EuroTimes October 2016

SPECIAL FOCUS OPHTHALMIC IMAGING CORNEA

PRESBYOPIA TREATMENT – HYDROGEL IMPLANT WELL TOLERATED IN STUDY

RETINA

KREISSIG LECTURE EXAMINES NUTRITION AND AGE-RELATED MACULAR DEGENERATION October 2016 | Vol 21 Issue 10

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

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ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS OPHTHALMIC IMAGING 4 Cover Story: The evolution of OCT, and where it is going in the future

with instruments and techniques

RETINA

9 Custom corneal ablation

21 The EURETINA Video

10 ‘VISTA visualisation’: a

23 All the key news from

guided by stromal topography to correct irregular astigmatism

method for mapping data into a colour-coded format

11 Motion-free OCT –

a novel scanning protocol and algorithm

FEATURES CATARACT & REFRACTIVE 12 ‘The biggest biotech

discovery of the century’

14 Scleral fixation of aspheric plate-haptic lens produces good visual outcome

15 Cataract surgery

improves patients’ sleep, study shows

16 Presbyopia treatment – 18 ‘New technique for

performing SMILE retreatment appears to be safe and efficacious’

EuroTimes & JCRS 1996–2016

P.28

19 DMEK – advances

20 Kreissig Lecture examines

hydrogel implant well tolerated in study

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2015 and 31 December 2015 is 46,515.

CORNEA

8 Retinal imaging – the

importance of analysis

www.eurotimes.org

nutrition and AMD

Competition Awards

CONGRESS REPORTS this year’s congresses in Copenhagen

GLAUCOMA 28 Obtaining CSF pressure measurements in the optic nerve region

29 Remote case-finding for angle-closure glaucoma

OCULAR 31 Monitoring RNFL

thickness to help screen conditions such as Alzheimer’s disease

REGULARS 37 JCRS Highlights 39 Industry News 40 Review 42 ESASO Update 43 Ophthalmologica Update 45 Hospital Diary 46 Book Reviews 47 Calendar

PAEDIATRIC OPHTHALMOLOGY 33 The prevalence, incidence,

and progression of myopia among teenagers Supplement October 2016

YOUNG OPHTHALMOLOGISTS 34 Manish Mahabir’s winning John Henahan Prize essay on the theme of ‘Why Should I Publish?

SMALL APERTURE TECHNOLOGY: Extending Depth of Focus for a Broad Spectrum of Presbyopic and Cataract Patients

Supported by an educational grant from AcuFocus, Inc

Included with this issue...

AcuFocus supplement EUROTIMES | OCTOBER 2016

2

EDITORIAL A WORD FROM LEIGH SPIELBERG MD

SHARING INFORMATION We are lucky to have an elaborate system in which sharing is so highly valued

T

he speed with which new knowledge in ophthalmology If total immersion in the world of retinal disease is what you’re is currently disseminated would make every physician looking for, the 16th EURETINA Congress in Copenhagen was since Hippocrates green with envy. With a little luck the place to be. Although I love reading a well-written article and a lot of perseverance, anyone with a tried and tested on a selected topic, hearing well-prepared presentations by discovery can let the whole world know about it within the authors of the year’s most widely-read papers is tough to months. More importantly, anyone looking for this beat. I particularly enjoyed several of the 'Decision-Making information can readily find it, whether online, at conferences or in Challenging Cases: What to do when…' sessions, which in traditional printed journals. offered insights that only the most “We live in interesting times. The whole world is a motivated mentors are willing For those looking for a global village. When we publish, the whole world is our to share. Teaching other doctors audience,” writes Manish Mahabir, the winner of this during a busy schedule is tricky one-stop shop for year’s John Henahan Prize for ophthalmology writing business, but many presenters updates on innovations and a co-author of a paper published in Nature. The attend conferences to do just that. in anterior segment proliferation of informative sources has made everyone Without researchers’ pathology, the XXXIV part of this audience, including readers of EuroTimes. Dr enthusiasm for sharing their most Congress of the ESCRS in Mahabir’s prize-winning essay is being published in this promising discoveries, a new month’s issue. technology such as OCT would Copenhagen last month was But some might argue that the explosion in the number never have spread as quickly as the way to go. There was of published journals has diluted the pool of knowledge it did. This spread was not only something for everyone... available, making it difficult to figure out what’s really geographic (with OCT currently important. This is indeed true for anyone who has not featured in clinics worldwide) and developed a system to sift through the inevitable noise. There are, subspecialistic (with corneal, cataract, glaucoma and retinal however, solutions. specialists relying on it daily). The spread was also across PubCrawler, an update alerting service for PubMed, is a great medical specialties, being used in cardiology and oncology, way to keep up with what’s being published on particular issues. among others. As this month’s cover story reports, OCT I receive regular updates on topics of my choice (macular holes, incorporated itself into the world of ophthalmology within a capsular tension rings, submacular hemorrhage) right into my decade of its invention and introduction. inbox. The motto of PubCrawler: “It goes to the library – you go Medicine is rare in its enthusiasm for sharing information. We to the pub.” are fortunate to have devised an elaborate system in which sharing For those looking for a one-stop shop for updates on innovations is highly valued and well rewarded. Let us continue to nurture it. in anterior segment pathology, the XXXIV Congress of the ESCRS in Copenhagen last month was the way to go. There was something for everyone, from young residents and fellows, to university department chairs and ophthalmology clinic directors.

Dr Leigh Spielberg is a vitreoretinal and An instructional course entitled 'Refractive and Cataract Surgery cataract surgeon at Ghent University Hospital Nightmares' cannot be ignored, and the whole refractive world in Belgium. He is also a member of the seems curious enough about SMILE to attend at least a session devoted to the new technique.

EuroTimes International Editorial Board

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Soosan Jacob (India), Vikentia Katsanevaki (Greece), 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), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | OCTOBER 2016

Introducing Malyugin Ring 2.0 Nothing’s Changed... Except For Everything Less Compression Force

New Smaller Gauge Material

Easier Pupil Margin Placement

Increased Scroll Gap

New Smaller Cannula

Smaller Cannula means room to spare in incisions larger than 2.0 mm

When contemplating what the next version of the Malyugin Ring should provide surgeons and their patients, we established three goals: 1. Provide the same or better safety as surgeons have experienced and has made the Malyugin Ring “classic” the standard of care for pupil management.

2. Make it easier to place and remove from the pupil margin.

3. Allow for entry in 2.0mm incisions and more room in wounds larger than that.

After several years of work, we are proud to introduce the Malyugin Ring 2.0. The second generation of the Malyugin Ring that also can be used in 2.0mm incisions.

Mayugin Ring 2.0 requires no surgical technique changes for you, and we believe that you will find it easier to use, that you will appreciate the extra room it affords, and be glad to know that it has softer compression characteristics (in fact Malyugin Ring 2.0 exerts less than half as much pressure on the iris than the “classic” Malyugin Ring).

Malyugin Ring 2.0 Only from MST

Malyugin Ring 2.0 MST (MicroSurgical Technology), 8415 154th Avenue NE, Redmond, Washington 98052 425.861.4002 • 1.888.279.3323 • email: info@microsurgical.com • www.mst-surgical.com

4

COVER STORY: OPHTHALMIC IMAGING

PAST, PRESENT AND FUTURE OCT has become an essential tool in the diagnosis and management of ophthalmic disease, with exciting new applications on the way. Sean Henahan reports ince its development in the early 1990s by David Huang MD, PhD, James Fujimoto PhD, Carmen Puliafito MD and colleagues, optical coherence tomography (OCT) has evolved rapidly, with ongoing improvements in scanning speed, sensitivity, resolution and depth.

OCT relies on low-coherence interferometry and tomography to generate high-resolution images of ocular structures.

It was Dr Huang who coined the term OCT and first reported the method for converting the signal intensities recorded at adjacent A-scan positions into grey or false colour values, combining the signals to form tomographic images of the eye.

The intervening years have seen systematic evolution from time domain, spectral domain and swept source domain OCT, with each system bringing EUROTIMES | OCTOBER 2016

greater speed, depth and resolution.

Oliver Findl MD, Chief, Department of Ophthalmology, Hanusch Hospital, Vienna, Austria, was among the very first to be involved with clinical investigations of ophthalmic applications of OCT. He has been involved in virtually every aspect of OCT research and development during the past 25 years.

“I got involved with OCT early on, in my first year in residence in Vienna. It was still called partial coherence interferometry.

At the Institute of Medical Physics, the inventor of optical biometry produced a prototype and I was involved in some of the first clinical trials. It was huge apparatus, an optical bench one metre by one metre. We did our first measurements in eyes and published this in the 1990s.

This eventually led to phase III clinical trials, and six years later the IOLMaster (Zeiss) arrived on the market,” said Dr Findl in an interview with EuroTimes.

