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special focus Challenges in Ophthalmology CLOSE-UP

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May 2014 | Vol 19 Issue 5

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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

Contents SPECIAL FOCUS Challenges in Ophthalmology 3 IOLs can be used as drug delivery systems

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

4 Cover Story: A look at

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.

8 New lens refilling

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

new and developing lens designs

7 Femtosecond lasers can be useful for challenging cases

technique could solve persistent problems

9 Imaging technologies

help improve diagnosis of CME

FEATURES Cataract & Refractive 10 The evolution of

cataract surgery under the spotlight

11 High hyperopia and phakic IOLs

cornea 20 Cataract surgery in eyes with Fuchs’ dystrophy

22 A look at new options for treating Fuchs’ dystrophy

23 The future in endothelial

visual acuity with hydrophilic IOL

14 Accommodation in elderly patients

cataract surgery

16 Phakic IOLs good for myopes, but careful patient selection important



24 Corneal collagen

crosslinking may be beneficial in keratoconus patients

Glaucoma 26 Trial shows new stent

successfully reduces IOP

Retina 27 General treatment of

endophthalmitis consists of three components

28 Best treatment options for

diabetic macular oedema

Ocular 29 Lifestyle choices have definite impact on ocular health

12 Studies show good

15 Femtosecond laser and As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2013 and 31 December 2013 is 40,878.


REGULARS 32 Travel 33 Book Reviews 34 ESASO update 35 Resident’s Diary 36 Eye on Technology 38 Didactic Case Study 1 40 Close-up 41 Industry News 42 Viewpoint 43 Didactic Case Study 2 44 ESCRS and Charities 45 JCRS Highlights 46 Research 47 Journal Watch 48 Calendar CORRECTION: In an article on Endothelial Keratoplasty in EuroTimes Volume 19 Issue 3, Page 22, we stated: “Based on Kaplan-Meier survival analysis and defining rejection as any amount of corneal oedema after initial clearing with any amount of inflammation, the two-year cumulative probability of rejection was less than one per cent for DMEK, 12 per cent for DMEK, and 18 per cent for PK.” The article should have stated: “...the two-year cumulative probability of rejection was less than one per cent for DMEK, 12 per cent for DSEK, and 18 per cent for PK.”

Eurotimes | May 2014


editorial A Word from Roberto Bellucci MD

FACING CHALLENGES ESCRS provides forum for sharing of international expertise by ophthalmologists all over Europe


hat are the biggest challenges we face as ophthalmologists? The daily work of an ophthalmologist is a challenge in itself and we should look to solving the problems our patients present to us when they come into our hospitals and surgeries. But this is not enough. While taking care of our patients, we learn from them about the evolution of their disturbances and needs. We should also look for alternative and innovative ways to improve the efficacy and the safety of the treatments.

A member of the ESCRS Young Ophthalmologists Committee, Dr Sonia Manning, looks at the challenges facing ophthalmologists in training in an excellent article in this issue. These include the need for exposure to subspecialties, surgical experience, the highest standards of teaching and mentoring and the opportunity to carry out research.

Supporting members

Of course, the standard of training will be different in individual countries but one of the challenges the ESCRS is continuing to address is to support our members all over the world through projects such as iLearn and the Observership Driving change Programme. Through these It’s important for every one of us to take a more programmes ESCRS members holistic view of who we are and what we do. We can confront themselves with We can learn from the past can learn from the past and the present, but we the current international care and the present, but we must also plan for the future and prepare ourselves in the anterior segment of the must also plan for the for the changes that will take place in the next 10 eye, and can define their own future and prepare to 20 years. We can contribute to this change, in challenges. the final interest of our patients and of the general And finally, to perhaps the ourselves for the changes population. Actually we can drive this change. As greatest challenge of all. How that will take place in president of the ESCRS I am pleased to see our do we make sure that we are not the next 10 to 20 years society offering a forum for discussion and learning only good surgeons, but also which ensures that international expertise is shared respected members of society? by ophthalmologists all over Europe. By offering an international That is why the Special Focus in this month’s EuroTimes view of ophthalmology; by improving our knowledge; by is on: “Challenges in Ophthalmology”. In our Cover Story, considering innovation as normality; by encouraging us to we examine how new and developing lens designs combined face evaluation when submitting papers or courses – I think with new lenticular surgery technology hold out the promise ESCRS is helping us a lot in this respect. of clearer vision for all IOL patients as well as presbyopia treatment without optical compromise. That of course is a key challenge. How do we deliver the best and safest care to our patients using the latest technology available? As trained surgeons, we should be able to meet this challenge by a mixture of expertise and access to new technology, but what of the bigger challenges facing our younger colleagues. * Roberto Bellucci MD is president of the ESCRS

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 | May 2014

special focus: challenges in ophthalmology

iols and drug impregnation New technique to turn IOLs into drug delivery systems. Roibeard O’hEineachain reports


n innovative process using supercritical fluid technology can turn IOLs into sustained release drug delivery systems for steroids and antibiotics in the early postoperative weeks, said Prof Elisabeth Badens, Aix Marseille University, France. “This process can also be adapted to any polymeric matrix or implant for which a drug impregnation is required. The impregnation can also be carried out using a mixture of drugs,” she told the 18th ESCRS Winter Meeting in Ljubljana. Prof Badens described a series of experiments in which she and her associates used carbon dioxide in supercritical conditions as a vehicle with which to impregnate commercially available PMMA rigid IOLs and foldable hydrophilic IOLs with dexamethasone and cefuroxime salts. She explained that a supercritical fluid is a compound brought to a pressure higher than its critical pressure and a temperature higher that its critical temperature. As a result it has a liquid-like density and a gas-like viscosity. “Supercritical fluids are very interesting solvents. CO2 is the most used supercritical fluid because its critical pressure is easily accessible (73.8 bar) and its critical temperature is low; it's 31°C. Therefore, so we can process thermal labile and thermal sensitive products with CO2. The supercritical CO2 impregnation is more rapid, more homogeneous and leads to a higher drug loading rate than conventional impregnation with a liquid organic phase. Moreover, it is a clean process, because we Elisabeth Badens can avoid the use of organic solvents and it is suitable for liquid or solid drug solutes,” Prof Badens said. The impregnation technique involves placing the drug and IOL into two separate high-pressure vessels and pumping in CO2 until it reaches a supercritical fluid state. The CO2 causes the IOL to swell because of its polymeric nature and when the contents of two vessels mix together in a supercritical phase, the drug goes deeply into the IOL. The final step is to depressurise the vessel containing the IOL resulting in spontaneous separation of the CO2, leaving the IOL impregnated with the drug. Using this process they have achieved variable impregnation rates but have reached rates of 10 wt per cent. However, under certain conditions they observed a foaming phenomenon during the depressurisation step, with bubbles of CO2 forming within the polymeric matrix. The foaming resulted in a marked reduction in the IOLs' transparency. Ms Badens and her associates have therefore developed a new pre-treatment step involving conditioning the IOLs in presence of pure CO2 in either a static or dynamic mode with controlled conditions of pressurisation and of depressurisation. She noted that by using this technique they could preserve the transparency and optical properties of the lens material. In addition, they were able to show in an in vitro study that the impregnated drug passed into an aqueous-like fluid surrounding the IOLs over periods ranging from 10 and 30 days. Elisabeth Badens: Eurotimes | May 2014


Cover story: challenges in ophthalmology

Refractive surprise

developing lens designs




clear vision

New-era IOLs

Recent technology and designs promise clearer vision, accommodation. Howard Larkin reports


efractive surprise; glare and haloes; lens tilt, dislocation and decentration; residual astigmatism; aberrations and loss of contrast sensitivity – successful as cataract surgery is in restoring vision, these remain vexing challenges. They particularly affect presbyopia treatment, but also standard monofocal IOL implantation. New and developing lens designs combined with new lenticular surgery technology hold promise for finally overcoming these problems. The result could be clearer vision for all IOL patients as well as presbyopia treatment without optical compromise, proponents say. The precision offered by femtosecond laser-assisted cataract surgery has inspired new designs that address many of these issues, said Julian Stevens MRCP, FRCS, FRCOphth, DO, consultant surgeon at Moorfields Eye Hospital, London, UK. Perfectly sized, shaped and positioned capsulotomies enable capsulotomy-fixated lenses, with a groove in the optic that captures the capsulotomy edge much as a tyre fits into a bicycle rim, he explained. Eurotimes | May 2014

Marie-Jose Tassignon MD, PhD has long been a proponent of both the anterior and a posterior capsulorrhexis being captured at the edge of the lens implant optic, rather than rely on haptic fixation. Nishi first proposed capturing the lens optic by the capsulorrhexis, but it is only now with precise femtosecond laser capsulotomy that a reliable size, shape and position can be achieved, according to Dr Stevens. As long as the capsular bag remains stable, capsulotomy-fixated lenses should remain perfectly centred and settle at a predictable depth effectively eliminating aberrations resulting from lens tilt, decentration or incorrect distance from the retina, said Dr Stevens, who is working with Oculentis GmbH in the Netherlands developing a hydrophobic surface acrylic lens with capsulotomy fixation and which

Courtesy of Jack Holladay MD


Bag-in-the-lens – Tassignon

has CE marking. The wedge shape of the groove edge overlapping the anterior capsule surface also aims to eliminate internal reflections off the square edge of in-the-bag designs. The capsulotomyfixated lens also sits further forwards than

As long as the capsular bag remains stable, capsulotomy-fixated lenses should remain perfectly centred... Julian Stevens MRCP, FRCS, FRCOphth, DO


a bag-fixated lens, requiring a lower A constant in power calculations. A similar design developed by Samuel Masket MD, of the David Geffen School of Medicine, Jules Stein Eye Institute at the University of California Los Angeles, US, is manufactured by Morcher GmbH, Stuttgart, Germany. It was specifically designed to eliminate negative dysphotopsias, which Dr Masket found were caused by in-the-bag designs regardless of lens material. H Burkhard Dick MD, PhD, Bochum, Germany, is researching the Morcher anti-dysphotopsia lens, which was also CE marked last year. Five lenses implanted in five patients showed no negative or positive dysphotopsias or evidence of iris chafe, Jack Holladay MD, of Baylor College of Medicine, Houston, US, told Cornea 2013 at the annual meeting of the American Academy of Ophthalmology in New Orleans. The bag-in-lens designed by Prof Tassignon, University Hospital Antwerp, Belgium, also provides this benefit, Dr Holladay added. “Both anterior and posterior capsulotomy fit in a flange on the lens, eliminating PCO as well as any reflection from a rounded or square edge.” Dr Stevens noted that femtosecond laser technology may make it easier to create the precise capsulotomies required for the bag-in-lens. He also pointed out that it allows centring the capsulotomy to the desired coronal point; on the optical axis, visual axis or the dilated or undilated pupil, which is his preference. “The lens allows precise x-y coronal placement. This could make possible wavefront correction and topography optimisation similar to that offered by laser refractive surgery. For the first time we can have customised lenses.”

However, the long-term stability of capsulotomy-fixated lenses remains to be demonstrated, and some early expectations for the precision of femtocataract surgery with conventional IOLs have not panned out. “This may be because they are geometrically centred within the capsular bag, rather than over the laser capsulotomy, so there is a possible relative decentration,” Dr Stevens said. Several studies have found little or no significant difference in accuracy of effective lens position or visual outcomes between femto-cataract and ultrasound phaco patients.

In-situ lens adjustment Precisely positioning lenses becomes less critical if the characteristics of those lenses can be adjusted after they are implanted. Adjustable lenses may correct not only sphere and cylinder power, but also aberrations, said Dr Holladay, who highlighted three approaches. Available in Europe since 2008 and currently in US clinical trials, the Light Adjustable Lens, or LAL (Calhoun Vision) is an aspheric three-piece IOL with a 6.0mm optic constructed of ultraviolet-sensitive silicone polymers. This allows sphere and cylinder adjustment of about 2.0 D as well as correction of aberrations using a special lamp. Once good vision is achieved, the correction is locked in using a different light source. It has successfully corrected spherical aberrations and coma, Dr Holladay noted. The LAL is an especially good choice for eyes that have undergone LASIK or corneal crosslinking, or with cataracts making it impossible to get a precise intraocular lens power calculation, according to Tobias H Neuhann MD, Munich, Germany. He has

implanted LALs in more than 100 eyes and reported results at several ESCRS meetings. In a series of 65 eyes with an astigmatism not larger than 2.0 D, all achieved 20/30 or better uncorrected at 24 months – including 24 complicated eyes of which 13 were post-LASIK, two with keratoconus and nine with no IOL Master axial length reading. The LAL eyes also achieved good near vision, with two-thirds achieving J6 or better, compared with about two per cent of conventional monofocal eyes. Dr Neuhann believes the effect results from induction of coma in the LAL. The astigmatism of up to 2.0 D was reduced to a mean of about 0.5 D cylinder, Dr Neuhann reported. He considers the LAL the best option available for treating astigmatism of up to 2.0 D to 3.0 D cylinder because it corrects precisely based on the patient’s actual post-op refraction rather than a pre-op estimate. The LAL can also be used to apply monovision, Dr Neuhann said. The patient lives with the refraction for two weeks before locking in, ensuring that it can be tolerated. The biggest drawbacks of the LAL are cost – about €1,000 additional per lens – the need for two or three weeks' follow-up visits to adjust and set lens power, and the need for patients to wear UV-blocking sunglasses during the adjustment period to avoid power changes due to natural UV light, Dr Neuhann said. Nevertheless this investment lasts for a lifetime. A femtosecond laser capable of adjusting conventional IOLs in situ is also under development by Aaren Scientific of Ontario, California, US, Dr Holladay said. Laser energy selectively changes the refractive index of a layer of material approximately 50 microns thick within the IOL, creating a layer of higher refractive index material that can be shaped to adjust lens power, toricity and asphericity. Dual optics is a third approach, Dr Holladay said. The Harmoni lens under development by ClarVista Medical, Aliso Viejo, California, US, is a modular system incorporating a base with haptics implanted in the capsular bag with a removable optic. Lens power can be changed by replacing the optic without explanting the haptics. FluidVision Lens (Courtesy of Louis D Nichamin MD)

Eurotimes | may 2014

Cover story: challenges in ophthalmology


Courtesy of Jack Holladay MD

FlexOptic™ IOL: FEM VIEW Quarter Section View of FlexOptic IOL from Finite Element Model

We have a lot of new lenses in the pipeline and you will begin seeing these in the not-too-distant future Jack Holladay MD

Restoring vision across the entire distance spectrum is the Holy Grail of IOL design, Dr Holladay observed. But multifocal lenses, the most common current choice, also generate haloes, glare and loss of contrast sensitivity unacceptable to many patients. Several approaches are in the works that address these challenges. The extended depth of focus lens is an optical solution, Dr Holladay said. These combine a diffractive optical element with a refractive lens, creating a smooth focus over a greater depth field than a conventional monofocal lens, but without loss of contrast sensitivity or distance acuity. “We see several of these coming down the pipeline from several companies.” The Lumina lens from AkkolensTM, Breda, The Netherlands, provides mechanical accommodation with a dual optic lens that change power by moving laterally under contraction of the ciliary muscles. Inserted through a 2.8mm incision, the lens has been implanted in about 50 healthy eyes, and provides 4.0 D to 7.0 D of accommodation, according to company reports. The FluidVisionTM lens from PowerVision, Belmont, California, US,

consists of a central optic surrounded by fluid-filled haptics made up of a proprietary acrylic material containing ophthalmic-grade silicon. With contraction and relaxation of the ciliary muscles, fluid is pushed between the haptics and the flexible optic, changing its shape and refractive power. In trials of a non-foldable version reported by Louis D “Skip” Nichamin MD, Brookville, Pennsylvania, US, 14 patients achieved best corrected distance visual acuity ranging from 20/18 to 20/29, while subjective accommodation using push-down test exceeded, on average, 5.0 D. A foldable version that can be inserted through a sub-4.0mm incision has also been implanted now in 39 patients. The first 20 patients have been reported upon, with results showing that patients achieved an average of 4 D of accommodation with distance acuity averaging 20/19. The NuLens uses a similar concept, but fluid in a cylinder pushes the anterior optic back and forth, Dr Holladay said. The FlexOptic is a flexible lens designed using finite analysis to detract power from the periphery and increase it in the centre as the bag contracts.

