EuroTimes Vol. 19 - Issue 4

special focus Cataract & Refractive surgery VIEWPOINT

In pursuit of excellence in ophthalmology April 2014 | Vol 19 Issue 4

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Angela Sweetman Advertising Executive Mairin Condon Senior Designer Janice Robb Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird 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

Contents SPECIAL FOCUS

™

features

Cataract & Refractive

Cornea

4 Experts look at US

20 A look at the best

Refractive Surgery trends

5 Aspheric treatment for

light adjustable lens can improve visual acuity

6 New topography platform can aid in measuring astigmatism

7 Improved refractive

outcomes in cataract surgery with new system

8 Promising results with new oil-filled IOL

10 Formula for IOL power calculation may offer greater precision

12 A look at prevention

and treatment of CME

14 Minimising dry eye

symptoms following refractive laser surgery

15 New IOL with acrylic

material showing predictable visual results

16 Artificial iris implant surgery is becoming more popular

18 Precision of biometry

approaches to managing graft detachments after DMEK

22 Fewer rejection episodes

after DSAEK, study shows

Glaucoma 24 Screening for angle-

closure glaucoma could prevent blindness

25 Connection found

between oral birth control and glaucoma

26 A look at the safety

and efficacy of generic eye drops

retina 28 Optimum results achieved with individual screening of diabetic patients

30 A lot of progress has been made in discovering causes of CME

32 Optogenetics could be

solution for patients with incurable retinal diseases

34 Radiotherapy shows

promise in AMD treatment

important in hyperopic eyes

19 Study shows brand As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2013 and 31 December 2013 is 40,878.

p.28

name products favoured over generics

ocular 36 New technique for

treating presbyopia

38 New patient database could greatly improve ophthalmic care

40 Improvement in

ophthalmologyoptometry relations will benefit patients

Meeting report 42 News from the ESCRS

Winter Meeting in Slovenia

regulars 43 Journal Watch 44 Viewpoint 45 ESASO update 46 Travel 47 JCRS Highlights 48 ESCRS Observerships 49 Industry News 50 Didactic update 52 Calendar of Events

p.49 Eurotimes | april 2014

2

editorial A Word from Emanuel Rosen chief medical editor of EuroTimes

EXCITING OPPORTUNITIES EuroTimes has a new identity which will allow us to incorporate diverse new elements into the magazine

W

elcome to the April issue of EuroTimes This article is timely and the editors hope that it will open which comes to you in a new size and format. up a lively and stimulating debate on this issue.

The new A4 magazine is an ambitious step I am also very pleased to see that April EuroTimes includes for the publication and I believe it will offer a new didactic section focusing on some of the basic issues exciting new opportunities. The editors facing young ophthalmologists in training. The first article have felt for some time that A4 would be a in the series is by Dr Soosan Jacob, titled: “Making the much handier format especially now that we have iPad and perfect capsulorrhexis," and should be a valuable source of online formats. information and education for our trainees.

The magazine has a new identity which will allow us to So what else is new? As I mentioned earlier, we are now in incorporate exciting new elements. Our readers are highly an exciting era where traditional magazines like EuroTimes qualified, highly intelligent and eager to be kept up to date are being supported by online media through interactive with the latest developments in technology. Although the websites and applications for iPhones and tablets. magazine will have a new look, our core principles will While the print magazine will continue to be the flagship remain the same as we endeavour to be a trusted source of for the ESCRS, the editors are also conscious of the information and debate in the ophthalmology community need to meet the online needs of our readers. With that and a valuable source of reference. in mind, we are redesigning Now in its 19th year of publication, EuroTimes and rebranding our website, has seen many changes. We believe that the new www.eurotimes.org, and in an I am also delighted to see format will allow the magazine to continue to exciting new development we that as well as changing grow and it will be even more attractive to our are producing an application readers. We look forward to the challenges and that will give our readers the look and feel of the opportunities ahead as we continue to pursue better access to online tools magazine, the editors our mission statement of providing “a European such as video. have decided to introduce outlook on the world of ophthalmology”.

These are interesting I am also delighted to see that as well as times and over the next few some exciting new changing the look and feel of the magazine, the months we will announce content to EuroTimes editors have decided to introduce some exciting more initiatives. As always, new content to EuroTimes. This month’s issue thank you for reading and includes a new column “Viewpoint” where contributing to EuroTimes and key opinion leaders talk about some of the hot topics we look forward to hearing your views and comments on in ophthalmology. our new-look magazine.

This month’s column, written by Dr Peter Barry, past president and treasurer of ESCRS, asks the question: What does excellence look like? In this excellent article Dr Barry argues that while there have been exciting innovations in technology, ophthalmologists must never forget that their first duty is to their patients.

Medical Editors

Emanuel Rosen Chief Medical Editor

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

International Editorial Board Noel Alpins (Australia), Bekir Aslan (Turkey), Bill Aylward (UK), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), Hiroko Bissen-Miyajima (Japan), John Chang (China), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Vikentia Katsanevaki (Greece), Thomas Kohnen (Germany), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-Jose Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

Eurotimes | april 2014

4

special focus: cataract & refractive

US refractive surgery

N

Femto-cataract surgery catches on; laser volume flat in 2013.

Howard Larkin reports

For a 45-year-old +5.0 D hyperope, RLE remained the clear choice with 61 per cent in 2013, virtually unchanged since 2005, with laser correction also stable around 13 per cent...

early one-quarter of US refractive surgeons performed five or more femtosecond laser-assisted cataract procedures per month in 2013, while five per cent did 25 or more, Richard J Duffey MD, Mobile, Alabama, US, told the 2013 annual meeting of the American Academy of Ophthalmology in New Orleans.

He reported results from the 17th annual survey of US members of the International Society of Refractive Surgery, which Dr Duffey conducts with David Leaming MD, Palm Springs, California, US. Last year was the first time the survey asked about femtocataract surgery. “Already five per cent of us are doing 25 cases or more per month, which I thought was significant,” Dr Duffey said.

Toric and presbyopia correcting lenses are also gaining ground, with 50 per cent and 37 per cent reporting five or more cases in 2013. However, while volumes are growing, they are not as high as LASIK in its heyday, Dr Duffey said.

By contrast, reported laser refractive surgery volume was flat at 451,000 in 2013, the same as 2012 but down from 500,000 to 560,000 over the previous five years. Only 56 per cent reported doing five or more LASIK cases monthly, down from 64 per cent in 2011, while 26 per cent reported 25 cases or more, about even with 28 per cent in 2011 and 23 per cent in 2012. Surface ablation volume dropped more, with just 24 per cent reporting five or more procedures and just six per cent 25 or more in 2013, compared with 37 per cent and nine per cent in 2011.

Richard J Duffey MD For a 45-year-old +5.0 D hyperope, RLE remained the clear choice with 61 per cent in 2013, virtually unchanged since 2005, with laser correction also stable around 13 per cent, while phakic IOLs dropped to one per cent. Those opting to wait fell to a new low of 14 per cent, indicating most surgeons are now comfortable with the available correction options, Dr Duffey noted.

Astigmatism Surgeons were also more comfortable correcting astigmatism at cataract surgery, with two-thirds offering to correct at a preoperative level of 0.75 D cylinder or less, up from just over half in 2012. For 0.5 to 1.0 D, limbal relaxing incisions or arcuate keratotomy were the choices for 88 per cent. For 1.12 to 2.0 D, 75 per cent favoured toric lenses, rising to 96 per cent in cases with more than 2.0 D preoperative cylinder.

In LASIK, trends toward thinner flaps and thicker residual stroma continued with 97 per cent looking for flaps of 130 microns or less, and 61 per cent residual stroma of 275 microns or more.

Nearly three-quarters now use femtosecond laser flap cutters.

Reported post-LASIK ectasia rates continue to drop, Dr Duffey reported. “This is an important finding.”

Laser vs lens For a 30-year-old -10.0 D myope, laser vision correction remained the top choice, with 47 per cent opting for either surface ablation or LASIK. Phakic IOLs came in second at 38 per cent. These rates have remained stable for the past three years.

Laser vision correction, including LASIK and surface ablation, was also the top choice for a 45-year-old +3.0 hyperope, with 58 per cent, with refractive lens exchange (RLE) in second at 28 per cent. This marks an upward trend in RLE over the past decade, from about 11 per cent in 2005.

US refractive surgery trends, 2013 Laser refractive surgery volume continued its slide …

Source: Annual surveys of US members of ISRS by Richard Duffey MD and David Leaming MD, 2004-2013

… while premium cataract surgery grew (Respondents reporting five or more cases monthly)

Toric lenses were preferred for higher astigmatism corrections Cylinder 0.5-1.0 D

13%

68% 65% 64% 58% 56%

10% 15%

1.12-2.0 D

21%

37%

37%

30%

24%

37% 38%

50% 37% 23% 2.0 D+

2004

2007

2011

Surface ablation

2012 LASIK

2013

2012 Toric Lens Femto-cataract

Eurotimes | april 2014

55% 32%

75%

2% 2%

96%

2013 presbyopia-correcting IOL

LRI 2013 Data

AK

Toric Lens

special focus: cataract & refractive

MULTIFOCAL LENS Aspheric treatment can improve visual acuity.

Roibeard O’hEineachain reports

A

n aspheric treatment for the light adjustable lens (LAL®, Calhoun Vision) following the first refractive adjustment can improve uncorrected near and intermediate vision without sacrificing uncorrected distance visual acuity, said Fritz Hengerer MD, Ruhr University Eye Hospital, Bochum, Germany.

“Using this approach, the dominant eye can be adjusted to emmetropia while an aspheric treatment is applied to the non-dominant eye to improve near and intermediate visual acuity,” Dr Hengerer said at the XXXI Congress of the ESCRS in Amsterdam.

The LAL is a foldable three-piece silicone IOL with blue PMMA modified C haptics. The optic of the three-piece foldable silicone lens contains an unpolymerised silicone matrix polymer that becomes polymerised upon exposure to ultraviolet light, he noted. After implanting the lens, irradiating specific areas of the lens with a digital light delivery device induces the polymerisation of the unpolymerised silicone, causing a local shrinkage of the lens material. In this way it allows post-implantation correction up to plus or minus 2.0 D of sphere and up to -2.0 D of astigmatism, and multiple adjustments are possible, he explained.

In a series of eight patients, Dr Hengerer and his associates implanted the LAL in the non-dominant eye leaving the other eye emmetropic – whether prior to surgery or following implantation of an IOL – with a visual acuity of 20/20 or better.

The primary adjustment targeted a spherical refraction of 0.25 D to -0.50 D and a cylindrical refraction less than 0.75 D. The secondary adjustment aimed at inducing an asphericity of -0.20 (Z12) with a 4.0mm pupil. Two lock-in treatments completed the adjustment process.

At a follow-up of six months after the final adjustment, the mean uncorrected near visual acuity was J3 compared to pre-adjustment value of J5. In addition, pre-adjustment to post-adjustment, mean UIVA improved from J4 to J1 postadjustment and mean UDVA improved from J3 pre-adjustment to J2. There was a shift in measured asphericity at one month following the aspheric adjustment.

Dr Hengerer noted that the first two patients reported a reduction in their distance visual acuity following the aspheric adjustment because of a slight myopic shift postoperatively, but this was corrected by an additional myopic adjustment. In the following patients they aimed for a slight hyperopic outcome.

Dr Hengerer and his associates performed a bilateral aspheric adjustment in a patient whose left eye was dominant. The patient achieved an uncorrected near visual acuity of J2, an uncorrected intermediate visual acuity of J2 and intermediate visual acuity of J1 and a distance visual acuity of 20/32 in his non-dominant right eye and achieved respective values of J2, J2 and 20/25 in his dominant left eye.

Treatment can improve near and intermediate visual acuity, and distance visual acuity remains stable regardless of the pupil size. Bilateral aspheric treatment is optional but further investigations are necessary to individualise the amount of induced asphericity according to the patient’s needs, he said.

Booth Session at ASCRS2014

Fritz H Hengerer: fritz.hengerer@kgu.de Eurotimes | april 2014

5

special focus: cataract & refractive

Courtesy of Victor Arni Sicam, PhD

6

MEASURING ASTIGMATISM

A

New colour LED technology provides increased repeatability and accuracy, reports Cheryl Guttman Krader

ccurate determination of the axis of astigmatism is critical for optimising visual outcomes with toric IOLs. Therefore, in seeking precision, surgeons often obtain multiple keratometric readings.

However, results of a comparative study presented at the XXXI Congress of the ESCRS in Amsterdam suggest that the need for repeat astigmatism measurements and the extra time and effort involved can be avoided by using a new topography platform that uses colour LED triangulation technology and a unique ray tracing principle to analyse the corneal surface (Cassini, i-Optics).

In the study, the colour LED topographer, an optical biometer (Lenstar, HaagStreit), a Scheimpflug device (Pentacam, Oculus), and a Placido ring topographer (Keratron, Optikon) were used to obtain anterior corneal measurements (flat K, steep K and flat axis) in 60 eyes of cataract surgery patients. Three measurements were obtained in each eye with each device and the standard deviation of the three within subject values was analysed to evaluate repeatability for each system.

Although the four instruments had similar repeatability for determining the magnitude of astigmatism, the colour LED system had significantly better repeatability than each of the other devices in measuring astigmatism axis, reported Victor Arni Sicam PhD, inventor of the Cassini.

Mean standard deviation for the axis measurements was 4.8º using the colour LED topographer, 6.5º with the optical biometer, 9.4º using the Eurotimes | april 2014

Placido topographer and 14.9º using the Scheimpflug device.

Further analyses showed the repeatability of measuring astigmatism axis was improved for each of the instruments when only data from eyes with cylinder greater than 0.5 D was used. Again, however, the mean standard deviation values showed the colour LED topographer had significantly better repeatability than the optical biometer, Placido topographer and Scheimpflug device4.1º vs. 6.0º, 7.3º and 12.2º respectively.

“Results from previously published studies using various keratometric instruments highlight there is only moderate repeatability of multiple axis measurements. The current study shows that with the colour LED system, only one measurement is needed to obtain accurate astigmatism information for toric IOL implantation. The first time will be right,” Dr Sicam told EuroTimes.

He explained that the nature of its measurement technology accounts for the superior repeatability of the colour LED topographer.

“The measurements are taken instantaneously and the acquired information is simple points rather than rings so that image and data processing are easier, this study used a Cassini clinical

prototype and it is expected that the commercial version will perform much better,” Dr Sicam said.

The study also investigated agreement of astigmatism magnitude measurements between the colour LED topographer and the other instruments based on BlandAltman plots of the median data point for each eye. A systematic difference was noted between the colour LED topographer and the optical biometer and was even stronger comparing the colour LED topographer and the Placido ring topographer. In both cases, there was a trend for the inter-instrument difference to increase as the magnitude of astigmatism increased.

“The Bland-Altman comparison can only establish differences between technologies but cannot identify which device is more accurate. For that reason we used the instruments to measure an artificial toric surface,” Dr Sicam said.

For the latter measurements, the colour LED topographer and the optical biometer performed similarly and provided data within the confidence limits for accuracy.

The Placido ring system measurements had an error of four to five per cent.

Victor A Sicam: va.sicam@i-optics.com

The Bland-Altman comparison can only establish differences between technologies but cannot identify which device is more accurate Victor Arni Sicam PhD

special focus: cataract & refractive

IMPROVING OUTCOMES Study results show value of system.

Cheryl Guttman Krader reports

I

ntraoperative aberrometry-assisted IOL power selection using streaming refractive data (ORA System with VerifEye, WaveTec Vision) provides a means for achieving improved refractive outcomes in cataract surgery, according to the results of a multicentre study presented by Dan B Tran MD, at the XXXI ESCRS Congress in Amsterdam.

“When examining refractive outcomes in conventional cataract surgery, recent data show that when using preoperative measurements and conventional IOL power calculations, about 75 per cent of eyes are within 0.5 D of predicted postoperative spherical equivalent (SE) postoperatively. That is an improvement compared with previous reports in which this level of accuracy was achieved in less than 50 per cent of eyes. However, cataract surgeons would like their refractive outcomes to match those achieved with LASIK,” said Dr Tran, who was an investigator in the study, and is in private practice, Orange County, CA. New data from a recent study looking at the recently released ORA System with VerifEye show that refractive outcomes are superior to those reported in the literature and significantly better than what surgeons would have gotten had they used their preoperative IOL power calculations, he reported.

