA) has informed ThromboGenics NV that it has officially accepted the filing of the Biologics License Application for ocriplasmin intravitreal injection, 2.5 mg/ml and granted it Priority Review.

The proposed indication of ocriplasmin intravitreal injection is for the treatment of symptomatic Vitreomacular Adhesion (VMA) including macular hole.

Dr Patrik De Haes, ThromboGenics’ CEO, said: “The company is happy that the FDA has granted ocriplasmin Priority Review. We are looking forward to our discussions with the FDA as we work to make ocriplasmin available to the many patients in the US that could benefit from this novel treatment option.” n www.thrombogenics.com

Abbott Healon EndoCoat OVD

Dispersive OVD

Abbott has announced that it has expanded its Healon® family of ophthalmic viscosurgical devices (OVDs) with the US Food and Drug Administration approval of Healon EndoCoat OVD, a device intended for use as a surgical aid in cataract extraction and intraocular lens (IOL) implantation.

“A dispersive OVD is highly desirable at the beginning of the cataract removal process to help protect the eye from nuclear particles and ultrasonic energy,” said Roger F Steinert MD, Irving H Leopold Professor and Chair, director, Gavin Herbert Eye Institute, University of California, Irvine. “Healon EndoCoat OVD is ideal for this protective barrier. It has outstanding clarity and does not require refrigeration, which reduces surgicenter storage costs and improves ease of use compared to a cold syringe,” he said. n www.abbottmedicaloptics.com.

EUROTIMES | Volume 17 | Issue 9

Allergan OZURDEX®

Macular oedema

The Scottish Medicines Consortium (SMC) has accepted OZURDEX® (dexamethasone 700 microgram intravitreal implant) for use in the National Health Service in Scotland. The treatment is now accepted for use in adult patients with macular oedema following central retinal vein occlusion (CRVO) and in patients with branch retinal vein occlusion (BRVO) who are not clinically suitable for laser treatment including patients with dense macular haemorrhage or patients who have received and failed on previous laser treatment, said a spokesman for Allergan. n www.allergan.co.uk

69

Review

OPHTHALMOLOGICA

OCULUS SDI® 4 / BIOM® 4 The gold standard in non-contact wide-angle viewing

Genetic factors of myopia

A new genetic study supports the hypothesis that high myopia has an important hereditary component in the Chinese population. The study evaluated the association of single nucleotide polymorphisms (SNPs) in 321 individuals with pathological myopia and 310 control individuals with normal vision. The analysis revealed significant differences in the distribution of variants of the SNP rs1479617 located in the CTNND2 gene and 11q21.1 regions between the high myopes and control individuals. Previous research has implicated the same region of the CTNND2 gene and 11q21.1 regions in high myopia in this Chinese population.

The authors speculated that the variant in the CTNND2 gene may alter the behaviour of scleral fibroblasts, allowing the eye to lengthen abnormally, possibly in response to environmental factors. n (Yu

et al, Ophthalmologica 2012; DOI: 10.1159/000338188.)

Lesions pose significant threat to vision

Primitive retinal vascular tumours and telangiectasias can cause significant visual impairment and accurate diagnosis is important in determining which treatment will be most appropriate in any particular case, according to a review of literature carried out by Karl Anders Knutsson MD and associates at the San Raffaele Scientific Institute, Milan, Italy. The authors noted that if these conditions are left untreated, chronic macular oedema and exudation can lead to drastic complications such as retinal detachment and consequent neovascular glaucoma. OCT findings aid the diagnosis of these conditions and offer important information regarding the disease and eventual therapeutic management. The current therapeutic strategies are aimed at reducing lesion growth, amount of exudation and to prevent or resolve complications. They include laser photocoagulation, intravitreal injection of anti-VEGF drugs, cry therapy and PDT.

intravitreal anti-VEGF agents, according to the results of a retrospective casecontrol study. The two-centre study involved nine patients with epithelial retinal tears who received no treatment and 12 patients who received treatment with a mean of 5.75 intravitreal injections of 0.3mg/0.09ml pegaptanib, 1.25mg/0.05ml bevacizumab, or 0.5mg/0.05ml ranibizumab, depending on the time of the intervention and centre where the patients received their therapy.

From the third month to the final followup visit, the study’s investigators found a statistically significant difference between the mean visual acuities of the two groups (p = 0.034).

because...

Visit our booth S155 at the EURETINA Congress, Milan 6. – 9. September 2012

n (Coco

et al Ophthalmologica 2012; DOI: 10.1159/000338730).

Treatment of extrafoveal lesions

Intravitreal Ranibizumab appears to be more effective than thermal laser photocoagulation in the treatment of extrafoveal classic choroidal neovascularisation secondary to agerelated macular degeneration, according to the results of a retrospective study.