OPTICAL BIOMETRY This early work led to what is now called optical biometry. The OCT prototype proved to be a big step forward in measuring axial length, proving more accurate and reproducible than ultrasound biometry, the standard at the time. OCT proved easier to perform and much more comfortable for patients than the ultrasound technique.

“The IOLMaster really transformed biometry into what it is today. I bought the first IOLMaster in London, if not the whole of the UK. It was so accurate and had the convenience of non-contact. The whole thing transformed measurement of axial length, as the ultrasonic probe tended to indent the cornea, and you got artefact changes with them. The accuracy of optical biometry has continued to improve and is now extremely good,” said David J Spalton FRCS, FRCP, FRCOphth, President of the ESCRS.

COVER STORY: OPHTHALMIC IMAGING

Dr Hill reckons that 90 per cent of patients will be within 0.5D of emmetropia, which is pretty outstanding David J Spalton FRCS, FRCP, FRCOphth

measurements. If you make a 1.0mm error on the A-scan it works out to about 2.5D of IOL power error. If you make a dioptre of error in the K value it is about 0.9D in IOL power. New systems such as the Zeiss IOLMaster 700 and the Lenstar (HaagStreit) provide more accurate biometry and better prediction of K values,” explained Prof Spalton.

IMPROVING ELP PREDICTION However, the main problem cataract surgery has yet to solve is accurate prediction of the effective lens position (ELP). In spite of improvements in optical biometry, real-world figures from ‘big data’ sources such as the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) suggest that getting to within +/-0.5 dioptres of predicted refraction is problematic, with seven or eight per cent of patients still outside of +/-1.0 dioptres.

“This is real-world data. Some surgeons may have better numbers. It may be that they don’t have patients with very long or short eyes. But at the end of the day, if we look at big data, that is the kind of number we see. We are not where we want to be, especially if we are talking about premium lenses. You want to be close to emmetropia, that is when these lenses start working properly,” Dr Findl told EuroTimes.

The prediction of ELP is also limited by the biological wound healing process that occurs once the lens is removed. This process varies with the individual patient, with the amount of fibrosis having an effect on the healing process as the capsule shrinks around the implant.

“The problem with swept source biometry, even though it is so good, is that you don’t visualise the equatorial part of the lens because you can’t see through

the iris. The only way you do that is with ultrasound B-scan, or MRI, neither of which is practical. We don’t have a technology to show us the real position of the lens, and even if we did, you are still dealing with the biological healing process,” notes Prof Spalton.

However, new IOL calculation formula may help cataract surgeons reach the goal of getting patients to within at least 0.5 dioptre of emmetropia. The radial basic function formula, developed by US ophthalmologist Warren E Hill MD, does not depend on vergence formulas or ELP, but is based on artificial intelligence and pattern recognition.

“Dr Hill reckons that 90 per cent of patients will be within 0.5D of emmetropia, which is pretty outstanding. This is going to take out some of that variability that we see due to ELP,” Prof Spalton predicted.

PREMIUM IOLS A macula OCT is an essential part of the preoperative assessment of any patient who wants a multifocal IOL, says Prof Spalton.

Missing subtle macula pathology such as small holes or an epiretinal membranes can lead to a poor visual outcome and a dissatisfied patient. To be forewarned is to be forearmed.

Anterior segment OCT has also become an indispensable tool for penetrating and lamellar keratoplasty. It provides useful information during the surgery planning stage and is used postoperatively to evaluate graft and host interaction, and for detecting corneal problems. It has become key in lamellar procedures, helping in a variety of ways such as demonstrating Descemet’s membrane folds and detachment after deep anterior lamellar keratoplasty (DALK), and graft position and thickness after Descemet’s stripping automated endothelial keratoplasty

Courtesy of Oliver Findl MD

Optical biometry also allowed accurate measurement of anterior chamber depth, corneal pachymetry, as well as of the lens and retina. Ultimately, when combined with better intraocular lens (IOL) power formulas, this provided better IOL power prediction and refractive outcomes with cataract surgery.

“Early on, we were just measuring axial length, and then we started measuring anterior depth and IOL position. We did a lot of trials looking at IOL position with different lens models, how they change their axial position in the first days and weeks after surgery. This was of great interest to lens manufacturers, trying to find the ideal materials and haptic designs,” noted Dr Findl.

The early OCT research showed for the first time how the IOL looked in the eye after surgery. The technique provided clear images showing how the posterior and anterior capsule enclosed the IOL within the first one to two weeks after surgery.

It also showed differences in this process with different lens designs, haptic designs and materials.

Early research with intraoperative OCT revealed essential information about what happens in the eye after phacoemulsification and cataract removal, but before IOL implantation. “Once you’ve removed the cataract, done the phaco, and done the irrigation and aspiration, you have the empty bag. We learned that measuring the empty bag position actually gives you better prediction of the IOL position after surgery, and therefore better refractive outcomes,” Dr Findl explained.

OCT coupled with IOL power calculation formulas improved, and continue to improve the prediction of refractive outcomes after cataract surgery.

Newer systems have added significant improvements in corneal measurement, which, combined with already accurate axial length measurements, have further improved the ability to predict outcomes.

“As far as swept source biometry is concerned, in terms of axial length it’s not a lot different from doing A-scans with partial coherence, but the advantage of swept source is that it penetrates denser cataracts and improves corneal

5

Measuring lens capsule position after removing lens matter to better predict post-op axial IOL position

EUROTIMES | OCTOBER 2016

COVER STORY: OPHTHALMIC IMAGING

Courtesy of Oliver Findl MD

6

Lens fragments touching the endothelium during phacoemulsification

(DSAEK). Anterior segment OCT has also proven essential for Descemet’s membrane endothelial keratoplasty (DMEK) surgery.

“I believe that OCT is absolutely essential in DMEK. Intraoperatively we can judge the proper positioning of the graft injected into the anterior chamber by observing the orientation of the scrolled edges of the membrane. This may be very challenging, especially for the beginner surgeon or sometimes even for the experienced one, when the corneal stroma is cloudy.

"Intraoperatively, OCT also allows us to check whether or not there are any irregularities of the posterior corneal contour that may lead to Descemet’s membrane detachment postoperatively. I can also say that, without having OCT in your diagnostic armamentarium, one would not be able to perform and manage DMEK patients pre- and postoperatively according to the current standards of care,” Boris Malyugin MD, Chief of the Department of Cataract and Implant Surgery, Fyodorov Eye Microsurgery Complex, Moscow, Russia, told EuroTimes.

INTRAOPERATIVE OCT In the last couple of years a number of microscope-mounted intraoperative systems have become available. Two large prospective clinical studies, the PIONEER and DISCOVER studies, provided considerable support for the use of these systems in a variety of ophthalmic surgical settings. However, the cost of these systems continues to be an issue.

“I could imagine in a few years’ time most microscopes will have integrated OCT. It’s a nice thing, you don’t even have to look up. You have an overlay that you see in the eyepiece. It doesn’t slow you down during surgery, and helps you stay very concentrated and focused. These are the tools that will definitely move us forward into the future,” Dr Findl commented.

While initially used primarily for retinal

surgery, intraoperative systems are now finding many clinical applications in cataract, refractive and corneal surgery.

For example, OCT has also proven to be an indispensable element in femtosecond laser-assisted cataract surgery (FLACS).

While FLACS surgical systems show a lot of variety in terms of hardware and software, most include some form of high-resolution OCT image-guidance system. The integrated systems provide detailed visualisation of the cornea, iris, iridocorneal angle, and lens, including both the anterior and posterior capsules.

Intraoperative systems are also potentially very useful research tools. For example, one recent study (Amir-Asgari et al, JCRS, Volume 42, Issue 7, 10291036) used intraoperative OCT to look at the eye during the phacoemulsification stage, to study how many lens fragments actually hit the endothelium. This helped to explain why the endothelium gets damaged during surgery. The study showed a correlation between the number of fragments hitting the endothelium and endothelial cell loss, one day after surgery. The researchers developed a fragment score that predicts the operative endothelial cell loss.

Continuing developments in the technology can also open new avenues of clinical benefit. For example, the new IOLMaster 700 uses swept source OCT biometry, providing excellent images of the cornea and lens. But it also provides a small image of the central fovea. This is already showing promise as a way to screen cataract patients for unsuspected macular disease.

TEACHING RESIDENTS Microscope-integrated OCT also shows promise as a surgical training aid, another recent study suggests (B Todorich et al, Investigative Ophthalmology & Visual Science July 2016, Vol.57, OCT146-153). In the randomised study, 14 ophthalmology

It doesn’t slow you down during surgery, and helps you stay very concentrated and focused Oliver Findl MD EUROTIMES | OCTOBER 2016

residents performed anterior segment surgical manoeuvres on porcine eyes with or without the aid of swept source intraoperative OCT. Residents using the integrated OCT system performed better when doing corneal suture passes at 50 per cent and 90 per cent depth and corneal laceration repair, when compared with those not using the system. Moreover, the residents who had used the system showed superior skills subsequently, even when not using the system.