The study included data from 262 eyes operated on by 14 surgeons. Eligible eyes had no ocular disease or history of corneal refractive surgery and underwent uncomplicated cataract surgery. They were implanted with a variety of IOLs, including various multifocal and toric models.

Preoperatively, surgeons calculated IOL power using their preferred formula, but the implant power was ultimately selected based on the aphakic refraction and the intraoperative aberrometer manufacturer’s proprietary formula. In toric IOL cases, the intraoperative aberrometer was also used to calculate cylinder power and to guide IOL rotation to minimise cylinder.

Dr Tran reported that in two-thirds of the cases, the surgeon changed the IOL power based on the intraoperative ORA measurement. In most of those cases, 82 per cent, the power change was 0.50 D, in 12 per cent of those cases, the change was 1.00 D or more. ORA confirmed the calculated preoperative power 34 per cent of the time.

Mean absolute value of the prediction error (MAVPE), which was calculated using the difference between the predicted SE and actual refraction at one month, was significantly lower with the use of intraoperative aberrometry than had the surgeon’s preoperative determinations been used, 0.29 ±0.20 D vs. 0.33 ±0.27 D (P<0.03).

Distribution analyses showed 84 per cent of eyes were within 0.50 D of the predicted spherical equivalent after surgery whereas that proportion would have been 78 per cent had the surgeon’s preoperative calculation been used.

When the refractive outcomes were analysed with the eyes categorised by IOL model, the results showed good accuracy across all platforms. Data from the subgroup of 33 eyes implanted with a toric IOL showed astigmatism was reduced from a mean of 1.94 D ± 1.11 preoperatively to 0.39 D ± 0.36 D at one month postoperatively.

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Dan B Tran: danbtran@gmail.com Eurotimes | april 2014

7

special focus: cataract & refractive

IOL TECHNOLOGY Oil-filled IOL may reduce PCO. Dermot McGrath reports

A

new accommodating fluid-filled IOL has shown considerable promise in reducing the capsular bag opacification that frequently occurs after cataract surgery, according to Nick Mamalis MD, professor of ophthalmology, John A Moran Eye Centre, University of Utah, US. “We found that when the capsular bag is maintained in an expanded and open configuration that there is little to no anterior or posterior capsule opacification formation.

The results we achieved with this lens in the rabbit model are very impressive, as even the best IOLs will usually have significant PCO after six weeks,” he told a session of the XXXI Congress of the ESCRS in Amsterdam when reviewing results of a published study (Floyd AM, Werner L, Liu E, Stallings S, Ollerton A, Leishman L, Bodnar Z, Morris C, Mamalis N. Capsular bag opacification with a new accommodating intraocular lens. J Cataract Refract Surg 2013; 39:1415-1420).

Both eyes of same rabbit; 6 weeks

Courtesy of Nick Mamalis MD

8

Posterior view of globes sectioned post mortem showing the clear capsule in the study lens (right) compared to the control IOL

Posterior capsular opacification (PCO) prevention methods have traditionally focused on design factors such as the IOL material and the utilisation of square-edge optics. Researchers have recently been exploring the potential of open and extended capsular bag models to prevent PCO and fibrosis. The FluidVision IOL (Powervision) is a hydrophobic acrylic accommodating lens with a hollow, fluid-filled optic and oversized haptics.

“The large balloon-like haptics are filled with index-matched silicone oil which flows back and forth between the haptics and the optic with accommodation, thereby changing the curvature and the power of the optic,” he said.

Dr Mamalis performed bilateral phacoemulsification with IOL implantation in six rabbits, with each animal receiving both a FluidVision IOL and a control lens – a single-piece hydrophobic acrylic PCIOL (AcrySof, SA60AT, Alcon Inc.).

At six weeks, the PCO clinical score was 0.5 in the study group and 3.0 in the control group. Anterior capsule opacification was practically absent in the study group and mild in the control group. Miyake-Apple posterior view showed central PCO of zero in the study group and 3.0 in the control group, peripheral PCO of 0.66 in the study group and 3.5 in the control group, and Soemmering’s ring of 2.33 in the study group and 7.0 in the control group. Histopathology confirmed the relatively clean capsules in the study group and showed no signs of toxicity in either study or control eyes, said Dr Mamalis.

Nick Mamalis: nick.mamalis@hsc.utah.edu Eurotimes | april 2014

Recognize both.

Recommend AcrySof IQ Toric IOL. ®

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10

special focus: cataract & refractive add_april2014.pdf 1 07/03/14 08:43

IOL FORMULAS Race and gender parameters are incorporated in fifth-generation IOL formula. Dermot McGrath reports

A

new formula for calculating IOL power may offer greater precision for biometric calculations by incorporating the demographic specifics of individual patients based on race and gender. Kenneth J Hoffer MD, clinical professor of ophthalmology at Stein Eye Institute, University of California, said that human average values for biometric measurements are used in the fourth-generation formulas, specifically the Holladay 2 and the Hoffer H. The new formula, known as the Hoffer H-5, uses the basic structure of the widely used Holladay 2 formula but adds race and gender parameters to its logarithm of mean human biometry averages, he told a session of the XXXI Congress of the ESCRS in Amsterdam.

“I discovered that the biometry of women and men are different, with males having an axial length of about 0.50mm longer than women and having a cornea that is flatter by about 0.50 D. There are also racial differences in biometry values, so the new formula aims to take account of these important differences for even greater precision.”

The new Hoffer H-5, the “H” of which pays tribute to the work of Jack Holladay MD, represents the first fifth-generation formula Kenneth J Hoffer MD available. “We have gone through various generations over the years by adding different parameters to help us predict where the IOL will sit in the eye. The first-generation formulas used a constant for the anterior chamber depth and then the second-generation incorporated data on the axial length of the patient’s eye. The third-generation saw the introduction of keratometry values and the fourth-generation used lens thickness and corneal diameter and other factors,” he said.

C

M

Y

CM

MY

CY

CMY

K

Starting point The starting point of the Hoffer H-5 formula was to perform a search of the published scientific literature looking at the biometric measurements of human eyes in large series. Based on data from 212,740 eyes, Dr Hoffer was able to produce average values for different populations based on race and gender.

“We found a consistent difference between male and female biometry in every racial group in terms of axial length, K readings and anterior chamber depth. The average lens thickness, however, showed very little difference between genders,” he said.

Dr Hoffer also found statistically significant differences in biometry between Caucasian, Latino, Asian-Indian, Oriental, and Middle Eastern eyes. “Obviously the next step is to test the formula with much larger patient numbers and more diverse population groups which we are doing now. We have started a global collaborative study that has now collected 3,000 eyes from surgeons from around the world and are still amassing more data. We think that this new formula definitely has the potential to improve on existing formulas,” he concluded.

Kenneth Hoffer: Khoffermd@aol.com Eurotimes | april 2014

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special focus: cataract & refractive

CME AFTER CATARACT SURGERY Some new treatments now under investigation include anti-VEGF therapy. Roibeard O’hEineachain reports

ffective prevention and treatment of pseudophakic cystoid macular oedema (CME) requires careful surgery that avoids iris trauma in higher risk patients and involves the judicious use of steroids and non-steroidal antiinflammatory drugs (NSAIDs) in all cases, and vitrectomy in certain cases, notes Conceição Lobo MD, PhD, University Hospital, Coimbra, Portugal.

“Correct preoperative evaluation is essential for identifying patients at high risk for CME so that the therapeutic schema can be adapted according to the nature of the patient’s risk,” said Dr Lobo at the 13th EURETINA Congress in Hamburg.

Studies suggest that clinical, symptomatic CME occurs in 0.1 per cent to 2.35 per cent of eyes undergoing cataract surgery when prophylactic measures are taken.

Angiographic CME occurs at least 10 times as often. Chronic CME occurs in about one per cent to two per cent of uncomplicated cases and in about eight per cent of complicated cases.

Eurotimes | april 2014

The inflammatory condition typically occurs from 4-12 weeks after surgery and its incidence reaches its peak at 4-6 weeks postoperatively. Patients will commonly complain of impaired vision after an initial period of improved vision. OCT examination is usually sufficient to confirm the diagnosis. “In about 90 per cent of patients with macular oedema following cataract surgery, there is a spontaneous resolution of the oedema and recovery of visual acuity. In specific situations there is an excessive leakage that can lead to severe and irreversible impairment of visual acuity, “Dr Lobo said.

Diabetic patients are at an increased risk of CME, especially when they have preexisting diabetic retinopathy. The presence of uveitis may also increase the risk. In some studies the incidence of CME reaches 50 per cent among patients with uveitis associated with juvenile rheumatoid arthritis or pars planitis. Other reports suggest uveitis carries a less elevated risk.

Certain surgical complications can also raise the risk of CME. They include rupture of the posterior capsule, vitreous loss or incarceration, iris trauma, dislocated IOL, retained lens fragments and YAG laser capsulotomy. Lengthy cataract procedures, even when uneventful, can also increase the risk for the complication.

The prevention and treatment of pseudophakic CME is centred on the use of drugs that block the inflammatory mediators released in response to surgical trauma. Treatment with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) appear to have a synergistic effect on CME. Corticosteroids interfere with the activity of phospholipidase A, thereby selectively inhibiting Cox-2, and NSAIDs inhibit both Cox-1 and Cox-2.

All cataract patients should routinely receive postoperative topical steroids and NSAIDs. Patients should instill the steroid drops, prednisolone or dexamethasone, five times a day during the first postoperative week and three times a day during the second and third postoperative week. They should use topical NSAIDs 2-4 times a day (depending on the NSAID used) during the first postoperative week then 2-3 times a day for the following four postoperative weeks.

As an additional prophylaxis against pseudophakic CME, patients at high risk for the complication should receive topical steroids and NSAIDs preoperatively and patients receiving prostaglandin analogues should replace them with another IOPlowering agent.

“There is some controversy regarding the optimal regimen for prophylaxis of CME. Given the low incidence of CME, it

Given the low incidence of CME, it is not possible to prove scientifically what the best schema is Conceição Lobo MD, PhD

special focus: cataract & refractive

13

Courtesy of Conceição Lobo MD, PhD

CME – OCT images

is not possible to prove scientifically what the best schema is. However, data from the large multicentred randomised PREMED study, led by University of Maastricht and funded by ESCRS, once completed, should provide some clarity and enable us to standardise these protocols.”

There is less controversy regarding the treatment of CME. The results of randomised clinical trials show that steroids and NSAIDs improve visual acuity and have a synergistic effect. Therefore, the currently recommended regimens for the treatment of clinical CME are to administer topical steroids and NSAIDs four times a day for one month. If there are improvements in visual acuity and OCT, the treatment should be continued for another two months.

If there is no improvement, the possible next step is to add acetazolamide to the regimen at a dosage of 500mg a day for four weeks, first isolated or together with a sub-Tenon’s injection of 40mg of triamcinolone. If there is then a response, the triamcinolone injection should be repeated two or three times over a period of 3-6 weeks. If there is still a poor response then consider injecting triamcinolone intravitreally at a dosage of 4mg.

Some new treatments now under investigation include anti-VEGF and immunomodulatory therapy. Both require further evaluation to precisely determine their therapeutic value in eyes with CME, Dr Lobo said.

Vitrectomy is a useful option in the treatment of CME in some of the more complicated cataract cases. Such cases include those with pupillary or IOL distortion or prolapse, eyes with vitreous incarceration and retained led fragments, and those where vision continues to decline despite pharmacological therapy.

“The rationale for performing vitrectomy in cases with CME following cataract surgery is that it enables the removal of vitreous adhesions and inflammatory mediators and also allows improved access of topical medication to the back of the eye,” Dr Lobo added.

Conceição Lobo: clobofonseca@gmail.com

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Eurotimes | april 2014

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special focus: cataract & refractive

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CORRECTION SCREENING Tear osmolarity testing useful for deciding on patient eligibility.

Cheryl Guttman Krader reports

A

dding tear osmolarity testing to the routine dry eye screening protocol will allow refractive surgeons to minimise dry eyeassociated problems following refractive laser surgery, Richard Corkin MD told a session of the XXXI ESCRS Congress in Amsterdam. “Our analyses demonstrate that the results of a Schirmer’s I test, which is widely used as a standard screening test for refractive surgery, correlate poorly with the presence of dry eye. Tear film Osmolarity when used as a screening test, has higher sensitivity and specificity in identifying patients with this condition,” said Dr Corkin, consultant ophthalmic surgeon, UPMC Beacon Hospital and co-director at the Wellington Eye Clinic, Dublin.

The study included 111eyes of 58 consecutive patients presenting for laser refractive surgery in January 2012, of which 91 went on to surgery with either LASIK (39 eyes) or LASEK (52 eyes). The preoperative assessments included a Schirmer’s I test, tear osmolarity (TearLab) and examination for superficial punctate keratitis (SPK).

Preoperative evaluations demonstrated dry eye symptoms were absent in 58 per cent of all screened eyes, 73 per cent had no evidence of SPK. Despite this, a very low Schirmer’s I result ≤5.0mm was present in 34 per cent of the 111 screened eyes. According to eligibility criteria in use at the time at the Wellington Clinic, these patients would have been considered unsuitable for surgery, Dr Corkin explained.

Tear osmolarity was >308 mOsm/L in 38 per cent of the 111 eyes and >318 mOsm/L in 22.5 per cent (>318 mOsm/L would be considered dry). There was no correlation demonstrated between the preoperative Schirmer’s I result and tear osmolarity, Dr Corkin reported.

Twenty-six (68 per cent) eyes with a low Schirmer’s I ≤5mm went on to have LASEK (20 eyes) or LASIK (six eyes).

Eight (31 per cent) of those 26 eyes (with Schirmer’s<5) had tear osmolarity <308 mOsm/L and 21 eyes (81 per cent) had a tear osmolarity <318 mOsm/L. Dr Corkin said that all 26 eyes had uncomplicated surgery with excellent visual outcomes. None developed significant dry eye symptoms postoperatively, and while two-thirds of the LASEK eyes had some SPK after surgery, it was mostly grade 1. In the 91 operated eyes, there was a trend for higher preoperative tear osmolarity to correlate with presence of postoperative SPK. He also observed that an increasing number of older patients are now seeking laser refractive surgery. Of the 58 patients included in the study, nearly 25 per cent were older than age 50. “This shift in population demographics of patients seeking laser surgery is adding to concern since older patients are more likely to have dry eye problems and also have higher expectations for outcomes.”

He said that no single modality can be used as a de facto standard to identify dry eye, however, routine Tear Osmolarity testing is standard on all refractive patients at the Wellington Eye Clinic. Decisions to accept candidates for laser vision correction must still be based on a combination of tests along with patient history and clinical findings.

Richard Corkin: r.corkin@wellingtoneyeclinic.com

Eurotimes | april 2014

special focus: cataract & refractive

ACRYLIC MATERIAL New lens provides predictable visual outcomes.

Roibeard O’hEineachain reports

T

he iPure IOL (Physiol), which is composed of a new hydrophobic acrylic IOL material designed to be less prone to glistening, appears to provide an optical performance and intracapsular stability similar to lenses composed of an older hydrophobic material. “Early results reveal a good optic performance compared to a gold standard acrylic IOL. One month postoperatively, subjective refractive outcome and UCVA were satisfying and there were only a few cases of traces of glistenings or surface deposits with both IOLs,” said Sophie Maedel MD, Hanusch Hospital, Vienna, Austria, at the XXXI Congress of the ESCRS in Amsterdam.

Dr Maedel presented results of a randomised, controlled trial involving 50 eyes of 50 patients who underwent implantation of either the new hydrophobic acrylic IOL or a hydrophobic acrylic control IOL (Tecnis ZCB00, AMO) using standard phacoemulsification.

Mean target refraction was -0.58 D for the iPure and -0.35 D for the control IOL. In 47 eyes with one month’s followup, the mean absolute difference between subjective spherical refraction and target refraction was 0.54 D for the iPure and 0.49 for the control IOL. The two groups had similar UCVA at 0.09 logMAR for the iPure and 0.06 logMAR (p t-test= 0.60).