In a study involving 24 eyes with the extrafoveal neovascularisations, the mean best corrected visual acuity was significantly better in eyes receiving the anti-VEGF agent than in those undergoing the laser treatment (logMAR 0.16 vs 0.92, p = 0.02) at a mean follow-up of 26 weeks.

Moreover, the recurrence rate in the laser group was 84.6 per cent, compared to only 18.2 per cent in the ranibizumab group (p < 0.001). n (Ladas

et al, Ophthalmologica 2012; DOI: 10.1159/000337347.)

... it can be adapted to most surgical operating microscopes including Zeiss OPMI Lumera® 700 ... it is sterilizable according to the latest recommendations ... it can be used with focal length of f =175 mm, f = 200 mm, f = 225 mm

n (Knutsen

et al, Ophthalmologica 2012; DOI: 10.1159/000338230.)

Epithelial retinal tears Retinal epithelial tears may prove to be yet another indication for the use of EUROTIMES | Volume 17 | Issue 9

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

www.oculus.de

70

Review

JCRS HIGHLIGHTS

JCRS Symposium CONTROVERSIES IN CATARACT AND REFRACTIVE SURGERY 2012 Sunday, September 9, 2012 14.00–16.00 Intraoperative Aberrometry: Of Value or Not Proven?

Stephen S. Lane, MD, Paul-Rolf Preussner, MD, PhD

Pediatric Refractive Surgery: LVC or pIOL? William F. Astle, MD, FRCS, Michael O’Keefe, FRCOphth, MD

Femtosecond Cataract Surgery Outcomes: An Advance or Not? H. Burkhard Dick, MD, PhD, Steve A. Arshinoff, MD, FRCSC Chairs: Emanuel S. Rosen, MD, FRCSEd, Thomas Kohnen, MD, PhD, FEBO

Journal of Cataract and Refractive Surgery

Novel free flap rescue

A free flap or free cap is a rare but bothersome complication seen in LASIK procedures. In conventional microkeratomeassisted flap creation, free flaps are more likely to occur with flat corneas. In contrast, in femtosecond LASIK, free flaps can occur while the flap is being handled at any point in the surgery; ie, during flap lifting, repositioning or refloating.

Proper management of a free flap includes realignment and attachment. Traditional methods of securing the free flap include repositioning and air drying, pressure patching, a bandage contact lens and suturing.

US researchers now describe the successful use of a single loose anchoring suture to secure a femtosecond laser-created free flap.

In an otherwise normal LASIK procedure they report that a free flap occurred as the flap was being pushed down the irrigation cannula. The surgeon repositioned the free flap and placed a single 10-0 nylon suture at the 9 o'clock position with an air knot to keep the suture loose with minimal vector force on the flap and the corneal bed. The suture position allowed an adequate manoeuvring field while staying as far from the visual axis as possible. A bandage contact lens was placed over the sutured free flap. One day post-op the free flap was clear and well centred, and the suture was removed. The uncorrected distance visual acuity was 20/40 in the eye with the free flap. The flap remained clear and centred at the three-month mark, with CDVA of 20/20 and a refraction of -2.50 sphere. The procedure is simple and safe while offering the advantages of stability and minimal invasiveness. A video is available at www. jcrsjournal.org n CJ Choi et al., JCRS, “Loose anchoring suture to secure a free flap after laser in situ keratomileusis”, Volume 38, Issue 7, 1127-1129.

Glistening and IOLs

During the XXX Congress of the ESCRS, Milan, Italy

EUROTIMES | Volume 17 | Issue 9

The influence of glistenings (small - 1.0 to 5.0 mm - fluid-filled microvacuoles that form within the intraocular lens (IOL) optic when the IOL is in an aqueous environment) remains controversial. J Colin and colleagues in Bordeaux, France evaluated the incidence of glistenings in a large series of consecutive eyes implanted with a blue light-filtering hydrophobic IOL. This study included 111 eyes of 74 patients (age range 33 to 86 years). All cases had cataract surgery with AcrySof SN60WF monofocal IOL implantation and had a routine postoperative examination between March 2011 and June 2011. Glistenings occurred in 96 eyes (86.5 per cent).

Glistenings were of grade 1 severity in 45 eyes (40.5 per cent) and of grade 2 severity in 51 eyes (45.9 per cent). The follow-up

was significantly longer in eyes with grade 2 glistenings. A limited, but significant, correlation was found between glistening severity and length of follow-up. Although there was a trend toward decreased visual acuities at higher glistening grades, there were no significant differences in CDVA between the glistening severity groups. n J Colin et al, JCRS, “Incidence of glistenings with the latest generation of yellow-tinted hydrophobic acrylic intraocular lenses”, Volume 38, Issue 7, 1140-1146.