“The current study demonstrates that microscope-integrated feedback can not only guide a surgeon's intraoperative decision-making, but also has the potential to improve surgical performance, enhance anatomic outcomes, and be used as a training tool that is directly translatable to the operating room for use in live human surgery. As intraoperative OCT technology continues to evolve, so will our understanding of its potential, which will allow for its increasing creative applications in many aspects of ophthalmic surgery,” the researchers concluded.

OCT AND OCULAR SURFACE DISEASE New highly sensitive OCT platforms have also extended research to the very front of the eye, providing hitherto unavailable objective data on dry eye disease. Leopold Schmetterer MD and colleagues at the Medical University of Vienna, Austria, report developing a method to image the human cornea with a resolution of approximately 1.3 microns (Schmetterer et al, IOVS, Vol 56, 4482.). They have used the technique to visualise and quantify the pre-corneal tear film, and to observe the effect of various eye drop lubricants on tear film thickness.

“It is amazing. They are looking at the tear film thickness with OCT resolution of 1-2 microns. That will be very interesting in the management of dry eye problems, where obtaining objective measurements has always been challenging. We’re going to get a lot of good objective information from the very front of the eye,” Prof Spalton observed.

David J Spalton: profspalton@gmail.com Oliver Findl: oliver@findl.at Boris Malyugin: boris.malyugin@gmail.com

LISBON2017 7–11 OCTOBER

XXXV CONGRESS of the ESCRS FIL – International Fair of Lisbon, Portugal

Instructional Course Submission Deadline: 31 October 2016

www.escrs.org

8

SPECIAL FOCUS: OPHTHALMIC IMAGING

RETINAL IMAGING In an article sponsored by ISOPT Clinical, Gisèle Soubrane MD, PhD, FEBO says analysis of images by experienced ophthalmologists is crucial

N

ew imaging can have two meanings – either new information from the recently available imaging systems, or imaging systems resulting from new concepts. When fluorescein angiography became popular in the late 1960s, one of the indirect advantages was that ophthalmologists started to collect more documents which markedly improved the quality of the follow-up and thus the knowledge of natural history and treatment results.

We now have numerous techniques at our disposal: fluorescein angiography, indocyanine green (ICG) angiography, optical coherence tomography (OCT) with its various modalities, autofluorescence imaging, ultrasonography… And the latest toy that retinologists have received is OCT angiography (OCTA).

Although not yet in current clinical use, this new tool in our diagnostic armamentarium has already provided us with new information on the clinical features, as well as on the pathogenesis of diseases. For example, OCTA has confirmed that retinal angiomatous proliferations (RAPs) are located in the outer retinal layers. OCTA has unequivocally demonstrated their origin from the deep retinal capillary plexus.

Of course, multimodal imaging had already suggested a retinal origin for RAP, but OCTA demonstrated it. In addition, it also confirmed the two different ways of progression of the disease, towards the retinal pigment epithelium (RPE) or towards the choroid. Finally, it added clues to evaluate the results of anti-vascular endothelial growth factor treatment in confrontation with OCT B-scans. However, the preliminary results of these clinical studies must be confirmed in larger series.

It has become mandatory to compare the results of the various imaging techniques available, at least initially to come to a proper diagnosis. In case of doubt during follow-up, classic imaging, such as fluorescein and ICG angiography, remains essential. The inclusion of OCTA into modern multimodal imaging systems seems reasonable.

However, one has to take into account its limitations. Although OCTA is based on motion of blood flow, it does not provide information on haemodynamic characteristics or on vascular permeability changes.

Its major advantage is to specify the morphology and in-depth location and extent of vascular lesions, without the need of dye injections.

My feeling is that OCTA will be largely used for posttreatment follow-up and will complete the information obtained with OCT B-scans.

This new imaging method is only at its beginning, and no doubt the meticulous analysis of all slabs will open further insight in the pathogenesis of some wellknown diseases.

Already now, better use can be made of combining Gisèle Soubrane MD, PhD, FEBO

It has become mandatory to compare the results of the various imaging techniques available, at least initially to come to a proper diagnosis

EUROTIMES | OCTOBER 2016

different imaging modalities. A good example is central serous chorioretinopathy (CSC). Enhanced depth imaging OCT (EDIOCT) permits a more precise study of the choroid. It has been shown that in CSC the choroid is thickened. ICG angiography has demonstrated sectorial choroidal permeability changes.

Combining the results of EDI-OCT and ICG angiography has permitted a better understanding of the underlying phenomenon in CSC, but also an improvement in monitoring of treatment.

When one suspects the presence of active new vessels in CSC, with OCTA it is possible to extract the picture of a network from the background, thus rectifying the diagnosis and guiding to an adapted treatment.

PERSONAL DREAM Ophthalmologists have long dreamed of a handy and easy clinical tool permitting them to visualise the morphology of a lesion together with its functional repercussion. This could allow a cellular identification of the initial dysfunction and possibly lead to preclinical diagnosis.

My additional personal dream is to be able to visualise and to assess the function of cells in the human eye, in health and disease, especially of the functional skeleton of the retina, the Müller cells. This is not utopic. These dreams will certainly be fulfilled relatively rapidly.

Techniques such as autofluorescence imaging have permitted an insight in the biochemical mechanisms in a number of diseases. Stargardt disease is an excellent example. The dark choroid on fluorescein angiography was described in patients with Stargardt disease. Histologically, the accumulation of lipofuscin was demonstrated in RPE cells of Stargardt patients.

Autofluorescence permits a rapid and noninvasive study of the distribution of lipofuscin, improving an early diagnosis and allowing a better follow-up. The amount of information contained within the various imaging modalities is staggering. However, only a relatively small portion is extracted. The impressive improvements in information technology should permit a more thorough analysis of the various data and also a better correlation of the results from the different techniques. This will permit a better understanding of the physiopathology of diseases, of their natural history and also of their response to treatment.

To conclude, without doubt images are essential, but even more important is the analysis of these images by experienced ophthalmologists. Images are a means to allow progress of our understanding of pathogenesis of retinal diseases and to help the progress of our knowledge.

Gisèle Soubrane was Professor of Ophthalmology and Chair of the Department of Créteil, Paris. Currently she is Professor of Ophthalmology at Hotel Dieu,University Paris V. She has a passion for imaging and retinal neovascularisation, both clinically and in basic research Gisèle Soubrane: soubraneg@gmail.com

13

December 1-3, 2016, Rome, Italy

SPECIAL FOCUS: OPHTHALMIC IMAGING

IRREGULAR ASTIGMATISM Stromal topography-guided ablation may reduce higher order aberrations. Howard Larkin reports

C

Courtesy of Aleksandar Stojanovic MD

ustom corneal ablation guided by stromal topography may correct irregular astigmatism better than ablation guided by anterior corneal topography, Aleksandar Stojanovic MD told the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. The result may be better corrected visual acuity outcomes for patients with keratoconus, corneal refractive surgery complications or corneal scarring from trauma or keratitis.

Corneal optic asymmetries, such as coma and trefoil, are readily diagnosed by anterior corneal topography, noted Dr Stojanovic, of the University Hospital of North Norway, and SynsLaser in Tromsø, Norway. However, these higher order aberrations (HOAs) measured at the corneal surface usually are less pronounced than the stromal defects underlying them.

step surgery, though differential ablation rates may still reduce the accuracy of this approach as well, especially if the laser used is not primarily made for such a purpose.

One solution to the problem is offered by a new Scheimpflug topography-tomography system that generates a stromal topographic map by subtracting its epithelial map from its corneal surface map. Programming this data into the laser ablation planning software will generate stromal topographyguided custom ablation, which can be accurately performed after epithelial removal, Dr Stojanovic said.

Accurate and mutually registered data for the corneal topography and the epithelial thickness map can be obtained only by using a single instrument for both measurements performed at the same time. In that case any laser can be programmed for separate ablations of the epithelium and the stroma, circumventing the issue of the different ablation rates.

Because irregular astigmatism typically occurs in already compromised corneas, the trade-off between correcting corneal optics and preserving corneal integrity must be carefully balanced, Dr Stojanovic said. He treats HOAs first because they cannot be corrected with spectacles or soft contact lenses. Lower order aberrations are addressed only if enough corneal tissue is available. He targets a reduced optical zone if necessary.