She noted that mean BCVA for both groups was 0.0 logMAR. One month postoperatively, there were no glistenings in 87 per cent of the iPure group and 91 per cent of the control group. In all instances the glistenings were found to be mild and may in actual fact have been small cellular deposits on the IOL surface in some cases. There were no cases of PCO.

Double-C-loop The results of a laboratory study suggest that a new double C-loop haptic lens, the PodEye IOL (PhysIOL), which is made of the same hydrophobic acrylic material as the single C-loop iPure lens may have superior stability within the capsular bag, and may recover its optical properties better than other hydrophobic acrylic lenses, Dimitriya Bozukova PhD, Liege, Belgium told the ESCRS congress.

Dr Bozukova and her associates compared the results of four one-piece hydrophobic acrylic IOLs, the double C-loop PodEye, (PhysIOL) and the Envista MX60 (Bausch + Lomb) packed in physiological solution, and the dry-packaged Acrysof® SN60WF (Alcon) and Tecnis® ZCB00.

They found that the time required for recovery of 70 per cent of the pre-folding MTF after simulated injection was less than 30 seconds for the PodEye IOL, compared to around three minutes for Acrysof and Tecnis lenses, and more than five minutes for the Envista lens.

In addition, in the absence of a posterior capsule, the PodEye and the Tecnis lenses shifted comparably by 1.7mm and 1.6mm, respectively. It was slightly higher than the Acrysof lens (1.0mm) but much better than Envista (2.8mm).

Sophie Maedel: sophie.maedel@gmx.at Dimitriya Bozukoval: d.bozukova@physiol.be

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Eurotimes | april 2014

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16

IRIS DEFECTS

Artificial iris implant surgery is not a very difficult procedure and is becoming more popular. Priscilla Lynch reports

C

ataract surgery in eyes with iris defects can be challenging, but careful preparation as well as recent advances in surgical instruments and iris implants mean outcomes are significantly improving for these patients, Sathish Srinivasan FRCSEd, FRCOphth told the XXXVII UKISCRS Annual Congress in Manchester.

Dr Srinivasan, University Hospital Ayr, Ayr, Scotland, gave a comprehensive overview on how to approach cataract surgery in patients with iris defects, with detailed surgical video demonstrations of his work on these patients.

The main causes of iris defects are either congenital, eg, colobomas or ICE syndrome; and acquired, eg, from a trauma, tear, iris melanomas/cysts, iridodialysis or traumatic mydriasis; or iatrogenic – from an iridectomy or collateral iris damage from previous surgery.

Dr Srinivasan said these patients can be difficult to operate on and advised taking a practical, comprehensive approach to surgical preparation.

“If you are dealing with patients with iris defects, they need a lot of planning and a practical approach, so prepare,” he stressed.

Eurotimes | april 2014

Proper preparation includes taking a thorough history, understanding fully the nature of the injury or defect, identifying what has been done previously to treat the patient and assessing the current collateral damage to the cornea, sclera and lens.

Lens status becomes a very significant issue even if patients do not have a very visually significant cataract, Dr Srinivasan explained.

“When it comes to the lens status it is very important to know if the patient has a clear lens, cataract or is pseudophakic because when it comes to iris suturing this becomes a very important issue because it is very difficult to do intraocular suturing in a phakic eye,” he told the meeting.

The size of the iris defect is also very important in relation to iris suturing, as

Custom-made artificial iris (HumanOptics, Erlangen, Germany) based on the photograph of the fellow normal eye

is the availability of tissue, Dr Srinivasan noted, advising that the patient’s eye is fully measured, photographed and all details documented carefully pre-surgery.

Discussing the different suturing techniques, Dr Srinivasan mentioned the McCannel Technique, and Siepser Knot, which helps do a sliding knot into the anterior segment.

‘We now also have the new concept of intracameral suturing, where you can suture inside the anterior chamber because of several advancements in microsurgical instrumentation, with 23-gauge instruments now available with micrograspers, microscissors and microforceps, which helps us do all these steps,” he said.

When it comes to selecting the suture material, Dr Srinivasan recommended using a non-reactive suture such as a monofilament polypropylene one in the anterior chamber so as to avoid intraocular inflammation. Regarding needle choice, he said a straight or curved one can be used, and he prefers a CIF-4.

When an iris defect is just too large to close there is the option of artificial iris implants. Candidates for artificial iris implants include patients who have sustained trauma or have congenital aniridia.

Dr Srinivasan, who has extensive expertise in this area, explained that these implants are not designed to be placed in the sulcus; they go into the capsular bag.

There are now three different brands on the market made by Morcher, Ophtec and HumanOptics.

Depending on the iris defect, it is possible to decide what type of partial aniridia rings to use and customise the implant, he said. If the defect is larger it is possible to use scleral-fixated lenses, which have an artificial iris diaphragm with a customised IOL optic in the centre, Dr Srinivasan added.

17

Courtesy of Sathish Srinivasan FRCSEd, FRCOphth

special focus: cataract & refractive

Pre- and postoperative pictures showing implantation of a custom-made artificial iris in a 60-year-old male with traumatic superior iris defect and cataract. Patient underwent cataract surgery combined with sulcus implantation of custom artificial iris from HumanOptics

“The lens of choice goes into the capsular bag and it is very important to note the edge of your capsulorhexis to help guide you putting in the implant,” he noted. These implants are “very fragile” so it is advisable to have a spare one in the operating theatre. Protecting the corneal epithelium is also very important during this surgery, he cautioned.

Dr Srinivasan showed the meeting a number of videos and images of his surgery on these patients to illustrate how to conduct the surgery and avoid pitfalls and to assess the postoperative result.

The physical appearance of artificial iris implants postoperatively is very good and looks very natural, especially with customisation to the patient’s own eyes,

he reported. Patients are very happy with the surgery, not just because of the cosmetic and visual improvement, but because of the reduction in glare, which can be a serious issue for patients with iris defects.

Speaking to EuroTimes, Dr Srinivasan said artificial iris implant surgery is on the whole not a very difficult procedure, and is becoming increasingly popular.

He advised surgeons interested in the procedure to check out the implant companies’ websites, where he said there is a lot of useful literature as well as many surgical videos.

Sathish Srinivasan: Sathish.srinivasan@gmail.com

Eurotimes | april 2014

18

special focus: cataract & refractive

HYPEROPIC PATIENTS Precision of biometry crucial in hyperopic eyes.

Roibeard O’hEineachain reports

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ighly precise biometry and the correct IOL calculation formulas are essential ingredients to achieving good visual outcomes in hyperopic cataract patients, said Wolfgang Haigis PhD, University of Wuerzburg, Wuerzburg, Germany.

“Refractive outcomes in hyperopic eyes are more sensitive and less forgiving of measurement errors than are normal eyes,” Dr Haigis told the XXXI Congress of the ESCRS in Amsterdam. He noted that contact lenses have a distorting effect on the cornea which continues for some time after patients take the lenses off their eyes. For example, research has shown that an eye’s keratometry can change from 46.88 D to 46.04 D three hours after removal of a hard contact lens (Haigis W: unpublished data). Therefore, surgeons must insure that patients remove hard contact lenses at least two weeks before they undergo keratometry. Soft contact lenses should be removed at least three days prior to keratometry, he added.

He stressed that the amount of refractive error induced by mistakes in determining the effective lens position is magnified in short eyes compared to long or normal eyes. For example, when an IOL’s optic is in front of or behind its predicted position by 1.0mm, the difference from the intended refraction will be only 0.6 D in an eye with an axial length of 27mm, compared to nearly 2.0 D in an eye with an axial length of 21mm.

Another potential source of error is the fact that IOL manufacturers’ maximum allowed deviation from the nominal dioptric power of an IOL increases as the IOL power increases.

Thus, the maximum allowed deviation of an IOL with a nominal dioptric power below 15 D is only 0.3 D, compared to 1.0 D in an IOL with a nominal dioptric power above 30 D. Optical biometry has become the preferred type of biometry instrumentation in Europe and the US because of its highly reproducible measurements.

Immersion ultrasound can provide similarly consistent results, Dr Haigis said. “With immersion ultrasound and optical biometry you can expect a consistent result, but you have no idea what to expect from contact ultrasound.” He added that although research has yielded conflicting results regarding the interchangeability of the different OCT devices’ measurements of the anterior chamber depth and keratometry, the Wolfgang Haigis PhD majority of studies show consistency between the instruments regarding axial length measurements.

Several of the IOL power calculation formulas, such as the SRK/T and the SRK II will provide inaccurate results in short eyes. The recommendation is that in eyes with an axial length below 22mm the most accurate formulas are the Hoffert Q or the Haigis or the Holladay 2. None of the usual formulas will work in extreme cases of hyperopia because the lenses required are so thick, Dr Haigis said. Instead, in those cases he provides the patients biometry information to an IOL manufacturer who will make a customised lens based on raytracing calculations.

Wolfgang Haigis: w.haigis@augenklinik.uni-wuerzburg.de

Eurotimes | april 2014

special focus: cataract & refractive

lowering cme Analysis supports NSAID-only regimen after cataract surgery.

Cheryl Guttman Krader reports

W

hen it comes to prevention of pain and inflammation after cataract surgery, brandname products are preferred over their generics; it is better to use an NSAID in allcomers than in just high-risk patients; and routine use of a brand-name NSAID started two days preoperatively and continued for one month after surgery, is as or more effective than postoperative treatment with a corticosteroid alone.

These are the conclusions of a retrospective study reported

by Keith Walter MD, associate professor of ophthalmology, Wake Forest Baptist Medical Centre, Winston-Salem, NC, at the XXXI Congress of the ESCRS in Amsterdam.

That study included data from 5,380 eyes operated on by Dr Walter and two other colleagues between July 2007 and December 2012. Only 13 eyes operated on during the study were excluded from the analysis.

All three surgeons used the same phacoemulsification machine and implanted the same IOL, but they used different anti-inflammatory medication regimens.

Three regimens, each prescribed by a different surgeon included a five-week tapering course of prednisolone acetate one per cent postoperatively with an NSAID (bromfenac 0.09 per cent BID, ketorolac tromethamine 0.5 per cent QID, or ketorolac tromethamine 0.4 per cent) given postoperatively for one month only to patients with a history of cystoid macular edema (CME) or otherwise considered at high risk. Two of the three groups were treated with all brand-name products (Pred Forte one per cent and either Acular 0.5 per cent or Xibrom 0.09 per cent). Generic prednisolone acetate one per cent and ketorolac tromethamine 0.4 per cent were allowed in the third group and received by 80 per cent of patients.

The fourth study group, representing a second cohort operated on by Dr Walter during the latter half of the study period, received treatment with brand-name Bromday (bromfenac 0.09 per cent) QD, started two days preoperatively and continued one month postoperatively.

Charts were reviewed to identify eyes that developed OCTdiagnosed CME within one month after surgery. Dr Walter said OCT was not performed routinely, but only if a patient exhibited BCVA loss.

CME occurred among 0.09 per cent of 1,090 eyes treated with Bromday only, 0.44 per cent of 1,128 eyes treated with Pred Forte±Xibrom, 0.9 per cent of 2,437 eyes in the Pred Forte±Acular group, and 2.44 per cent of 725 eyes in the group where generic substitution was allowed. Statistical analyses showed the Bromday only group had a lower rate of CME compared with the Pred Forte±Acular and the generic substitution groups.

“Steroids are a mainstay of anti-inflammatory treatment after cataract surgery, and NSAIDs are often added for greater efficacy. However, according to this study, once-daily treatment with brand-name bromfenac is as reliable as a combination regimen for controlling inflammation and suppressing CME rates,” said Dr Walter.

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Keith Walter: kwalter@wakehealth.edu Eurotimes | april 2014

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Cornea

DMEK GRAFT DETACHMENT Management algorithm incorporates multiple factors to determine need for intervention. Cheryl Guttman Krader reports

G

raft detachment is one of the most common complications after Descemet membrane endothelial keratoplasty (DMEK), but in determining the best approach to management, corneal surgeons must use the proper technology to make the diagnosis and recognise that not all graft detachments are the same, said Isabel Dapena MD, PhD, at the 4th EuCornea Congress in Amsterdam, The Netherlands.

“Remember that the presence of corneal oedema does not always mean there is a graft detachment as patients may have an attached graft with delayed corneal clearance

that will spontaneously resolve. And not all graft detachments require secondary surgery,” said Dr Dapena, cornea specialist, Melles Cornea Clinic, Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands.

“If vision is not affected, the detachment is not clinically significant and it does not require surgical repair.”

Although by definition, a graft detachment is lack of adherence between the Descemet graft and the posterior stroma of the host, the extent of the detachment generally predicts whether the detachment is clinically significant and will require intervention.

Small graft detachments, defined as those involving no more than one-third of

the graft surface area, are generally benign and can be left alone. These grafts usually reattach spontaneously and the cornea clears without any additional treatment, Dr Dapena said.

In contrast, graft detachments involving more than one-third of the graft surface area are generally clinically significant, but do not always require intervention. This group of detachments is comprised of large partial detachments, upside down grafts or complete detachments with a free-floating Descemet roll in the anterior chamber.

“It is important to be discriminative about the need for intervention in an eye with a larger detachment. In some large partial detachment cases, the cornea clears by itself

Slit-lamp photographs of the same transplanted cornea 3 (A, B), 8 (C, D), and 12 weeks (E, F) after DMEK. Notice that the oedema (yellow arrows) overlying the detachment (white arrows) resolves with time and that stromal thinning with coincident corneal clearance progresses from the periphery toward the corneal centre (green arrows) [Image reprinted with permission of Elsevier, Am J Ophthalmol. 2011;152:543-555. Dirisamer M, Dapena I, Ham L, van Dijk K, Oganes O, Frank LE, van der Wees J, Melles GR. Patterns of corneal endothelialization and corneal clearance after Descemet membrane endothelial keratoplasty for Fuchs’ endothelial dystrophy.]

Eurotimes | april 2014

cornea and the patient achieves very good visual acuity,” Dr Dapena said.

Dr Dapena recommended the use of anterior segment optical coherence tomography (AS-OCT) to diagnose graft detachment as it enables the surgeon to distinguish between true detachment and delayed corneal clearance.

She noted that slit lamp biomicroscopy does not always allow a conclusive diagnosis, and the presence of corneal oedema can obscure visualisation of a graft detachment through Pentacam imaging (Oculus).

“Importantly, the findings from AS-OCT can also allow us to predict if the detachment will reattach, which is important for determining what treatment to do,” Dr Dapena added.

“In a published study [Yeh RY, et al.

Ophthalmology 2013;120(2):240-5], we reported that about 30 per cent of patients had some kind of graft detachment at one week. However, many of those resolved with time, which we believe was the result of some kind of healing process. We also found that the one-hour AS-OCT was the most important aid for predicting whether a graft that was detached at one week remained detached in the longer term.”

If a detachment is seen on AS-OCT at one week after surgery and was also visible in the image taken after one hour, surgeons should assume that spontaneous reattachment is unlikely. In these cases, the next step is to

consider whether the detachment is visually significant. If it is not, no intervention is required. However, even if the patient has decreased vision, it is worth waiting a few weeks to see if there is spontaneous corneal clearance/reattachment, Dr Dapena said.

If there is no improvement, intervention (rebubbling or retransplantation) is indicated.

“Remember not to rush into a rebubbling.

However, if you come to the decision that rebubbling is necessary, then it is better to do it early or not at all.”

Dr Dapena also presented information on the rate of DMEK graft detachments and their management from a series of 300 eyes operated on at the Melles Cornea Clinic.

At six months after surgery, detachment involving less than one-third of the graft area was identified in 34 eyes (11 per cent) and 44 eyes (15 per cent) had a larger, clinically significant graft detachment.

However, when the latter rate was analysed with eyes divided into two groups representing the first 100 eyes and the

subsequent 200 cases, it was clear that increasing surgeon experience with DMEK and the opportunity to refine the surgical protocol led to an important reduction in the detachment rate.