IOL calculation for humanitarian missions

Biometric data are not necessarily available in the developing world during humanitarian missions. A US Navy humanitarian team looked at the possibility that the correlation between corneal power and axial length might be used for intraocular lens (IOL) power calculation when biometric data are incomplete. They collected measurements of K and AL from all adult cataract surgery charts and used these to calculate emmetropic IOL powers. A formula for estimating K or AL was derived by Deming regression analysis. The emmetropic IOL powers were calculated by hypothetical scenarios as follows: (1) K estimated from the formula and measured AL, (2) mean population K and measured AL, (3) measured K and estimated AL, and (4) measured K and mean population AL. The mean absolute refractive error (MAE) was calculated for each hypothetical scenario and an additional scenario (scenario 5) using single IOL power for all eyes. An analysis indicated that the correlation between K and AL could be used to improve accuracy of IOL calculation when K is unavailable. When the AL is unavailable, the mean population IOL power was the most accurate. n JW Schmitz, JCRS, “Intraocular lens power calculation for humanitarian missions based on partial biometry”, Volume 38, Issue 7, 11871191.

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

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1. Nagpal M, et al. Comparison of clinical outcomes and wound dynamics of sclerotomy ports of 20, 25, and 23 gauge vitrectomy. Retina, 2009.

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Indications for Use: The CONSTELLATION® Vision System is an ophthalmic microsurgical system that is indicated for both anterior segment (i.e., phacoemulsification and removal of cataracts) and posterior segment (i.e., vitreoretinal) ophthalmic surgery. Caution: Federal (USA) law restricts this device to sale by, or on the order of, a physician. Warnings and Precautions: • Attach only ALCON® supplied products to console and cassette luer fittings. Improper usage or assembly could result in a potentially hazardous condition for the patient. Mismatch of surgical components and use of settings not specifically adjusted for a particular combination of surgical components may affect system performance and create a patient hazard. Do not connect surgical components to the patient’s intravenous connections. • Each surgical equipment/component combination may require specific surgical setting adjustments. Ensure that appropriate system settings are used with each product combination. Prior to initial use, contact your Alcon sales representative for in-service information. • Care should be taken when inserting sharp instruments through the valve of the Valved Trocar Cannula. Cutting instrument such as vitreous cutters should not be actuated during insertion or removal to avoid cutting the valve membrane. Use the Valved Cannula Vent to vent fluids or gases as needed during injection of viscous oils or heavy liquids. • Visually confirm that adequate air and liquid infusion flow occurs prior to attachment of infusion cannula to the eye. • Ensure proper placement of trocar cannulas to prevent sub-retinal infusion. • Leaking sclerotomies may lead to post operative hypotony. • Vitreous traction has been known to create retinal tears and retinal detachments. • Minimize light intensity and duration of exposure to the retina to reduce the risk of retinal photic injury. ATTENTION: Reference the Directions for Use labeling for a complete listing of indications, warnings, precautions, complications and adverse events.

! w o tN gs

Ac

avin r S r be me Sum Septem in End lline g n o r r e t .o Regis erUpdate .Wint w w w

Revitalize Your Practice.

Innovate and Strategize in a Relaxing Environment.

Attend the Educational Retreat for Anterior Segment Surgeons.

Join us for an open exchange of ideas and solutions to help improve your practice.

Cataract | Cornea | Glaucoma | Refractive

www.WinterUpdate.org

73

Review

Book REVIEW ESCRS Lunchtime Symposium LENSTAR LS 900®

‘Blade-free’ incisions Femtosecond lasers (FSLs) are the big story in anterior segment surgery these days. A PubMed search of “femtosecond+LASIK” returns more than 250 results.

“Femtosecond+cornea” provides more than 450 published articles.

The 2011 annual meeting of the ESCRS had two entire free paper sessions dedicated exclusively to femtosecond laser applications.

Despite the intense excitement surrounding this new treatment modality, the vast majority of anterior segment surgeons worldwide have never laid eyes on an actual FSL, much less used one to treat a patient.

The FSL produces ultra-short pulses of near-infrared light whose duration is on the order of a femtosecond. Strong focusing of the beam concentrates the laser pulse to an extremely fine point. This compression of the laser pulse in both time and in space allows for the delivery of energy with great precision, reducing unintended or “collateral” destruction of surrounding tissues.

The targeted tissue is photodisrupted by local vaporisation. Because the laser light is created at a near-infrared wavelength, the beam is not absorbed by optically clear tissue, allowing anterior chamber targeting at various depths.

As the foreword notes, the FSL can create incision architecture in patterns not repeatable even by skilled surgeons.

Drs Ashok Garg and Jorge Alió have decided to elucidate the recent advances and future possibilities of femtosecond laser-assisted surgery. In their new book, Femtosecond Laser – Techniques & Technology, the editors bring together more than two dozen specialists to help explain the various applications, both current and future, of FSL treatment of the anterior segment.

Considering the fact that cataract surgery ranks among the most common surgical procedures worldwide, any significant changes in the way it might be practised can have wide-reaching consequences.