Courtesy of Jack Holladay MD

Extend Depth Of Focus IOLs (“EDOF”)

The LAL is an especially good choice for eyes that have undergone LASIK or corneal crosslinking... Tobias H Neuhann MD Eurotimes | May 2014

Several companies are also working on injectable polymers, Dr Holladay said. One is the SmartIOL from Medennium, Irvine, California, US, which is injected shaped as a rod, but changes shape when it warms up to body temperature. It fills the capsular bag and is malleable enough to change shape similar to the crystalline lens. LiquiLens from Vision Solutions Technologies, Rockville, Maryland, US, uses gravity to accommodate, Dr Holladay said. When looking down, a high refractive index fluid flows from a reservoir producing a 3.0 D or more add. Elenza, Roanoke, Virginia, US, is developing an electronic accommodating lens, Dr Holladay said. It consists of two rechargeable batteries, integrated circuits and a central 3.0mm liquid crystal optic zone hermetically sealed inside a hydrophobic acrylic IOL. Lens power is controlled by a complex algorithm that relates pupil contraction and eye conditions with accommodative intent. The speed and amplitude of pupillary response to accommodation differs from that in response to light changes. “This circuitry is set up so that when the eye looks closer, the lens detects the pupil constriction and increases power. But it also measures light level so it is not fooled by walking outside on a bright day, which also causes pupil constriction,” Dr Holladay explained. AcuFocus, Irvine, California, US, is developing an IOL implant similar to its corneal inlay. Based on the pinhole concept, the lens increases depth of focus in the non-dominant eye, Dr Holladay said. New lenses that darken to block unwanted wavelengths when exposed to sunlight, similar to photochromic spectacle lenses, will block unwanted rays when needed, but be completely clear in low light. “We have a lot of new lenses in the pipeline and you will begin seeing these in the not-too-distant future,” he concluded. Julian Stevens: Jack Holladay: Tobias H Neuhann: Louis D Nichamin:

special focus: challenges in ophthalmology


Courtesy of Pavel Stodulka MD, PhD

Capsulotomies yellow (left). Corneal ring red reflex 1 (below)

INNOVATIONS An ever-expanding range of indications for femtosecond lasers. Roibeard O’hEineachain reports


he Femtosecond laser systems used for cataract surgery are extremely versatile instruments and have numerous uses beyond those for which they were originally designed. They can, therefore, come in very useful in some challenging cases, said Pavel Stodulka MD, PhD, Zlin, Czech Republic. “These lasers are changing our daily practice in really amazing ways. In the future they may change things even more than we would like them to,” Dr Stodulka said at the 18th ESCRS Winter Meeting in Ljubljana.

Ring segments no barrier One reason for the femtosecond laser’s expanding range of indications is the shrinking range of contraindications for the devices in cataract surgery. For example, intracorneal ring segments might seem a logical contraindication for their use, since the laser energy must pass through the cornea. However, he noted that such is the precision of the femtosecond laser cataract systems that he and his associates have been able to successfully perform capsulorhexis and lens fragmentation with the devices in eyes with the intracorneal implants. “When performing laser-assisted surgery in the presence of intracorneal ring segments we choose a smaller, 4.25mm diameter for the capsulotomy so that it will fit into the area defined by the inner edge of the corneal ring. In this way we achieve perfect alignment of the ring, the capsulotomy and the IOL,” Dr Stodulka said. Another new use to which Dr Stodulka and others have put the femtosecond

laser is the creation of posterior laser capsulotomy. He noted that the capsulotomies may be performed with the laser in eyes with or without IOLs. They can also be performed in eyes with silicone oil. In fact, capsulotomies created in this way can be used to remove the silicone oil in the course of a cataract procedure. He noted that he has performed the procedure in several eyes using the Victus™ femtosecond laser (Bausch + Lomb). The laser has no difficulty reaching the depth of the posterior capsule and the system’s high-contrast OCT provides accurate guidance for application of the laser energy. The laser easily cuts through the thick and elastic capsular tissue that is often present in eyes that have had silicone oil in their vitreous cavity for a long time. Another novel technique for which Dr Stodulka has used the Victus femtosecond laser is corneal tattooing as a cosmetic treatment for leukocoria. He presented a video demonstration of the technique, which he carried out in the blind eye of a woman with leukocoria due to an old retinal detachment. The technique involves creating a corneal pocket in the cornea 5.0mm in diameter and at depth of 250 microns and injecting black tattoo dye to cover the white pupil. Dr Stodulka uses a diamond knife to create the entrance through which to inject the dye. He enlarges the incision with an instrument designed for the placement of intracorneal ring segments to inject the dye. He noted that other more complicated and traumatic options for leukocoria include cataract surgery with implantation of a black IOL and implantation of a black anterior chamber IOL. Another, simpler option is the use of a coloured contact lens

with a black centre. However, the patient did not want to use a contact lens and Dr Stodulka therefore offered her the option of the novel cornea tattooing option. “The cosmetic effect is quite nice and three or four months later the tattoo has not changed in any significant way and the patient is still quite happy with the results,” Dr Stodulka said.

Brave new world of femto The range of indications for femtosecond lasers is likely to increase over the coming years, Dr Stodulka said. One possibility under investigation is the use of the laser to soften and restore the deformability of the lens in presbyopic eyes. The technique involves using laser to create a pattern of intralenticular microincisions, transforming the hardened lens into a system of gliding planes. Dr Stodulka said that among the innovations he would like to see in femtosecond cataract surgery technology is noncontact laser surgery with the type of 3-D eye tracker used in LASIK and PRK. A smaller suitcase-sized system would also be a helpful advance. But what could really propel the femtosecond laser into more general use in cataract surgery is a better pricing structure. The current per-use fees are too high for most patients and most surgeons, he said. “One possible future scenario we need to keep an eye on is robotic surgery. Already, automated structure-recognition is in place. If robots perform the manual part in the future that will make a significant impact on our practices,” he added. Pavel Stodulka: Eurotimes | May 2014

special focus: challenges in ophthalmology

REFILLABLE IOL Refined lens refilling technique for presbyopia.


Dermot McGrath reports

refined capsular bag-refilling procedure using an accommodating-membrane IOL has been successfully tested in monkey eyes and now warrants further study for possible clinical application in humans, according to Okihiro Nishi MD, PhD. “This new procedure required 20 to 30 minutes surgical time and was found to be highly reproducible. This approach prevents leakage of the injectable silicone polymer from both anterior and posterior continuous curvilinear capsulorhexis (CCC) and some useful accommodation of the order of 2.5 D can be obtained by this refilling technique,” Dr Nishi told delegates at the XXXI ESCRS Congress in Amsterdam. Dr Nishi noted that the accommodation attained was a consequence of the anterior curvature change of the membranous optic. He added that the new procedure goes some way towards solving two of the persistent problems that have hampered previous lens refilling techniques, namely leakage of the injectable silicone and capsular opacification. “We now need further studies to resolve some key issues associated with the procedure such as consistently achieving emmetropia and perhaps intraoperative refractometry might help in this regard. We also need to know more about how capsular opacification affects the amplitude of accommodation attained as well as the influence of YAG laser capsulotomy on the accommodative effect,” he said. To address potential problems of silicone leakage and capsule opacification, Dr Nishi used a modified version of the foldable silicone accommodating-membrane IOL used in previous rabbit eye and pig cadaver eye experiments. Capsular opacification was eliminated by anterior and posterior CCCs at least in the visual axis in rabbit eyes, which have a much higher propensity for LEC proliferation. Okihiro Nishi MD, PhD

We now need further studies to resolve some key issues associated with the procedure...

Significant modification The new accommodating IOL has a 9.0mm overall diameter and serves as an optic as well as a plug in order to seal the capsular opening (Figure 1). At the margin, there is an 0.8mm delivery hole for insertion of a 22-gauge needle, while more central to the optic is a 0.2mm positioning pocket through which the IOL can be positioned using a Sinskey hook. The IOL, which is thick at its margins, tapers to a 100 μm centre. The most significant modification of the original IOL is the absence of a transition zone between the optic and the haptic, with this zone now constituting a disk-shaped IOL, said Dr Nishi. For the latest study, a central 3.0 to 4.0mm continuous curvilinear capsulorhexis was created in the monkey eyes, after which phacoemulsification was performed in the usual manner. After the accommodating-membrane IOL was implanted in the capsular bag, silicone polymers were then injected beneath the IOL into the capsular bag through the delivery hole.

Successful results In three study groups, each with six monkey eyes, the lens capsule was refilled with 0.080ml of silicone polymers, corresponding to a 65 per cent bag volume; 0.100ml, corresponding to an 80 per cent bag volume; or 0.125ml, corresponding to a 100 per cent bag volume. To calculate the accommodation amplitudes achieved, automated refractometry was performed before and one hour after topical pilocarpine 4.0 per cent application preoperatively and four weeks postoperatively (Figure 2). In terms of results, Dr Nishi reported that the refilling technique was successful without polymer leakage in all monkeys. Four weeks after surgery, the mean accommodation amplitudes were 2.56 D (± 0.74), 2.42 (± 1.00) and 2.71 (± 0.63) respectively, in the three study groups. “Despite the creation of a central CCC in young monkey eyes, approximately 2.5 D of accommodation amplitude was obtained independent of the volume of capsular bag filling. Furthermore, leakage of the injectable silicone polymers and anterior capsule opacification in the visual axis were avoided,” he concluded. Okihiro Nishi:

Figures 1 and 2 reprinted with permission from the JCRS


Figure 1: Foldable silicone accommodating-membrane IOL. The central part is between the two arrows

Eurotimes | May 2014

Figure 2: Scheimpflug photography of a Macaca monkey eye in Group B. Note that the lens capsule after surgery is optically empty due to the silicone polymers

special focus: challenges in ophthalmology

IMAGING TECHNOLOGY OCT shines in diagnosis and treatment of macular oedema. Dermot McGrath reports


maging technologies and optical coherence tomography (OCT) in particular, have helped to improve the diagnosis and management of cystoid macular oedema (CME) in daily clinical practice, according to Gisbert Richard MD. “CME remains the most important complication we can expect to encounter after cataract surgery with an incidence of between five per cent to seven per cent in uncomplicated cases and up to 28 per cent for complicated cases such as diabetic patients without retinopathy,” he told delegates at the XXXI ESCRS Congress in Amsterdam. Prof Richard noted that there are a lot of different parameters to be taken on board in the clinical evaluation of macular oedema, including the extent and distribution of the oedema in the macular area. “Do we have central foveal involvement, and what about fluorescein leakage? Are there intraretinal cysts, as this is a very important prognostic factor. What about signs of ischemia with broken perifoveolar capillary arcade and/or areas of capillary closure? The presence or absence of vitreous traction needs to be borne in mind, as well as any increase in retinal thickness, cysts in the retina and chronicity of the oedema,” he said. Amsler grid testing is a very good qualitative method for screening for early macular oedema, said Prof Richard. While fluorescein angiography is not needed for evaluation of the oedema it can help to provide more precise information about the focal loss of Gisbert Richard MD capillaries, he added. It is OCT, however, which shines in the evaluation of macular oedema. “OCT has major advantages such as high-resolution measurements and cross-sectional images of the retina. It gives us reproducible retinal thickness measurements in normal eyes and eyes with diabetic macular oedema. The technology is noninvasive, well tolerated, fast and easy to perform. The scans are minimally influenced by media opacities, it involves a short learning curve for the clinician and it is easily understandable by patients with no medical background,” he said. Limitations of OCT include patient-related factors such as poor visual acuity and eccentric, erratic or unstable fixation, and also operator-related factors such as misidentification of artefacts or correct positioning of the callipers when manually obtaining retinal thickness measurements, said Prof Richard. “We need to remember that OCT provides information on morphologic features but it is not capable of distinguishing the origin of macular fluid or assessing macular perfusion. Information obtained by fluorescein angiography about the source of leakage and presence of macular ischemia cannot be replaced by OCT,” Prof Richard said. The very latest generation of OCT permits much higher resolution, greater control of artefacts, option of volumetry, 3-D imaging and correlation with fluorescein angiography, he added. Information derived from the OCT scans should always be supplemented with other examinations, he concluded.

Epithelial Removal Has Never Been Easier Corneal Xlinking, PRK & Advanced Surface Ablation Improved Clinical Outcomes of CXL and PRK with Amoils Epithelial Scrubber

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cataract & refractive

REWARDING PROCEDURE Recipient of the UKISCRS Lifetime Achievement Award, Prof David Spalton, reviewed the early history of cataract surgery


ataract surgery is one of the most important and rewarding surgical procedures ever devised. Its evolution has been a story of amazing human achievement, tarnished sometimes by arrogance and jealousy. Cataract surgery started in India 1000-600 BC when Sushruta described a procedure to rupture the anterior capsule of a white mature cataract then asking the patient to express the liquefied lens matter by performing a Valsalva manoeuvre by holding his nose and breathing out. This evolved into couching where a lance was used to push the opaque lens backwards into the vitreous. Couching was probably introduced to western Europe by the conquests of Alexander the Great whose campaigns penetrated into the Hindu Kush in 350 BC and is still performed in some remote parts of western Africa today. The next great advance came from the French surgeon Daviel who pioneered extracapsular cataract extraction (ECCE) in 1745. In 1756 he reported on 434 operations with only 50 (12 per cent) failures and ECCE rapidly became the treatment of choice. It is remarkable that this surgery was performed without any anaesthesia until the introduction of cocaine over 100 years later in 1884. A notable proponent was the flamboyant charlatan ‘Chevalier’ John Taylor who toured Europe as the self-styled oculist to King George II, the Pope and sundry European royalty. He had the distinction of blinding both Bach and Handel in the same year and eventually died in poverty.

Method of choice ECCE was a relatively safe and easy operation to perform but required a hard lens or mature cataract and hence there were a lot of problems with secondary membrane and inflammation post-surgery. On the other hand intracapsular cataract extraction (ICCE), with complete removal of the lens, could be performed on more immature cataracts with less risk of membrane and inflammation. However, it was a much more difficult operation requiring increased surgical expertise, larger incisions and the risk of capsular rupture and vitreous loss. Through the pioneering work of Col Henry Smith, a British army doctor in India, it gradually became the method of choice by the mid-20th century. Surgical safety was greatly improved by Barraquer who used alpha chymotrypsin to break the zonule and it is not widely known that Charlie Kelman’s first Eurotimes | May 2014

Courtesy of David Spalton FRCOphth

Left image: ‘Chevalier’ John Taylor was an itinerant charlatan and flamboyant character. (Note the eyes embroidered along the edge of his coat.) Right: Daviel’s operation involved an inferior corneal limbal incision, opening of the anterior lens capsule and expression of the nucleus by pressure on the inferior lid. It was done without sutures or anaesthesia

contribution to ophthalmology was the invention of a cryo probe for extraction of the lens which unfortunately was never fully commercialised. By 1960 ICCE was the operation of choice. I carried out many of these operations myself as a training resident in the mid-1970s at Moorfields Eye Hospital. The next major advance in cataract surgery was the development of the lens implant by Harold Ridley at St Thomas’ Hospital. He designed and inserted an intraocular lens (IOL) made of Perspex, after a medical student suggested the idea to him. Surgical records from St Thomas’ show that the patient had routine ECCE in November 1949 and the first implant was actually performed in February 1950 as a secondary procedure on a unilateral aphake. In hindsight, this was the ideal situation as by three months postsurgery the capsule would have thickened and supported the heavy IOL, leading to an anatomical (but not visual) success.

Design advances Later operations when the heavy implant was inserted at the initial surgery lead to posterior dislocation and it is interesting to speculate how events might have turned out if the first case had been done as a primary procedure. Primary posterior chamber implantation was soon abandoned in favour of AC and iris-supported IOLs, frequently with devastating complications from corneal endothelial damage, uveitis and glaucoma. IOL design has since progressed with

innumerable advances in design and surgical technique but one of the most important was the return to posterior chamber fixation pioneered by Shearing with the development of his posterior chamber IOL with flexible haptics. In tandem Charlie Kelman was pioneering phaco emulsification. His first operation was performed in 1967 with a phaco time of 79 minutes, the eye being enucleated two days later. We forget today the trials, tribulations and controversy surrounding these pioneers and the development of cataract surgery into the successful procedure we have today. It took 30 years from the 1950s to the 1980s to establish implant surgery as a safe procedure and about 20 years for phaco to be accepted as the technique of choice. Looking forwards, the only certainty is that the operation will continue to change and improve and I am sure the United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) will be there pioneering the future. David Spalton: In September 2013 Prof David Spalton FRCOphth, St Thomas’ Hospital, London, was the recipient of the inaugural UKISCRS Lifetime Achievement Award, at the XXXVII UKISCRS Congress in Manchester.

cataract & refractive

HIGH HYPEROPIA Phakic IOLs can provide good long-term safety in high hyperopes.