“We saw a clear learning curve effect with a 25 per cent rate of larger graft detachments in the first 100 cases and a decline in the rate to just nine per cent after the learning curve period,” Dr Dapena explained.

None of the eyes with a small detachment needed any treatment. Among eyes with a larger detachment within the initial 100 cases, rates of rebubbling and retransplantation were about four per cent and five per cent, respectively.

In a paper published in 2012, Dr Dapena and colleagues describe the incidence and type of graft detachments observed in the first 150 consecutive DMEK cases, their management and strategies for prevention [Dirisamer M, et al. Arch Ophthalmol.

2012;130(3):280-91].

Isabel Dapena: dapena@niios.com

If vision is not affected, the detachment is not clinically significant and it does not require surgical repair Isabel Dapena MD, PhD

5th EuCornea Congress

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12-13 September 2014

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Registration, Hotel Bookings & Preliminary Programme Online www.eucornea.org

Eurotimes | april 2014

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Cornea

DSAEK OUTCOMES Danish study provides evidence on mid- to long-term success.

Cheryl Guttman Krader reports

A

lthough posterior lamellar keratoplasty has emerged as the preferred transplantation technique for eyes with corneal endothelial disease, there remains a need for more information on long-term outcomes, reports Jesper Hjortdal MD, PhD. He presented information at the 4th EuCornea Congress in Amsterdam indicating that mid- to long-term graft survival as well as the rate of rejection-related graft failure is similar after Descemet’s stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK). However, DSAEK is associated with fewer rejection episodes.

“The years to come will be important in determining the long-term prognosis for eyes undergoing transplantation with new surgical modalities, and we need data from more eyes and with longer follow-up,” said Dr Hjortdal, clinical professor of ophthalmology and head, corneal & refractive surgery, Aarhus University Hospital, Denmark.

“Follow-up can be done locally in individual clinics, but national or international corneal registries are an important source of information,” he told EuroTimes.

Dr Hjortdal and colleagues at Aarhus University began performing DSAEK in 2006. They analysed data for 202 eyes of 202 patients with Fuchs’ dystrophy who were operated on between January 1, 2000 and December 31, 2010. There were 100 eyes in the DSAEK cohort, all operated on by one surgeon; 102 eyes had PK performed by two surgeons.

The two groups were comparable in their median age (82 years) and gender distribution (about two-thirds were female).

Six per cent of patients in each group had glaucoma at the time of their transplant procedure. The number of at-risk patients was also similar in the two groups at the various follow-up intervals through five years.

PK patients received more intensive corticosteroid treatment after surgery as they were treated with a three-month tapering course of oral prednisone in addition to a topical corticosteroid tapered over one year. Despite this difference, early rejection episodes were more common after PK than after DSAEK. Almost all of the rejections occurred within the first two years after surgery. From three years on, the freedom from rejection rate was similar in the PK and DSAEK groups, ~85 per cent and ~90 per cent, respectively.

Eurotimes | april 2014

Treatment for a rejection episode was also more aggressive in the PK group where the regimen included subconjunctival dexamethasone, prednisolone ointment and oral prednisone, whereas DSAEK patients received only topical dexamethasone drops and prednisolone ointment.

With these respective regimens, most of the rejection episodes were reversible in both groups. At five years, the freedom from rejection-related failure rate was >95% in both groups.

“Typically, the rejection episodes that occur after DSAEK appear less aggressive than those seen after PK, and in our series, all rejection episodes after DSAEK could be controlled with topical steroid drops. However, the long-term cumulative frequency of rejection episodes was similar for the two procedures,” noted Dr Hjortdal.

“We know from recent studies that rejection episodes are considerably less frequent after Descemet’s membrane endothelial keratoplasty than after DSAEK and PK. This information supports older experimental findings suggesting higher immunogenicity of the corneal stroma compared with the endothelium.”

Considering all causes of graft failure, the five-year survival rate was significantly less in the DSAEK group than for PK, 80 per cent vs. 95 per cent. The difference reflects more early failures after DSAEK. “These data are explained by our learning curve with DSAEK and an attempt with femtosecond laser graft preparation that was associated with interface opacities and a need for regrafting,” said Dr Hjortdal.

“However, we can still say that we have a high proportion of functioning grafts at five years after DSAEK.”

Typically, the rejection episodes that occur after DSAEK appear less aggressive than those seen after PK Jesper Hjortdal MD, PhD

cornea

Courtesy of Jesper Hjortdal MD, PhD

23

Slit-lamp photo of a DSAEK-operated patient. Note presence of precipitates on the endothelium of the graft, but not on the peripheral recipient cornea

Dr Hjortdal also compared the outcomes he reported with data published by other groups. In a 2013 article from the US, Price et al. analysed graft survival based on three years of prospective follow-up for 173 DSAEK eyes and 1101 PK cases. Limiting the Octoberto CRSTEthe ADVANCEFuchs’ AD 18 SEPT FINAL.pdf 1 18/09/2013 three-year 10:25:23 analysis patients, graft survival was 96 per cent in both the DSAEK and PK groups. Rejection-related graft failure rates were 1.7 per cent for the DSAEK eyes and 3.1 per cent for PK, and the difference was not statistically significant.

Including the bullous keratopathy cases, the probability of a rejection episode at three years was significantly higher for the PK group than for DSAEK, 20 per cent vs. nine per cent, respectively.

“These data on rejection-related failure and rejection episodes correspond to our own findings. We also found rejection episodes

were less common after DSAEK, although we had fewer eyes and the difference between groups was not statistically significant,” Dr Hjortdal said.

In 2012, Ang et al. from Singapore reported their outcomes for 119 DSAEK eyes and 87 eyes that underwent PK. They also found no significant difference between groups for the three-year graft survival rate (87 per cent, PK 85 per cent) or the rejection-related failure rate (DSAEK 3.4 per cent vs. zero per cent).

Dr Hjortdal observed that the lower graft survival rates reported in this study can be explained by the inclusion of eyes with bullous keratopathy in the analysis.

Jesper Hjortdal: jesper.hjortdal@dadlnet.dk

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24

glaucoma

ANGLE CLOSURE Prevalence of disease increasing as cases go undetected, reports Roibeard O’hEineachain

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He said that a difficulty in determining the prevalence and incidence of angle-closure glaucoma is the different criteria used to define the disease in different parts of the world. In Japan there was a tendency some years ago to class all cases of angle closure suspects as angle closure glaucoma if they had undergone peripheral laser iridotomy, even in the absence of visual field loss or detectable damage to the optic nerve head, Dr Thygesen said.

Even the definition of an occludable angle has been controversial. In 2002, the International Society of Geographical and Epidemiological Ophthalmology (ISGEO) defined angle closure as being cases where 270 degrees or more of the posterior trabecular meshwork is not visible by gonioscopy. In 2003 the ISGEO modified that definition to include eyes where only 180 degrees of the posterior trabecular meshwork is obscured.

Therefore, among 1,233 individuals in the Salisbury Eye study, the rate of angle-closure glaucoma would be 0.65 per cent by the 2002 ISGEO definition, but would be 1.54 per cent by the ISGEO definition (Day et al, Br J Ophthalmol 2012: 96:1162-1167).

In the natural history of the disease, 10-40 per cent of eyes with an occludable angle develop angle closure within 10 years.

Among eyes with angle closure, 28 per cent develop glaucoma after a further five years. Vision loss can be prevented in most cases if they are detected early enough, Dr Thygesen said.

He added that since the initiation of screening for angleclosure glaucoma in the high-risk Inuit population of Greenland, the proportion of the country’s blind population whose vision loss was due to angle-closure glaucoma went from 64 per cent in 1962, to only nine per cent in 1999.

John Thygesen: thyge-lind@webspeed.dk

Eurotimes | april 2014 EuroTimesEU_apr2014_GALILEI_G4_ad_93x266.indd 1

Courtesy of John Thygesen MD

ngle-closure glaucoma accounts for a relatively low proportion of glaucoma cases occurring in Europe and worldwide, but a high proportion of patients become bilaterally blind from the condition despite the availability of effective treatment, John Thygesen MD told a session of the Glaucoma Day of the XXXI Congress of the ESCRS in Amsterdam.

In 2010 there were an estimated 45 million patients worldwide with primary open-angle glaucoma, 4.5 million of whom were bilaterally blind and 16 million cases of primary angle closure glaucoma, 3.9 million of whom were bilaterally blind (Quigley et al. Br J Ophthalmol 2006; 9 : 262-to 267), said Dr Thygesen, Copenhagen University Hospital Glostrup, Copenhagen, Denmark. “Angle closure glaucoma accounts for approximately 25 per cent of all glaucomatous optic neuropathy worldwide, but for nearly 50 per cent of bilateral glaucoma blindness. Therefore, it’s much more dangerous to have angle closure glaucoma compared to open-angle glaucoma,” he added.

06.03.14 08:28

glaucoma

CONTRACEPTIVES AND GLAUCOMA Three years of oral birth control use may double glaucoma risk.

Howard Larkin reports

This study should be an impetus for future research to prove the cause and effect of oral contraceptives and glaucoma

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omen who have taken oral contraceptives for three or more years are twice as likely to also report a diagnosis of glaucoma, according to research presented at the 2013 Annual Meeting of the American Academy of Ophthalmology in New Orleans. The researchers caution gynaecologists and ophthalmologists to be aware that oral contraceptives might play a role in glaucomatous diseases and inform patients to have their eyes screened for glaucoma if they also have other risk factors.

The study – conducted by researchers at University of California, San Francisco and Duke University School of Medicine in the US, and Third Affiliated Hospital of Nanchang University, Nanchang, China – is the first to establish an increased risk of glaucoma in women who have used oral contraceptives for three or more years. The researchers utilised 2005-2008 data from the National Health and Nutrition Examination Survey (NHANES), administered by the US Centres for Disease Control. It included 3,406 female participants aged 40 years or older from the US. The study found that females who had used oral contraceptives for longer than three years are 2.05 times (p=0.004, CI=1.27-3.26) more likely to report that they have the diagnosis of glaucoma.

The study also found longterm oral contraceptive use associated with the presence of visual field defects as measured by frequency doubling technology, but Shan Lin MD this association was not statistically significant.

The researchers noted that while these results do not speak directly to the causative effect of oral contraceptives on the development of glaucoma, it indicates that long-term use of oral contraceptives might be a potential risk factor for glaucoma, and may be considered as part of the risk profile for a patient together with other existing risk factors.

Previous studies in the field have shown that oestrogen may play a significant role in the pathogenesis of glaucoma. These include studies linking early menopause to higher risk of primary open angle glaucoma. A separate prospective cohort study of reproductive factors and the risk of POAG as part of the Nurses’ Health Study found a 25 per cent increase in POAG in subjects with more than five years of oral contraceptive use (Lang et al.

Eye (Lond). May 2011;25(5);633-641).

“This study should be an impetus for future research to prove the cause and effect of oral contraceptives and glaucoma,” said Shan Lin MD, lead researcher and professor of clinical ophthalmology at the University of California San Francisco.

www.oculus.de

Shan Lin: lins@vision.ucsf.edu Eurotimes | april 2014

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glaucoma

TOPICAL ISSUE Generic glaucoma eye drops not always equal in terms of safety and efficacy. Roibeard O’hEineachain reports

G

eneric eye drops should not be considered identical to branded versions due to differences in composition and possibly efficacy.

Therefore, the re-evaluation of IOP reduction when switching to generic drugs seems reasonable, Jean-Philippe Nordmann MD, PhD, University Paris V, Paris, France told a Glaucoma Day session of the XXXI Congress of the ESCRS in Amsterdam.

He noted that when the patents expire for popular branded IOP-lowering eye drops, generic alternatives quickly account for a greater market share than the original product.

For example, in the case of latanoprost (Xalatan, Pfizer), which lost its patent in 2011, the generic versions already accounted for 82 per cent of the agent sold in France and 66 per cent of latanoprost sold in Italy.

“To third-party payers, generics offer the potential for saving money. For pharmacists it provides the potential Eurotimes | april 2014

for generic substitution. Government regulators can legislate for the routine prescription of generic alternatives where possible in order to save money, as has happened in France and Spain. But for physicians, generic-first substitution policies may present the possibility of less control over their prescribing practices.

As for patients, the change in the drug’s appearance can influence compliance with medication,” he said.

Dr Nordmann noted that for a new drug preparation to obtain FDA approval as a generic equivalent of a branded product, it must have the same quality and performance as the original branded preparation. In the case of systemically

administered agents, that means that the candidate generic agent must achieve the same blood concentration levels of the active ingredients within a specified period and using the same route of administration.

However, there is no such requirement for agents that have local rather than systemic activity, such as eye drops.

Moreover, although the candidate generic agent must have the same active ingredients at the same concentration, there is no prohibition against using different concentrations of inactive ingredients, which include the preservatives, pH adjusters, antioxidants, buffers and thickening agents.

For physicians, generic-first substitution policies may present the possibility of less control over their prescribing practices Jean-Philippe Nordmann MD, PhD

glaucoma

As for patients, the change in the drug’s appearance can influence compliance with medication Moreover, differences of up to 10 per cent in the concentration of the active ingredients are considered acceptable and added compounds can be present in generics to improve stability.

Physical characteristics As a result, generic eye drops may differ from the original product in their physical characteristics. For example, a study comparing two generic latanoprost eye drops with Xalatan showed that an increase in temperature lowered the concentration of latanoprost in both of the generic preparations but not in the branded product. The same study showed that there were significantly higher levels of particulate matter in the generic products compared to Xalatan (Kahook et al. Curr Eye Res 2011;epub).

Another study comparing a branded version of timolol eye drops (Timoptic XE, Merck) to two generic versions showed that the branded and generic versions differed in terms of viscosity by a factor of 100. Furthermore, the size

of the drop the generic bottle dispensed was lower by 25 per cent than that of the branded timolol preparation (Mammo et al, Can J Ophthalmol, 2012;47(1):55–61).

The ultimate test of a generic drug’s bioequivalence is its efficacy, but generic preparations do not need to undergo the same type of clinical evaluation as the original branded product. Furthermore, the results of studies comparing generic preparations with branded products suggest that some generics are better than others in terms of efficacy, he noted.

For example, a generic latanoprost preparation was not inferior to Xalatan in IOP-lowering efficacy in a six-week multicentre, randomised, investigator masked study involving 260 patients with primary open angle glaucoma or ocular hypertension. That is, the generic preparation reduced IOP by 7.29 mmHg, compared to a 7.29 mmHg reduction with Xalatan (Allaire et al. Eur J Ophthalmol 2012;22:19–27).

However, in another randomised open-label crossover study of 30 patients

with glaucoma reported a significant difference between Xalatan and a generic product, with the respective IOP reductions of 9.35 mmHG and 5.76 mmHg (Narayanaswamy et al. Indian J Ophthalmol 2007;55:127–31.

There are also safety issues to be considered. There have already been anecdotal reports of unexpected adverse events occurring to patients when they switch to a generic formulation. For example, there was a case reported of an 88-year-old Japanese patient who developed corneal ulceration after each of two attempts to switch to generic latanoprost but whose symptoms resolved upon returning to the branded product. The adverse reaction may have resulted from the preparation including stearic acid polyester, a surfactant agent, as a stabiliser (Takada et al., Case Rep. Ophthalmol. Med., 2012).

On the other hand, given their current widespread use of and the relative rarity of adverse events reported with them, most generic glaucoma eye drop formulations provide an acceptable alternative to branded products for most glaucoma patients, Dr Nordmann said.

Jean-Philippe Nordmann: jpnordmann@quinze-vingts.fr

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retina

DIABETIC RETINOPATHY Individualised screening is better for patients whether at high or low risk.

Roibeard O'hEineachain reports

Phone Application

I

ndividualised screening as opposed to routine annual screening of diabetic patients for sightthreatening diabetic retinopathy delivers medical attention more efficiently to where it is needed, thereby achieving optimum results at minimum cost, said Einar Stefansson MD, PhD, University of Iceland, Reykjavik, Iceland.

Speaking at the 13th EURETINA Congress in Hamburg, Dr Stefansson noted that the prevalence of diabetes is rising throughout the world. In fact, if present trends continue there will be half a billion diabetic patients worldwide by the year 2030. The prevention of vision loss and blindness from diabetic retinopathy will therefore require highly efficient screening in order to contain costs without reducing the detection rate of cases at risk of sight-threatening disease.