Current FSL applications include several steps in cataract and corneal surgery. With endophthalmitis remaining the most feared complication of cataract surgery, FSL researchers have focused on developing better and safer “blade-free” incisions. The goal is to create highly precise, pre-calculated entry ports that will reduce wound gape and its associated problems. The next step in cataract surgery, the capsulorhexis, also lends itself to laser-assisted creation. The EUROTIMES | Volume 17 | Issue 9

FSL can generate a strong, circular rhexis of a predetermined size. The third step, phacoemulsification, can be a traumatic experience for intraocular structures, leading to peri-operative thermal damage and postoperative inflammation. It has been suggested that FSL-assisted phacofragmentation might decrease the average energy required to emulsify hard cataracts, although significant hard evidence is still in the making.

The FSL has applications beyond cataract surgery. Indeed, it started with flap creation during LASIK and incision creation for the placement of intracorneal ring segments.

Further corneal applications include the construction of an intrastromal pocket for riboflavin application via a 10-degree side cut prior to UV-crosslinking for keratoconus.

Research is ongoing in this field and continues to drive new developments across a broad spectrum of applications.

This book helps delineate the shift from “analog” to “digital” surgery, a movement from the ophthalmic surgeon as a mechanical machine to the surgeon as part programmer.

The included DVD nicely illustrates this shift, with videos of 23 procedures.

This book is appropriate for anterior segment surgeons considering incorporating FSL surgery into their practice; for residents transitioning into fellowships that use the FSL; and for general ophthalmologists looking to get up to date on the current state of the art of this promising new tool.

BOOKS EDITOR Leigh Spielberg PUBLICATION Femtosecond Laser Techniques & Technology Editors in Chief Ashok Garg and Jorge Alio PUBLISHED BY Jaypee Highlights

Improved Refractive Outcomes for Toric IOL and Post Refractive Patients with LENSTAR LS 900 Venue: Milano Congressi, Room: Amber Hall 4 Date: Sunday, September 9th, 2012 Time: 1:00 – 2:00pm.

With improved surgical procedures as well as sophisticated lens designs, the refractive outcome of cataract surgery is depending more and more on the precision of biometry used and on the IOL calculation method employed.

At the Haag-Streit lunchtime symposium three well recognised surgeons are going to share with you their success strategies how to improve the refractive outcome based on biometry with the LENSTAR LS 900.

Samuel Masket, MD Advanced Vision Care, Los Angeles, California USA

Thomas Olsen, MD University Eye Clinic, Aarhus, Denmark

Kjell Gunnar Gundersen, MD Privatsykehuset, Haugesund, Norway

www.haag-streit.com

Biometry

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 ADV_Eurotimes_120700_LS900_LunchtimeSymposium.indd 1

02.08.2012 08:13:01

E E R AR

IP H F YE RS EES 3 BE IN A EM TR M R FO

ESCRS

Feature

EYE ON TRAVEL

WONDERS OF WARSAW

Get to know Warsaw through its royal past when you attend the ESCRS Winter Meeting next year

by Maryalicia Post

S

ince the 19th century, stylish Varsovians have gone to Nowy Swiat – New World Street – to stroll, shop and sample cafe life.

It is home to the city's most fashionable boutiques, jewellery shops, restaurants and cafes, including the venerable café, Blikle at 33 Nowy Swiat. (General Charles de Gaulle loved Blikle's doughnuts.)

In the 18th century, however, it would have been better known as a section of Warsaw's Royal Way that linked the summer palace and the winter castle of the last monarch of Poland. As King Stanislaw Augustus Poniatowski changed residences with the season, so was his collection of 2,246 paintings carted down this route from his winter castle to his summer palace – and back again. The king made this trip for the last time in 1794. The following year, Poland was split between its neighbours, Prussia, Austria and Russia, and Poland's last monarch was to live out the last three years of his life as a virtual prisoner in Russia.

Surprisingly, given the city's devastation in World War II and its subsequent long period as a Communist state, it's still possible to get a feeling for the refined court life of this enlightened, well-meaning ruler. Begin at the baroque Royal Castle in the Old Town, where one richly furnished gilded room follows the other. Even more remarkable than the opulence hidden behind these austere walls is the fact that this is a reconstruction of the castle that was demolished by the Nazis.

A catastrophic fire had preceded the ultimate destruction of the castle in 1944. Townspeople joined castle workers in salvaging all they could carry of the furnishings, works of art and elements of the interiors. In the decades that followed, private individuals risked their lives to hide these treasures from the Communist authorities. The rescued elements were invaluable when work on the reconstruction began in 1971. The Polish community at home and abroad provided the funds, and in 1984, the reconstructed rooms were open to the public for the first time.

Five kilometres down the Royal Route from the castle is the exquisite Lazienki Palace, the Palace on the Water. Originally the bathing place of an aristocrat, it was bought by King Stanislaw in 1764 and after considerable alteration, became the royal

EUROTIMES | Volume 17 | Issue 9

Chandelier in the Palace on the Water

Warsaw’s Royal Castle

Throne room in the Royal Castle, Warsaw

The Palace on the Water, Lazienki Park

summer residence. Set on an island in a lake, a pair of classic colonnades links the palace with the shore on either side.