Roibeard O'hEineachain reports

hakic IOLs continue to be the best refractive surgery option available for the treatment of high hyperopia, said Beatrice Cochener MD, PhD, CHU Brest, Brest France. “Phakic IOLs are better than photoablation for high hyperopia in terms of predictability and stability. They also provide better quality of vision because of the larger optical zone. Moreover, photoablation procedures can be difficult to centre properly, and highly hyperopic eyes that undergo LASIK are at an increased risk of epithelial in-growth and induced dry eye,” Prof Cochener said at the XXXI Congress of the ESCRS in Amsterdam. She added that clear lens removal is less risky for the retina in high hyperopes than it is in high myopes, and it is the only option for the surgical correction of high hyperopia in eyes with a very small anterior chamber. However, the loss of accommodation that the treatment causes makes it less suitable for younger patients. There are two phakic IOL models available for high hyperopia with or without astigmatism. They are the iris claw IOL (Artisan®, Ophtec)/Verisyse®, AMO) and the posterior chamber implantable collamer lens (VisianICL®, Staar). Both have undergone refinements over the years and have toric versions for the twothirds of hyperopic eyes that have astigmatism greater than 1.5 D.

Published studies The iris-claw anterior chamber lens has been used in high hyperopia since 1997. To be suitable for the iris-fixated implants, eyes must have an anterior chamber depth greater than 3.0mm and normal iris insertion conformation, criteria which high hyperopic eyes do not always meet. Published studies tend to demonstrate good safety and efficacy for the implant in low to moderate hyperopia but an increase of complications in the treatment of moderate to high myopia. In a study that included 51 hyperopes who underwent implantation of the Artisan/ Verisyse lens to correct a mean hyperopic error of +4.92 D, refraction at two years’ follow-up was +0.02 D. In addition, endothelial cell density was not significantly reduced, remaining at 2560 cells/mm2 at two years' Beatrice Cochener MD, PhD

Phakic IOLs are better than photoablation for high hyperopia in terms of predictability and stability

follow-up, compared to 2735/mm2 at preoperatively. (Güell et al Ophthalmology2008;115: 1002-1012.) In another study, where the iris-fixated IOL was combined with LASIK to correct hyperopia in 39 eyes with a mean preoperative spherical equivalent of 7.39 D, there was similar predictability in terms of refractive results. However, one-third of patients lost one line of BCVA, there were frequent complaints of glare and haloes at night and endothelial cell counts fell by 10.9 per cent (Munoz et al J Cataract Refract Surg. 2005; 31:308–317). In addition, an ultrasound biomicroscopy study of hyperopic eyes with the lens showed indentation of iris tissue by the IOL haptics and optic edge, which could lead to pigment erosion. (Pop et al, J Cataract Refract Surg 2002; 28:1799-1803.) The implantable collamer lens currently reigns supreme among the phakic IOLs. More than 375,000 have been implanted worldwide, with hyperopic eyes accounting for 10 per cent of the implantations. The lens can be inserted through a 2.8mm incision and requires an anterior chamber depth of only 2.8mm, making it more suitable for hyperopic eyes, Prof Cochener said. The studies published to date show high long-term efficacy and safety for the lenses in moderate to high myopia. For example in a study involving 59 eyes of 34 patients who underwent implantation of the ICL for hyperopia ranging from +2.50 to +11.75 D (mean; +5.78 D), the mean postoperative spherical was +0.07 and remained stable throughout a 10-year follow-up period. Furthermore, the UCVA was 20/20 or better in 49.78 per cent of eyes and 20/40 or better in 87.58 per cent of eyes (Pesando et al, J Cataract Refract Surg. 2007;33(9):1579-84).

Follow-up In addition, the mean endothelial cell loss was 4.7 per cent, which remained almost unchanged throughout the follow-up period. Complications included cataract in one eye, apparently due to surgical trauma, pupillary block glaucoma in one eye, which resolved when the ICL was explanted, and iris-chafing in two eyes, because of an oversized ICL, which resolved when the ICL was replaced with a smaller one. Prof Cochener noted that she and her associates have also achieved good results with the ICL lens. She presented a retrospective study of 22 eyes of 12 patients who underwent implantation of the V4 version of the lens at her centre. At five years’ follow-up, decimal corrected visual acuity was better than 1.0 in 68 per cent and better than 0.5 in 87 per cent. Moreover, endothelial cell loss after three months' follow-up occurred at a mean annual rate of only 0.6 per cent. There was one case of pupil block with irreversible mydriasis. Beatrice Cochener:

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cataract & refractive

SMALLER INCISIONS New micro-incision hydrophilic IOL provides predictable results. Roibeard O’hEineachain reports


he new hydrophilic acrylic micro-incision Incise™ IOL™(Bausch + Lomb) provides very predictable refractive results, good visual acuity and a well centred positioning within the capsular bag, according to a series of presentations at the 18th ESCRS Winter Meeting in Ljubljana. “The lens can be implanted through an 1.8mm incision into the capsular bag, providing excellent visual and refractive outcomes,” said Antonio Toso MD, S Bassiano Hospital, Bassano del Grappa (VI), Italy He presented the preliminary results achieved with the Incise IOL in 25 eyes of 25 patients participating in a multicentre FDA trial. The patients in the study had a mean age of 72.0 years. All underwent sub-2.0 coaxial MICS using the Stellaris® (Bausch + Lomb) phacoemulsification system and implantation of an Incise IOL through an 1.8mm incision using the Viscoject 1.5™ IOL inserter. Dr Toso noted that the Incise IOL is a one-piece lens composed of an enhanced hydrophilic material with 22 per cent water content. It has an aberration-free optic 6.0mm in diameter with a sharp posterior edge. Its overall length is 11.0mm. It has four fenestrated angulated haptics.

Good visual outcomes After a follow-up period ranging from four to six months, uncorrected visual acuity ranged from 20/32 to 20/25 and had a mean value of 0.156 logMAR. In addition, mean corrected distance visual acuity was 20/20. Furthermore, the mean manifest refractive spherical equivalent was -0.28 with a standard deviation of zero, precisely equal to the target refraction. Absolute total centration, that is, the distance of the centre of the optic from the centre of the pupil margin as measured by digital slit-lamp biomicroscopy, was 0.29mm. That is statistically comparable with the centration achieved with conventional one- or three-piece IOLs, which ™ typically have a centration of 0.2mm to 0.6mm. Simonetta Morselli MD

The postoperative effective lens position is very predictable with Incise IOL

Eurotimes | May 2014

He added that long-term results will be evaluated to assess the posterior capsule opacification.

Predictable lens position Another study involving 26 eyes of 26 patients were implanted with Incise™ IOL, anterior segment OCT indicated that the postoperative effective lens position is very stable and predictable with the new lens, said Simonetta Morselli MD, also at S Bassiano Hospital. The mean postoperative distance of the optical plate from the cornea after the first month was 3.18mm and 3.13mm after the six months. “The postoperative effective lens position is very predictable with Incise™ IOL. This means that the A constant was correctly calculated and the IOL stays stable in the capsular bag, avoiding postoperative refractive surprises,” she said.

Biaxial MICS 1.4mm incision The results of yet another study indicated that the lens can be safely and effectively implanted into the eye through an even smaller, 1.4mm incision using biaxial MICS with even less trauma to the cornea than occurs with 1.5mm incisions, said Giulio Torlai MD, Institute of Ophthalmology, University of Modena & Reggio Emilia, Modena, Italy (head of the institute is Prof Gian Maria Cavallini). The prospective study compared 30 eyes which underwent bi-axial-MICS and implantation of the INCISE MJ14 IOL through 1.4mm corneal incision with 30 eyes which underwent B-MICS and implantation of the Akreos MI60 IOL (Bausch + Lomb) through 1.5mm corneal incision, between April and July 2013. The same experienced surgeon (Prof G M Cavallini) performed all of the procedures, using the same technique for cataract extraction. The technique involved the creation of two trapezoidal clear corneal incisions at 10 and 2 o’clock, capsulorhexis is performed with a cystotome or with the dedicated microforceps, and phacoemulsification is performed with a 20-gauge, 30 degree-angled sleeveless probe and an irrigating chopper, by stop-and-chop technique. The Akreos® MI60 IOL is the direct predecessor of the Incise® lens and, like the newer lens, is a one-piece aberration-neutral aspheric IOL with four angulated haptics. However, unlike the Incise it is composed of an older less stiff hydrophilic material. The results in terms of safety and predictability were essentially the same in the two groups. At 30 days' follow-up the mean corrected distance visual acuity was 0.93 in the Incise group

1.4mm incision group and 0.94 in the Akreos 1.5mm incision group. The endothelial cell counts 2026.99 cells/mm2 and 2102.96, respectively. There were no severe complications in either group. “Both techniques appeared to be safe and effective with a rapid visual recovery and high patient satisfaction. The incisions in both the groups achieve a fast healing since the first week of follow-up with only temporary morphological alterations detectable through anterior segment imaging,” Dr Torlai said. However, he noted the Incise groups had significantly fewer instances of endothelial gaping (p = 0.04) and local detachment of Descemet’s membrane (p = 0.03) in the first postoperative days. “Biaxial-MICS and implantation of the Incise IOL through 1.4mm incisions is both minimally invasive and the corneal healing is faster, even comparing it to a similar surgical technique in which incisions are slightly larger,” Dr Torlai concluded.

Local detachment of Descemet’s membrane in the main CCIs

Simonetta Morselli: Antonio Toso: Giulio Torlai:

Both techniques appeared to be safe and effective with a rapid visual recovery and high patient satisfaction Giulio Torlai MD

Endothelial gaping of the wound in the main CCIs

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cataract surgery


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Courtesy of Giulio Torlai MD

cataract & refractive

14.03.2014 15:44:10

Eurotimes | May 2014

cataract & refractive

ACCOMMODATION Restoration of accommodation is possible in the elderly. Dermot McGrath reports


urgical restoration of accommodation in elderly patients has already been successfully achieved in a few isolated cases, but a lot more research needs to be done before the technique can be successfully extended to the majority of presbyopic or older patients, according to Adrian Glasser PhD. Addressing delegates at the XXXI ESCRS Congress in Amsterdam, Dr Glasser, professor of optometry and vision sciences and biomedical engineering, Benedict/ Pitts Professor College of Optometry, University of Houston, said that the results of some trials have shown that it is possible to obtain a significant accommodative response in some patients implanted with accommodating intraocular lenses (IOLs). “I am going to be a little controversial here and say that I do believe that accommodation has actually successfully been achieved with accommodating IOLs, albeit only in a very limited number of individual cases. Most presbyopes would be satisfied with 1.0 D to 2.0 D of accommodation. While 1.0 D will help, 3.0 D would likely be quite satisfactory and probably more than 5.0 D is not necessary for most patients. I believe the biggest obstacle remains the biological challenges associated with the postoperative healing response of the eye,” said Dr Glasser.

Dynamic process Defining accommodation as an increase in the optical power of the eye due to ciliary muscle contraction, Dr Glasser emphasised that it is an active and dynamic process and is not simply the ability of a distance corrected eye to see clearly at near. He noted that age-related changes occur in just about every aspect of the accommodative anatomy including the crystalline lens, capsular bag and ciliary

Courtesy of Adrian Glasser PhD


Age-related variation in shape and size of isolated human donor lenses

muscle. The critical factor, however, seems to be increasing stiffness of the lens as the patient ages to the point where the shape of the lens can no longer be changed by the accommodative mechanism, said Dr Glasser. With some studies showing that the ciliary muscle continues to contract even in presbyopic eyes, a lot of research has focused on the potential of intracapsular accommodative IOLs to mimic the accommodative effect of the crystalline lens, with generally disappointing results thus far, said Dr Glasser. Numerous challenges exist in trying to manufacture an IOL that can successfully restore dynamic accommodation, he said.

“The considerable variation in the size and shape of individual human lenses at all ages of life is just one obvious hurdle to be overcome in trying to manufacture an artificial replacement,” he said. (See attached image which shows the agerelated variation in shape and size of isolated human donor lenses.)

Diminishing PCO

I am going to be a little controversial here and say that I do believe that accommodation has actually successfully been achieved with accommodating IOLs...

Another key problem for intracapsular accommodative IOLs is the likelihood of postoperative lens epithelial cellular proliferation, said Dr Glasser, noting that techniques such as maintaining an open capsule to aqueous fluid exchange or ensuring a tight fit of the lens in the capsular bag may help to diminish the incidence of PCO and fibrosis. Another approach is to bypass the capsule altogether by using accommodative IOLs specifically designed to be placed into the sulcus. Dr Glasser added that customising the fit of the IOL into each individual capsular bag may ultimately be necessary for dynamic accommodation to be achieved.

Adrian Glasser PhD

Adrian Glasser:

Eurotimes | May 2014

cataract & refractive

good predictability Corneal incisions created with femtosecond enhance cataract surgery results. Roibeard O’hEineachain reports


he precision afforded by the FEMTO LDV Z6 power plus femtosecond laser in the creation of clear corneal incisions for cataract surgery and astigmatism correction can translate into more predictable visual outcomes than is achieved with standard cataract surgery, said Bojan Pajic MD, PhD, FEBO, Reinach AG, Switzerland. “The FEMTO LDV Z6 results in a highly predictable quality resection for cataract surgery with a significantly smaller range of visual acuity and significantly less induction of higher-order aberrations compared with conventional phaco,” he told the 18th ESCRS Winter Meeting in Ljubljana. In a study involving 48 eyes of 24 patients who underwent cataract surgery with the Femto LDV Z6 (Ziemer) femtosecond laser in one eye and conventional phacoemulsification in the other, the mean visual acuity at one month’s follow-up was around 0.85 in both groups (p=0.47), but the standard deviation was significantly wider in the conventional phaco group than in the femtosecond laser group. In addition, while higher-order aberration RMS did not change significantly from baseline onward (p=0.10) in the femtosecond laser group, there was a significant difference in the higher-order RMS postoperatively than preoperatively among eyes that underwent the conventional procedure (p=0.014). Dr Pajic noted that compared with some other femtosecond laser platforms the Femto LDV Z6 is easily incorporated

into standard cataract surgery suite. It therefore does not require the patient to be moved. The laser combines adjustable low nanojoule pulse energy delivered at a frequency above 5.0 MHz.

Precision planning As with all femtosecond laser systems, the planning of corneal incisions with the FemtoLDV 6 requires not only biometry

and topography but also pachymetry, particularly in eyes where arcuate corneal incisions are indicated. The laser’s clear corneal incision module for cataract surgery is designed for the creation of one main and up to two side-port incisions. The cuts can be made along one, two or three planes, it is said three different shapes. “These cuts take about 80 seconds at the moment but the new algorithm will decrease that to 40 seconds or less. What is good is that there are no tissue bridges, so even the side-port incisions are open,” Dr Pajic said. The laser also has an arcuate incision module with nomograms for up to three arc-shaped incisions. In two patients with 2.0 D of astigmatism preoperatively, the cylinder decreased to 0.66 D on day three and 0.4 D at day 10 and remains stable till one month postoperatively at 0.53 D after the creation of arcuate incisions with the laser. “Our nomograms for arcuate incisions will be undergoing some fine-tuning over the next few months as we treat more patients, but the results we’ve achieved so far are quite good,” Dr Pajic said. Bojan Pajic:

These cuts take about 80 seconds at the moment but the new algorithm will decrease that to 40 seconds or less Bojan Pajic MD, PhD, FEBO

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cataract & refractive

PHAKIC IOLS Safe and effective for high myopia, but patient selection is crucial. Howard Larkin reports


everal currently available phakic intraocular lenses (IOLs) generally provide excellent short-term safety and refractive outcomes in moderate to high myopia patients, Rudy MMA Nuijts MD, PhD told the 2013 ESCRS Congress in Amsterdam. These include iris- and angle-supported anterior chamber lenses and posterior chamber designs. In addition to reversibility, phakic IOLs offer advantages for high myopes, including improved best-corrected vision due to less minification of images at the retinal plane, and less aberrations than corneal laser surgery, noted Prof Nuijts, of the Academic Hospital Maastricht, The Netherlands. However, careful patient selection is crucial to minimise complication risks.

lens placement in an OCT image can help determine if sufficient clearance exits, he noted. Two iris-fixated IOLs currently available are the Artisan/Verisyse, a non-foldable PMMA lens and the Artiflex/Veriflex, a foldable silicone optic with PMMA haptics, from Ophtec or Abbott Medical Optics. Both offer toric options. Introduced in 1986, the Artisan has proven stable, predictable and safe in several long-term studies, including a 10-year follow up by Prof Nuijts and colleagues (Tahzib et al. Ophthalmol 2007; 1133). In follow-up studies of at least three years, efficacy in

Angle-supported anterior chamber lenses fall into two categories, Prof Nuijts said. Early rigid designs led to endothelial cell loss of up to 30 per cent and iris ovalisation in up to 40 per cent of eyes, leading to their removal from the market. However, a newer angle-supported lens, Cachet from Alcon, has performed much better, Prof Nuijts said. In five studies, between 97.1 per cent and 100 per cent of patients achieved 20/40 or better uncorrected with two line best corrected loss ranging from 0.0 to 0.9 per cent. Endothelial cell loss ranged from 4.0 to 6.2 per cent at one year (see figure below).

achieving at least 20/40 uncorrected ranged from 33 per cent to 95 per cent of patients. Safety is also excellent with loss of two lines best corrected vision rates ranging from 0.0 to 2.6 per cent. Endothelial cell loss ranged from 0.6 to 14.1 per cent annually, he noted.