“We all know that screening this is very effective and in the countries that have done this, the UK and Nordic countries,

the prevalence of blindness among diabetics goes from somewhere like three per cent to five per cent to something like half a per cent,” he added.

Annual screening not best for all The earliest systematic diabetic retinopathy screening programme began in Iceland in the early 1980s, Dr Stefansson said.

The choice of one year as the interval for screening was actually very arbitrary, but it proved to be effective in reducing blindness and has since been endorsed

by WHO, the American Academy of Ophthalmology and all the European ophthalmological societies.

However, the Iceland investigators who initiated the screening programmes saw that in any given year only a small percentage of patients needed to be referred for further consultation and treatment. Moreover, they were able to demonstrate that patients with no retinopathy were extremely unlikely to

progress to sight-threatening retinopathy where they needed treatment within a period shorter than two years.

They accordingly adopted a new protocol of screening diabetic patients without retinopathy only every two years.

After 10 years they published a study that appeared to prove the safety of the approach (Ólafsdóttir, Br J Ophthalmol 2007;91:12 1599-1601). Dr Stefansson and his associates have since taken things one step further and have devised software that enables the calculation of each individual patient’s diabetic retinopathy risk profile as a guide for their screening interval.

“When we do annual screening as is the norm we take the whole group of diabetics,

We developed an algorithm using these known risk factors to calculate each individual’s risk for disease progression Einar Stefansson MD, PhD Eurotimes | April 2014

Online Database

retina

Diabe c eye screening Individualised screening

Annual screening

SCREENING

Interval

One size fits all

High risk patient

6 months

High risk patient 1 year

Courtesy of Einar Stefansson

2 years

1 year

Annual screening for all

3 years

SCREENING

Interval

4 years

5 years

Low risk patient Low risk patient

they may have high risk or they may have low risk, but we screen them all at the same interval once yearly. That means that those who are at high risk may not be getting enough screening, but those who are at low risk are screened again and again even though they are always fine,” he said.

Risk factor algorithm The software’s calculations are based on risk factors for diabetic retinopathy that have been identified in numerous large epidemiological studies. They include such factors as duration of diabetes, type of diabetes, glycaemic control, hypertension, retinopathy status and to a smaller degree, gender.

“We found out that if we combine these six risk factors in an algorithm we can account for 80 per cent of the risk of progression. The remaining 20 per cent can be accounted for by genetics and other factors which have lesser weight in the

risk. We developed an algorithm using these known risk factors to calculate each individual’s risk for disease progression and we use that risk profile to determine the appropriate screening interval for each individual patient.

A validation study carried out in Denmark and involving 5,200 diabetics showed that using the algorithm to manage the screening of diabetic patients for retinopathy reduced the average screening interval from 12 months to 29 months (Aspelund et al, Diabetologia 2011 54:2525–2532).

“This is a 58 per cent reduction in the frequency of screening, cutting the cost in half, but maintaining the same level of safety. Simply because we are bringing those who are at high risk back sooner but those who are at low risk don't need to come back every year. They can come back every other year or every third year and so forth,” Dr Stefansson said.

Further validation studies, as yet unpublished, have now been concluded in

the Netherlands and in England and their results showed even greater reduction in the average interval, also without evidence of safety having been compromised.

Dr Stefansson said that he and his associates plan to make the algorithm available to patients, practitioners and health authorities. One version will mainly be used in conjunction with the databases at screening centres, and the other is a mobile app which patients can use themselves to check their own risk status and advise them as to how they might reduce their risk. “It is clear, and I think it is now proven after the validation studies in Denmark, The Netherlands and England in that individualised diabetic screening of retinopathy risk assessment makes diabetic screening even better,” Dr Stefansson said.

Further details are available at: www.risk.is.

Einar Stefansson: einarste@landspitali.is

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Eurotimes | April 2014

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retina

MACULAR OEDEMA Significant advances have been made in unlocking the complex causes of CME, reports Dermot McGrath

W

hile the exact pathogenesis of cystoid macular oedema (CME) remains uncertain, significant advances have been made in recent years in understanding the complex cellular and molecular processes involved in the disruption to the blood-retinal barrier (BRB) implicated in the development of CME, according to Prof Reinier Schlingemann.

“There is still a lot that we do not understand about the pathogenesis of macular oedema but we have made a lot of progress in recent years in learning more about BRB breakdown and the role played by endothelial cells and transcellular transport of large molecules in this complex process,” he told delegates attending the XXXI Congress of the ESCRS in Amsterdam.

Prof Schlingemann, Medical Retina Unit and Ocular Angiogenesis Group at the University of Amsterdam, the Netherlands, noted that CME represents a common pathologic sequel of the retina and occurs in a variety of pathological conditions such as intraocular inflammation, central or branch retinal vein occlusion, diabetic retinopathy and after cataract extraction.

He explained that the rules that determine whether oedema forms in tissue were first elucidated by the English physiologist Ernest Starling in 1896. His eponymous equation illustrated the role of hydrostatic and oncotic forces in the movement of fluid across capillary membranes and has direct relevance for BRB disruption.

Of the known pathogenetic factors that determine whether macular oedema will develop in tissue, Prof Schlingemann cited capillary hydrostatic pressure and the properties of the inner blood-retinal barrier, among others, as potentially important catalysts.

“Other factors to bear in mind are what actually happens in the tissue itself such as retinal ischemia, inflammation or para-inflammation as a response to any tissue damage or tissue stress. This releases growth factors and cytokines from the tissue and can create the conditions for oedema.

The role of retinal glial cells and the vitreous should also be borne in mind, and there might also be a role played by the outer blood-retina barrier although very little is known about that for the moment,” he said.

There is also a case to be made for chronic macular oedema perhaps being treated as a separate disease entity, said Prof Schlingemann.

"We really do not understand the processes underling chronic CME and it may be that factors such as Prof Reinier Schlingemann ischemia and inflammation

When there is another condition that could cause macular oedema like DME or uveitis there is an enhanced risk of pseudophakic CME

Eurotimes | April 2014

and so forth are less important here and that the inherent properties of the blood vessels are primarily responsible for this chronicity," he said.

Trying to unravel the complex pathophysiological factors at work in each incidence of macular oedema is fraught with difficulty, said Prof Schlingemann.

"In a patient with branch retinal vein occlusion, for instance, a small vein is occluded by a thickening of the retinal artery wall leading to increased hydrostatic pressure and retinal ischemia.

Together they will cause macular oedema, so the balance of the Starling equation is disturbed by increased permeability causing increased colloid osmodic pressure in the tissue on the one hand and increased hydrostatic pressure on the other hand. By contrast, in diabetic macular oedema this increased hydrostatic pressure might be less important and the most important causes might be factors such as cytokines such as VEGF produced by ischemic retinal tissues," he said.

Prof Schlingemann said that research has primarily focused on two proposed pathways for blood-retinal barrier loss, one concerning the loss of endothelial cell tight junction integrity and the other, which has received less attention, related to the endothelial transcellular pathway mediated by endocytotic vesicles.

Based on Starling's equation, active transcellular transport of plasma proteins by the BRB endothelial cells causing increased interstitial osmotic pressure is probably the main factor in the formation of macular oedema, he said.

"We know that colloid osmodic pressure is mainly determined by the dynamics of protein transport which happens through transcellular rather than paracellular transport. That suggests that that mechanism is basically the most important in causing macular oedema and might be a very interesting target for therapeutic intervention," he said.

Prof Schlingemann noted that vascular endothelial growth factor (VEGF) has also been shown to be associated with breakdown of the blood retinal barrier and increased vascular permeability, thereby contributing to the development of macular oedema.

"We know that VEGF is important in CME in diabetics because when we treat it with intravitreal anti-VEGF injections we can see the profound effect on their oedema. But inflammation has also been identified as an important mechanism and these are some cytokines that are found in the vitreous of eyes of patients with diabetic macular oedema suggesting that the inflammatory mechanism and inflammatory media are also important," he said.

In terms of pseudophakic CME, Prof Schlingemann said that known risk factors include posterior capsular rupture, vitreous loss, diabetic macular oedema, uveitis and use of prostaglandin analogues.

"When there is another condition that could cause macular oedema like DME or uveitis there is an enhanced risk of pseudophakic CME. It is easy to envisage that based on Starling's equation you have a patient that is just keeping the balance of not having macular oedema caused by diabetic retinopathy in the retina but if you add the effect of a cataract operation you will tip the balance of the equation and get oedema," he concluded.

Reinier Schlingemann: r.o.schlingemann@amc.uva.nl

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retina

OPTOGENETICS INNOVATIONS

Research paves the way to restore vision in blind patients.

Dermot McGrath reports

rapidly evolving field of research known as optogenetics offers exciting potential for the restoration of vision in patients with incurable degenerative retinal diseases such as retinitis pigmentosa and advanced macular degeneration, according to Sonja Kleinlogel PhD, head of Optogenetics Group, Institute of Physiology, University of Bern, Switzerland.

“This is an exciting area of research that will hopefully in a few years enable patients with photoreceptor degeneration to get back almost complete vision. The target diseases for this novel treatment are mainly retinitis pigmentosa and age-related macular degeneration, particularly the advanced forms where the photoreceptors have almost completely degenerated,” she told the 13th EURETINA Congress in Hamburg.

Eurotimes | April 2014

While research into stem cells and retinal prostheses hold some promise in the treatment of degenerative retinal diseases, optogenetics may offer some advantages over both these approaches, said Dr Kleinlogel.

“The problem with the stem cell approach is that when the photoreceptors have already degenerated, the implanted cells usually do not survive. Similarly, while the retinal prosthesis is undoubtedly a great step forward, there are limitations to maximal achievable resolution so vision will never be restored to normal high-resolution healthy vision allowing the patient, for example, to drive a car or read a book.”

Defining optogenetics as a combination of optics and genetics, Dr Kleinlogel explained that the inception of the discipline began in earnest with the discovery of a rhodopsin-like lightsensitive protein in green algae called channelrhodopsin-2. This visual pigment allows the green algae to perceive light, important to sustain photosynthesis.

Channelrhodopsin-2 reacts to blue light by making the cell membrane

permeable to positively charged ions and the resulting influx of ions triggers a nerve impulse that activates the cell.

“For neuroscientists, this prompted the idea of isolating this gene and implanting it by targeted genetics into neurons of choice. Researchers then succeeded in isolating halorhodopsin, a chloride pump activated by yellow light, which acts as the perfect counterpart to channelrhodopsin-2 since it lowers the membrane potential effectively switching off the neurons,” said Dr Kleinlogel.

Since channelrhodopsin-2 and halorhodopsin react to light of different wavelengths, together they comprise a useful tool for switching cells on and off at will, said Dr Kleinlogel.

The therapeutic concept of Dr Kleinlogel’s optogenetics approach is to target the neurons in the middle layer of the retina – the bipolar cells – which remain intact even when the photoreceptors in the outer layers of the retina have degenerated. Custommade membrane proteins equipped with a rhodopsin-based light antenna are introduced into the bipolar cells

This is an exciting area of research that will hopefully in a few years enable patients with photoreceptor degeneration to get back almost complete vision Sonja Kleinlogel PhD

retina using adeno-associated viral (AAV) shuttle vectors as delivery systems. This renders the naturally light-insensitive bipolar cells light-sensitive and capable of detecting visual information, which is subsequently relayed to the brain without receiving input from photoreceptors.

Working with channelrhodopsin-2, however, it soon became obvious to Dr Kleinlogel and her team that they would need a next-generation optical genetic tool if the approach were to have any chance of being successful in the clinic.

“There are some limitations to tools such as channelrhodopsin that prevent their use in the clinic. The first is that they require extremely high light intensities to be activated, laser light that is 100 times brighter than sunlight. So when you treat a patient and you have to illuminate the retina with this highintensity blue light you very quickly induce phototoxicity that will kill all of the retinal cells,” she said.

The second issue related to the fact that such proteins are isolated from algae and other microbes and will most probably be immunogenic for the human

Naturally we now want to transfer the technology from the mouse tissue into human tissue to see if it works as well, and of course perform toxicology studies

Sebastian Wolf (left), general secretary of EURETINA and Einar Stefansson, chairman of the judging panel, present Sonja Kleinlogel of the University of Bern, Switzerland, with the First Prize in the third EURETINA Innovation Award

retina. Thirdly, Channelrhodopsin-2 activation of bipolar cells is artificial and does not comply with normal processing of visual information in these cells.

The strategy to overcome these deficiencies was to biotechnologically engineer a custom-made protein equipped with a retinal light antenna.

“We came up with a chimeric protein that consists of parts from two retinal proteins. It is based on the bipolar cell specific metabotropic glutamate receptor and contains the light-antenna of melanopsin, thus it will be nonimmunogenic and non-toxic to bipolar cells and the retina. We further profit from the bipolar cell intrinsic and bipolarto-ganglion cell amplification of the visual signal, which makes this novel chimeric protein much more light sensitive compared to channelrhodopsin-2.So now we can actually activate the neurons in normal daylight conditions,” she said.

Studies in transgenic mice have confirmed the “proof of principle” that the therapy can potentially restore

vision, said Dr Kleinlogel, with future efforts being geared towards optimising the gene delivery system and setting up phase I clinical trials in humans.

“Naturally we now want to transfer the technology from the mouse tissue into human tissue to see if it works as well, and of course perform toxicology studies. The mice treated with gene therapy that we sacrificed eight months after treatment did not show any obvious immunological or toxic effects within the retina. So it seems quite promising and we are hopeful that positive outcomes can be obtained beyond animal models,” she said. * At an award ceremony held during the EURETINA Congress, Dr Kleinlogel’s research was awarded first place in the EURETINA Science & Medicine Innovation Awards. Dr Kleinlogel received a cheque for €20,000 on behalf of her research team for its pioneering work in optogenetics research.

Sonja Kleinlogel: kleinlogel@pyl.unibe.ch

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retina

AMD RADIOTHERAPY Promising results for treatment of AMD with stereotactic radiotherapy, reports Dermot McGrath

S

tereotactic radiotherapy (SRT) seems to offer a safe and efficacious treatment for neovascular age-related macular degeneration (AMD), with patients achieving a statistically significant reduction in ranibizumab retreatment after 24 months, according to Timothy L Jackson PhD, FRCOphth.

“Our study showed that stereotactic radiotherapy produced a 25 per cent reduction in the anti-VEGF injection frequency over the course of two years.

With appropriate case selection we can bring that reduction down to 45 per cent with the possibility of better visual acuity, in particular treating lesions that are within the 4.0mm treatment zone, those with active leakage and those with limited fibrosis,” he told delegates attending the 13th EURETINA Congress in Hamburg.

Wet AMD treatment Dr Jackson presented the results of the INTREPID study, the first shamcontrolled double-masked trial to evaluate the effectiveness and safety of a one-time radiation therapy (IRay™, Oraya Therapy) in conjunction with as-needed anti-VEGF injections for the treatment of wet AMD. A total of 21 sites in five European countries participated in the trial with a total enrolment of 226 patients.

The aim of the study was to demonstrate the safety and efficacy of the Oraya Therapy IRay system at two dose levels for the treatment of choroidal neovascularisation (CNV) secondary to neovascular AMD, said Dr Jackson. The primary end point was not visual acuity, but rather the reduction in the number of as-needed 0.5mg ranibizumab (Lucentis, Roche) anti-VEGF injections over the course of 12 months.

Secondary outcomes included ETDRS visual acuity and independent assessment of total lesion size and CNV lesion size based on fluorescein angiography to determine the correlation, if any, between the functional changes and the morphology of the lesions.

The study was randomised, doublemasked and sham-controlled, with patients assigned to one of four treatment groups: 16 Gy IRay radiotherapy and PRN ranibizumab (sham 16 Gy radiotherapy and PRN ranibizumab, 24 Gy radiotherapy and PRN ranibizumab and sham 24 Gy radiotherapy and PRN ranibizumab.