Aleksandar Stojanovic: aleks@online.no

Section of superior cornea: A (red line) - Corneal epithelial surface; B (green line) - Stromal surface; C (blue line) - Stromal surface after PTK (replicating epithelial surface morphology); Yellow area - Epithelium; Striped area - Stroma subjected to remodelling by the epithelium; Area between the red and blue line - Tissue ablated by the PTK; Blue area - Stroma

“If the anterior corneal surface is irregular, the stromal surface is even more irregular, since the epithelium is always attempting to smooth the stromal surface up to its compensatory capability,” Dr Stojanovic explained.

Therefore, using ablation profiles based on surface topography to guide a custom ablation after removing the epithelium will not remove stromal tissue correctly to regularise its shape. The magnitude and axis of astigmatism corrections also are incorrect due to compensatory epithelial remodelling.

One solution is to apply phototherapeutic keratectomy (PTK) to the greatest epithelial depth, as measured by ultrasound or optical coherence tomography (OCT), to replicate the anterior surface morphology on to the stromal surface (see figure). Hence, this PTK will include the epithelium as well as the remodelled stroma (the yellow and the striped area on the figure). Applying custom ablation generated upon the anterior topography map will be viable only if such PTK is performed first, Dr Stojanovic said.

Theoretically, the PTK ablates the surface topography into the remaining stroma where the custom ablation corrects it.

But in practice, surface topography is not always accurately replicated on the stroma because the epithelium and stroma ablate at different rates, which introduces smaller or larger errors depending on the laser used. More elegantly, PTK can be integrated with topography-guided custom ablation for a oneEUROTIMES | OCTOBER 2016

9

SPECIAL FOCUS: OPHTHALMIC IMAGING

NEW VISTA FOR OCTA Algorithms differentiate and depict degrees of flow impairment.

Cheryl Guttman Krader reports

V

ariable interscan time analysis (VISTA) is a step towards quantitative optical coherence tomography angiography (OCTA) that allows determination of relative blood flow speeds. As a next innovation, the VISTA developers have created ‘VISTA visualisation’, a method for mapping the VISTA data into a colour-coded format to make image interpretation intuitive and easy for clinicians.

Speaking on behalf of his colleagues, Stefan Ploner BSc presented the techniques at the 2016 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Seattle, USA. “Although OCTA allows visualisation of ocular blood flow, it provides little information about blood flow speed, and that is an important limitation considering that progression of many retinal diseases is thought to involve a gradation of flow impairment and not just vascular loss,” said Mr Ploner, who is affiliated both with the Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology (MIT), Cambridge, USA, and the Friedrich-Alexander-University Erlangen-Nürnberg, Germany.

“The core VISTA algorithm provides the theoretical framework for using OCTA to

resolve different blood flow speeds, and we believe it is a promising tool for studying and eventually aiding in the treatment of ocular disease. VISTA visualisation bridges the gap between the engineering lab and the clinic by transforming the VISTA output into a readily understandable form.

Our long-term technical goal is to extend the algorithm to achieve truly quantitative OCTA,” he said.

Currently, VISTA is limited to measuring a marker of relative blood flow speed, and does not provide measurement of absolute blood flow speed. VISTA resolves blood flow speeds by varying the interscan time between repeated B-scans.

The VISTA visualisation algorithm transforms the VISTA data to a single value that describes relative blood flow speed and maps the value into an image in which the colour of a vessel indicates the relative blood flow speed.

Courtesy of the OCT Research Group, MIT-NEEC

10

VISTA visualisation in a 30-year-old proliferative diabetic retinopathy patient taken over a 3mm × 3mm field of view (red indicates faster blood flow speeds; blue indicates slower speeds).

Notice how the lesion is associated with slower blood flow speeds

Although OCTA allows visualisation of ocular blood flow, it provides little information about blood flow speed...

diabetic retinopathy, exudative age-related macular degeneration, and geographic atrophy (GA).

“VISTA was first applied for imaging the choriocapillaris in GA, where it was leveraged to look at subtle blood flow impairment occurring at the GA borders (Choi W et al, Ophthalmology 2015;122(12):2532-2544). The next step is to run larger cohort studies of patients with GA and other diseases to investigate what insights can be uncovered with VISTA,” he told EuroTimes.

The development of VISTA and VISTA visualisation represents a collaboration between teams of clinicians, optical engineers and computer scientists at MIT and the New England Eye Centre, Boston, USA; Bascom Palmer Eye Institute, Miami, USA; and the Friedrich-AlexanderUniversity Erlangen-Nürnberg, Germany.

Stefan Ploner BSc

Stefan Ploner: Stefan.ploner@fau.de

COLLABORATION Mr Ploner illustrated VISTA visualisation with several representative flow maps.

Showing the image from an eye with non-proliferative diabetic retinopathy, he highlighted the presence of slow blood flow through capillary loops. “This observation provides clinical validation that the algorithm is doing what we expect,” he said.

Mr Ploner also presented VISTA flow maps from eyes with proliferative

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SPECIAL FOCUS: OPHTHALMIC IMAGING

MOTION-FREE OCT METHOD Novel scanning protocol and algorithm used to generate images.

Cheryl Guttman Krader reports

T

he evolution of optical coherence tomography (OCT) has brought technology with faster scanning speeds that allow more data to be collected faster with a reduction in artefact. However, the scanning process of 3D OCT imaging still takes several seconds, and eye motion artefacts still occur.

At the 2016 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Seattle, USA, researchers from the Computational Optics Group, University of Tsukuba, Japan, reported on a technique they have developed for motionfree 3D OCT. Their method uses a Lissajous scanning protocol and a custom motion correction algorithm.

“Eye motion artefacts cause two potential problems. First, they can result in missing data that may contain important structures and features. In addition, the motion artefacts can corrupt shape information along the slow scanning direction. Our method provides the true shape in both the horizontal and vertical directions,” said Yiwei Chen PhD, who presented the technique.

Yiwei Chen To assess its performance, imaging of the optic nerve head and macula was performed in five normal dominant eyes of five subjects. Both areas were scanned twice. Data were excluded if there was severe vignetting or blinking.

Comparisons of en-face projection images, acquired before and after lateral motion correction, showed the technique had a 90 per cent success rate as only two of the 20 cases exhibited severe artefacts. In the remaining images, continuity of vessels and structure clarity were obvious after applying lateral motion correction.

GROUND TRUTH Further demonstrating the performance of the technique, Dr Chen noted perfect co-registration between lateral motioncorrected images and those obtained using scanning laser ophthalmoscopy (SLO). “Because the SLO measurement is so quick, we can ignore the potential for any motion artefact and treat it as a ground truth,” he said.

Repeatability of the lateral motion correction was shown through comparison of two motion-corrected en-face projection images from volume OCT obtained in a single eye.

“Because each volume measurement takes 5.2 seconds, we would expect eye motion to be different during the two acquisitions. Considering the repeatability of the lateral motion correction, we believe this method is useful for total motion-free OCT angiography,” Dr Chen said.

Performance correcting for axial motion was demonstrated by comparing images obtained in the same eye with and without motion correction, serial images obtained with motion correction, and using a horizontal B-scan image taken with a fast raster scan protocol (24 milliseconds) as a “ground truth” reference.

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CATARACT & REFRACTIVE

GENOME ENGINEERING CRISPR/Cas system holds promise for carrying understanding and treatment of genetic diseases into a new era. Cheryl Guttman Krader reports

D

escribed as the “biggest biotech discovery of the century”, clustered regularly interspaced short palindromic repeats (CRISPR) has the potential to revolutionise the treatment of genetic disease. The eye is a prime target for the early clinical use of this genome engineering technology, according to reports at the 2016 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Seattle, USA. Genome editing using bacterial CRISPR offers several advantages over previous techniques, including lower cost, higher efficiency, better specificity and greater flexibility, with the potential for multiplex genome editing. Its flexibility and specificity makes CRISPR/Cas genome editing a good fit in today’s era where there is a focus on personalised medicine, noted Alex Hewitt MBBS, PhD, Head, Clinical Genetics, Centre for Eye Research Australia, Melbourne.

“Few other medical applications could be considered as personalised as specifically tailoring a gRNA to target an individual patient’s disease-causing variant,” he told EuroTimes.

Furthermore, unlike some other gene therapy approaches such as transient siRNA treatment, genome editing with CRISPR/Cas is considered to offer the possibility for a permanent treatment of genetic diseases, said Tara Moore PhD, Director of Biomedical Science Research Institute, Ulster University, Northern Ireland, and Director of R&D at Avellino Labs, Menlo Park, California, USA.

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Achievement

Based on characterisation of an individual’s genetic profile, the enzyme system is relatively easy to reprogramme to target a particular disease-causing mutation through development of a personalised gRNA expression vector. Depending on the disease, the goal may be to knock out, repair or replace the mutant allele.