Although the 18th century painted ceiling of the Bacchus Room was deliberately destroyed by the Nazis, they were routed before carrying out their plans to blow up the building; the walls were even drilled for dynamite charges, but Lazienki Palace was spared and is today the favourite summertime destination of Varsovians.

The Royal Route continues to Wilanov, a 17th century palace, some 10 kilometres from the Royal Castle and a one-time summer residence of King Jan III. By the time Stanislaw came to the throne, Wilanov was the private property of a noble family.

Exceptionally, Wilanov, known as the “Polish Versailles,” suffered only minor war

damage and was turned into a museum by the Communists. For details, visit: http:// www.wilanow-palac.pl/palace.html.

Because February temperatures in Warsaw range from 1 degree centigrade above to 6 degrees below zero, a hat or earmuffs, gloves and a muffler are essential.

Waterproof, slip-proof shoes are a good idea. A winter tip: warm up with a hot, spiced beer in any pub or savour the legendary hot chocolate in an E Wedel “chocolate lounge”.

Interacting with Chopin As you walk along the Royal Way, you'll come upon granite benches programmed to play Chopin at the press of a button. Fourteen of them were installed in 2010 as part of the celebrations of the composer's bicentenary.

Chopin often strolled these avenues when he and his family lived in rooms that are now a museum in the Academy of Fine Arts at 5 Krakowskie Przedmieście Street.

(As he had requested, the composer's heart is buried in a pillar of the neighbouring Church of the Holy Cross.)

The Fryderyk Chopin Museum is a five-minute walk from Nowy Swiat. The 21st century museum, installed in the 17th century Ostrogski Palace, employs cuttingedge audiovisual technology to bring the Chopin story to life. There are five floors of exhibitions. A swipe card activates monitors, projectors and speakers; there are 14 individual music-sampling stations. You can see Chopin's last piano, a lock of his hair, letters to his sister, portraits and first editions of his manuscripts. The museum is open Tuesday through Sunday from 11.00 to 20.00. Free entry on Tuesday. On other days, tickets are issued for admission on the hour. Book online at www.chopin.nifc.pl or through your concierge.

The 17th ESCRS Winter Meeting will be held in Warsaw from 15-17 February.

Visit Maryalicia Post’s website at: www.maryaliciatravel.com.

75

Feature

RESIDENT’s DIARY

OPHTHALMOLOGY AS ART

The thrill of solo success can be counterbalanced by the anxiety of lonely failure

by Leigh Spielberg

L

ike sport, ocular surgery demands mastery of equipment, technique and performance to succeed where others have failed Extreme sports have long interested me as an art form. Videos of out-of-bounds skiing, big-wave surfing, alpine hang-gliding and open-ocean speed sailing have always been able to grab my attention and hold it until the athlete crashed or the video ended, whichever came first.

There’s something visually magnificent about a skier flying down a mountain peak through waist-high powder, or a mountain biker soaring through the air between the trees and into the valley below. Just like Quentin Tarantino is a master at exploiting the aesthetic qualities of violence to produce beauty – witness the fantastic samurai sword fights in Kill Bill – extreme sports movie directors take advantage not only of the scenery but also of the fluid movements of the athlete to create a beautiful whole.

Recently, I’ve come to recognise the same splendour in ocular surgery. Witness an experienced surgeon reattaching an uncooperative retina or replace an ailing cornea with one of crystalline clarity. This is to behold elegant performance art with a higher purpose than perhaps any other: the restoration of health, happiness and vision to what would otherwise have become a dark and painful life.

So if extreme sports and ocular surgery can both be exciting and beautiful, there must be other similarities between the two. Surgery and extreme sports both start with a mastery of basic technique. The basics form the underpinning of performance and a foundation to fall back on in case of trouble. And the ambitious surgeon/athlete must be willing to enlarge this foundation and go beyond the normal boundaries of standard practice and develop deep knowledge of the many potential pitfalls as well as the ability to get out of unexpected situations with minimal harm to one’s patients – or, in the case of extreme sports, to oneself.

Extreme sports might be defined as activities in which there exists a realistic possibility of serious bodily harm. Put an average skier on the top of a black diamond slope and (s)he will likely end up in trouble. This possibility also applies to the complications of surgery. Ask an inexperienced young ophthalmologist to replace a severely diseased cornea with a

HOW DO YOU LIKE YOURS? EUROTIMES | Volume 17 | Issue 9

Credit: Eoin Coveney

76

new one and the patient will likely not fare much better. Of course, surgical risk applies primarily to the patient rather than to the surgeon, but for the practitioner they are to be avoided with equal fervour, for uncontrollable variables abound. Surgical risk factors like high myopia, vitreoretinal traction, anticoagulants and tamsulosin, just like their environmental counterparts – wind, rain, rocks and snow – make the terrain unpredictable, dangerous, interesting… and ultimately worthwhile.