Inclusion criteria included patients of 50 years or older with CNV due to AMD diagnosed within the year preceding the study enrolment who had received at least three anti-VEGF injections, and who were without serious systemic illness such as diabetes.

Exclusion criteria included intraocular surgery within the preceding six months, prior vitrectomy, contraindication to radiation or suction-coupled contact lens and the presence of retinal vascular anomalies other than neovascular AMD, such as those associated with diabetes mellitus.

All patients received an anti-VEGF injection within 14 days prior to radiotherapy and returned every four weeks thereafter to be assessed on the need for anti-VEGF retreatment. The retreatment criteria were a 100-micron increase in central subfield thickness from best prior OCT scan, evidence of new or increased macular haemorrhage or a loss of more than five letters of visual acuity.

Fewer injections After 12 months, the data conclusively showed that the trial achieved its primary end point demonstrating a statistically

Our study showed that stereotactic radiotherapy produced a 25 per cent reduction in the anti-VEGF injection frequency over the course of two years Timothy L Jackson PhD, FRCOphth Eurotimes | April 2014

significant reduction in as-needed injections. The actively treated patients required approximately 35 per cent fewer injections than the sham group with similar or in some cases better visual acuity outcomes. Twenty-five per cent of Oraya Therapy patients needed no further injections.

Vision benefit A defined population sub-group comprised of roughly half of the study participants experienced even lower injection rates while exhibiting meaningful vision benefit compared to sham. A post hoc analysis of this subgroup found that patients with more fluid on the macula whose lesions were confined within a designated 4.0mm central zone of the macula seemed to derive most benefit from the Oraya Therapy.

Reported adverse events were very low over the two-year follow-up period, said Dr Jackson, with no particular pattern emerging comparing the treatment arms and the control arms, except for one case where the investigator identified radiation-related retinopathy within the 24 Gy treatment arm.

Detailed images were also sent off to an independent central reading centre to try to identify any microvascular abnormalities such as cotton-wool spots or retinal haemorrhages which might arise due to the radiation treatment, said Dr Jackson.

“Overall there were up to nine cases where the microvascular changes could be attributable to radiation and two of these where it may have had a possible impact on their vision. However, these were in patients where the disease was very advanced and it was extremely difficult to discriminate whether or not it was radiation or the advanced AMD itself that may have affected the vision,” he said.

Summing up, Dr Jackson said that overall the two-year results of the INTREPID trial are very encouraging for people with wet AMD. The prospect of fewer eye injections will appeal to all those receiving anti-VEGF therapy, and for certain subsets there is the added advantage of an improved visual outcome, he said.

Timothy L Jackson: timljackson@doctors.org.uk

E M A S IG DD REACH

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ocular

Changing refraction Sean Henahan talks to the inventor of a novel presbyopia technique Left image: One month after test treatment, surgery on both eyes; four incisions,150µ depth, 6.8mm internal diameter and 9.3 external diameter. Below: Pigment injection

Courtesy of Francis Ferrari MD

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novel approach to treating presbyopia could also allow patients to change eye colour.

The inventor of the new technique, Francis Ferrari MD, France, described the preliminary work in a recent issue of the Journal Français d'Ophtalmologie (J Fr Ophtalmol.,36(6):481-7.)

“You may create a small or a large ring in the cornea. Creating a small ring is a new refractive technique for treating presbyopia.

It is like a Kamra, but without a Kamra,” Dr Ferrari, Expert Vision Center, Strasbourg, France, told EuroTimes. You may also create a large ring to change the eye colour (this last procedure will not treat presbyopia).

The presbyopia treatment, dubbed PresbyRing®, (US Patent Application No. 14/051,622), involves creating an intrastromal ring centred on the visual axis with a femtosecond laser. Then a black or coloured pigment is injected into the ring. The internal diameter of the ring is designed to create a pinhole and improve the near and intermediate vision of the nondominant eye while only slightly altering the distance vision of that eye, he explained.

The initial in vitro research involved five pig eyes in a post-mortem feasibility study.

The eyes were treated with the Intra Corneal Ring program of the Visumax® laser, and then injected with the Biochromaderm dye.

Subsequent spectral domain OCT examinations showed complete opacity of the dye. Histological analysis showed a continuous pigmented layer located along the incision, which did not diffuse in the adjacent stroma.

“To our knowledge, this study represents the first experimental attempt to combine two ideas which did not appear to have anything in common: the creation of an intracorneal pinhole to treat presbyopia, and corneal tattooing,” he wrote in the journal article.

The surgery in order to change eye colour, dubbed aesthetic annular keratopigmentation, (US Patent Application No. 14/051,622) involves creating a large intrastromal ring located close to the limbus.

Then a coloured pigment is injected into the ring. Dr Ferrari has performed the surgery on one patient, a 49-year-old female.

She was treated in both eyes under topical anaesthesia. The procedure took 30 minutes

You may create a small or a large ring in the cornea. Creating a small ring is a new refractive technique for treating presbyopia Francis Ferrari MD Eurotimes | April 2014

for both eyes. He injected the dye at 150µ depth; with a 9.3mm external diameter and 6.8mm internal diameter.

Preoperative and postoperative visual acuities were 20/20. The patient did not complain of glare or halo following the treatment.

Dr Ferrari had conducted a test treatment earlier to confirm that the patient would tolerate the dye. He injected the dye in one eye in ¼ of a ring located in a superior location.

The dye, Biochromaderm®, (Biotic Phocea) is approved in the EU for human corneal use. It is essentially used for cutaneous chromatic repair, eg, tattooing a pathological area of skin or to mask a scar. The dye, which comes in a wide range of colours, has been used in the past to treat iris pathology.

“If I need to reverse the procedure, I could put the original colour on the top of the changed colour. For example, for a patient with brown eyes, I would put a green colour 180µ deep. If she decided she didn’t like the new colour, I could put a brown colour at 150µ deep,” he explained.

“In the first patient on whom I’ve performed the surgery, I used a green pigment. The patient is very happy with the result,” he added.

Additional safety and efficacy studies are still required, he emphasised.

Francis Ferrari: francisferrari@icloud.com

Registration, Hotel Bookings & Preliminary Programme Online

14th EURETINA Congress

LONDON 11-14 September 2014

www.euretina.org

38

ocular

IRIS REGISTRY AAO says new data collection tool could revolutionise care.

Howard Larkin reports

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comprehensive ophthalmology patient database that could greatly improve ophthalmic care launches at the end of March, leaders of the American Academy of Ophthalmology (AAO) announced. The IRIS Registry, for Intelligent Research in Sight, debuted at the 2013 AAO annual meeting in New Orleans and is the first of its kind in the US. “With the wide adoption of electronic health records, the time is right to fully utilise the power of information technology to produce evidence-based, statistically valid information that can help ophthalmologists determine how to improve patient care,” said William L Rich III MD, AAO medical director of health policy.

IRIS is a centralised collection and reporting software tool that compiles and processes data drawn directly from electronic health records in participating ophthalmology practices. It enables ophthalmologists to statistically analyse their own care, compare it to that of their peers and pinpoint opportunities for improvement.

The database allows ophthalmologists to manage their patients at a population level; study a specific group of patients based on conditions, risk factors, demographics or outcomes; identify trends and track interventions; and answer specific clinical questions.

Longitudinal record

Far Intermediate Near

THE NEW TRIFOCAL DIFFRACTIVE TORIC IOL

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Eurotimes | April 2014

IRIS was developed with input from several existing registries, including the ESCRS-supported EUREQUO, the Aravind system medical record in India and registries operated by other specialties, Dr Rich said. But unlike most previous registries, IRIS continually collects data on patients before, during and after procedures, creating a longitudinal record rather than one built around discrete episodes of care. He believes that eventually specialty registries will be aggregated into a broader dataset, enabling research into how treatments of one organ or body system affects others.

When it was introduced at the AAO Meeting, the IRIS Registry had been piloted with 120 ophthalmology practices, representing roughly 370,000 patient encounters across 35 states. As of March, more than 400 practices have joined the registry. The AAO estimates that the database will be populated with data from more than 18 million patients by 2016.

One challenge is developing standardised measures for each subspecialty that are clinically meaningful but not overly burdensome to collect, said Michael F Chiang MD, chair of AAO’s Committee on Medical Information Technology, and Knowles Professor of Ophthalmology & Medical Informatics and Clinical Epidemiology at Oregon Health and Science University.

An AAO working group is collaborating with subspecialty groups drafting standards, Dr Chiang said. “Each subspecialty compiles its own panel of specific outcomes of interest. In some cases they are specific clinical or surgical outcomes; in some cases there is interest in disease-specific registries.”

The real advantage will be improved care, Dr Chiang said.

“Best practice guidelines, side effects of various drugs, postmarketing surveillance – the potential is really amazing.”

Linda Apeles: lapeles@aao.org

13-17 September

2014

London XXXII Congress of the ESCRS

Registration, Hotel Bookings & Preliminary Programme Online

www.escrs.org

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Ocular

EYE CARE RECONSIDERED Growing demand drives thaw in US ophthalmology-optometry relations. Howard Larkin reports

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s a prominent researcher in the fields of optics, aberrations in refractive corrections and early ocular disease detection, Raymond A Applegate OD, PhD used to present regularly at American Academy of Ophthalmology meetings. Then one year he was not invited. In part responding to optometry groups pushing state laws permitting them to practise refractive surgery, the American Academy of Ophthalmology had banned optometrists from attending educational activities at its meetings.

Relations between ophthalmology and optometry had been cool since before he entered the field in the 1970s, said Dr Applegate, who served the eye care profession for 14 years as a professor of ophthalmology at the University of Texas Health Science Center San Antonio and is currently professor and Borish Chair of Optometry at the University of Houston.

But in his mind, the ban on the open exchange of information strikes at the core interests of both professions, and is bad for patient care.

“The mark of most successful healthcare professions is the open exchange of information. The American Academy of Ophthalmology action put a stake in that. We should always, regardless of the letters after our name, exchange information for the benefit of patients and the public,” says Dr Applegate, who has served on the editorial boards of several optics, ophthalmology and optometry journals, and presents regularly at ESCRS meetings.

The American Academy of Ophthalmology hasn’t yet reversed the ban.

But late last year, the society took two steps toward thawing relations with optometry.

We need to build an ophthalmologistled care team, but one that relies on optometrists to help in screening, primary diagnosis and care management...

Paul A Sternberg Jr MD In his opening remarks at the 2013 American Academy of Ophthalmology annual meeting, the then academy president, Paul A Sternberg Jr MD, called for better integration of optometrists and other health professionals into the eye care team. As the baby boom generation ages into retirement – and many prolific ophthalmologists among them exit practice – demand for services will greatly exceed the supply of ophthalmologists, he noted. Meeting growing patient needs, not to mention rising service and outcomes expectations, will require not just a truce, but a new collaborative relationship with optometry.

“We need to build an ophthalmologistled care team, but one that relies on optometrists to help in screening, primary diagnosis and care management of our patients with eye disease. It is a more efficient model. It addresses our emerging supply side problems, and maybe it can help us reallocate the resources that both professions have expended fighting a seemingly endless scope of practice battle,” Dr Sternberg said.

Educational initiative Three weeks later, the American Academy of Ophthalmology announced formal dialogue with the American Academy of Optometry. “What prompted this was not

In a team-based care delivery world, it makes sense that we open an ongoing dialogue in the interest of our patients David W Parke II MD Eurotimes | April 2014

an event but a growing realisation that even though many ophthalmologists and optometrists have good, patient-focused relationships on an individual basis, the two professions have negligible interface on the educational front. In a team-based care delivery world, it makes sense that we open an ongoing dialogue in the interest of our patients,” American Academy of Ophthalmology chief executive officer David W Parke II MD told EuroTimes.

“When the American Academy of Ophthalmology reached out to us, we thought it was an excellent opportunity to move forward our education for our patients and improve patient care,” said Bernard J Dolan OD, MS, president of the American Academy of Optometry.

The initiative was taken by decision of the two organisations’ boards. The next step is to get feedback from members, and appoint a joint taskforce to focus on the details – possibly joint symposia, educational programmes and standards of care and care guidelines for team-based practice.

“The first thing we needed to do was build the bridge. Now we get down to the nitty gritty,” Dr Parke said.

The organisations anticipate these programmes will be developed over the next 12 to 18 months.

The American Academy of Ophthalmology’s move follows development by the American Society of Cataract and Refractive Surgeons (ASCRS) of the Integrated OphthalmicManaged Eyecare Delivery Model (IOMED). It debuted at the ASCRS meeting in April 2013 with a slate of educational programming for optometrists employed by ophthalmologists or organisations that integrate optometric and ophthalmologic practice. According

Ocular

We should always, regardless of the letters after our name, exchange information for the benefit of patients and the public Raymond A Applegate OD, PhD

to an ASCRS survey, 34 per cent of US ophthalmologists employ optometrists and 38 per cent anticipate doing so in the future. Dr Applegate notes that many more optometric practices are hiring ophthalmologists as well to meet patient needs. More than 130 ODs registered for the first programme.

Integrated eye care creates a system in which ophthalmologists and optometrists work together synergistically so that total care of a patient is coordinated.

“Integrated eye care makes sense, given the state of affairs we are presently in,” said Stephen S Lane, MD, chairman of the ASCRS Committee of Integrated Eyecare. “We have an increasing number of patients and a diminishing number of eye care providers to take care of them. We need a system available so patients receive good care and are seen efficiently and cost effectively. ASCRS has taken a leadership

role in developing and nurturing an educational process directed at optometrists and ophthalmologists to promote this practice model.”

These moves toward accepting and making fuller use of trained optometrists don’t end friction between the professions.

But it does create a framework for working together in the interest of optimal patient care, Dr Parke said.

“Realistically, there is no chance any two organisations will agree on everything.

The key is to identify likely areas for productive engagement.”

The American Academy of Optometry steers away from politics, Dr Dolan said.

“We are an educational organisation.

We were approached on patient-focused

We have an increasing number of patients and a diminishing number of eye care providers to take care of them Stephen S Lane MD

education and research, and we are very interested in the opportunity,” Dr Dolan said. Other optometry organisations are responsible for advocacy, he pointed out.

For Dr Applegate, the legislative fights have never really reflected the view of most practitioners. “Unfortunately in political/economic decision-making, the people who buck the hardest often ignore advances in education, training and research and ever changing societal needs in their decision making while the people who actually deliver care are often left on sidelines.”

Dr Applegate notes that as knowledge and training advances, practice scope inevitably expands for all healthy professions. He hopes for a more productive relationship to come between optometry and ophthalmology that better respects the fact that education, research and training evolve to meet unmet needs and consequently practice patterns, skill sets and associated reimbursements change.

Raymond A Applegate: rapplegate@uh.edu Linda Apeles: lapeles@aao.org Cindy Sebrell: csebrell@ascrs.org

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Eurotimes | April 2014

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Meeting report

Slovenian hosts welcome ESCRS Poster prizes

Pictured on the opening day of the 18th ESCRS Winter Meeting were (left to right); Vladimir Pfeifer, Roberto Bellucci, ESCRS president, and Marko Hawlina

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ddressing the ESCRS Winter Meeting in Ljubljana, president of the ESCRS, Roberto Bellucci, said he was delighted to welcome delegates as this was the first time that an ESCRS meeting had taken place in Slovenia.

“We are very pleased to be working with our friends and colleagues from the Slovenian Society of Cataract & Refractive Surgeons [SSCRS],” said Dr Bellucci, “and I would like to give special thanks to Dr Vladimir Pfeifer and Dr Marko Hawlina for their assistance and encouragement,” he said.

Dr Bellucci said that this was his first meeting as president of ESCRS and he looked forward to working with members of the society over the next two years. “The members are the ESCRS and with their support we will continue to grow,” he said.

Cornea Day The congress opened with the Annual Cornea Day organised in conjunction with EuCornea and chaired by Dr José Güell, president EuCornea and Dr Rudy Nuijts, chairperson of the EuCornea Committee.

Other first-day highlights included a symposium on Enhancements in Pseudophakia, courses in Basic Optics, Cataract Surgery and Refractive Surgery and a Young Ophthalmologists Programme.

There were also Free Paper sessions on Special Cases and Cataract.