Such in vivo genome editing may represent the ultimate dream for application of CRISPR/Cas technology, but it has other potential uses. CRISPR/Cas genome editing could be applied ex vivo for modification of autologous induced pluripotent stem cells (iPSCs) to develop cell replacement therapy for patients with a genetically defined disease, or the patient’s own corneal epithelial stem cells could be genetically corrected ex vivo and transplanted. Additionally, in vitro models are being developed that could facilitate studies of disease pathogenesis or pharmacological screening.

A growing number of reports show success is being achieved in all of the above applications. To cite just a few examples, Bassuk et al (Sci Rep. 2016;Jan 27;6:19969) reported using CRISPR/Cas to correct a pathogenic mutation in iPSCs derived from fibroblasts of a patient with retinitis pigmentosa. Work by Dr Hewitt and colleagues provided proof of principle for using CRISPR/Cas to achieve in vivo gene modification of retinal cells in adult transgenic mice, and electroretinography studies showed that the gene editing was achieved without any adverse effects on retinal function. (Invest Ophthalmol Vis Sci. 2016; 57:3470–3476) Others have used the CRISPR/Cas system for in vivo mutation repair in animal models of retinitis pigmentosa (Mol Ther. 2016 Jun 28; Mol Ther. 2016;24(3):556-563). With an interest in heritable corneal diseases, Dr Moore, and colleagues were the first to show in vivo gene editing of a heterozygous disease-causing missense mutation in a humanised mouse model of Meesmann epithelial corneal dystrophy (MECD). (Gene Ther. 2016;23(1):108-112) Now they are working to increase the targeting efficiency of the gene-editing system, optimise its delivery, and characterise disease regression post-intervention. “This approach could work in approximately one-third of mutations known to cause corneal genetic disorders, of which Meesmann is just one, and for a number of the dominant negative retinal disorders,” she said.

THE ROAD AHEAD Progress leading to clinical implementation of CRISPR/Cas genome editing faces some technical obstacles, including the need for techniques that can improve targeting specificity and the efficiency of mutation correction. Further investigation of the safety of CRISPR/Cas gene editing is also required before it can move into the clinical arena. “Unwanted gene editing at sites distinct from the intended target remains a concern that needs to be allayed before regulatory bodies are likely to approve any CRISPR/Cas gene therapy trials,” said Dr Moore.

There are also ethical issues to address, and in that regard public opinion may influence whether gene therapy becomes a viable option. According to the findings of a global online survey conducted by Dr Hewitt and colleagues, however, there seems to be a favourable majority view about using CRISPR/Cas-based genome editing for curing life-threatening or debilitating diseases in patients of all ages. (Cell Stem Cell. 2016;18(5):569-572) “Nonetheless, it is clear that both somatic and germ line genome editing using CRISPR/Cas must not be rushed into ophthalmic care,” Dr Hewitt warned.

Alex Hewitt: hewitt.alex@gmail.com Tara Moore: t.moore@ulster.ac.uk

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CATARACT & REFRACTIVE

STABLE FIXATION Scleral fixation of aspheric plate-haptic lens produces good visual outcome.

Roibeard O’hEineachain reports

A

new small incision scleral fixation technique for eyes lacking capsular support can provide good results with implanting the Acriva UDM 611 (VSY Biotechnology) foldable plate-haptic intraocular lens (IOL), with reduced surgery time and complications, along with excellent centration and stability with good visual results, according to a study conducted by Hasanov Jamil V MD, Zarifa Aliyeva National Eye Centre, Baku, Azerbaijan.

“The use of plate-haptic design versus C-loop haptic design eliminates complications such as: suture slippage or entangling, IOL-donesis, tilting, decentration, and possibility minimising manipulation in the anterior chamber during IOL implantation,” Dr Jamil told EuroTimes in an interview.

In his study, Dr Jamil performed cataract surgery in four eyes of four patients with a mean age of 47.75 years (range 23-70) using 2.4mm incisions and a modified trans-scleral suturing, to implant the Acriva UDM 611 plate-haptic foldable IOL. He noted that, in addition to its ultra-definition aspheric optic, the lens has a unique haptic design which makes it particularly suitable for small incision trans-scleral fixation surgery.

At six months follow-up, best corrected visual acuity ranged from 20/100 to 20/25, compared to 20/800 to 20/40, preoperatively. In addition, the IOL achieved excellent centration and stability in all eyes. Rapid postoperative recovery and minimal induced astigmatism were observed. He noted that those findings have held up since the six-month assessment and that he has achieved similar results with a further 25 patients who underwent the surgery, he said.

When performing the procedure, Dr Jamil first creates two 3.0mm-wide corneoscleral pockets at 3 and 9 o’clock.

Then he threads a10/0 prolene suture through the eyelet of each haptic using

The needles are threaded into the loop of the suture and thus a hitch-cow knot is formed at the haptic of the Acriva UDM 611

Courtesy of Hasanov Jamil V MD

14

One month after surgery: the Acriva UDM 611 IOL excellently centred and stable

two needles each, and loads the needles and the lens into the cartridge, with the tips of the needle extending outside of the cartridge.

He then creates a 2.4mm clear corneal incision, through which he first places the needles with the suture, drawing them out though the corneoscleral pockets, where, after injecting the lens into the anterior chamber he securely sutures the haptics

in place and completes the procedure by closing the scleral pockets.

“This approach allows for a faster procedure than a traditional triangular flap procedure, because there is no conjunctival dissection or scleral cautery.

In addition, it is easier to perform dissection and induces less astigmatism.

In addition, the healing period after surgery is very rapid,” Dr Jamil said.

Hasanov Jamil V: jgasanov@yahoo.com

This approach allows for a faster procedure than a traditional triangular flap procedure...

Hasanov Jamil V MD EUROTIMES | OCTOBER 2016

All stages of the operation can be viewed at: https://eyetube.net/video/idugi https://www.youtube.com/ watch?v=KUX8G0JriAE

CATARACT & REFRACTIVE

HELPING TO SLEEP EASY Cataract surgery not only improves vision and quality of life, but also sleep. Priscilla Lynch reports

P

oor sleep is common in cataract patients.

While surgery helps, intraocular lens (IOL) choice does not appear to affect sleep quality improvement, according to Gokulan Ratnarajan MD, Oxford Eye Hospital, UK. Dr Ratnarajan explained the findings of a major UK study, which examined the impact of two different types of IOLs on sleep quality pre- and post-cataract surgery.

He said that, as cataracts make the crystalline lens cloudy, they can reduce the amount of light that reaches the retina, which may cause an abnormal circadian rhythm that affects sleep.

The dual centre prospective study compared patients at Oxford Eye Hospital who received an ultraviolet blocking IOL and patients at Prince Charles Eye Unit, UK, who received a blue-filtering IOL, using the Pittsburgh Sleep Quality Index (PSQI) at one month preoperatively, one month postoperatively, and 12 months postoperatively.

“With our sample of over 1,000 patients the results showed that half our patients undergoing cataract surgery were poor sleepers,” Dr Ratnarajan said.

PSQI IMPROVEMENT Postoperatively, the PSQI improvement at one month was 0.40 in the study patients and this reached statistical significance, he reported. However, at 12 months, while there was still an improvement in sleep compared to preoperative levels (0.30), it did not reach statistical significance.

The primary endpoint was the difference, if any, between the lenses with regards to sleep quality. In fact, the sleep improvement trend was mirrored in both patient groups. So although there was a statistically significant improvement at one month and improvement at 12 months, it was Gokulan Ratnarajan not statistically significant, he reported.

Other key findings included that sleep quality and sleep latency, i.e. the time it takes to fall asleep, were the greatest improvement noted in the patients, added Dr Ratnarajan.

The study also found that patients with poor visual acuity were 1.62 times as likely to have poor sleep. Female patients (1.32 times versus males) and elderly patients were also more likely to be poorer sleepers.

“So in summary, poor sleep is common in our patients undergoing cataract surgery and this is worth considering.

Subjective quality of sleep postoperatively is independent of IOL choice, and both groups had a statistically significant improvement at one month, but this was not maintained at 12 months," said Dr Ratnarajan.

Overall, the study showed that cataract surgery not only improves patients’ vision and quality of life, but also their sleep, he reiterated.

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Gokulan Ratnarajan: g.ratnarajan@gmail.com EUROTIMES | OCTOBER 2016

15

CATARACT & REFRACTIVE

PRESBYOPIA TREATMENT Hydrogel implant well tolerated in French study.

Dermot McGrath reports

T

he Raindrop® hydrogel corneal inlay (ReVision Optics), which has recently received FDA approval, appears to offer a safe and effective treatment for presbyopia, although further studies are needed on the implant’s biocompatibility and its possible impact on the corneal epithelium over the long-term, according to Béatrice Cochener MD, PhD, Brest University Hospital, France.