Of course, specialised equipment helps. It builds one’s confidence to get started on a vitrectomy with the newest trocars. Forget about starting a corneal transplantation without a very precise trephine. And who knows where the current developments of the femtosecond laser will lead

cataract surgery? But it might well be spectacular.

Cutting-edge of athletic performance has attracted people for ages, and great athletics preceded medical progress by thousands of years. While the ancient Greeks were sprinting their way to Olympic glory, their contemporary, the Greek physician Alcmaeon, postulated that the eye contains not only water but also fire. That is very poetic, and our patients with a burning sensation in their eyes might be inclined to agree with him. But reliable restoration of sight would have to wait until modern times.

Fortunately, ophthalmology has come a long way since then, and has consequently come to attract some of the best and brightest in medicine and research. Thousands of people have dedicated their lives to the field of ophthalmology, and millions of patients have benefited from their efforts. But in the end, medicine and surgery are solitary pursuits. Only one surgeon has the blade in hand, ready to enter the anterior chamber.

The solitary aspect of both extreme sports and ocular surgery can either attract or repel. The thrill of solo success can be counterbalanced by the anxiety of lonely failure. If a suprachoroidal haemorrhage occurs during your procedure, or if your rope fails during a rock-climbing ascent, you’d better know what to do, because you’re all alone at that point.

Saving the eye and saving your life boils down to secondnature knowledge and rapid execution of what needs to be done. In other words, it’s back to the basics.

Encouragingly, a big advantage of ocular surgery is that we can practise it far longer than we can practise extreme sports.

We can continue beyond the moment at which our knees no longer tolerate icy ski trails, beyond the time when our wrists can no longer take the pounding of bike handlebars on a rutted mountain trail, and beyond the time when we might truly fear that something might go wrong while we are all alone in some distant corner of the Earth.

Extreme sports are for the young and agile, while ocular surgery can continue to be performed as long as we’ve got our wits, our vision and our fingertip precision. So, as residents, we can take comfort in the idea that the effort we make now will continue to pay dividends for several decades to come, after we’ve passed the baton of extreme sports to the next generation. If we’re lucky, we can continue working along with a talented and dedicated team of colleagues, anaesthesiologists and nurses who will support our ambitions and will pick us up in the unlikely event that we fall.

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

From the freshest source and in the company of market leaders Enjoy a relaxed breakfast with exhibitors and fellow delegates.

Discover new ideas, meet your peers, surround yourself with cutting edge technology and innovative research.

Join us in the Exhibition Halls

am ur 13th EURETINA Congress

26â&#x20AC;&#x201C;29 September 2013

www.euretina.org

Feature

PRACTICE DEVELOPMENT

PRIVATE EQUITY

Non-surgeon capital partners fund technology and quality, but model won’t suit all surgeons

by Howard Larkin

F

our years ago, Brendan Moriarty, MA (Cantab), MB, B Chir, FRCS FRCOphth, MD, opened the Prospect Eye Clinic, a state-of-theart laser and surgery centre in Altrincham, Cheshire, near Manchester, UK. This summer, he sold Prospect to Optegra, a privately held firm that operates five specialist ophthalmic hospitals and numerous clinics in the UK, and five eye surgery centres in Germany.

As is typical with Optegra acquisitions, Dr Moriarty will continue as a consultant.

Four days a week at Prospect, he will do laser surgery and see patients. One day a week he will operate at Optegra Manchester Eye Hospital, where he has introduced the Implantable Miniature Telescope (IMT), for end-stage macular degeneration. “It is a delight to be operating in a dedicated eye facility using disposable equipment and thereby avoiding TASS. Previously, private eye surgery largely took place in theatres which were shared with orthopaedics, ENT etc. This was not ideal,” he said.

The arrangement makes sense for many reasons, Dr Moriarty says. It provides access to the latest high-tech diagnostic and treatment equipment – without a huge upfront investment.

Highly trained technicians and low-vision optometric services at the hospital will allow introduction of IMT implantation and support other intraocular surgery.

Optegra was recently awarded AQP status

(any qualified provider) which enables contracting with the UK National Health Service, bringing private-sector efficiency and capital investment at a time of shrinking public resources.

Coverage by other Optegra-affiliated surgeons will allow Dr Moriarty to return to working abroad with ORBIS and other charities, he explains. Optegra supports all specialities of ophthalmology as well as research and training programmes.

Investment For Optegra, investing for the long run is the key to success, says Tim Clover, who heads London-based Moonray Healthcare, the private equity firm that owns Optegra and other health-related businesses.

He presented on the role of private capital in ophthalmology at last year’s ESCRS Practice Development Weekend in Dublin, Ireland.