The second day of the congress featured symposia on Applications of the Femtosecond Laser and Update on Endophthalmitis and courses in Cataract Surgery, Refractive Surgery and Cornea, Free Papers on Cataract and ePoster presentations.

The meeting concluded with a symposium on The Perfect Phaco, the SSCRS symposium and a Refractive Surgery Free Paper Session.

A re-examination of autorefraction after cataract surgery and the results achieved with small incision lenticule extraction (SMILE) were the topics of the winning posters in the cataract and refractive categories respectively in the poster competition.

In the cataract category, Kunal Gadhvi MD,UK compared the findings of subjective autorefraction and objective retinoscopy in 43 patients who had undergone cataract surgery.

They found that, in general, there was no significant difference between the two measurements regarding spherical equivalent, although there were a few outliers with a difference of up to 2.0 D. There was a significant difference between the two types of measurement regarding cylinder which was +43 D higher with autorefraction (p<0.001).

In the refractive category, Paula Verdaguer MD, Spain and associates compared visual outcomes in 35 patients with the small incision lenticule extraction (SMILE) technique performed at four different depths, 130 µm, 140 µm, 150 µm and 160 µm using the Carl Zeiss Meditec AG VisuMax femtosecond laser system.

They found that there were no significant differences between the four groups in terms of visual acuity, refractive outcomes or complication rates using the four different deepness of SMILE procedure. Overall, patients’ mean postoperative UCVA was 0.76 and was 20/25 in 70 per cent of patients. In addition, mean postoperative spherical equivalent SE was -0.22 D and mean postoperative cylinder was 0.20 D (SD 0.55). In addition, there were no complications in any of the groups.

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Eurotimes | April 2014

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journal watch

JOURNAL

WATCH

NEW APPROACH Adjunctive corticosteroid improves eyesight

The addition of the corticosteroid fluocortolone to standard therapy improves short- and long-term visual acuity in patients with nonarteritic anterior ischemic optic neuropathy (NAION), according to a study in Restorative Neurology and Neuroscience.

In a prospective randomised trial of 60 patients with NAION, researchers from the Institute of Experimental Ophthalmology, University of Münster, Germany found that patients treated with pentoxifylline alone had no significant beneficial effects in either visual acuity or visual field after three days and six months of treatment. However, adding fluocortolone patients were significantly more likely to experience improvement and less likely to have worsened visual acuity. After six months of therapy two thirds of patients treated with the combination therapy had better long-term vision compared to only 14 per cent of those only treated with pentoxifylline alone.

The researchers note that the effects were especially pronounced when the combination therapy was given soon after the onset of symptoms. They hypothesise that since NAION is caused by ischemia of the optic nerve head, the restriction of blood supply, depending upon its degree, results in primary irreversible loss of retinal ganglion cells (RGC) and secondary delayed RGC loss related to subsequent optic-disc edema.

Corticosteroids do not appear to reduce primary cell death, explaining the lack of benefit of steroid therapy in patients with a BCVA score worse than 0.05. There may be a therapeutic window for patients with moderate BCVA loss who suffer secondary RGC loss due to optic-nerve swelling.

V. Prokosch et al., Restorative Neurology and Neuroscience, “Visual outcome of patients following NAION after treatment with adjunctive fluocortolone,” 2013.

DOI 10.3233/RNN-120292.

JOHN HENAHAN

PRIZE 2014

Call for entries Young ophthalmologists are invited to write a 900 word essay on

“HOW DO I SEE CATARACT SURGERY IN 30 YEARS?” The winner will receive a €1,000 travel bursary to the XXXII Congress of the ESCRS in London, UK

http://www.escrs.org/London2014/ programme/Henahan-prize.asp See www.facebook.com/ESCRSYO

FROM THE ARCHIVE

CLOSING DATE: FRIDAY 6 JUNE 2014

Intracorneal ring for keratoconus treatment Corneal intrastromal implantation surgery (CSIS) for the treatment of keratoconus appears to be safe and effective and offers potential advantages over existing treatments, according to Albert Daxer MD, PhD. "CSIS is a reversible, minimally invasive procedure which is quick and easy to perform. It significantly improves corneal topography and offers iterative adjustment of the implant position towards the optimal placement at any stage after implantation which is an advance on any treatments available," he told the XXVI Congress of the ESCRS. Dr Daxer concluded that CSIS is a safe and effective treatment modality for keratoconus, which allows for subsequent repositioning of the implant in order to find the optimal placement relative to the optical axis and deliver optimised refractive results for patients.

From EuroTimes, Volume 14, Issue 2 , February 2009

Eurotimes | April 2014

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viewpoint

PURSUIng EXCELLENCE In the first of a new series where key opinion leaders look at trends in ophthalmology, Peter Barry discusses the concept of ‘excellence’ in the field

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would like to reflect on this topic under four headings: Money, Quality, Safety and Measurement.

Money:

Y E N

months”. Be honest in discussion with your patients. Spectacle independence “most of the time” is true for monofocals. Clear lens extraction does not prevent cataract and who knows the long-term risk of retinal detachment following cataract surgery and likely subsequent Yag Laser Capsulotomy when performed in the middle-aged?

A reputation for excellence is not built by marketing but by achievement in the public hospital system. Is “neuro-adaptation” a fancy name for surgically induced amblyopia? Remember Tannenbaum’s dictum – “the diagnosis of cataract is like the diagnosis of cancer; it requires immediate surgery lest it metastasise across the street!”

Safety: Safety is doing common things uncommonly well. To achieve a culture of safety, we need a culture of improvement and a culture of improvement must come from the top. Inertia is unsafe. You must get out of your comfort zone if you wish to improve.

Do not repeat the same mistake with ever-increasing confidence and call it experience.

MEA SU R

T EN EM

Firstly, we must dissociate affluence from healthcare. Femto-assisted cataract surgery is not better because it is more expensive, but this message is often implied. “Premium” IOLs is a misnomer. It implies that toric and multifocal IOLs are the better option if you can afford them and the monofocal is a shoddier article and the poor man’s choice! All modern IOLs used in Europe are “premium” with different sub-types suitable for different patients and different patients’ requirements.

One never hears a cardiologist advocating “premium” heart valves. In my country, Ireland, FRCS (Fellow of the Royal College of Surgeons) is a testimony to achievement and a badge of honour. It should not be used as a marketing acronym for Femto Refractive Cataract Surgery.

MO

Quality: Quality can only be achieved by listening to patient feedback.

Cataract care pathways are full of detail but light on symptoms and, too often, by the time the patient meets the surgeon, it is too late to abort. PROMS (Patient Reported Outcome Measures) are as important as clinical trials.

Quality is never an accident – it is the result of high intentions.

Quality can only be assessed at follow-up. Surgery does not end at the door of the operating theatre: it ends when the patient is cured and discharged by the specialist. Quality is being transparent and professional when things go wrong. It is not “getting rid” of the problem-patient back to primary care whilst fooling yourself their problem will be adequately sorted there.

This irresponsibility is often justified by the need to adhere to the healthcare managers’ requirements of NTFUR (New to Follow Up Ratio). Do not pass the buck. Do not refer a postoperative IOP of 26mm Mercury to the Glaucoma Clinic or the cystoid macular oedema to the Retinal Service. Be responsible and manage your own problems.

Quality is not “goodbye, thank you and enjoy your multifocal – you’ll get used to the glare and haloes over the next six

Measurement:

EXCELLENCE

A

Eurotimes | April 2014

TY

Y

QU

LI

Surgeons who don’t count, don’t count.

Measurement is the key; with it we can compare better or worse, today or yesterday, me or someone else.

It is for these reasons we published “Evidence based guidelines for cataract surgery based on data in the EUREQUO database” (Lundstrom, M. et al. J Cat Refract Surg, 2012: Jun; 38(6):1086-93).

It is for these reasons the ESCRS is conducting a registry of FLACS (Femto Laser Assisted Cataract Surgery) wherein consecutive FEMTO cataract procedures in multiple European clinics will be compared to non-Femto phaco procedures matched from the EUREQUO database. The aim is to determine if FEMTO cataract surgery has the ability to achieve a superior outcome by the cumulative benefit of multiple detailed steps which surpass the human hand or whether it is simply an expensive method for improving a number of details which, ultimately, do not count. The study is in progress and results will be presented at the ESCRS Annual Congress in London in September 2014.

ET

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Peter Barry: peterbarryfrcs@theeyeclinic.ie

esaso

ESASO COURSE SERIES Books make perfect addition to ESASO education service

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n 2012, ESASO launched the ESASO Course Series – a compilation of knowledge and the essence of ESASO teaching transferred into print. Since then, it has released publications on Medical Retina, Surgical Retina and Cataract Surgery. This year, the series has been extended with a newly launched volume on Optical Coherence Tomography.

Series editors Francesco Bandello and Borja Corcóstegui, select the hottest topics and the best experts for the series. Dr Corcóstegui, president of the ESASO Foundation Board, stated: “The evidence-based books not only contain preparatory and approved learning material for module participants, they also serve as works of reference for established ophthalmologists”.

New launch Building on the success of the ESASO course on Optical Coherence Tomography held in Lugano last year, a new volume edited by Gabriel Coscas, Anat Loewenstein and Francesco Bandello exploring the recently improved diagnostic technique was published in February 2014.

The introduction covers the equipment and basic techniques and presents the imaging features of various pathological findings in retinal diseases, followed by the outer layers including new modalities for choroid imaging, outer-layer diseases including various types of macular degeneration, retinal diseases such as diabetic retinopathy and vascular occlusion and retina and vitreous interface pathologies.

The book concludes by discussing the practicality of using OCT for the pre- and postsurgical evaluation of the posterior segment and for the differential diagnosis of vitreoretinal diseases as well as in the management of patients with retinal and neuro-ophthalmological diseases.

Upcoming volume Later this year ESASO plans to release a new volume on Oculoplastic Surgery by Luz María Vásquez and Ramón Medel, and a volume entitled Cornea by José Güell.

Giuseppe Guarnaccia, global executive director of ESASO, enjoys watching the ‘ESASO family’ grow with the release of each new book. “Indeed, being a member of the ESASO family is rewarding for everyone from faculty members to module participants,” he said.

ESASO Course Series books are available in print and electronically. E-books are convenient as the reader can highlight important passages, set bookmarks and work on a mobile device. Keep an eye out for this series at ophthalmology events or at the Karger website (www.karger.com/esaso).

Sandra Braun: s.braun@karger.com

ESASO PUBLICATIONS Medical Retina by F Bandello; G Querques, 2012 (ISBN 987-3-8055-9990-0).

Surgical Retina by F Bandello; M Battaglia Parodi, 2012 (ISBN 978-3-318-02158-5).

Cataract by J L Güell, 2013 (ISBN 978-3-318-02410-4).

Optical Coherence Tomography by G Coscas, A Loewenstein, F Bandello, 2014 (ISBN 978-3-318-02563-7).

Eurotimes | April 2014

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travel

City Centre

3

must see...

LONDON

average september temperature: 16˚C CURRENCY: British Pound (GBP)/Sterling TIME ZONE: Greenwich Mean Time

The Burlington Arcade linking Bond Street with Piccadilly was built by Lord George Cavendish in 1819 for the employment of ‘industrious females’. Members of his family regiment, the 10th Hussars, were recruited to serve as a private security force – the elaborately costumed Beadles. Beadles still patrol the covered Arcade enforcing Lord Cavendish’s code of behaviour: no whistling, singing, playing of musical instruments, running, carrying of large parcels or opening of umbrellas and no babies’ prams. The Queen’s own nephew, son of the late Princess Margaret and Lord Snowden, has a shop at No 41 where the magnificently crafted furniture and objects Viscount Linley produces are sold. Linley also designed the Arcade’s new carpet celebrating 92 of the world’s most celebrated buildings. www.burlington-arcade.co.uk/ From the Burlington Arcade it’s a five-minute taxi ride to Kensington Palace and the exhibition, ‘Fashion Rules’, a close-up look at 21royal frocks: the 1950s haute couture of Queen Elizabeth, the more daring 1960s and 1970s costumes of Princess Margaret and the sometimes over-the-top choices of Diana, Princess of Wales. Many of the dresses are familiar from photographs, some are shown for the first time. Photographs, film footage and music set the scene. Coincidentally, Britain’s current style icon, the Duchess of Cambridge, lives in Kensington Palace a few paces away from the exhibition.

With Prince William and their son Prince George she occupies the four floors of apartment 1A which once housed Princess Margaret.

Open daily 10-18.00. Last admission 17.00. www.hrp.org.uk/KensingtonPalace Seven Dials, a picturesque cobbled area between Covent Garden and the Theatre District, is named for the monument in the centre of seven convergent streets. The fact that the pillar carries six, not seven, sundial faces seems to worry no one. Seven Dials is home to some of London’s best independent boutiques with a particular nod towards men’s fashions. Browse here for modern classics, British heritage brands, fashion-forward looks, designer labels, wardrobe staples and denim styles. Round off a shopping trip with a cocktail and a ‘dictionary thick’ steak at Hawksmoor Seven Dials in the historic Watney-Coombe brewery. www.thehawksmoor.com

Eurotimes | April 2014

Haute coutoure invades Mayfair

A MAGNET FOR style

Delegates attending London congresses can enjoy a top fashion destination. Maryalicia Post reports Until a few years ago, understatement was the hallmark of Bond Street in London’s Mayfair. This corner of central London, by the East edge of Hyde Park, boasts the highest concentration of shops holding Royal Warrants (issued to suppliers of goods or services to the royal family); “no splash; no glitter” was how Virginia Woolf described Bond Street’s shops in Mrs Dalloway.

It all began to change in 2010 when Louis Vuitton moved to Bond Street. Numerous international fashion houses have planted their flags in Mayfair since then. According to the New West End Company, which represents 600 retailers in the area, this square mile now has the highest proportion of ‘haute couture’ stores in the world.

As Mayfair has become a magnet for stylish British (some say ‘footballers and their friends’) and the world’s wealthiest tourists, splash and glitter has become more the rule than the exception. Chanel’s Bond Street boutique features a strand of ‘pearls’ three stories long. Belstaff – whose biker jackets are worn by Angelina Jolie and Johnny Depp – closed down Bond Street for a motorbike parade to mark the opening of its Mayfair superstore.

Alexander McQueen’s shop is decorated with elaborate plaster panels incorporating seashells, wings and skulls, the house motif.

It all makes for great shopping ‘theatre’.

The venerable jeweller, Asprey’s, on Bond Street since 1847, survives as a reminder of what Bond Street used to be.

to-measure – bespoke – suit takes two to three months to make, requires 50 hours of hand work and several fittings, costs around £3,000 but is typically worn for decades. A few steps away on Old Burlington street, near enough to make Savile Row merchants fall on their shears, is trendy Abercrombie and Fitch. Their bid to open a children’s shop at No 30 Savile Row faced serious opposition and though they won, they were prohibited from staging one of their signature launch parties.

Fitting in less controversially is Dover Street Market a few blocks from Bond Street, part department store, part museum, part ‘happening’, it offers four floors of fashion for men and women plus a tranquil coffee shop on the top floor.

The creation of Rei Kawakubo, the Dover Street Market showcases her fashions – Comme des Garcons – and those of likeminded designers.

Bespoke Tradition lives, for the moment, on nearby Savile Row – the very name of which is synonymous with the best in British tailoring. A number of bespoke tailors have shops on this street; a hand-tailored made-

Rustic setting, high fashion at Dover Street Market

JCRS

JCRS highlights

Vol: 40 Issue: 3 month: march 2014

Best approach to correcting astigmatism?

Approximately 40 per cent of patients having cataract surgery have astigmatism of more than 1.0 D. Surgeons know that optimising refractive outcomes following cataract surgery requires good management of pre-existing corneal astigmatism.

But how best to accomplish this? Researchers at Moorfields Eye Hospital conducted a prospective masked bilateral randomised study comparing the two standard approaches now used to reduce preoperative corneal astigmatism during cataract surgery, toric IOLs and peripheral corneal relaxing incisions. The study enrolled 60 eyes of 30 patients with preoperative corneal astigmatism of 1.0 to 2.5 D. Toric IOLs and relaxing incisions both reduced astigmatism. However, toric IOLs reduced astigmatism to a higher extent and were more predictable. N Hirnschal et al., JCRS, “Correction of moderate corneal astigmatism during cataract surgery: Toric intraocular lens versus peripheral corneal relaxing incisions,” Volume 40, Issue 3, 345-361.