“This hydrogel inlay works by changing the anterior curvature of the cornea and is a potentially interesting option for suitable presbyopic patients. It provides very good visual outcomes and works particularly well in emmetropic to low hyeperopic patients, with the added advantage of being reversible in the event of any problems. Moreover, the option of concurrent LASIK offers the ability to treat combined ametropia with the placement on the inlay in the nondominant eye,” Dr Cochener told the French Implant and Refractive Surgery Association (SAFIR) annual meeting in Paris.

AVOID HAZE The Raindrop corneal inlay is a transparent, permeable, positive meniscus-shaped hydrogel implant which is placed under a flap created by femtosecond laser at a depth of 35 per cent of the corneal thickness, as the recommended threshold to avoid haze.

Comprised of approximately 80 per cent water with a refractive index very similar to the cornea, the inlay produces a variation in focal power across the pupil by microscopically altering the surface shape of the cornea.

“The inlay works by gently remodelling the epithelium anteriorly to give a prolate shape to the cornea, with near vision generated by the central zone which has the steepest curvature. The curvature diminishes progressively towards the periphery, creating zones for intermediate and distance vision,” she said.

Courtesy of Béatrice Cochener MD, PhD

16

The Raindrop inlay at four years

The goal of the retrospective study of 11 patients carried out at Brest University Hospital, France, was to evaluate the evolution of the corneal epithelium after implantation and correlate it with visual stability over the follow-up period of 48 months.

Patients had an average age of 54 years and were implanted with the Raindrop inlay in the non-dominant eye. The visual results at one month showed that moderate hyperopes were most likely to benefit most from the procedure.

“This is not surprising as the mechanism of action of the implant is to generate a slight myopisation of the eye.

The intermediate vision is rarely as good as the near vision, with around 30 per cent of patients needing to wear some correction for computer use and other intermediate tasks,” said Dr Cochener.

Both the optical coherence tomography and aberrometry evaluations confirmed the stability of the implant over the follow-up period, with no evidence of

This hydrogel inlay works by changing the anterior curvature of the cornea and is a potentially interesting option for suitable presbyopic patients Béatrice Cochener MD, PhD EUROTIMES | OCTOBER 2016

The remodelling seems to be independent of preoperative and intraoperative factors adverse corneal thinning and/or oedema in the study group.

“The remodelling seems to be independent of preoperative and intraoperative factors. However, specific care is required for ocular surface management, with prevention of dry eye to maintain visual performance.

“The anterior stromal above the inlay takes the shape of the inlay when the epithelium thins slightly and increases the profocal zone. Obviously this is a very small group of patients so we still need more prospective studies with longer follow-up to really determine the stability of this remodelling,” she concluded.

Béatrice Cochener: beatrice.cochener@ophtalmologie-chu29.fr

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CATARACT & REFRACTIVE

SMILE RETREATMENT Early results with sub-cap-lenticule-extraction show promise.

A

new technique for performing retreatments in small incision lenticule extraction (SMILE) cases appears to be both safe and efficacious in initial clinical studies, according to David Donate MD. “While we clearly need a lot more patients and longer follow-up, early results with this new approach indicate that enhancements after primary SMILE procedures to eliminate residual refractive myopic error are feasible,” Dr Donate told EuroTimes.

The new approach to SMILE enhancements is called “sub-cap-lenticuleextraction” (sub-cap-LE), explained Dr Donate, who is in private practice in Lyon, France. “The aim is to leave the cap of the primary SMILE procedure untouched in order to conserve the benefits associated with SMILE. No new superior lenticule is cut to avoid the risk of a multiple dissection plane. The interface of the primary SMILE procedure then becomes the superior plane of the new lenticule, and the laser is used to create only the inferior plane and sidecut of the new lenticule. Once this has been achieved, the surgeon stops the ablation and the new lenticule is removed through the original corneal incision,” he said.

OPTIMAL SOLUTION? Dr Donate’s original report of sub-capLE included a single case presentation of a successful use of the technique in a 53-year-old woman who experienced blurred distance vision after bilateral SMILE for correction of moderate myopia.

The same technique has now been used in a series of 12 eyes with similarly successful results, he said.

While the appeal of flapless refractive surgery has encouraged many surgeons to try SMILE in recent years, one of the frequently cited drawbacks of the procedure was the lack of an efficient and safe retreatment method.

Although photorefractive keratectomy (PRK) offers a viable means of correcting residual refraction after SMILE, issues such as pain, slow recovery and postoperative haze make it a less than optimal solution.

Carl Zeiss Meditec has also sought to address the issue by developing an option within the VisuMax platform to create a corneal flap after previous refractive correction with SMILE. This approach uses the laser to create four circle patterns that enable the original SMILE incision pocket to be converted into a LASIK-like flap that EUROTIMES | OCTOBER 2016

Dermot McGrath reports

Courtesy of Dan Z Reinstein MD, FRCSC, FRCOphth, FEBO

18

OCT B-scan, slit-lamp photograph, refractive outcome and Atlas topography after a LASIK procedure in a patient with previous myopic SMILE

can be easily lifted to allow for stromal ablation of the residual refractive error with an excimer laser.

Another safe and effective method of retreating after SMILE is to perform a thinflap LASIK procedure. This is the approach preferred by Dan Z Reinstein MD, FRCSC, FRCOphth, FEBO, who was one of the early adopters of SMILE in his London clinic.

“My protocol is to use a cap thickness of at least 135 microns for the primary SMILE procedure, something that we want to do anyway in order to take advantage of leaving the stronger anterior stroma and nerve plexus untouched. We know that the epithelium will have thickened centrally after a myopic correction to partially compensate for the tissue that has been removed, but we also know that the epithelium will not be thicker than about 80 microns. Therefore, we have a gap between 80 microns and 135 microns in which to make a flap,” Dr Reinstein told EuroTimes.

This leaves a more than sufficient safety margin to perform a thin-flap LASIK procedure, said Dr Reinstein.

“Given that the standard deviation of flap

thickness with the VisuMax is 4.4 microns, if we aim for a 100-micron flap, then the flap will be more than four standard deviations away from both the epithelium and the existing SMILE interface, even if the SMILE interface was more superficial than intended. In reality, we are even safer than this because we measure both the epithelial thickness and SMILE cap thickness by optical coherence tomography (OCT) and very high-frequency digital ultrasound, so we can plan the flap thickness to use based on direct measurements,” he said.

While the method works very well, Dr Reinstein said the new technique proposed

by Dr Donate is something that will definitely interest a lot of surgeons.

“If the results continue to be as promising as the initial case report by Dr Donate, then this may well become the standard method for retreatments after SMILE,” he said.

David Donate: david.donate@yahoo.fr Dan Z Reinstein: dzr@londonvisionclinic.com

CORNEA

ADVANCES WITH DMEK New instruments and techniques could boost reliability and reduce complications. Howard Larkin reports

N

ew techniques and instruments are needed to make Descemet’s membrane endothelial keratoplasty (DMEK) less challenging and more reliable, Donald TH Tan FRCS told the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. Dr Tan, a corneal surgery pioneer and current President of the Asia Cornea Society, believes these advances will occur, and DMEK and other lamellar surgeries will continue to supplant full-thickness penetrating keratoplasty (PK) for many indications. “Lamellar surgery is a revolution, but it is still in evolution,” he said.

DMEK is currently controversial. Because it adds no excess stroma, it generally delivers better visual outcomes – but at the cost of higher complications than Descemet’s stripping automated endothelial keratoplasty (DSAEK), Dr Tan said.

“What’s more important, the extra line of visual acuity or endothelial cell loss?”

Have you made your choice yet?

IMPROVED OUTCOMES However, DMEK is currently in its infancy as a procedure while DSAEK is mature, benefitting from years of refinement dramatically improving outcomes, Dr Tan noted. For example, the Singapore National Eye Centre, where he practises with a series of improved DSAEK techniques and instruments, reduced endothelial cell loss from 60 per cent in early cases to 15 per cent now.

The biggest problem in DMEK is handling donor Descemet’s tissue. Because it is so delicate and flimsy, it is hard to unscroll and place without damaging it using nothing more than an intraocular lens inserter BSS, and an air bubble, Dr Tan said.

The solution may be to utilise a small amount of stroma to improve handling characteristics, and use inserters designed for DSAEK such as the EndoGlide to maintain better control during surgery – the stroma acts as a carrier, but only the donor DM graft is pulled into the eye – a procedure he calls hybrid DMEK. In his first 14 hybrid DMEK cases, Dr Tan saw a mean endothelial cell loss of 28 per cent, with no graft failures or dislocations. That compares with 60 per cent cell loss with one graft failure and three re-bubblings in his first 15 straight DMEK cases, and 40 per cent cell loss with no graft loss or re-bubbling in his second 15 straight DMEK cases.