Mr Clover will also be presenting at the Practice Development Workshops during the XXX ESCRS Congress in Milan, Italy.

Mr Clover notes that Moonray has no minority investors or debt financing, so it faces no outside pressure for short-term gains. All of its financing is cash from Fidelity, a private company seeking longterm sustainable growth. Ophthalmology fits the bill perfectly, he says. “Healthcare is driven by ageing demographics. In ophthalmology, we believe there will be not only demographic but also technological growth. One area is presbyopia and another is AMD,” Mr Clover says.

But high-tech comes at a high cost that few ophthalmologists can afford on their own, Mr Clover adds. At the same time, there’s plenty of downward pressure on payments. As a result, sustaining future operations will require increasing efficiency and maximising utilisation of capital equipment.

Optegra’s model of developing eye hospitals that include every speciality help provide the volume needed to support investments in a broad range of technologies, Mr Clover says. “No singlesurgeon practice can provide all the different lasers and diagnostic equipment required by modern ophthalmology – SLT, OCT, femtosecond lasers. At the very minimum you need seven or eight surgeons to be able to use them effectively.” Optegra shoots for about 20 surgeons at each hospital and has about 70 independent practitioners using its facilities.

One advantage of scale is the ability to develop and mass market branded services, such as Clarivu, Optegra’s refractive lens exchange programme that is nationally advertised in the UK. Another advantage is buying supplies in bulk at a discount.

Optegra operates a technology assessment panel that includes affiliated surgeons and a medical director that evaluates new technologies and products. The best are introduced throughout the firm’s facilities.

The firm also supports a not-for-profit research arm, Optegra Eye Sciences, which supports basic research in ophthalmology.

When acquiring practices, Optegra buys all practice assets, sometimes including real estate. Generally, the selling surgeons remain as independent contractors, Mr Clover says.

The process takes time as the company is looking for established practices in higher population areas that have potential to grow.

“We have yet to acquire a business that people are stepping away from. Usually the owners become key contributors.”

contacts

78

James O’Reilly – jimoreilly3@hotmail.com Brendan Moriarty – deryn@brendanmoriarty.com Tim Clover – finola.bromley@fil.com

This commitment was a major consideration for Dr Moriarty, he says.

Loss of autonomy? But as benign as a private equity partner may appear, partnering with one does entail a loss of autonomy and possibly accepting a sales-focused corporate ethos that makes some surgeons uncomfortable, says James O’Reilly MB, BCh, BAO, MMedSc (Hons) FRCOphth, EBOD, who practices in Kilkenny and Waterford, Ireland.

Corporations have nearly taken over laser refractive surgery, squeezing out most independents, he notes. With providers like Optegra branching out into glaucoma, cataract surgery and medical retina, Dr O’Reilly anticipates fierce corporate competition for national health contracts for these services as well.

“Practices need capital and to some extent Optegra is pointing out this deficiency,” says Dr O’Reilly, who also attended Mr Clover’s presentation at last year’s ESCRS Practice Development Weekend. But he believes that the capital needs of a successful integrated practice may not be as great in future.

“A lot of technology has or is reaching a plateau, including phaco, excimer lasers and femtosecond lasers. SCHWIND has developed lasers that are less expensive to service, and the capital cost will be less in the future. OCT was very expensive, but it is becoming more affordable,” Dr O’Reilly says.

Drawing inspiration from Irish farmers who in the early 20th century organised to form farmer-owned regional co-operative companies that have since grown to become international food giants, such as Kerry Foods, Dr O’Reilly suggests that ophthalmologists need to contract with business experts to build and market fullservice practices. “If we want to remain independent we need to develop innovative ways of working together.”

Introducing

Powered by Nature ®

MKT 056 REV B 07/12

EUROTIMES | Volume 17 | Issue 9

Raindrop is a trademark and ReVision Optics is a registered trademark of ReVision Optics, Inc.

Booth N320

Call for submissions open August 15 â&#x20AC;&#x201C; September 25, 2012

5 reasons you should be with us in San Franciscoâ&#x20AC;Ś 1. Cutting edge clinical and surgical education 2. Immediately applicable pearls for improving patient care 3. Emerging techniques from the global perspective 4. Superb networking with like-minded surgeons 5. Extensive practice management educational opportunities

Preview the meeting at www.ASCRS.org or www.ASOA.org Reserve your hotel today at www.ASCRS.org/gethousing