However, in one three-year follow-up, after an acute loss of 3.3 per cent, chronic endothelial loss came in at 0.41 per cent, or about the physiological rate, suggesting the lens may have better long-term stability (Knorz., JCRS 2011; 37:469). The Visian ICL from Staar also delivers excellent refractive and safety results, Prof Nuijts said. In three studies of the latest version, ICM V4, including the FDA prospective study, 68 per cent to 95 per cent achieved 20/40 or better uncorrected with 0.0 to 0.8 per cent losing two lines or more at three, four and five years. Endothelial cell loss rates in a few reports up to five years' follow-up appear similar to anterior chamber designs.

Long-term follow-up Adequate endothelial cell density and anterior chamber depth are critical to avoid corneal decompensation, as are sufficient clearance of the iris and crystalline lens to avoid elevated IOP and cataract, Prof Nuijts said. He also recommended avoiding patients who rub their eyes. He also advised long-term follow-up to detect endothelial cell loss or changes in anterior chamber anatomy that threaten endothelial health. According to Dutch Society for Refractive Surgery guidelines, phakic IOLs generally may be implanted in patients 18 years old or older with -2.0 to -23.5 D myopia, +3.0 to +12.0 D hyperopia or 2.0 to 7.0 D astigmatism. Minimum endothelial cell density varies, ranging from 2,800/mm2 for 21-25 year-olds to 2,000/mm2 for patients over age 45. Contraindications include mesopic pupil diameter >7.0mm, anterior chamber depth <3.2mm including corneal thickness and irregular or abnormal anterior chamber anatomy or iris configuration, such as a forward bulging iris, Prof Nuijts said. He cautioned that anterior segment diameter measurements may vary among instruments. Other safety criteria Prof Nuijts recommends for anterior chamber lenses include >2.8mm distance from the dome of the natural lens to the endothelium (Baumeister. AJO 2004; 723-31); 1.5mm or more from lens edge to endothelium (Baikoff.,JCRS 2006; 1827-35); 2.0mm or more from lens centre to endothelium (Guell, JCRS 2007; 1398-404). Simulating Eurotimes | May 2014

Courtesy of Rudy MMA Nuijts MD, PhD


Deposition Only one two-year follow-up exists of the Artiflex lens, introduced in 2003, Prof Nuijts said. It showed good predictability, efficacy and safety, with 0.8 per cent losing two lines best corrected, though 4.8 per cent experienced pigment depositions and 1.4 per cent non-pigment depositions (Dick. Ophthalmol 2009; 116). Deposition has also been an issue with the toric Artiflex. A new version using a hydrophobic acrylic optic will go into trials shortly, Prof Nuijts said.

Rudy Nuijts:

13-17 September


London XXXII Congress of the ESCRS Ridley Medal Lecture Professor G端nther Grabner Paracelsus Medical University, Salzburg, Austria

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CATARACT Protecting endothelium, lens material and power calculation are critical.


ataract surgery can be complex and delicate, but especially so in eyes with Fuchs’ dystrophy, said Terry Kim MD, professor of ophthalmology, Duke University School of Medicine, Durham, North Carolina, US. He shared pearls for assessing patients, protecting the corneal endothelium, selecting lenses and determining when cataract extraction should be combined with endothelial keratoplasty at the American Academy of Ophthalmology annual meeting in New Orleans. Fuchs’-cataract cases generally fall into four clinical scenarios, Dr Kim said. The cataract is significantly worse; the Fuchs’ is significantly worse; the cataract and Fuchs’ are similar; or both diseases are advanced with anterior stromal haze present. Along with factors such as patient age and anterior chamber depth, these scenarios help determine whether to perform endothelial keratoplasty (EK) or cataract surgery alone, or to combine them. A slit-lamp exam is essential in making the decision to perform cataract surgery alone or combined with endothelial keratoplasty. Specular refection is a useful but often overlooked tool. Grading the severity of Fuchs’ dystrophy (FECD MultiCenter Study Group. Cornea 2012;31:2635) according to guttae number, location and extent of coverage, and the presence of clinically apparent stromal or epithelial oedema is useful. Specular microscopy may be indicated but is generally not necessary in most cases. Lens density and anterior chamber depth are also important. Also consider other ocular co-morbidities, such as an abnormal iris/pupil, pseudoexfoliation and weak zonules, that can make a combination procedure more challenging. Eurotimes | May 2014

Howard Larkin reports

Published guidelines for central corneal pachymetry vary, with some calling for 600 microns as a threshold (Duane’s Clinical Ophthalmology, 2003, Chapter 16A), and more recent data suggesting up to 640 microns (Seitzman et al. Ophthalmology. 2005 Mar: 112;441-6), Dr Kim noted. “But based on the variation of corneal thicknesses I’ve encountered in evaluating refractive surgery patients, I’ve found you can have quite a variation in pachymetry with a normal cornea, so you have to take this into account.”

Clinical decision According to Dr Kim, the decision to proceed with a cataract surgery alone vs. a combined procedure with Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (DSAEK), or Descemet membrane endothelial keratoplasty (DMEK) is mainly a clinical decision based on the aforementioned factors. “I generally proceed with just cataract surgery if there is no morning blurring of vision, which means an absence of microcystic oedema, mild signs of Fuchs’ dystrophy and a lens density that I feel comfortable handling.” He recommends being comfortable with the ability to handle the density of the lens and depth of the anterior chamber in the setting of a potentially cloudier cornea and a smaller anterior capsulorhexis (which is generally performed in combined procedures to help prevent the intraocular lens from prolapsing forward during graft insertion and manipulation). Hard nuclei and/or shallow chambers may expose the corneal endothelium to greater risk of damage. Dr Kim also considers other factors including patient vision, age and aftercare compliance with medications, postoperative instructions, etc. Strong indications for combining EK with phaco include blurred morning vision, any sign of epithelial oedema, or

A case of severe Fuchs’ dystrophy with confluent guttae on retroillumination

significant guttae in terms of density or area of involvement. Documented increasing corneal thicknesses on pachymetry or asymmetric pachymetry also suggest endothelial dysfunction. Patients with occupational or other needs for clear vision may also require keratoplasty at the time of the cataract surgery. When performing phaco alone in patients with Fuchs’ dystrophy, Dr Kim suggested several surgical steps that could help relieve stress on the corneal endothelium during cataract surgery, often leading to better outcomes. “I highly recommend the use of dispersive viscoelastics in these cases,” Dr Kim said. These include Viscoat, Healon D and Ocucoat. Whereas cohesive viscoelastics wash out quickly once irrigation and aspiration begin, dispersive agents are much more retentive and stay in the anterior chamber, providing superior corneal endothelial protection.” Dr Kim also recommends performing phaco and irrigation/aspiration at or below the iris plane. This helps keep ultrasound energy, fluid turbulence and fragments away from the endothelium. Phaco power modulation, available on systems including the Bausch + Lomb Stellaris with Hyperburst, Alcon Infiniti/ Centurion with Torsional IP, and AMO


Courtesy of Terry Kim MD

Signature with Ellips FX, also reduce total ultrasound energy and improve outcomes, Dr Kim noted. His own research has shown that utilising torsional IP can increase ultrasound power efficiency, reduce fragment repulsion, decrease turbulence, enhance followability and reduce the risk of thermal wound burns. The result is lower ultrasound energy use, less endothelial trauma and less endothelial cell loss at six months (Berhahl et al. JCRS. 2008;34(12):2091-2095).

Phaco techniques Employing various phaco techniques such as horizontal and vertical chop manoeuvres can help minimise endothelial stress by substituting mechanical energy for ultrasound energy whenever possible. “As much as I can, I try to disassemble the lens into smaller fragments with the chopper as opposed to using ultrasound energy to emulsify these larger pieces. This further reduces stress on the endothelium,” Dr Kim said. For very dense brunescent cataracts, the Ultrachopper phaco tip, developed by Dr Luis Escaf for the Infiniti system, has been extremely useful for approaching those cataracts that have a resilient, leathery posterior plate that can be difficult to fracture with conventional techniques, Dr Kim said. The short, curved tip allows for the creation of a deep, narrow channel with phaco that can then be extended through a leathery posterior plate with a pre-chopper, reducing both ultrasound energy and the risk of a posterior capsule rupture. “I find many of these cases have a clear cornea on post-op day one.” Dr Kim recommends hydrophobic monofocal lenses for Fuchs’ patients. Hydrophilic lenses exposed to air injections in the anterior chamber during EK can opacify due to hydroxyapatite deposition (Werner et al. JCRS 2010; Patryn et al. Cornea 2012). Multifocal lenses can also be problematic because even mild corneal guttae can compound the reduction in contrast sensitivity.


The Ultrachopper phaco tip and settings for Dr Kim. The Ultrachopper tip extends only 2mm from its base so as to maintain an appropriate depth

Fuchs’ Endothelial Corneal Dystrophy Grading scale (FECD Multi-Center Study Group. Cornea 2012;31:26-35)

The refractive impact of EK also must be considered, Dr Kim said. DSEK and DSAEK induce about a 1.0 to 1.25 D hyperopic shift, which should be offset in combined cataract cases by aiming -1.0 to -1.25 D with the intraocular lens (Jun et al. Cornea 2009). DMEK causes much less hyperopia, with a correspondingly lower myopic offset.

Hopefully, these pearls can help the clinician approach the patient with Fuchs’ dystrophy and cataract with a more systematic approach for surgical planning that will hopefully lead to better patient outcomes. Terry Kim:






DMEK or DMET? Floating donor Descemet prompts corneal clearing in Fuchs’ dystrophy.


Howard Larkin reports

s surgeons around the world contemplate shifting from DSAEK, or Descemet stripping automated endothelial keratoplasty, to the more effective but technically challenging DMEK (Descemet membrane endothelial keratoplasty), a third, simpler, option may be emerging for treating Fuchs' dystrophy, Gerrit R J Melles MD, PhD told Cornea 2013 at the annual meeting of the American Academy of Ophthalmology in New Orleans. Unlike earlier endothelial keratoplasty techniques, DMET, or Descemet membranemediated endothelial transfer, does not involve replacing damaged host endothelium with healthy donor cells. Instead, after a Descemetorhexis is performed on the host, donor Descemet tissue is injected and allowed to float freely in the anterior chamber. Over several weeks the cornea spontaneously clears and returns to normal thickness, with endothelial tissue covering the exposed posterior stroma despite a completely detached graft, Dr Melles reported. The early success of DMET calls into question not only the concept of keratoplasty to replace damaged host endothelium. It also suggests that the nature of Fuchs' should be reconsidered, said Dr Melles, director of the Netherlands Institute for Innovative Ocular Surgery in Rotterdam, which pioneered DMET, DMEK and other endothelial keratoplasty advances. “Maybe we should all take a step back and ask what are we actually treating. Does Fuchs' endothelial dystrophy actually exist or not? And is it really a dystrophy or something else? Because a dystrophy is something you really have to treat by doing surgery. But if it is not a dystrophy, but something you can reverse like a cellular dysfunction, it may open the door to completely different ways of treatment,” Dr Melles said.

“We saw several DMEK eyes in which the graft detached but the corneas cleared. We received medical ethical approval to do this surgery on purpose,” Dr Melles said. In a prospective non-randomised series of 12 eyes, seven diagnosed with Fuchs' and five with bullous keratopathy, all the Fuchs' eyes cleared and returned to normal pachymetry with an average endothelial cell density of 797 cells/mm2 at six months. However, none of the eyes with bullous keratopathy cleared (Am J Ophthalmol. 2012 Aug;154(2):290-296). The research is ongoing. “At one month you have oedema, at three months the cornea starts to clear and at six months you have a fairly normal cornea,” Dr Melles said. These results suggest that, unlike bullous keratopathy, in Fuchs' the remaining peripheral host endothelium is capable of massive cell migration or regeneration to repopulate the exposed posterior stroma. “The series is so large that we now get the impression that the host cells are maybe somehow involved in the clearance or redistribution of endothelial cells after surgery,” Dr Melles said. This is also consistent with the observed pattern of re-endothelialisation, which moves from the peripheral toward the central cornea, and the cell densities observed. If the host cornea is capable of restoring corneal clarity, DMET may become a viable surgical approach for treating Fuchs' – and one that is much simpler than DSAEK or DMEK. It also raises the possibility of other management approaches, Dr Melles said. If Fuchs' is not truly a dystrophy, it might be that topical eye drops or other pharmaceuticals may be useful in managing it. Pre-clinical and early clinical results with rho-kinase inhibitors may bear this out.

Evidence of Fuchs' reversal

For now, however, DMEK may be the best alternative for Fuchs', Dr Melles said. In his clinic, 80 per cent of DMEK patients achieve 20/25 or better corrected visual acuity six months after surgery with 44 per cent at 20/20 or better. DMEK rejection rates are also very low at less than one per cent, and most rejection events seem mild and can commonly be managed with intensified corticosteroid therapy, he added. Preparing the donor graft can be tricky, but beginning the dissection at the trabecular meshwork and moving in makes it easier, Dr Melles said. It may be desirable to let eye bank technicians do it as they generally are much more experienced. Before inserting the donor tissue, Dr Melles recommends irrigating with BSS to open it, and letting it roll up as a double roll, which is easier to unroll in the anterior chamber. Inside the eye, an air bubble on the Descemet side unrolls the graft, or tapping on the cornea may be enough. A bubble under the graft pushes it against the host tissue. The remaining bubble should be about 30 per cent of the graft diameter to avoid sliding under the pupil, which risks angle closure.

As with many medical breakthroughs, DMET began with a clinical accident. DMEK surgery on an 80-year-old patient failed, leaving a roll of donor Descemet floating in the anterior chamber. The patient asked that the roll be left in place. One month later, the cornea began clearing, eventually thinning from 1,000 microns at centre to normal pachymetry. At six months, only slight oedema remained at the superior periphery, and endothelial cell density measured 830 cells/mm2 (Cornea. 2012 Feb;31(2):194-7). Eurotimes | May 2014

Maybe we should all take a step back and ask what are we actually treating. Does Fuchs’ endothelial dystrophy actually exist or not? Gerrit R J Melles MD, PhD

DMEK pearls

Gerrit Melles:


Courtesy of Mor Dickman MD

Periodic acid-Schiff (PAS) stained 25-μm thick Bowman membrane graft (top) and Hematoxylin-Eosine stained 25-μm thick PDAEK (Pre-Descemetic Automated Endothelial Keratoplasty) graft (bottom), both harvested using the Gebauer SLc Expert microkeratome system

TRANSPLANTATION New microkeratome opens the door to PDAEK. Cheryl Guttman Krader reports


ndothelial keratoplasty using a pre-Descemetic graft is being looked to as the future in endothelial keratoplasty. Focusing on the development of preDescemetic automated endothelial keratoplasty (PDAEK), corneal specialists at the University Eye Clinic, Maastricht, The Netherlands, have established proof of concept that safe, standardised harvesting of planar, preDescemetic grafts is possible using the Gebauer SLc Expert microkeratome system. Mor Dickman MD, reported on the study at the 4th EuCornea Congress, Amsterdam.