Dr Tan believes developments such as this hybrid approach could reduce DMEK complications, just as development dramatically reduced cell loss and graft rejection in DSAEK. As visual outcomes improve and complications recede, better procedures will drive greater acceptance of all types of lamellar surgery worldwide.

“DMEK epitomises the current distillation of our ability to replace the corneal endothelium, but the surgery needs to evolve with improvements in surgical techniques or instrumentation before the tipping point for widespread adoption can be achieved,” Dr Tan concluded.

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Donald TH Tan: donald.tan.t.h@singhealth.com.sg EUROTIMES | OCTOBER 2016

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20

RETINA

NUTRITION AND AMD Kreissig Lecture reviews evidence for supplements and healthy diet.

Howard Larkin reports

S

trong evidence suggests that targeted nutritional supplements can slow progression of age-related macular degeneration (AMD) in patients with bilateral intermediate disease and unilateral late disease, but have no effect for patients with earlier-stage AMD or a family history of the disease, according to a leading researcher for the American National Eye Institute (NEI).

Observational studies also suggest a diet rich in fish and leafy green vegetables may reduce the incidence of AMD and slow its progression. “I want to say – and this is very true – we are what we eat,” said Emily Y Chew MD in her recent Kreissig Lecture at the 16th EURETINA Congress in Copenhagen, Denmark.

And while research through the international AMD Gene Consortium has made great progress in identifying AMD genotypes, so far no actionable differences in response to existing supplements have been identified, Dr Chew said. This makes the cost and risk of routine genetic testing hard to justify, she added. “We are not ready to change the recommendation from the American Academy of Ophthalmology task force that suggests avoiding genetic testing of AMD patients, at least for now. We need further studies on this.”

SAFER SUPPLEMENT The initial supplement formula validated by the Age-Related Eye Disease Study (AREDS) contains vitamin C (500mg), vitamin E (400IU), beta-carotene (15mg), zinc oxide (80mg) and cupric oxide (2mg), and resulted in a 25 per cent reduction in risk of progression to late AMD in five years (Arch Ophthalmol. 2001;119(10):1417-36).

Notably, the full combination had beneficial effects that individual components did not.

However, it was not recommended for smokers since beta-carotene increases the risk of lung cancer.

Evidence for the more effective revised supplement combination comes from the massive Age-Related Eye Disease Study 2 (AREDS2), Dr Chew said.

AREDS2 found that replacing betacarotene with lutein/zeaxanthin (L/Z) (10mg/2mg) incrementally reduced the chances of AMD progression compared with the original AREDS formula, while eliminating the carcinogenic risk of betaEUROTIMES | OCTOBER 2016

Dr Emily Y Chew, who delivered the prestigious Kreissig Lecture at the 16th EURETINA Congress in Copenhagen, with Prof Ingrid Kreissig

carotene – which the study also found doubled the lung cancer incidence overall, with former smokers particularly susceptible.

AREDS2 also tested the effects of adding omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), but found no effect on AMD progression. A lower zinc oxide dose, 25mg, was also tested and no difference was found from the original 80mg. The resulting formula recommended based on AREDS2 is vitamin C (500mg), vitamin E (400IU), L/Z (10mg/2mg), zinc oxide (80mg) and cupric oxide (2mg). (JAMA. 2013;309(19):2005-15) The AREDS2 supplement formula is both safer and more effective than the original for slowing AMD progression in patients with intermediate disease, defined as large drusen in both eyes, or late disease, but not for patients with early disease or no disease, Dr Chew noted. The public health benefits from both formulae continue to accrue, she added.

DIETARY EVIDENCE Despite the negative results for omega-3 supplements, evidence suggests dietary intake of these nutrients is important, Dr Chew said. Observational studies strongly suggest that high dietary intake of total omega-3 long-chain

polyunsaturated fatty acids found in fish such as salmon and trout, as well as high dietary intake of L/Z found in spinach, kale and collard greens, is associated with reduced incidence of AMD and reduced progression from bilateral drusen to central geographic atrophy (GA) over six years. (Arch Opththalmol 2007;125:671-67) Higher total DHA and EPA also were associated with slower progression of bilateral drusen to central GA over 6.3 years. (Arch Ophthalmol 2008;126(9):1274-1279) Ancillary studies found AREDS2 supplements also had no discernible effect on cardiovascular disease (JAMA Intern Med. 2014 May;174(5):763-71), yet observational studies suggest dietary sources may be important here as well, Dr Chew said. “Essentially most trials of omega-3 LCPUFAs have been negative.

Patients are still encouraged to eat fish rather than take supplements for cardiovascular disease.”

Observational studies associate nutritional factors, especially fish consumption, with cognitive function, and cognitive function is associated with AMD, Dr Chew noted. These findings also emphasise the importance of a healthy diet in reducing AMD risk, she said.

Emily Y Chew: echew@nei.nih.gov

RETINA

EURETINA VIDEOS Surgical management of PVD in complex cases takes top prize at EURETINA Video Awards

D

r Hemanth Murthy’s prize-winning entry in this year’s EURETINA Video Competition Awards gave an elegant example of the surgical techniques that can be successfully employed to induce posterior vitreous detachment (PVD) in vitrectomy surgery.

Dr Murthy, of India, took first prize for his entry entitled ‘Facing the challenge – posterior vitreous detachment in difficult situations’.

Second prize went to Vishal Agrawal, India, for ‘The last hurdle – comprehensive management strategies of posterior hyaloid removal in pars plana vitrectomy (PPV) for paediatric retinal detachment’.

Third prize was awarded jointly to Jay Chhablani, India, for ‘Dye extrusion technique in a challenging case of posterior pole retinal detachment’, and Sarah Karam of Spain for ‘How to solve a large size disparity between a big foreign body and the vitrectomy surgery instruments’.

CHALLENGING SITUATIONS Dr Murthy’s winning video entry examined the surgical techniques that can be successfully used to induce PVD in vitrectomy surgery.

While PVD can usually be induced with cutter suction, there are some challenging situations where alternate methods of PVD induction may be necessary, such as young patients with adherent posterior hyaloid, cases of high myopia with frequent vitreoschisis, and vascular proliferations on the posterior hyaloid face.

In the video, Dr Murthy showed an effective method for breaking the surface tension or forces of adherence between the posterior hyaloid and retina, using a pick or spatula as well as the use of active suction using a soft tipped cannula.

The key to the technique is the use of a fine polythene film on a moist smooth surface.

If suction is attempted, it appears inadequate to Hemanth Murthy break the bond, noted Dr Murthy.

However, if a fine opening is made in the polythene film, the same suction successfully separated the posterior hyaloid and retina.

Using this approach, Dr Murthy and co-workers were able to achieve PVD induction in cases involving younger patients.

The use of triamcinolone enabled easy identification of the posterior hyaloid, and a pick or spatula was then used to create a small opening. Active suction with a soft-tipped cannula then achieved PVD. In cases of high myopia, however, the posterior hyaloid was irregularly adherent and a forceps was required in order to peel the hyaloid, which was adherent to the retina.

PVD also featured strongly in Dr Agrawal’s video, which demonstrated a step-by-step approach to inducing PVD in paediatric rhegmatogenous retinal detachments.

The video highlighted how paediatric rhegmatogenous retinal detachments are vastly different from adult detachments in terms of cause, presentation and final visual outcomes.

EUROTIMES | OCTOBER 2016

21

17th EURETINA Congress 7–10 September 2017

www.euretina.org

CONGRESS REPORTS

2016

XXXIV Congress of the ESCRS

The late Peter Barry

ESCRS President David J Spalton addressing delegates at the recent ESCRS Congress Opening Ceremony

INNOVATION SPURS ESCRS ON TO NEW HEIGHTS

N

ew initiatives and consolidation of existing projects in key areas of research, education and training will continue to drive the society forward in its mission to provide the highest quality service to its members, ESCRS President David J Spalton told the Opening Ceremony of the XXXIV Congress in Copenhagen, Denmark.

“The ESCRS is a charity and our charitable objectives are focused on education, research, and training, as well as direct donations. Last year our budget for this was €1.7million, making us one of the largest ophthalmic charities in Europe,” he said.

Prof Spalton told assembled delegates that this year’s congress rounds off an exceptional year for the ESCRS. “Our last congress in Barcelona attracted over 8,500 delegates from 127 countries and at the winter meeting in Athens we had 2,232 delegates from 73 countries. This means that the ESCRS annual congress is now the second largest ophthalmic meeting in the world outside the US,” he said.

The ESCRS will continue to support and promote research activities such as the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) and the recently-launched

European Cornea and Cell Transplantation Registry (ECCTR), said Prof Spalton.