Physician see thyself How do physicians feel about laser vision correction when they themselves undergo it? A 12-question survey of 132 physicians who underwent refractive surgery suggested a positive overall experience. The mixed group of surgeons and non-surgeons reported an overall satisfaction rate of 95.3 per cent. Most, 84.8 per cent reported an improvement in the quality of vision, with 39.0 per cent reporting an improvement in the ability to perform procedures accurately. Theodore A. Pasquali et al., JCRS, “Long-term follow-up after laser vision correction in physicians: Quality of life and patient satisfaction,” Volume 40, Issue 3, 395-402.

Ancient ophthalmology Contrary to oft heard claims, primitive cataract surgery was not performed in ancient Egypt. A recently conducted review of the available sources from that time concludes that ophthalmology was indeed one of the most important specialties in the time of the Pharaohs. However, it appears to have been of a purely noninvasive nature, with no example of cataract surgery or of any other invasive ophthalmologic procedure found in the original sources. Indeed, the first clear mention of cataract surgery comes from the Greek stoic Chrysippus in the third century BC. The true origin of cataract surgery remains unknown. P Blomstedt, JCRS, “Cataract Surgery in Ancient Egypt,” Volume 40, Issue 3, 485-489.

jcrs syMposiuM IMPROVING PRECISION IN OPHTHALMIC SURGERY: ARE WE DOING ENOUGH? Monday, april 28, 2014 1:00 – 2:30 pM

Moderators: Nick Mamalis, MD William J. Dupps Jr, MD, PhD



Residual Astigmatism in Multifocal/Premium IOLs



Diagnostic Testing for Toric IOLs: Measuring Power and Axis



Femtosecond Laser–Assisted Cataract Surgery: Not Enough Data on Superiority



Dry-Eye Assessment and Treatment in Cataract and Refractive Surgery

during the ascrs symposium on cataract, iol and refractive surgery Boston, Massachusetts, USA

Thomas Kohnen European editor, jcrs

FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

Eurotimes | April 2014

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Young ophthalmologists are given the chance to see senior surgeons at work outside their own country

RS

SYMPOSIUM & CONGRESS

2014

APRIL 25–29 BOSTON

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

• Crossover access to ASCRS and ASOA presentations, Consultants-on-Call, roundtables, and the MediaCenters.

• Unmatched networking opportunities with the leaders in your field and hundreds of industry exhibitors.

• Innovative lectures and interactive panels on surgical techniques and practice management strategies.

www.ascrs.org

www.asoa.org

Follow @ASCRStweets on Twitter #ASCRSASOA2014

T

he ESCRS is inviting applications for its Observership Programme for young ophthalmologists who are starting or are already in surgical training.

Oliver Findl, chairman of the ESCRS Young Ophthalmologists’ Committee said the observerships, now in their third year, were an important part of the ESCRS’s programme supporting trainees and residents.

“The observerships are held for one to two weeks in different European centres,” he said. “The participating centres draw up a special curriculum to give our observers the opportunities to see patients in a clinical setting," he said. “While the young ophthalmologists taking part in the programme cannot carry out surgery, they get the opportunity to see senior ophthalmologists working. The observerships also give them the opportunity to see the logistics of how an ophthalmological department is run," said Dr Findl.

Dr Findl pointed out that many young ophthalmologists will go on for further education and training outside of their own countries, which is why the ESCRS Observership Programme has been established to give them a chance early in their education to see how ophthalmology is practised in different settings. “While there are existing observership programmes in different countries, the ESCRS Observership Programme gives young ophthalmologists the chance to travel abroad and see how their colleagues in different countries train and operate,” said Dr Findl "I think this is one of the big strengths of the ESCRS, the European Union and Europe. We have different cultures and different health systems and we should try to broaden our horizons and learn from seeing other systems, other surgeons and other techniques."

Valuable experience Dr Findl said that the Observership Programme was also a valuable experience for the centres taking part.

“We got a lot of enjoyment working with the young ophthalmologist who visited our department in the Hanusch Hospital, Vienna Austria,” he said. “We organised a tour around the Department of Ophthalmology and explained the procedures, duties and purposes of every unit. In the operating room, we explained the point of each procedure and also gave the young ophthalmologist the opportunity to interpret every surgical action with the purpose of providing a holistic presentation of the surgical cases and any possible pattern in order to prevent complications,” said Dr Findl.

Grants of €1000 are available for trainees and residents living and working in Europe who wish to take part in the programme. The grants are available for residents in the second half of their training programme or fellows of age 35 years and younger that are licensed to practise and are currently subspecialising in cataract or refractive surgery. Forty grants will be awarded annually in a competitive process.

Full information is available on the ESCRS website at: www.escrs.org/youngophthalmologist/default.asp Oliver Findl: oliver@findl.at

Eurotimes | April 2014

Industry news

Renato Ambrosio Jr examines a patient with the OCULUS Pentacam at the Metro Station, Rio de Janeiro, Brazil

industry

NEWS

Extend your Vision!

informing the population Increasing the awareness of keratoconus among the population was the aim of an event which took place on 7 February 2014 in Rio de Janeiro, Brazil. "Dr Renato Ambrósio Jr, was part of an ophthalmological team who provided a free-of-charge Pentacam® examination to 250 volunteers in Rio’s busy Central Metro Station. OCULUS distributor Technicall supported the important event by providing OCULUS Pentacam® HR devices for the examinations," said an Oculus spokesman.

Dr Ambrósio pointed out that the initial stage of keratoconus was asymptomatic and that early diagnosis was essential as there were methods to prevent progression of the disease. Therefore, he added, it was urgently necessary to inform the population.

Patients who were diagnosed with keratoconus were referred to specialised practices and clinics immediately. Other patients left the temporary Pentacam “medical office” at the Metro Station with the recommendation for regular eye examination. ww.oculus.de

The neXt generation of the world‘s unique multifocal Mplus-IOL-technology The unique optical design of the rotationally asymmetric LENTIS Mplus has revolutionised ®

the multifocal IOL market worldwide. Well over 200,000 Mplus implantations in 4 years and a significant number of clinical studies prove the superiority of this patented technology to conventional diffractive multifocal lenses.

With the LENTIS MplusX Oculentis goes a ®

Vitreous cutter Geuder says the new MACH2 vitreous cutter fulfills the divergent requirements of faster vitrectomy and Improved patient safety. “The innovative double-blades allow for up to 12.000 cuts with megaTRON devices,” said a Geuder spokeswoman.

“Together with a permanently open cutting window core vitrectomy is significantly faster compared to single blade cutters. Also in vitreous base shaving the new vitreous cutter shows significant advantages,” she said. www.geuder.de

Specular microscope speedy and straightforward NIDEK has announced that the Food & Drug Administration (FDA) has issued 510K clearance for the CEM-530 Specular Microscope.

The company says the microscope acquires images of the corneal endothelium and provides analysis very quickly and easily.

“The auto tracking capabilities make acquisition speedy and straightforward,” said a company spokesman.

The features of the microscope include paracentral specular

microscopy as well as peripheral images, twosecond auto analysis, automatic indication of the optimal image, 3-D auto tracking, auto shot and a tiltable touch screen with built-in printer. www.nidek.com

step further and presents an advanced and improved version of the previous Mplus model.

For even better visual results and happier patients and doctors!

Further information about the LENTIS MplusX at: ®

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Oculentis GmbH Am Borsigturm 58 | 13507 Berlin | Germany Phone. +49 (0)30 43 09 55 0 Fax. +49 (0)30 43 09 55 11 www.oculentis.com

Eurotimes | April 2014

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CAPSULORHEXIS Everything you want to know about the perfect capsulorhexis. Soosan Jacob reports INSTRUMENTATION: Rhexis can be performed with a cystitome or a capsulorhexis forceps.

Using a cystitome is simple, be it selffashioned from a needle (preferably 26/27 gauge) or a pre-bent one. While fashioning the cystitome, the tip should be bent bevel up only at the very end.

Having too long a bend can tear the corneal valve incision. Having a more oblique angle rather than an extreme right angle for the tip is preferable to be able to always visualise the tip during the rhexis. The shaft angle should be such that there is no distortion of the corneal incision secondary to excessive pressure on the anterior or posterior lip of the incision. For rhexis with forceps, either the Utrata forceps or microrhexis forceps may be used.

INCISIONS: Whether performing a superior or temporal clear corneal phaco, the main port and the side ports should be made at a comfortable, ergonomic angle â&#x20AC;&#x201C; ideally between the vertical rectus and the corresponding horizontal rectus. A common mistake is an anterior entry into the anterior chamber (AC) necessitating excessive Eurotimes | April 2014

posterior angulation of instruments with consequent stress on zonules.

Excessively posterior incision can cause iris prolapse and conjunctival ballooning. The ideal incision should be a square tunnel just anterior to the limbus avoiding conjunctiva. Too short a tunnel can cause iris prolapse while an excessively long tunnel can cause oarlocking of instruments. For beginners, it is advisable to enter only partially so as to allow better retention of viscoelastic in the AC. The incision can be enlarged to its full extent after completion of rhexis.

SIZE OF RHEXIS: The rhexis should be well centred. A uniformly dilated pupil may be used as a guide for centration and sizing. In small pupils, care should be taken not to make the rhexis too small. Ideal size is about 0.5 to 1mm smaller than IOL optic size. This allows the rim to overlap the optic on all sides and prevents posterior capsular opacification. It also allows easy optic capture of IOL in case of a posterior capsular rent.

RHEXIS WITH NEEDLE: The AC should be kept deep throughout with viscoelastic and the anterior lens

capsule flat. A shallow AC can cause the anterior lens capsule to be nicked while entering. It also allows the convex shape of the lens and intra-lenticular pressure to cause a run-away rhexis.

Performing the rhexis without distortion of corneal wound allows better retention of viscoelastic inside the AC and hence better control over the rhexis.

The bent cystitome is connected to a 1cc viscoelastic filled syringe to allow the surgeon to refill the AC without having to withdraw the cystitome. The microscope light is kept at coaxial and the cystitome is introduced through the incision keeping the bent tip horizontal to avoid incision tears.

Once inside, the AC is filled again and rhexis initiated by creating a tear in the anterior capsule from the centre outwards.

Length of tear is kept just short of desired rhexis size as lifting the flap increases the size slightly. The tear is then continued in a circular manner aiming for a continuous curvilinear capsulorhexis. Pressure exerted against the capsule should be minimal.

Digging and churning of cortex should be avoided to maintain optimal visualisation throughout. According to preference, rhexis may be continued so that the subincisional part of the rhexis is tackled either first or kept for last. The flap is

didactic flap is made to lie flat) in order to allow it to be grasped by forceps. It is grasped about a millimetre from the lifted edge for good control and the rhexis created (Figure C). Whenever required, the flap edge is released and regrasped closer to tearing edge for better control. Viscoelastic should be refilled whenever AC shallows to avoid a peripheral run-off. Spiral enlargement may be done if required (Figure D). As with needle, the rhexis is ended from outside in to avoid weak spots.

Edge of rhexis should mirror curve of capsular flap edge in order to get perfectly circular rhexis

Turn needle tip horizontal while entering/exiting the main port to avoid incision tears

CAPSULAR DYE: Using a capsular dye (Trypan blue 0.06 per cent) allows better visualisation of the capsular edge and is especially useful in cases without good red reflex such as white cataracts, dense nuclei, vitreous haemorrhage etc. Dye is injected prior to viscoelastic.

CONCLUSION: Once a rhexis is created successfully, the rest of phacoemulsification can be continued. As you get more and more accustomed to making a rhexis, you will find that certain variations from this technique may feel better in your hands Rhexis with forceps

Enlarge spirally if required. Always end from outside in

always kept flat against the lens surface by injecting viscoelastic as and when required.

The edge of the rhexis mirrors the curve of the capsular flap edge (Figure A). Turning the flap inwards or outwards can make the rhexis smaller or larger respectively. Once the desired size is obtained, the flap should be kept symmetric to the torn edge so as to get as circular a rhexis as possible. While nearing the main port, avoid the flap from sliding out through the incision which can lead to peripheral extension of rhexis. If the rhexis is smaller than desired, it is possible to go around a second time to enlarge the rhexis further. It is imperative to end the rhexis from outside in to avoid any weak spots.

Once complete, inject viscoelastic again

and turn the needle tip horizontal while exiting from the main port (Figure B).

Finally, it is crucial to remember to enlarge the main port to its full extent prior to hydrodissection to avoid pressure build-up and a posterior capsule blow-out.

* Dr Soosan Jacob is a senior consultant ophthalmologist at Dr Agarwalâ&#x20AC;&#x2122;s Eye Hospital, Chennai, India and can be reached at: dr_soosanj@hotmail.com.

RHEXIS WITH CAPSULORHEXIS FORCEPS: The Utrata forceps requires full entry into the AC whereas a partial entry suffices for microrhexis forceps. Hence, the latter has the advantage of less viscoelastic loss and correspondingly better control. The initial radial cut is initiated either with a cystitome or with a sharp-tipped forceps.

Flap edge is lifted up with viscoelastic (unlike in rhexis with cystitome where the

Scan this QR code to go to video link for surgery.

Glaucoma Day2014 ESCRS

Friday 12 September Registration Fee: â&#x201A;Ź150 www.escrs.org

Eurotimes | April 2014

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calendar

sePtember

XXXII congress of the escrs

soI International congress

International Annual course and Workshop on Diagnostic ultrasound in ophthalmology

4–8 may orlando, Florida, usA www.arvo.org

30-31 may Algarve, portugal www.spoftalmologia.pt/cirp2014

11th egs congress

XIII International congress of cataract and refractive surgery 2-5 April rio de Janeiro, brazil www.cataratarefrativa2014.com.br/

World ophthalmology congress 2-6 April tokyo, Japan www.woc2014.org

International symposium on cornea: clinical Approach 11 April belgrade, serbia www.cornea-belgrade2014.org

7-11 June nice, France www.eugs.org/eng/default.asp

August

nordic congress of ophthalmology (nok 2014) 20-23 August stockholm, sweden www.nok2014.com

sePtember

14th euretInA congress

11-14 september london, uK www.euretina.org

22-26 september vienna, Austria www.echography.com

noVember

the 112th Dog congress of ophthalmology

soI national congress

25-28 september leipzig, germany www.dog-kongress.org

12-15 november rome, italy www.congressisoi.com

2nd Asia-Pacific glaucoma congress 10th International symposium of ophthalmology

27th APAcrs Annual meeting 13-16 november Jaipur, india www.apacrs2014.org

26-28 september hong Kong www.apgc-isohk-2014.org/

NEW ENTRY joint Irish/ukIscrs refractive surgery meeting

october

21 november Dublin, ireland Email: hmurphy@materprivate.ie

AAo Annual meeting 18-21 october Chicago, illinois, usA www.aao.org

februArY 2015 NEW ENTRY 19th escrs Winter meeting

noVember

femto congress 2014

7-9 november budapest, hungary www.femtocongress2014.hu

20–22 February istanbul, turkey www.escrs.org

escrs glaucoma Day 12 september london, uK www.escrs.org

WsPos Paediatric sub speciality Day 12 september london, uK www.wspos.org

5th eucornea congress

12-13 september london, uK www.eucornea.org

rome

FOUR EVENTS ONE VENUE e

Corn

WSPOS

a

Eu

a

25-29 April boston, usA www.ascrs.org

NEW ENTRY Portuguese Implantorefractive Annual meeting

june

APrIl 2014

ASCRS•ASOA Symposium and congress

21-24 may milan, italy www.congressisoi.com

13-17 september london, uK www.escrs.org

C o r n

XXXII Congress of the ESCRS 13-17 September

14th EURETINA Congress 11-14 September

e

↙

lAst cAll

↙

mAY

Arvo

Eu

52

European Society of Cornea and Ocular Surface Disease Specialists

5th EuCornea Congress 12-13 September

WSPOS Paediatric Sub Specialty Day 12 September

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