Easier handling “Pre-Descemetic grafts are expected to provide the same visual results as DMEK grafts since they are very close in thickness. However, because the pre-Descemetic grafts have added stromal support, they should offer easier handling and possibly better graft adhesion. Automated donor preparation of pre-Descemetic grafts is desirable because manual dissection requires advanced surgical skills. However,

the use of existing microkeratomes has been limited by poor thickness predictability. In addition, the previously available technology cuts grafts with a meniscus profile that contributes to a hyperopic shift, and it has been unclear how forces applied during mechanical harvesting might affect endothelial cells,” said Dr Dickman. “We have established the possibility for reproducible automated Pre-Descemetic graft harvesting. Now, clinical studies are needed to evaluate patient outcomes.” The Gebauer SLc expert microkeratome can dissect corneal lamellae of any desired thickness in the range between 30 and 950 microns with a diameter of 9.5mm. It uses vacuum applanation to fixate the cornea and can be fit with rigid reference members (RRMs) that are profiled to correct for differences between peripheral and central corneal thickness in order to create planar grafts. The performance of the Gebauer SLc Expert for harvesting pre-Descemetic grafts was investigated using organ-cultured human corneas unsuitable for transplantation. Measurements made using Fourier domain OCT showed mean intended central graft thickness was 32 ± 6 microns and the mean


achieved thickness was 44 ± 7.7 microns. Use of the RRMs resulted in grafts that were almost perfectly planar. Assessment for endothelial damage performed by Zhigou He PhD, and colleagues at Laboratoire BiiGC, France, showed satisfactory viability and morphology of the central endothelial cells.

Refractive surgeries The investigators also demonstrated the feasibility of using the microkeratome to prepare 25 micron thick Bowman grafts. “With the Gebauer SLc Expert, we can optimise tissue use by obtaining a graft for endothelial keratoplasty as well as material from the anterior cornea that can be used for ocular surface and refractive surgeries,” said Dr Dickman. He noted that manually harvested Bowman grafts have recently been described for treating keratoconus. These grafts can be used as a scaffold for epithelial regeneration in vivo and epithelial/endothelial cultivation in vitro and may prove useful for treating neurotrophic ulcers as well as for refractive purposes. Mor Dickman:



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Eurotimes | May 2014


CORNEAL CROSS-LINKING Procedure affects mainly myopic component of refraction. Roibeard O’hEineachain reports


orneal collagen crosslinking (CXL) procedures have an unpredictable but generally beneficial effect on the refraction and visual acuity of patients with keratoconus, said Mohammed Iqbal Hafez Ahmed MD, lecturer of ophthalmology, Sohag University Hospital, Egypt. “Crosslinking can both preserve and improve vision. The greatest improvements in the cornea appear to be in the myopic component, astigmatism did not change dramatically,” Dr Ahmed told a Cornea Day Session at the 18th ESCRS Winter Meeting in Ljubljana. He presented a retrospective study involving 58 eyes of 40 keratoconus patients who had at least 24 months of follow-up after undergoing conventional epi-off CXL. The patients in the study ranged in age from 12 to 39 years and had a mean age of 17 years. Dr Ahmed carried out the crosslinking procedures using riboflavin 0.1per cent (Ricrolin®, SOOFT Italia) and the Opto XLink Corneal Cross-Linking System (Opto). After a follow-up of 24 to 30 months, the best-corrected visual acuity had improved from postoperative values by one line in 54 per cent of eyes, remained unchanged in 36 per cent and decreased by one line in 10 per cent. Astigmatism remained within half a dioptre of preoperative values in 86.2 per cent of eyes, and decreased by a mean of 1.2 D in 13.8 per cent eyes. The K value of the apex decreased by a mean of -2.73 D in 65.5 per cent of eyes, a

Courtesy of Mohammed Iqbal Hafez Ahmed MD


Figure 1: Topographies of the case study

statistically significant change. This value remained stable in 25.9 per cent of eyes and increased by 1.0 D in the remainder. The maximum K value decreased by a mean of 2.47 D in 55 per cent of eyes, remained unchanged in 38 per cent and increased by 1.0 D in the remainder. Spherical and higher-order aberration showed no significant variations, but there was a very significant reduction in the coma component from six months onward. To illustrate the kind of results that can be achieved with collagen cross-linking, Dr Ahmed presented a case-study of a patient who had undergone the procedure.

CXL Hammered Cornea Hypothesis

Figure 2: Post CXL forces affecting cornea

Eurotimes | May 2014

He noted that postoperative pachymetry showed that at two years’ follow-up, the eye’s central corneal thickness had decreased markedly from a preoperative 389 microns to 308 microns, whereas the peripheral corneal thickness increased from 623 microns to 668 microns. In addition, the average K decreased from 51.66 D to 49.2 D, but the astigmatism remained unchanged. In this case the uncorrected visual acuity improved from 3/60 to 5/60 and the best corrected visual acuity improved from 6/30 to 6/20. Figure 1 shows pre-and postoperative corneal topographies in this case with marked postoperative central corneal thinning and remarkable central corneal flattening. Dr Ahmed attributed the decrease in myopia that occurred in many patients to a synergistic interaction between the increased radius of curvature of the flattened cross-linked corneal surface and a reduction in the cornea’s refractive index resulting from the thinning of central cornea. Figure 2 shows the postoperative forces affecting the cornea explaining the good results obtained post CXL. He added that an analysis of findings obtained from 23 cases with more than three years of follow-up showed that for every seven microns decrease in the average central corneal thickness, the average K decreased by one dioptre. Mohammed Iqbal Hafez Ahmed:

5th EuCornea Congress

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Deep Anterior Lamellar: The Best Keratoplasty option in Keratoconic eyes?

Current controversies and hot topics in keratoconus

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NEW MIGS DEVICE Suprachoroidal stent showing promising results in treatment-resistant glaucoma. Roibeard O’hEineachain reports


ne-year results with a new suprachoroidal stent called the iStent Supra (Glaukos) indicate that the device can bring about a satisfactory reduction of IOP and a reduced requirement for medication in open-angle glaucoma patients resistant to hypotensive topical therapy, said Anselm Jünemann MD at the XXXI Congress of the ESCRS in Amsterdam. In the prospective trial, 73 patients with elevated IOP resistant to treatment with two medications underwent ab interno implantation of a single iStent Supra suprachoroidal stent through a 1.0mm temporal clear corneal incision under topical anaesthesia and under gonioscopic view, said Dr Jünemann, University Hospital, Erlangen, Germany. All had a preoperative IOP between 18.0 mmHg and 30.0 mmHg, on two medications, and between 22.0 mmHg and 38.0 mmHg after medication washout. Their mean preoperative medicated diurnal IOP was 20.4 mmHg, and their unmedicated baseline IOP was 24.8 mmHg (SD 1.7). All were prescribed travoprost postoperatively, which they were to discontinue if their IOP fell below 6.0 mmHg. Among 42 eyes with 12 months of follow-up, mean IOP decreased by 47 per cent compared with baseline values and remained at 13.2 mmHg or less throughout one year of follow-up. In addition, 98 per cent of eyes met the primary efficacy endpoint of a reduction of 20 per cent in IOP with one medication. The IOP reduction in the remaining patient was 18.2 per cent. Furthermore, all eyes met the secondary efficacy endpoint of IOP less than 18.0 mmHg on one medication and 90 per cent achieved IOP 15.0 mmHg or less on one medication. After a medication washout at 13 months' follow-up, mean IOP was still only 16.8 mmHg and it reduced back down to 12.3 mmHg among 32 eyes that reached 18 months of follow-up. The implantation procedures were performed without complications in all eyes. There was transient hypotony with

Courtesy of Anselm Jünemann MD


iStent Supra on finger

IOP less than 5.0 mmHg in two eyes at one week. One of those eyes had a choroidal attachment which resolved by three months and the two eyes had best-corrected visual acuities of 20/20 and 20/22, respectively. There were no other postoperative sequelae. Best-corrected visual acuity improved or stayed the same as preoperative BCVA in 40 of 42 patients. However, one patient had a reduction in BCVA from 20/22 preoperatively to 20/50 at 18 months postoperatively due to pre-existing cataract. “The results of this study suggest that the iStent Supra implanted as a sole procedure with postoperative travoprost is feasible, safe and capable of significant reduction in IOP and medication burden in open-angle glaucoma patients previously uncontrolled on two topical hypotensive medications,” Dr Jünemann concluded. Anselm Jünemann:

Glaucoma Day2014 ESCRS

Friday 12 September

A New and Unique Fixed Combination Lunchtime


Eurotimes | may 2014


ENDOPHTHALMITIS Evidence supports a hard and fast approach when dealing with intraocular infections. Roibeard O'hEineachain reports


rompt aggressive treatment with intravitreal antibiotics, corticosteroids and vitrectomy appear to provide the best outcomes in eyes with endophthalmitis, Lars Wagenfeld MD told the 13th EURETINA Congress in Hamburg. “The treatment of endophthalmitis in general consists of three components. First is the administration of sufficient drugs to inactivate the infective organism. Second is anti-inflammatory therapy to reduce the inflammatory response and third is the mechanical elimination of the pathogenic microorganisms and pus,” said Dr Wagenfeld, University Hospital Hamburg-Eppendorf, Hamburg, Germany. He emphasised that it is critically important to start treatment of endophthalmitis immediately after diagnosis. However, just before administering antibiotics, samples should be taken from the vitreous and the anterior chamber. When performing a vitrectomy, a vitreous cutter is the best tool for obtaining the samples. In hospitals without the facilities for vitrectomy, a vitrector will usually suffice. Vitreous taps deliver the highest rate of positive results. The positive rates for anterior chamber taps are not as high. In the Endophthalmitis Vitrectomy Study, the anterior chamber was the only means by which microorganisms could be identified in around four per cent of cases. Surface swabs are not helpful in identifying the infecting organism, he noted. Gram-staining the sample obtained can give a quick but not very specific indication of the pathogen in most cases. Polymerase chain reaction (PCR) is very precise and highly sensitive and can identify the causative microorganism in around 90 per cent of cases. It also works well in culture-negative cases, which account for 30 to 60 per cent of cases. Nonetheless a positive culture is the gold standard because it enables microbiologic sensitivity testing. The Ultrasound showing massive vitreous infiltration

Anterior segment with hypopyon in a case of endophthalmitis

microorganisms most frequently identified in cases of endophthalmitis are Gram-positive bacteria, followed by some Gram-negative species and fungi. Current ESCRS guidelines recommended administering antibiotics intravitreally and systemically. Systemic antibiotics reduce the osmotic gradient and therefore reduce the flow of the antibiotic out of the eye and prolong the half-life of the antibiotic in the eye. The antibiotics of first choice in cases of endophthalmitis are vancomycin and ceftazidime or another thirdgeneration cephalosporin. In case of any contraindication of those agents, alternatives include combinations of ciprofloxacin and cilastin or imipenem. The use of corticosteroids is more controversial. The rationale for using them in cases of endophthalmitis is that they will reduce the inflammation that occurs in response to the toxins that bacteria release when they die. They limit tissue destruction and lower the toxic effects of cytokines. Research indicates that intraocular application of dexamethasone can diminish the inflammation. However, reports from clinical and laboratory studies have yielded Ultrasound after vitrectomy

contradictory findings regarding the effect of corticosteroids on salvaging visual acuity in such cases. The best route of administration is also debated. The alternatives are intravitreal, systemic, conjunctival or topical administration. The ESCRS recommend the intravitreal route, although in the Endophthalmitis Vitrectomy Study patients received the agent systemically. The last part of the treatment of endophthalmitis is the mechanical elimination of pus and detritus from the eye. Vitrectomy offers the advantage of providing more material to use in identifying the pathogenic microorganisms involved. In addition the removal of pus reduces the bacterial load and the amount of inflammatory mediators and toxins. The endophthalmitis vitrectomy study showed that in severe cases, where the retina is completely obscured and the visual acuity is light perception or less, vitrectomy reduces the risk of a severe vision loss by 50 per cent and increases by three-fold the chance of achieving a visual acuity of 20/40 or better. In less severe cases, where the larger retinal vessels are visible and the vitreous cavity is not filled with pus, vitrectomy had no significant effect on mean visual acuity, although it reduced the incidence of severe vision loss from 15 per cent to eight per cent. “Surgical techniques have evolved since the publication of the Endophthalmitis Vitrectomy Study back in 1995. Today there are an increasing number of reports showing that a complete vitrectomy gives better results than previously reported in less severe cases,” he said. Lars Wagenfeld: Eurotimes | may 2014




DME TREATMENT Aflibercept excellent anti-VEGF agent but unanswered questions need consideration. Cheryl Guttman Krader reports


atients with diabetic macular oedema (DME) receiving intravitreal aflibercept (Eylea, Regeneron) every four or every eight weeks have superior visual acuity outcomes compared to patients treated with laser photocoagulation. These findings come from the recently announced primary efficacy analysis conducted at week 52 in the Phase 3 VISTA-DME trial. The study has a planned duration of 148 weeks, but a recent topline analysis of data from ongoing follow-up show the functional treatment benefit of aflibercept is sustained at two years. VISTA-DME is one of three double-masked Phase 3 studies comparing aflibercept against laser photocoagulation for the treatment of DME. Eligible eyes had centre-involved disease, BCVA of 20/40 to 20/320, no active proliferative diabetic retinopathy, and no history of vitreoretinal surgery in the study eye. A total of 461 patients were randomised into the three treatment groups, of which 43 per cent had a history of prior anti-VEGF treatment in the study eye (not within 90 days). In the primary efficacy analysis at week 52, mean change from baseline BCVA was 12.5 letters in patients treated with aflibercept every four weeks, 10.7 letters in those receiving aflibercept every eight weeks and only 0.2 letters in the laser group. At two years, mean change from baseline BCVA in the aflibercept four week, aflibercept eight week groups, and laser groups was 11.5, 11.1 and 0.9 letters, respectively. No important safety signals have emerged. Rates of serious ocular and non-ocular adverse events, arterial thromboembolic adverse events, and deaths were similar comparing the aflibercept and laser treatment groups. Speaking to EuroTimes, Pravin U Dugel MD, managing partner, Retinal Consultants of Arizona, Phoenix, and investigator in the VISTA-DME trial, commented that the two-year results are not surprising and reaffirm that aflibercept is an excellent anti-VEGF agent. However, he was careful to point out that in looking for take-home messages from the study about the use of aflibercept in clinical practice, there are a number of issues and unanswered questions to consider.

Comparisons First, VISTA-DME compared aflibercept to laser photocoagulation. How aflibercept measures up against ranibizumab (Lucentis, Genentech) or bevacizumab (Avastin, Genentech) is of greater interest because those agents represent the current standard of care. In seeking an answer to that question, however, cross-trial comparisons of outcomes in VISTADME and the pivotal ranibizumab trials (RISE Eurotimes | may 2014

All studies of anti-VEGF treatment for DME have shown a direct correlation between the number of injections and outcome Pravin U Dugel MD

There is no reason to believe that one single agent will be best for every stage... and RIDE) should not be made considering differences between the studies in their patient populations and design, said Dr Dugel. He also pointed out that the results achieved with aflibercept in VISTA-DME or with ranibizumab in its pivotal trials or Protocol I may not translate into the real world where patients may not receive the same rigorous care with four weekly treatment group follow-up. “Compliance with such an intensive visit schedule is very difficult to duplicate in clinical practice and particularly in the population of patients with DME who are younger on average and more likely to be working than patients with age-related macular degeneration,” he explained. Clinicians should also not assume that real world patients treated with aflibercept every eight weeks will achieve the same benefit as their counterparts in VISTA-DME if they are seen only at their injection visits. “Outcomes are influenced not just by the frequency of treatment, but also by how often the patient is evaluated,” Dr Dugel said.