80

Reference

CALENdAR OF EVENTS

Dates for your Diary

September

September

September

October

3rd EuCornea Congress

2nd World Congress of Paediatric Ophthalmology and Strabismus

2nd Thessaloniki International Vitreo-Retinal Summer School

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

www.wcpos.org

UKISCRS – XXXVI Annual Congress

2012

6-8 MILAN, ITALY www.eucornea.org

2012

12th EURETINA Congress

7-9 MILAN, ITALY

www.euretina.org

XXX Congress of the ESCRS

6-9 MILAN, ITALY

8-12 MILAN, ITALY

2012

14-16 CHALKIDIKI, GREECE

27-28 BRIGHTON, UK www.ukiscrs.org.uk

www.escrs.org

2012

4-6 BUENOS AIRES, ARGENTINA

www.congresos-rohr.com/alaccsar2012

8th Annual Congress of the CSCRS

5-7 DUBROVNIK, CROATIA www.cscrs.hr

October

October

October

November

Practice Development Weekend

EVER 2012 Congress

AAO•APAO Joint Meeting

http://pddublin.escrs.org

www.ever.be

Modern Technologies in Cataract and Refractive Surgery – 2012

2012

2012

5-7 DUBLIN, IRELAND

10-13 NICE, FRANCE

8th International Symposium on Uveitis

2012

25-27 MOSCOW, RUSSIA www.mntk.ru

19-22 HALKIDIKI, GREECE

2012

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

New Horizons in Cataract Surgery 16 LONDON, UK

www.ISU2012.org

www.newhorizons2012.co.uk

November

December

January

January

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

5th Amsterdam Retina Debate

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

28th Congress of APAO & 71st Annual Conference of AIOS

2012

2012

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

30 LONDON, UK

www.mclosa.org.uk/annualmtg.html

2013

2013

17-20 HYDERABAD, INDIA

www.ophthalmictrainings.com

www.apaoindia2013.org www.aios.org

9-11 VIENNA, AUSTRIA

February

April

June

July

17th ESCRS Winter Meeting

4th World Congress on Controversies in Ophthalmology (COPHy)

European Society of Ophthalmology (SOE) 2013

26th APACRS Annual Meeting

www.soe2013.org

5th World Glaucoma Congress

2013

15-17 WARSAW, POLAND www.escrs.org

2013

4-7 BUDAPEST, HUNGARY

www.comtecmed.com/cophy/2013/

ASCRS ASOA Symposium & Congress •

2013

8-11 COPENHAGEN, DENMARK

2013

11-14 SINGAPORE www.apacrs.org

17-20 VANCOUVER, CANADA www.worldglaucoma.org

19-23 SAN FRANCISCO, CA, USA www.ascrs.org

Advertising Directory: Abbott Medical Optics: Pages: 3, 31; AcuFocus: Pages: 12, 37; Alcon: Pages: 7, 29, 34-35,45, 65, 71, IBC, OBC; Alsanza: Page: 44; Angiotech: Page: 42; A.R.C. Laser Ag: Pages: 8, 18, 53; ASCRS / Eyeworld: Pages: 66, 72, 79; Avedro: Pages: 39; Bausch + Lomb: Pages: 22-23; Benz: Page: 15; Croma-Pharma: Pages: 19, 48, 63; CXL: Page: 24; D.O.R.C.: Page: 58; Geuder: Page: 52; Haag Streit: Page: 73; iCare Finland: Page: 13; Katena: Page: 51; KC Solutions: Page: 9; MBI: Page: 10; Medicel: Page: 67; Medicontur: Page: 11; Moria: Page: 27; NIDEK: Page: 33; Oasis: Page: 61; Oculus: Pages: 14, 36, 47, 69; Oertli Instruments Ag: Pages: IFC; OWL: Page: 64; Reichert: Page: 55, 57, 59; Rumex: Page: 30; RVO: Page: 78; Schwind: Page: 17; Surgistar: Pages: 25, 41; Technolas: Page: 16; VSY: Page: 46; Zeiss: Page: 21; Ziemer: Page: 28.

Game Changer In 1968, Dick Fosbury revolutionized the high jump by developing a technique that elevated him to Olympic gold, raising the bar for athletes the world over.

It’s time to rewrite the rules of vitreoretinal surgery.

• Experience the ULTRAVIT ® 5000 cpm probe with surgeon-controlled duty cycle to reduce iatrogenic tears and post-op complications1 • Trust in integrated and stable IOP compensation2 • Enhance patient outcomes and achieve faster visual recovery with ALCON® MIVS platforms3 • Improve your OR turnover by 39% with V-LOCITY® Efficiency Components4

© 2012 Novartis

2/12

CON11241JAD-EU

Welcome to the new possible.

1. Rizzo S, et al. Comparative Study of the Standard 25-gauge Vitrectomy System and a New Ultra-high-speed 25-gauge system with duty cycle control in the treatment of various vitreoretinal diseases. Retina, 2011; Vol. X; No. X. 2. Riemann C, et al. Prevention of intraoperative hypotony during vitreoretinal surgery: an instrument comparison. ASRS. Poster Presentation, 2010. 3. Nagpal M, Wartikar S, Nagpal K. Comparison of clinical outcomes and wound dynamics of sclerotomy ports of 20, 25, and 23 gauge vitrectomy. Retina. 2009;29(2):225-231. 4. Alcon data on file 954-0000-004.