Subgroup Analysis He noted he would like to see a subgroup analysis of outcomes for the patients with a history of anti-VEGF therapy. However, he cautioned that the information still cannot be used to reach any conclusions about the efficacy of aflibercept in patients who respond suboptimally to another anti-VEGF agent in the absence of details to determine the quality of their previous anti-VEGF treatment. “All studies of anti-VEGF treatment for DME have shown a direct correlation between the number of injections and outcome. We know that in VISTA-DME, patients were followed and treated on a regular basis. However, we do not know how thoroughly they were treated previously,” he explained. Dr Dugel is also looking forward to more information on systemic safety because he believes that the available anti-VEGF agents are similarly efficacious in the various indications where they are used but will be differentiated based on safety profiles. This insight will likely come from post-marketing data. In addition, looking ahead to an expanded portfolio of DME treatment options, including extended-release steroid delivery devices and more sophisticated, targeted laser systems, and considering that DME is a dynamic, evolving condition, Dr Dugel emphasised the need for research to define optimal mono- and combination therapy approaches for the different presentations of the disease. “There is no reason to believe that one single agent will be best for every stage and more likely we will find that different agents and different combinations are preferred,” he concluded. Pravin U Dugel:


LIFESTYLE CHOICES New data quantify functional impact of modifiable behaviours. Cheryl Guttman Krader reports


new report from the Beaver Dam Eye Study (BDES) provides evidence that reinforces existing messages about lifestyle choices for preserving ocular and general health. The research, which was published recently in the journal Ophthalmology (Vol. 104, Issue 11), examined associations between smoking, alcohol consumption and physical activity and the development of visual impairment. “The BDES and other epidemiological studies found relationships between these modifiable lifestyle factors and specific age-related eye diseases. We thought it would be of interest to quantitate the effect of these behaviours on a functional outcome associated with those diseases,” explained Ronald Klein MD, MPH, lead author, and professor of ophthalmology and visual sciences, University of Wisconsin School of Medicine and Public Health, Madison. In the cohort of nearly 5,000 patients followed for up to 20 years, the cumulative incidence of visual impairment was 5.4 per cent. Results from the final multivariate adjusted model found that being physically active and having an occasional drink significantly reduced the odds of becoming visually impaired. Persons with a physically active lifestyle had a 60 per cent lower risk of developing visual impairment compared to their “sedentary” counterparts who engaged in regular activity less often. Those reporting not drinking alcoholic beverages in the past year were about twice as likely to become visually impaired than occasional drinkers (persons having less than one alcoholic beverage per week). Although there was also about a two-fold higher risk of incident visual impairment among current smokers compared to never smokers, the difference was not significant. However, current and past smokers had greater loss in the number of letters read correctly during follow-up than never smokers.

Unmeasured variables Commenting on the results to EuroTimes, Dr Klein noted that these epidemiological data do not establish causality and it is possible that the lifestyle factors are markers of unmeasured variables. “In particular, dietary factors that are thought to be protective against AMD development were not considered in the analyses,” he said. “However, ophthalmologists should tell their patients about our findings on vision. In addition, they should be telling all patients not to smoke for general health reasons and patients at risk of AMD not to smoke because of evidence that smoking increases their risk.” He noted ophthalmologists should be careful to acknowledge there is little evidence that stopping smoking, drinking an occasional alcoholic beverage and becoming physically active will prevent visual loss. “However, physicians are already warning patients not to smoke, to engage in physical activity and unless there are contraindications, to consider one to two drinks per week because these behaviours have been found to protect against cardiovascular disease,” Dr Klein observed. Ronald Klein: Eurotimes | may 2014


14th EURETINA Congress 11 – 14 September

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14th EURETINA Congress

LONDON 11-14 September 2014

9 Main Sessions 15 International Society Symposia 21 Free Paper Sessions 38 Instructional Courses 5 Surgical Skills Courses EURETINA LECTURE


Robert MacLaren UK

Johanna Seddon USA

Gene Therapy for Retinal Disease – What Lies Ahead

Understanding the Mechanisms and Etiology of Macular DegenerationGenetics and Modifiable Factors






main airports: Heathrow and Gatwick Driving: Keep on the left-hand side Main public transport: The Underground

Charlotte Street in Bloomsbury is lined with restaurants. Try Roku, an innovative Japanese restaurant. Reservations are advised. Lunch and dinner Monday to Friday; weekends dinner only. For details, visit: Booked out? A short stroll will present you with lots of alternatives. I enjoyed Brasserie Blanc, one of seven operated by chef Raymond Blanc in London. Open daily. For details, visit: For a beer in the evening, drop in at the Duke of York, around the corner on Rathbone Street (closed Sundays). Possibly the most picturesque shop in Bloomsbury belongs to James Smith and Sons, Umbrellas. A holdover from Victorian days it was founded in 1830; it’s still family-run and still famous for quality umbrellas and walking sticks for gentlemen and ladies. Call in to marvel at the varieties available. Have an umbrella or stick made to measure (your height determines its ideal length) or choose from the massive display. Prices range from thousands of pounds to the very reasonable; the perfect souvenir of London. Once bought, the umbrella may be returned for mending forever more (you pay cost and postage). The shop is at 53 New Oxford Street, very close to Tottenham Court Road Underground station and the British Museum. Open 11:00-17:45, Monday-Friday; Saturday until 17:15. For details, visit: The Foundling Hospital in Bloomsbury was an orphanage for abandoned children, founded in the 18th century by a philanthropic sea captain, Thomas Coram. Handel was an early patron; annual performances of the Messiah were vital sources of income for the charity. The building, demolished in 1926, was recreated on a smaller scale and is now a museum. It includes original 18th century interiors, furniture and fittings, a staircase from the boys’ wing and the Rococo Court Room. The Museum also houses the Gerald Coke Handel Collection, one of the largest privately-owned collections of Handel memorabilia. 40 Brunswick Street. Open from 10:00 to 17:00 on Tuesday through Saturday, and on Sunday from 11:00 to 17:00. Closed on Monday. For details, visit:

Eurotimes | may 2014

The Duke of York pub in Bloomsbury

taking a walk?

There’s more to see in Bloomsbury than the British Museum. Maryalicia Post reports A tourist can look at London as a dauntingly big city, studded with attractions separated by a tube or taxi ride or as Londoners do, as a cluster of villages, each with its own individual character. One prime example of a village within London is Bloomsbury, home to the British Museum. Bloomsbury is also home to one of the most fascinating offbeat museums to be found anywhere – the Petrie Museum of Egyptian Archaeology. The principal draw in Bloomsbury is, of course, the British Museum where the Rosetta Stone and the controversial Elgin Marbles are but two of the museum’s 4,000 “highlights”. The museum’s website suggests what to see if you have only an hour to spare. General admission is free; the museum’s special exhibitions, for which there’s a fee, pull enormous crowds. During the XXXII ESCRS Congress in London, the featured exhibit will be “Ancient Lives, New Discoveries,” a close-up look at the life and death of eight individuals who lived in ancient Egypt. Book tickets online. For details, visit: It’s a 20-minute walk from the British Museum to the Petrie Museum on Malet Place, where the finds of an extraordinary English Egyptologist, Sir Flinders Petrie, are exhibited. It’s an old-fashioned museum stuffed with fascinating objects (80,000 of them) including one of the oldest garments known to exist – a pleated linen dress worn by a woman in 2,800 BC. The museum is open five afternoons a week from Tuesday to Saturday. For details, visit: A stroll down Gower Street takes you past Bedford Square, one of London’s best preserved Georgian set pieces. At 7 Gower

Street, a Blue Plaque commemorates the founding of the Pre-Raphaelite Brotherhood, the artists who sought to free art from the Victorian grip of the 19th century. Next, look to the right, down Kepel Street, for a glimpse of the towering Senate House on Malet Street. It housed the Ministry of Information between the two world wars and was the inspiration for the “Ministry of Truth” in George Orwell’s 1984. At 62-64 Gower Street is the Royal Academy of Dramatic Arts. John Gielgud, Anthony Hopkins and Richard Attenborough are three of its famous alumni. Book a tour at: You’re now nearing the Petrie Museum. Where Gower Street meets Torrington Place cross the road and turn right for the entrance to Malet Place. Follow this laneway almost to the end; the Petrie Museum on the left, is marked with a banner.

The British Museum’s inner court, the largest covered piazza in Europe


complex cases Cataract surgery remains the ophthalmologist’s staple procedure. And yet, despite great advances in technique and equipment, complex cases remain surprisingly difficult for most surgeons. Cases in eyes with pre-existing pathology have much higher complication rates than those in “standard” eyes. This is, in part, because PUBLICATION these eyes are often inherently cataract Surgery in more susceptible, and because Complicated Cases many are referred to tertiary EDITORS centres, where much of the lucio buratto, stephen f brint expertise resides. & luigi caretti Cataract Surgery in PUBLISHED BY slack incorporated Complicated Cases covers essentially all non-standard cataract operations. Chapter 1 covers Paediatric Cataract, a pathology with which most ophthalmologists have very little first-hand experience. “A good outcome requires absolute precision in every step of surgery; having said that, late complications may develop with even the most successful surgery, and these may lead to a poor anatomical and functional result,” the authors remind us. The book continues with more frequently encountered cases, such as cataract in glaucoma patients; in pseudoexfoliation; small-pupil; brunescent cataract; high myopia and severe hyperopia; in retinitis pigmentosa; uveitic eyes; floppy iris; diabetic eyes; traumatic cataract; iris abnormalities; corneal pathology; cataract surgery following implantation of a phakic intraocular lens; secondary lens implants; and IOL explantation and replacement. This book is appropriate for advanced residents, cataract surgery fellows, young ophthalmologists with significant experience in standard phaco procedures, and all those who are looking to expand the range of patients that they can operate.




surgical options Maria da Luz Freitas’ Adult Glaucoma Surgery (Jaypee) is a brief introduction to the world of IOP-lowering surgery. Through eight chapters and 65 pages, this book begins with the standard trabeculectomy, “the most widely used surgical option for glaucoma at a global level. The reasons for its success are its efficacy, relatively low cost and vast experience.” Equally useful is the chapter on posterior drainage devices such as the Molteno, Ahmed and Baerveldt implants. “The fear of late trabeculectomy complications with MMC…along with increasingly positive results from newer drainage devices have changed the scene of surgical options in glaucoma.” The ExPress Mini Glaucoma shunt is briefly covered, as is trabecular micro-bypass surgery and canaloplasty. Particularly interesting are the chapters on combined surgery, in which glaucoma surgery is combined with cataract extraction; and lens surgery in glaucoma. This book is most appropriate for glaucoma fellows and general ophthalmologists who are considering adding glaucoma surgery to their arsenal.

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Leigh Spielberg Books Editor

FURTHER STUDY If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

Eurotimes | may 2014




RETINA ACADEMY Registration open for 14th ESASO Retina Academy in Istanbul, Turkey


he ESASO Retina Academy will be held in Istanbul, Turkey, 14-15 November 2014, and will offer new and additional interactive clinically relevant sessions led by world-leading ophthalmologists. The two-day meeting will be run by a faculty of more than 40 experts with main plenary sessions on specific topics of the retina. These sessions will include presentations, prestigious Lectio Magistralis keynote lectures, debates between experts and two Retinamor interactive case study discussions. The main sessions will focus on diabetic macular edema, vascular pathologies, macular edema in retinal vein occlusions and the management of retinal ischaemia. The meeting will host a unique set of ESASO MasterClasses on topics including paediatric retinal diseases, vitreolysis and central serous chorioretinopathy. These sessions are limited to small groups to provide the opportunity for direct discussion with global experts. The ESASO Retina Academy accepts abstract submissions on eight categories of topics relating to the retina. Accepted abstracts can be offered as posters, with winning abstracts presented within the main programme, and as rapid-fire presentations â&#x20AC;&#x201C; a new interactive format within the meeting. All accepted abstracts will be published in Ophthalmologica, the journal of the European Society of Retina Specialists (EURETINA). The abstract submission deadline is 23 June 2014. Delegates may also submit case studies for presentation and discussion in the Retinamor sessions. Francesco Bandello The winner of the annual humanitarian Excellence in Ophthalmology Award (XOVA) will be presented at the meeting. This award, sponsored by Novartis corporation, is for an initiative that is expected to have significant impact on unmet needs in ophthalmology. Other awards will be made to those graduating from the ESASO fellowship programme and the ESASO graduation scheme. This year's scientific programme is developed by the Scientific Committee chaired by Francesco Bandello, professor and chairman, Department of Ophthalmology Scientific University Institute San Raffaele, Milan, Italy. Prof Bandello says: "The meeting has been re-focussed this year to prioritise and align with the objectives of the ESASO school. Our meeting will offer clinically relevant education led by the best experts from around the globe with a new name, the ESASO Retina Academy. This reflects the high level of education we offer to ultimately improve the clinical and surgical practice of specialists in ophthalmology." * Francesco Bandello: Gabriella Skala: Eurotimes | may 2014

resident’s diary

MORAL obligation Leigh Spielberg ponders what he owes the world


hat sort of moral Geoff Tabin, co-founder of obligation do the Himalayan Cataract Project, we, as young, calls cataract extraction “a well-trained little miracle – the single most ophthalmologists effective medical intervention on have to the rest earth.” This is particularly true of the world? What is expected of when the vision of patients with us in terms of “giving back” to a mature cataracts and functional world that has been so generous blindness can be restored for to us and so much less generous less than €20 per patient. And to the rest of humanity? this operation can be repeated This question has been popping hundreds of thousands of times up with increasing frequency with outcomes comparable in my mind, largely due to the to those seen in Europe. A connections between our eye National Geographic journalist, hospital in Rotterdam and an observing Dr Tabin examining extraordinary clinic in Rwanda: patients postoperatively, wrote, the Kabgayi Eye Hospital. It all “Dozens of patients who have started with a recent vitreoretinal regained their sight stand to (VR) surgery fellow, Dr Piet Noë. sing. Sometime in my life, I Dr Noë is a Belgian may hear a sound that expresses ophthalmologist who lives and joy more purely. But I can’t works full time in Rwanda. imagine when.” There, he performs thousands of eye operations of every sort Responsibilities and per year. He came to Rotterdam possibilities for an intense surgical training So, back to my original question: programme. Since Dr Noë What is our responsibility, returned to Rwanda, two of my as residents and young colleagues have gone to work ophthalmologists, to the world’s with him. blind? With few exceptions, One colleague went to teach; we have all been handed the the other went to learn. Marc “We can permanently improve world on a silver platter. We Veckeneer, a senior retinal a person’s quality of life with just have benefited from excellent, surgeon, went to Rwanda for inclusive educations in safe several months to operate. He also one operation” environments. Our futures put the finishing touches to Dr Marc Veckeneer look rosy, despite our general Noë’s VR skills. Peter van Etten, tendency towards fear and ophthalmology resident, spent a obsession over every financial “crisis” of our highly developed month assisting Dr Noë in the clinic and in the operating room. and generally stable economies. In an email to us during his first week there, Peter wrote: “What And besides our responsibilities, whether they are measured Piet Noë does here is truly amazing. Here’s an example of today’s in financial or surgical assistance, what are our possibilities? operating schedule: one enucleation for retinoblastoma, two Can we just get up and go to Rwanda or Bhutan, live there for a congenital cataracts, two corneal perforations, three vitrectomies year or two and operate as many cataracts as we possibly can in for retinal detachments, a conjunctival flap for a Mooren ulcer, that time? Half of the residents in my programme have children. debulking of what seems to be a periorbital lymphangioma, a few They have bought houses and have bank loans to pay. Getting pterygia, 10 cataract extractions and a dacryocystorhinostomy to away isn’t easy. drain an orbital/ethmoidal abscess. Oh, and a trabeculectomy.” And if we were able to leave our lives for a year or so, how useful could we be to the treatable blind? Could we successfully Quality of life operate a mature cataract? A post-traumatic cataract? A Impressive. I must admit, it’s difficult to concentrate on treating congenital cataract? The old maxim of “See one, do one, blepharitis (Is it anterior? Is it posterior?) when I know that teach one” might apply when it comes to placing an IV or a more significant problems exist just a half-day’s flight from my vaccination, but intraocular surgery is a complex skill. We get doorstep. It’s interesting to consider how many thousands of euros just enough surgical training to handle basic, uncomplicated can be spent on a single cataract operation in western hospitals, cases after graduation. Can someone train us to be of surgical knowing this amount of money could be spent treating hundreds help in Ethiopia? Or will we just get in the way of those who are of people in poorer countries. already there? “It’s amazing to fully realise that ophthalmology is really such After I graduate, I will probably follow a well-worn path a surgical profession and thus ideal for the tropical countries. We through fellowship and straight into practice. But maybe we can permanently improve a person’s quality of life with just one should all try to blaze a path outside our comfort zone and into operation,” Dr Veckeneer wrote in an email from Rwanda. the wider world, where we are greatly needed, while we still can. Eurotimes | may 2014



eye on technology

excellent visibility A new technique for endothelial keratoplasty.


orneal transplantation for endothelial decompensation is shifting predominantly to endothelial keratoplasty in suitable patients. Descemet stripping automated endothelial keratoplasty (DSAEK) has received widespread acceptance amongst corneal surgeons mainly because of ease of surgery and ability to procure prepared tissue from eye banks. However, Descemet membrane endothelial keratoplasty (DMEK) though better in terms of visual acuity achieved and decreased risk of graft rejection has not yet become widely practised. This is mainly because of greater difficulty in graft preparation and the more challenging nature of surgery as far as graft unrolling, orientation and flotation are concerned. DMEK also has the disadvantage of inability to harvest grafts from donor corneas less than 40 to 50 yrs old because of the high probability of damage to the graft while harvesting. Pre-Descemet endothelial keratoplasty (PDEK) is a new technique for endothelial keratoplasty recently introduced by Profs Amar Agarwal and Harminder Dua which combines many of the advantages of DSAEK and DMEK while avoiding many disadvantages that each individually has.

Corneal anatomy To understand this new technique better, let us take a re-look at some previous reports as well as at corneal anatomy. Air separation of a DMEK graft has been reported earlier by Busin et al and Jafarinasab et al reported additional tissue as “residual stroma” attached to Descemet’s membrane when separation is caused with injection of air in deep anterior lamellar keratoplasty. Prof Dua presented evidence regarding a distinct pre-Descemet’s layer (PDL) of tissue in 2007. The cornea was described as having six layers instead of the conventionally accepted five layers. A new fourth layer was introduced called the Dua’s layer or the PDL. In DMEK, only the Descemet’s membrane and healthy donor endothelium without the PDL are transplanted onto the recipient cornea. PDEK also includes the PDL as part of the grafted tissue along with the Descemet's membrane and endothelium. Eurotimes | may 2014

Dr Soosan Jacob reports

A: Type 1 big bubble formed on injection of air into corneo-scleral rim

B: Pseudophakic bullous keratopathy

C: Endoilluminator-assisted PDEK (E-PDEK) is used for enhanced three-dimensional visualisation and depth perception

D: One month postoperative appearance of patient

The PDEK graft is prepared by injecting air into the donor cornea to induce separation between the stroma and PDL by creating a Type 1 Big bubble. This is in a manner very similar to the Anwar's Big Bubble created for DALK except air is injected from the endothelial side of the corneo-scleral rim just outside the limbus. In PDEK, the objective is to retain the PDL with the endothelium-Descemet’s membrane complex, thereby providing additional support to the graft tissue used for the procedure. The presence of this layer, with its characteristics of relative rigidity and toughness, allows easy intraoperative handling and insertion of the tissue because it is not as flimsy and does not tear as easily as the Descemet’s membrane alone. Profs Agarwal and Dua said: "The most popular Descemet’s membrane-baring technique is the big bubble method, in which the big bubble forms a cleavage plane, leaving the Descemet’s membrane bare for the dissection in lamellar keratoplasties. The Descemet’s membrane is truly laid bare only when a type 2 (pre-

Descemetic) bubble is created between the PDL and the Descemet’s membrane. In the PDEK procedure, a type 1 big bubble, which typically lies between the PDL and the posterior corneal stroma, is formed, thereby creating a dome of PDL-Descemet’s membrane-endothelial complex above the air bubble. Including the PDL with Descemet’s membrane in endothelial keratoplasty would add tissue rigidity and potentially facilitate the procedure."

Classification of big bubble When air is slowly injected with a 30-gauge needle attached to a 5ml syringe inserted from the limbus into midperipheral stroma, it can form either a Type 1 or Type 2 big bubble. Type 1 big bubble is a well-circumscribed, central dome-shaped elevation measuring 7mm to 8.5mm in diameter (Figure 1A) which always starts in the centre and enlarges centrifugally, retaining a circular configuration. Type 2 big bubble appears as a larger bubble expanding to fill the space between the Descemet's membrane

eye on technology and the Dua's layer. Sometimes, a combination of Type 1 and Type 2 bubble can be obtained. Donor preparation: After achieving a Type 1 big bubble, trephination of the donor graft is done along the margin of the big bubble. The bubble is entered at the extreme periphery, and trypan blue injected into the bubble to stain the graft. The PDEK graft is then cut around the trephine mark with a pair of Vannas scissors and covered with tissue culture medium. The graft is loaded into an injector when ready for insertion. Once the donor is prepared, the rest of the surgery is similar to that of DMEK, wherein the host Descemet's membrane is stripped and the PDEK graft injected into the AC, oriented, unrolled, opened up and floated against the stroma with an air bubble. The Endoilluminator assisted DMEK (E-DMEK) technique which has been described by the author (SJ) and was discussed in the last issue of this series is translated into this surgery as Endoillumintaor assisted PDEK (E-PDEK) (Figure 1B, C). Says Prof Agarwal: "E-PDEK is an extremely useful technique for achieving excellent visibility in these cases and helps me immensely in being able to be certain about my graft orientation and positioning during the entire surgery just as it also helps in E-DMEK." At the end

E: OCT image, shows an attached graft

of surgery, light perception and IOP are checked for and the patient maintains a face-up position for 24 hours. "PDEK thus provides the benefits of DMEK, such as speedy visual recovery (Figure 1D) while overcoming the disadvantages posed by DMEK. PDEK takes ultra thin-DSEK to a “thinner level” while keeping its advantages, at the same time getting rid of the requirement for sophisticated instrumentation and keratome. Spectral-domain optical coherence tomography in vivo analysis of PDEK grafts showed mean graft thickness after one month to be 28 ± 5.6 µm, which is larger than the conventional DMEK graft and less than

the ultra-thin DSAEK graft. It also gives a faster visual recovery," Profs Agarwal and Dua said (Figure 1E). * Dr Soosan Jacob is a senior consultant ophthalmologist at Dr Agarwal's Eye Hospital, Chennai, India and can be reached at:

Scan this QR code to go to video link for surgery

EYE CHAT Exclusive interviews Up to date information Problem solving

Small Pupils and Floppy Iris Syndrome Scan this QR code to gain access to EuroTimes podcasts

Dr Oliver Findl speaks with Dr Boris Malyugin about how to handle these cases before, during and after surgery.


Also available on iTunes

Eurotimes | may 2014



Courtesy of Jose L Güell MD


Preoperative image and six months postoperative

ALTERNATIVE STRATEGIES Case study of patient with pseudomonas corneal ulcer in left eye. Roibeard O'hEineachain reports


n eye with a well recognised corneal pathology can still require careful weighing up of options, said José L Güell MD, Autonomous University of Barcelona, Spain, at the 18th ESCRS Winter Meeting’s Cornea Day in Ljubljana, Slovenia. He presented a case-report involving a 69-year-old who developed a Pseudomonas corneal abscess with significant anterior chamber reaction in his left eye after traumatic corneal erosion in May 2013. The patient's diseased eye had poor light perception and significant cortical cataract. The IOP was 14.0 mmHg and the B-scan was normal. Dr Güell said the patient was not in pain and it was not clear how much vision could be salvaged. He asked the audience which course they would have advised. One attendee suggested that because OCT showed a very deep scar, a lamellar keratoplasty would be indicated. Rudy Nuijts MD cautioned that more extensive investigation might be warranted. He added that he would recommend testing the corneal sensitivity at 12 o'clock and PCR-testing for possible herpes infection and an anterior chamber tap to determine if there was an intraocular infection. He noted that an active infection of any type could have a negative impact on the success of a corneal graft.

Corneal sensitivity Dr Güell responded that they had tested corneal sensitivity and found it normal, but they did not perform PCR Eurotimes | may 2014

because it had all the signs of a post -traumatic microbial silent infection. They ultimately decided to perform deep anterior lamellar keratoplasty, cataract extraction and IOL implantation in the same procedure. The plan was to visualise the cataract surgery through a thin layer of viscoelastic placed on top of the denuded Descemet’s membrane prior to placement of the corneal button. However, the scar tissue penetrated much deeper into the cornea than the initial 200 micron trephination and during the scraping of the residual stroma some liquid leaked out, indicating a gap in Descemet’s membrane and the endothelium.

Cataract Procedure Dr Güell therefore converted the procedure to a penetrating keratoplasty. He implanted an Ekhardt temporary prosthesis to prevent expulsive haemorrhage while he performed the cataract procedure. To widen the pupil, he first used adrenaline injections and mechanical and viscostretching manoeuvres. When these failed he used iris retractors. Upon completing the surgery, he sutured the donor cornea button in place and

injected bevacizumab intrastromally in those areas with significant reactive neovascularisation. At three weeks' follow-up the cornea was clear and there was no significant corneal oedema. However, visual acuity was unexpectedly low at 0.05. OCT revealed the presence of cystoid macular oedema. Dr Güell noted that CME is the most common cause of low vision after any type of keratoplasty procedure, especially when combined with another intraocular procedure. To treat the condition, he adopted a staged protocol, first adding topical NSAIDs to the topical steroids regimen. When that failed, he added oral acetazolamide but the oedema still proved resistant. He therefore injected triamcinolone intravitreally and three weeks later the patient’s decimal visual acuity was 0.7 despite a diffuse temporary epitheliopathy. "This case shows that even in a standard normal case there are a lot of things to discuss,” Dr Güell concluded. José L Güell: Rudy Nuijts:

This case shows that even in a standard normal case there are a lot of things to discuss José L Güell MD

WSPOS World Society of Paediatric Ophthalmology & Strabismus


Registration, Hotel Bookings & Preliminary Programme Online Preceding the XXXII Congress of the ESCRS 13 – 17 September 2014 London, UK

Clarity Satellite Meeting Lunchtime Sponsored by




PRIZE 2014

extra effort Resident describes her experiences while training to be a surgeon

Call for W 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 programme/Henahan-prize.asp See


hen I was at university I found the eye to be the most perfect creation of nature and the phenomenon of sight itself amazed me. I realised that my preferred goal would be to focus on a specialised field of medicine and to become expert and skilful in that field, instead of trying to cover a broad area. I always wished surgery would be a part of my profession. To qualify as an ophthalmologist in Slovenia requires six years of university, half-a-year of internship and four-and-ahalf years of residency. I started my PhD this year. If you want to work in the University clinic you are more or less expected to work on a PhD. In Slovenia it is not obligatory to do surgery as part of your residency. In fact, to receive training as a surgeon you have to be willing to put in the extra effort, and a resident has to gain some microsurgical skills prior to performing surgery on a live patient at our clinic. To that end we have a wet-lab where we can practise anytime. We also organise guided wet labs once or twice a year, and some attend guided wet labs abroad.

the right approach I was offered training in cataract surgery on live patients at our clinic in my second year as a resident. I do have to find my own patients, ask them if they are prepared to be operated by a beginner, letting them know that it will be under a specialist's supervision. I also have to organise the time and place to do it, insuring that both my mentor and the operating room is available and also insuring that someone is available to take over my duties at the ward where I would otherwise be assigned. I have the most wonderful and patient mentor, to whom I will be eternally grateful, because she is willing to take her time to supervise me and guide me. I would like to add that all of our cataract surgeons are willing to offer their mentorship as long as Neža Čokl MD the resident shows the right approach. When I complete my training as an ophthalmologist I would like to stay in Slovenia. It is my home country and I love it. Of course, the number of positions available in ophthalmology is limited in Slovenia and if I do not get a job here and a centre in some other country offers me a position I'm not sure what I will do. But I would like to stay here.

In Slovenia... to receive training as a surgeon you have to be willing to put in the extra effort...

Neža Čokl MD is chief resident at the Dept of Ophthalmology, Ljubljana Hospital, Ljubljana, Slovenia. Email: * Dr Cokl was interviewed by Roibeard O h'Eineachain Eurotimes | may 2014

Industry news


OPTICAL BIOMETRY & TOPOGRAPHY SYSTEM · Axial Length · Anterior chamber depth · Real Cornea Radii · Dynamic Pupillometry · White to White · Full Corneal Topography



Topographer launch Topcon has launched the ALADDIN Biometer and Corneal Topographer In Canada, Central and South America. "The ALADDIN combines axial length, corneal topography, pupillometry, corneal diameter and anterior chamber depth in one single instrument. It supports the eye surgeon not only in IOL power calculation but also in his or her choice of the right premium IOL for each individual eye," said a Topcon spokeswoman.

OCT system NIDEK has announced FDA clearance of the RS-3000 Advance. “This premier OCT system incorporating Scanning Laser Ophthalmoscope is designed for comprehensive evaluation of the retina and choroid. The RS-3000 Advance provides exquisite detail of the retinal and choroidal microstructures to assist in clinical diagnosis,” said a company spokesman.

Glaucoma treatment IOPtima Ltd has developed CLASS, CO2 Laser-Assisted Sclerectomy Surgery, as a minimally invasive, laserassisted surgical solution for long-term relief of intraocular pressure (IOP) and treatment of glaucoma. "CLASS utilises CO2 laser’s unique properties of tissue ablation and absorption in fluid to delicately ablate scleral tissue while being absorbed in the percolating intraocular fluid,” said a company spokeswoman.

Phase one study Novaliq GmbH has announced the commencement of a Phase 1 study for CyclASol (Cyclosporin solution). “We are pleased to receive the

USA & European patent and to announce the start of phase 1 CyclASol study,” said Bernhard Günther, CEO of Novaliq GmbH. “These are both significant new milestones for Novaliq, ” he said.

Our wish to improve vision care. Your wish to see the complete picture.

Restricted use Alimera Sciences has announced that the Scottish Medicines Consortium (SMC) has accepted ILUVIEN for restricted use within the National Health Service (NHS) Scotland. "The advice issued by the SMC provides NHS Scotland patients considered insufficiently responsive to available therapies with access to ILUVIEN, the only sustained-release treatment for chronic diabetic macular edema (DME),” said an Alimera spokesman.

Eurotimes | may 2014




the WISH LIST What do young ophthalmologists want? Sonia Manning investigates


elow are some of the important issues that I think should be addressed to help assist in the training and development of ophthalmologists.

Exposure to subspecialties

During the early years of training, we want exposure to as many ophthalmology subspecialties as possible in order to get a flavour for what each one is like to work in. This way we can decide which subspecialty holds the greatest appeal for us or indeed decide that general ophthalmology is the path we want to take. I have never met a young ophthalmologist who did not want to get surgical experience early on in his or her career. We do not all decide to pursue surgery in the end, but we all want to immerse ourselves in the surgical experience at the beginning. It is the only way to truly know if surgical ophthalmology is for us.

Teaching We want to be taught. We want to benefit from the experience and wisdom of more senior colleagues and this can be passed on in many ways. Teaching can take place in formal tutorials, at the bedside on ward rounds or at the slit-lamp in clinic. Journal clubs and case presentations are very educational for young ophthalmologists also.

Advice on which books to read or where to find good quality self-teaching material on the internet is also useful, or simply being told that a patient with interesting clinical findings has been admitted to the ward and it is worth examining. Some of us will be won over by the allure of laboratory research and some by the appeal of clinical projects. Regardless of which choice we make, we want to ask intelligent research questions and find ways to answer them! We want to learn how to critically appraise and write a paper, skills that are hard to teach but will be of great benefit in our practice of evidence-based medicine.

We want to meet fellow trainees from other countries and exchange ideas and experiences Sonia Manning

INDIA Eurotimes | may 2014

Role models/mentors We want role models. Someone to look up to, admire and aspire to. When we find ourselves in demanding clinical situations, we want to be able to ask (and answer) the question: “What would my role model do?”

Attending meetings We want the opportunity to go to international meetings of high educational value, to listen to experts talk about the current “hot” topics, to attend courses that will help us further our education and our careers. We want to meet fellow trainees from other countries and exchange ideas and experiences. And finally, we want career pathways, both surgical and non-surgical, that are well-defined and offer posts at the end of training. * Dr Sonia Manning is a member of the ESCRS Young Ophthalmologists Committee



lens disaster

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Case study examines how patient suffered endothelial cell loss. Roibeard O’hEineachain reports


aving the AcrySof Cachet angle-supported IOL implanted in an upside-down position is a disastrous situation that results in pupillary block, angle-closure glaucoma and endothelial decompensation,” said Thomas Kohnen MD, PhD, FEBO, Goethe-University, Frankfurt am Main, Germany at a Cornea Day session at the 18th ESCRS Winter Meeting in Ljubljana. He presented the case of a male patient 27 years of age who attended the emergency room at the University of Frankfurt because of a sudden onset of pain and loss of visual acuity in his right eye. The visual acuity was reduced to hand motions in the right eye but was 20/20 without correction in the left eye. The patient said that eight weeks previously he had undergone bilateral implantation of the AcrySof® Cachet anglesupported phakic anterior chamber IOL (Alcon) to correct -7.5 D of myopia at another centre in another country. Inspection of the anterior segment revealed conjunctival injections, severe corneal oedema with a large 6.04mm pupil and an intraocular pressure (IOP) of 60 mmHg. The fellow eye had a normal appearance and IOP of 14.0 mmHg. The resident on duty consulted with the faculty on duty and they decided to admit the patient to hospital. They immediately administered IOP reduction medication, including 500mg acetazolamide and 250mg mannitol intravenously combined with a topical 20mg timolol and 5.0mg dorzolamide eye drop combination (Cosopt®, Merck) and pilocarpine eye drops. Three hours later they attempted YAG-laser iridotomy but were unsuccessful and IOP remained at 60 mmHg.

Topography and advanced external imaging for dry eye assessment

Anterior concavity The following morning further examination with the Pentacam (Oculus) revealed that the central cornea had a thickness of 929.0 microns and an anterior chamber depth of 2.03mm, compared to 3.35mm in the fellow eye. Prof Kohnen brought the patient directly to the operating room and removed the phakic IOL from the patient’s left eye. Close inspection of the orientation markers on the haptic showed that the lens had been implanted upside down. Following removal of the IOL, the eye’s IOP rapidly returned to normal levels and there was a steady reduction in corneal oedema and a concomitant improvement in corrected distance visual acuity. By eight weeks' follow-up the eye had a corrected distance visual acuity of 20/20 and refraction in that eye was equivalent to the preoperative value of 7.5 D. However, endothelial cell density was drastically reduced and appeared to fluctuate. One week after surgery it was 963 cells/mm2. At six weeks it was 1562 cells/mm2 and at eight weeks it was 1057 cells/mm2. Prof Kohnen noted that this is the first and only case reported so far of the Cachet phakic IOL being implanted upside down. He added that the markings on the IOL’s haptics make it a mistake that is very easy to avoid. The complete case-report is in the May 2013 issue of JCRS.

High-resolution colour camera

Imaging of the upper and lower meibomian glands

Non-invasive tear film break up time and tear meniscus height measurements

Assessment of the lipid layer and tear film particles

Grading of the bulbar redness

Image and video documentation

Please note: The availability of the products and features may differ in your country. Specifications and design are subject to change. Please contact your local distributor for details.


Thomas Kohnen: Eurotimes | may 2014




long-term Commitment ESCRS continues support for Orbis and Oxfam. Colin Kerr reports



FRONTIERS the ESCRS is awarding 40 grants of €1000 to young ophthalmologists who want to travel abroad to improve their skills


SCRS president Roberto Bellucci has announced that the society will continue to support Orbis and Oxfam during the two years of his presidency. “Our support of Orbis and Oxfam continues to be very rewarding,” said Dr Bellucci, “and it is a very important part of the society's activities. “I am delighted to announce our continuing support for the Orbis and Oxfam projects for a further two years and I look forward to building on the work we have done to date. “We donated €35,435 to the two charities in 2013 thanks to the generous contributions from ESCRS members, in addition to a contribution from the society,” said Dr Bellucci. “We will make a further donation in 2014 to Orbis and Oxfam from donations through registrations at our 18th Winter Meeting in Ljubljana, Slovenia and the XXXII Congress of the ESCRS in London,” he said. Dr Bellucci told EuroTimes that the ESCRS Roberto Bellucci had a long-term commitment to charitable work and it would be making a further announcement about its future plans at the XXXII Congress of the ESCRS in London.

Orbis Gondar project ESCRS is supporting Orbis in its work with the Gondar University Hospital to establish a Child Eye Health Tertiary Facility (CEHTF) for North West Ethiopia from 2011 to 2015 and the development of a paediatric eye-care team. “We would like to say a heartfelt thank you to ESCRS for its continued support for Orbis’s work in Gondar and specifically for providing the sponsorship of our paediatric ophthalmologists,” said an Orbis spokesman. "Such support is vital for making a lifechanging difference to the lives of many children, like Mulawu, all across Ethiopia. ESCRS is not only giving back sight, but allowing these children the opportunity to learn, earn and fulfil their potential.”

Oxfam WASH programme

visit to apply

Limited access to safe water leading to poor hygiene and the spread of disease is a reality frequently faced by poorer rural communities or refugees living in over-crowded conditions. It leads to a variety of diseases including; onchocerciasis (river blindness), typhoid, guinea worm, schistosomiasis, malaria and trachoma, an infection of the eyes that may result in blindness after repeated re-infections. “These diseases can be successfully combatted by good personal and environmental hygiene and we are grateful for the ESCRS's support of Oxfam’s Water and Sanitation and Hygiene Promotion (also known as WASH) programme in the Democratic Republic of Congo (DRC) in 2013,” said an Oxfam spokesman.

How to donate ESCRS members and delegates can donate directly through registration for the XXXII Congress of the ESCRS in London. Eurotimes | may 2014


JCRS highlights

Vol: 40 Issue: 4 month: APRIL 2014

ANterior corneal topography Italian researchers looked at changes in anterior corneal topography following femtosecond incisions. They compared these with the effects of incisions created with disposable knives. Although the slight corneal changes were comparable to those created with a keratome, they observed local topographical differences in the form of higher steepening in the region of incisions performed with the knife. S Serrao, JCRS, Effect of femtosecond laser–created clear corneal incision on corneal topography Vol 40, Issue 4, 531-537.

Corneal incisions- under the microscope How do femtosecond and standard incisions differ under the microscope? Mayer and colleagues compared in vitro immunohistochemical and morphological aspects of penetrating corneal incisions. The femtosecond laser–created corneal incisions in human corneas showed no differences in inflammatory cell response but a significantly higher cell death rate than manually performed incisions, indicating an upregulated postoperative wound-healing response. WJ Mayer, JCRS, “In vitro immunohistochemical and morphological observations of penetrating corneal incisions created by a femtosecond laser used for assisted intraocular lens surgery,” Vol 40, Issue 4 632–638.

MISSION (IM)POSSIBLE We didn‘t believe that 1.8 mm was the limit of micro-incision cataract surgery!

No touch scleral sutured IOL

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Posterior chamber IOLs have a theoretical optical advantage over anterior chamber IOLs due to their anatomic location and proximity to the nodal point of the eye. Anterior chamber IOLrelated corneal complications, such as endothelial compromise, pseudophakic bullous keratopathy, peripheral anterior synechiae, and subsequent glaucoma, may be minimized by positioning the IOL in the more “normal” anatomic location behind the iris. Researchers reviewed 78 cases treated with a modified no-touch transscleral sutured posterior chamber IOL implantation technique with a 1-piece monofocal IOL (Alcon CZ70BD) or an aniridia IOL (type 67G, Morcher). Indications included ocular trauma (46.2%), nontraumatic crystalline lens subluxation (16.7%), post-complicated cataract surgery (10.3%), idiopathic IOL dislocation (10.3%), and congenital cataract/aphakia (10.3%). An aniridia IOL was required in 39.7% of eyes. Overall, 91.3% of eyes had improved visual acuity or were within one line of the presenting CDVA. In the better prognosis group, 73.9% achieved a CDVA of better than 6/12 and all achieved better than 6/30, with a moderate rate of complications. D Lockington et al., JCRS, “Outcomes of scleral-sutured conventional and aniridia intraocular lens implantation performed in a university hospital setting,” Vol 40, Issue 4, 609-617.

Thomas Kohnen European editor of jcrs

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

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Tel. + 41 71 727 10 50

Eurotimes | may 2014





EUREQUO RESEARCH A resource for evidence-based medicine. Dermot McGrath reports


ith over 1.4 million cataract extractions now included in its database, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) continues to go from strength to strength. A research project is now being funded by the ESCRS over a three-year period which will enable patient-reported outcomes to be added to the database. According to Mats Lundström MD, PhD, who led the initial development of EUREQUO, the drive to add patientreported data to the database is proceeding as planned. “The ESCRS research project was specifically aimed at including patient questionnaires in the database. Linked to this aim was the translation of questionnaires into different languages, validation studies in the new languages and finally adding a system that makes analyses of clinical and patient-reported data possible. Things are going well so far. The technical part is almost ready and we are translating the questionnaires into Spanish and Slovak at the moment,” he said. The actual implementation process of the EUREQUO system turned out to be more challenging and time-consuming than initially anticipated, said Dr Lundström. “The web-based model made it possible to enter data manually via the web. This meant for many surgeons and clinics, entering data twice, in both their own system and in EUREQUO. No one likes double entry of data, and so we had to start building interfaces for transfer of data from existing registries and electronic medical record (EMR) systems to EUREQUO. Building interfaces means incurring costs and also having to update them over time as new electronic versions of EMR systems appear. Today EUREQUO contains data from almost 1,450,000 cataract extractions and 90 per cent of this data comes from transfer from existing electronic systems and only 10 per cent from manual input of data,” he said.

Patient follow-up

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Eurotimes | may 2014

Another hurdle to be negotiated was the sometimes inadequate follow-up of patients, said Dr Lundström. “When we created EUREQUO we believed that quality control and quality improvement meant knowing what happened to the patient. We thought that the soul of all healthcare seeks to answer the question: what happened to the patient? If we don’t know what happened to the patient, how can we improve our care? Many surgeons don’t see their patients after surgery. This means that it is difficult for some potential users of the EUREQUO to register follow-up data. Different administrative and reimbursement rules in countries and clinics are behind this problem,” he said. An important next step for EUREQUO will be to use the database as a valuable resource for evidence-based medicine. “The whole database has already been used for analyses and publications but the next step will be to use the EUREQUO forms as Case Report Forms in new studies. The first study will be to compare the outcomes of femtosecond laser-assisted cataract surgery with conventional phacoemulsification. The database will serve as a source for control cases,” he said. Mats Lundstrom:

journal watch


new hope

from the archive

The long-held dogma that deprivation of vision during critical periods of childhood Glaring need for quality development results in irreversible vision loss is called into question of vision tests after by a recent US study. refractive surgery In a study of a group of paediatric Despite advances in laser technology, software algorithms patients in India who were blind and surgical techniques, problems such as glare, reduced during the critical childhood contrast sensitivity (CS) and night vision disturbances period before removal of bilateral continue to affect visual quality for a sizeable minority of cataracts, Peter Bex and colleagues patients after refractive surgery. at Harvard University found With renewed emphasis on quality of vision, some surgeons improvement in contrast sensitivity now believe that it is time for all refractive surgery patients to tests after vision returned. Some of be systematically tested for contrast sensitivity, glare and depth the patients were as old as 15 years. perception before and after surgery to identify such problems. “Our results show remarkable In a study presented at the 8th ESCRS Winter Refractive plasticity, and vision continues to Surgery Meeting, Christian Nischler MD said that while most improve in many children long Simulated views of an abstract painting to patients who undergo photorefractive surgery appear to be depict the development of pattern vision after the surgery,” said Dr Bex. following early and extended blindness quite happy with their postoperative vision, they may in fact The findings call into question have measurable and sometimes significant problems with the concept that there is a critical glare, haloes and contrast sensitivity. period of a few years during which the visual system can develop. "I think it would be very useful to systematically test glare and The research was conducted on patients in India under the contrast sensitivity values pre- and postoperatively because a auspices of Project Prakash a joint scientific and humanitarian effort e includes: significant number of patients show elevated stray light-values led by Pawan Sinha PhD, full professor at MIT. The project addresses or reduced contrast sensitivity, in spite of the fact that their ery & Cross Linking in Patients with Keratoconus, the problems of treatable blindness in India by providing surgeries visual acuity is very good. I think these additional tests will give free of cost to children with cataracts. Unlike patients in the western of Cataract Surgery, Amniotic Membranes & Clear Lens Extraction. important information about the quality of newly introduced world, Indian children with cataracts are not usually treated within techniques and laser systems," Dr Nischler told EuroTimes. the first year of life. Refractive Surgery ‘Current & Future’ aser Cataract Surgery Updates, From EuroTimes , Volume 9, Issue 5, May 2004 The research parallels changing attitudes towards the treatment Ls of amblyopia, where the window of opportunity, once though to be limited to the first few years of life,Technique, has been expanded the later Memorial Lecture Cross Linking Indications, Results,toComplications - David O’Brart teen years. These findings of neural plasticity in visual development morial Lecture have further implications for many areas of ophthalmology. y - Massimo Busin A Kalia et al., PNAS, “Development of pattern vision following early and extended blindness,” 2014 111 (5) 2035-2039. Image courtesy of Peter Bex



Moderate aerobic exercise could help to slow the progression of retinal degenerative disease, a new study hints. In an animal study US scientists trained wildtype BALB/c mice to run on a treadmill for one hour per day, five days per week, for two weeks. They then induced retinal degeneration with toxic bright light and exercised the animals for another two weeks. The exercised animals lost only half the number of photoreceptor cells as control animals. Moreover, the retinal cells of exercised mice were more responsive to light and had 20 per cent higher levels of the growthand health-promoting protein brain-derived neurotrophic factor (BDNF). After blocking the receptors for BDNF with systemic injections of a BDNF tropomyosin-receptor-kinase (TrkB) receptor antagonist reduced retinal function and photoreceptor nuclei counts to levels seen in inactive mice. Previous studies in animals and humans indicate protective effects of exercise in neurodegenerative diseases or injury, but less is known about how exercise affects vision. “This is the first report of simple exercise having a direct effect on retinal health and vision,” said Machelle Pardue PhD, one of the study authors. EC Lawson et al., Journal of Neuroscience, “Aerobic exercise protects retinal function and structure from light-induced retinal degeneration,” 12 February 2014, 34(7): 2406-2412; doi: 10.1523/JNEUROSCI.2062-13.2014.

The Joint Irish/UKISCRS Refractive Surgery Meeting Friday 21st November 2014 The Gibson Hotel, Dublin

The Programme Includes: • Cross Linking in Keratoconus Children • Amniotic Membranes • Femto & Laser Cataract Surgery Updates • Current & Future State of Refractive Surgery Dermot Pierse Memorial Lecture - David O’Brart Tom Casey Memorial Lecture - Massimo Busin

To Register Visit: url: email: or call: 00353 (87) 272 2755 - Limited Places Available -.

Eurotimes | may 2014




11th EGS Congress

7–11 June nice, france


20–24 July san francisco, california


Nordic Congress of Ophthalmology (NOk 2014) 20–23 august stockholm, sweden

MAy 2014 Arvo

14th EurETINA Congress


The royal College of Ophthalmologists Annual Congress 20–22 may birmingham, uK

SOI International Congress 21–24 may milan, italy

Portuguese Implanto-refractive Annual Meeting 30–31 may algarve, Portugal

2nd Asia-Pacific Glaucoma Congress 10th International Symposium of Ophthalmology


26–28 september Hong Kong



NEW ENTRY 6th Amsterdam retina Debate

AAO Annual Meeting

12 December amsterdam, the netherlands

18–21 october chicago, illinois, usa


4–8 may orlando, florida, usa

25–28 september leipzig, Germany

FEbruAry 2015


NEW ENTRY 73rd Annual Conference of AIOS

Femto Congress 2014

7–9 november budapest, Hungary

11–14 september london, uK

ESCrS Glaucoma Day 12 september london, uK

WSPOS Paediatric Sub Speciality Day 12 september london, uK

5–8 february new Delhi, india

SOI National Congress 12–15 november rome, italy

19th ESCrS Winter Meeting 20–22 february istanbul, turkey

27th APACrS Annual Meeting 13–16 november Jaipur, india

joint Irish/ukISCrS refractive Surgery Meeting

5th EuCornea Congress

21 november Dublin, ireland Email:

12–13 september london, uK

xxxII Congress of the ESCrS

13–17 september london, uK

International Annual Course and Workshop on Diagnostic ultrasound in Ophthalmology 22–26 september vienna, austria







C o r n

XXXII Congress of the ESCRS 13-17 September

14th EURETINA Congress 11-14 September



NEW ENTRY ISEr xxI biennial Meeting


The 112th DOG Congress of Ophthalmology



European Society of Cornea and Ocular Surface Disease Specialists

5th EuCornea Congress 12-13 September

WSPOS Paediatric Sub Specialty Day 12 September


Become an ESCRS Member

Free to members Access to iLearn Online interactive courses ESCRS on Demand Online library of presentations from ESCRS Congresses Subscription to Journal of Cataract & Refractive Surgery Reduced ESCRS congress fees

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EuroTimes Vol. 19 - Issue 5  

A European Outlook on the World of Ophthalmology

EuroTimes Vol. 19 - Issue 5  

A European Outlook on the World of Ophthalmology