As well as the ongoing PREvention of Macular EDema after cataract surgery (PREMED) study, the first results of which are expected next year, three new projects are being financed by the ESCRS: one on virtual refractive optics using high-resolution imaging of the anatomy of the eye for prevention of negative dysphotopsia, another looking at the influence of posterior vitreous detachment on retinal detachment in myopic eyes, and a final project on functional magnetic resonance imaging (MRI) to study cortical neuroadaption.

“Our budget for research this year is €750,000 and we have 43 applications for new research grants which we are currently assessing,” added Prof Spalton.

Speaking on behalf of the host country, Dr Thomas Olsen said he was honoured that the prestigious congress was taking place in Copenhagen, a city that offered many attractions to delegates.

Videos and presentations from the Congress are available on: escrsondemand.org

FELLOWSHIP TO HONOUR PETER BARRY The ESCRS has announced the creation of an annual travel fellowship in recognition of the immense contribution of Peter Barry FRCS to European and global ophthalmology. Dr Barry, who served as ESCRS President from 2012 to 2013, died after a short illness in May this year.

Announcing the Peter Barry ESCRS Travel Fellowship at the Opening Ceremony of the XXXIV Congress, ESCRS President David J Spalton said that the fellowship of €50,000 would enable a trainee ophthalmologist from Europe to train at a centre of excellence anywhere in the world.

FITTING MEMORIAL “The ESCRS Board decided that it would be a fitting memorial to Peter to commemorate him with an annual travel fellowship. We hope to make the first award of the fellowship at the congress next year in Lisbon, and I think this is going to train the future leaders of our society,” he said.

Prof Spalton said that Peter Barry had been a tireless advocate for European ophthalmology, helping to found the European Intraocular Implantlens Council, which later evolved into the European Society of Cataract and Refractive Surgeons.

“Peter had been a member of the ESCRS since its inception. He served as a Board member, Treasurer and President, and more recently as a Director. He was always a firm guiding hand in all that we did,” said Prof Spalton.

As well as being the instigator behind the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) database, Dr Barry was also the inspiration behind the landmark study that proved the efficacy of intracameral cefuroxime in reducing the risk of post-cataract endophthalmitis.

EUROTIMES | OCTOBER 2016

23

24

CONGRESS REPORTS

COPENHAGEN 16th EURETINA Congress

EURETINA President Ursula Schmidt-Erfurth addressing delegates at the Opening Ceremony of the 16th EURETINA Congress

‘GUARDIANS OF THE RETINA’ SHARE INSIGHTS

R

etinal specialists and researchers from across the globe gathered in glorious autumn sunshine in Copenhagen last month for the 16th EURETINA Congress.

As one of Scandinavia’s most vibrant and colourful cities, Copenhagen provided the ideal backdrop to this year’s gathering of clinicians and surgeons interested in the research and treatment of retinal and macular diseases.

Addressing the assembled crowd at the official Opening Ceremony, EURETINA President Ursula Schmidt-Erfurth welcomed delegates to Copenhagen and said that she was gratified to see the upward trajectory of the organisation in recent years.

“It is my great privilege and honour on behalf of the Board of the European Society of Retina Specialists, to welcome you to the 16th EURETINA Congress in Copenhagen.

Sixteen years after its inception in Hamburg, with a gathering of only 200 delegates, it is humbling to see the success of the EURETINA Congress, opening its doors to over 5,000 delegates at its 16th meeting,” she said.

Prof Schmidt-Erfurth reminded delegates of the important role they play as direct actors in fundamental issues of public health. “I think it is vital not to lose sight of the fact that we EUROTIMES | OCTOBER 2016

are guardians of the retina, with all the responsibility that entails,” she said.

She noted that, despite immense progress in diagnostics and treatments in recent years, many common retinal diseases still lead to debilitating visual loss.

“We need to remember that visual function has a direct impact on social functioning and impaired vision directly affects all levels of socio-economic wellbeing of individuals and society as a whole, including educational qualifications, employment status, social setting and condition and mental health,” she added.

As part of the opening ceremony, this year’s EURETINA Lecture was delivered

by Jose Cunha-Vaz of Portugal, discussing the key question of the blood-retinal barrier in retinal disease management.

STIMULATING MEETING Prof Cunha-Vaz’s lecture was followed by the presentation of the EURETINA Video Competition Awards by Jan van Meurs, the incoming President of EURETINA. Prof Schmidt-Erfurth brought proceedings to a close by wishing delegates a productive and stimulating meeting, and said that she looked forward to seeing everyone next January in Vienna for the EURETINA Winter Meeting, and Barcelona in September 2017 for the 17th EURETINA Congress.

RETINA RACE RUNNERS RAISE ORBIS FUNDS Enthusiastic runners turned out in force in predawn darkness to support this year’s Retina Race in aid of Orbis.

Organised by EURETINA and sponsored

by Novartis, the fifth annual Retina Race took place over five kilometres in a scenic park close to Copenhagen’s Bella Center.

Drawn from the assorted ranks of ophthalmologists, scientists and exhibitors in town to attend the 16th EURETINA Congress, over 150 runners of all ages took part in the event in perfect conditions. They were cheered on by colleagues, friends and family members.

After some gentle stretching, the runners made their way through the designated course.

Maximilian Pfau from Germany was the overall winner in a blistering time of just over 18 minutes. The first female competitor past the post was Cristina Irigoyen from Spain, who finished the race in a little over 23 minutes.

Speaking on behalf of Novartis, Susanne Diehl, Global Brand Director Ophthalmology at Novartis Pharma AG, said that the participants could be proud of their achievement in running for the noble goal of saving vision.

“This is a very important initiative for Novartis and we are proud to be associated with this race since it started five years ago. It is a great way to bring people from all over the world together, in a nice atmosphere and helping to raise money for the vital work of Orbis,” she said.

Kathryn Sweet, Head of Corporate Partnerships at Orbis EMEA, also thanked all the participants for playing their part in raising money to go towards much-needed prevention-of-blindness programmes in the developing world.

CONGRESS REPORTS

C

7th EuCornea Congress

OPENHAGEN2016

EuCornea President François Malecaze addressing delegates at the 7th EuCornea Congress Opening Ceremony in Copenhagen

EUCORNEA HAS A FIRM PLATFORM

C

orneal specialists from Europe and further afield gathered in Copenhagen last month for the 7th EuCornea Congress. Welcoming delegates at the Opening Ceremony, the society’s President François Malecaze expressed satisfaction with the momentum it has built up in a relatively short time.

Prof Malecaze said he was heartened to see so many delegates coming to Copenhagen to support the meeting and said it provided a firm platform for the future growth and wellbeing of EuCornea.

“The success of our annual congress shows that a European society dedicated to the cornea is completely justified. I am convinced that 2016 is going to be another successful year for EuCornea. We have taken a big step forward with the launch of our new journal, largely thanks to the efforts and energy of Prof Harminder Dua. I urge you all to submit papers to the journal and ensure its success,” he said.

Speaking on behalf of the Danish Ophthalmological Society, Prof Jesper Hjortdal welcomed delegates to Copenhagen.

As part of the Opening Ceremony, this year’s EuCornea Medal Lecture was delivered by Prof Paolo Rama of Italy, discussing the huge potential of cultivated limbal stem cells for ocular surface reconstruction and regeneration in cases of severe ocular surface disease.

Prof Rama’s lecture was followed by the presentation of a plaque to Prof Malecaze on behalf of EuCornea by incoming President Friedrich Kruse.

“We want to thank Francois for his tireless work on behalf of our society over the past two years,” he said.

Prof Malecaze concluded by thanking the assembled audience for their attendance and urged them to play an active role in making EuCornea a thriving organisation.

“I think, in large part due to the success of our congresses, that our society is now firmly established as a reference for corneal specialists,” he said.

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26

CONGRESS REPORTS

PICTURE GALLERY

EUROTIMES | OCTOBER 2016

GLAUCOMA

CSF PRESSURE Obtaining CSF pressure measurements in the optic nerve region a complex and challenging task. Roibeard O’hEineachain reports

C

erebrospinal fluid (CSF) pressure is attractive as a potential target for surveillance or modification in eyes with glaucoma, but its true value in those terms will not be known until accurate means are devised to measure the pressure locally in the optic nerve head, said Hanspeter Esriel Killer MD, Kantonsspital Aarau and University of Basel, Switzerland.

“The concept is still in the Platonic and infancy stage and really needs to be refined in order to fulfil the laws of physics and mathematics,” he told the 12th European Glaucoma Society Congress in Prague, Czech Republic.

He noted that pressure is scalar, obtained by dividing the force applied by the area to which it is applied. However, in the case of CSF pressure, neither the amount of force applied nor the size of the area involved can be determined accurately with current technology.

Courtesy of Hanspeter Esriel Killer MD

28

MATCH THE MODEL Intracranial CSF pressure is one of two components of the translaminar pressure gradient, a measure of the forces applied to the lamina cribrosa. The laminar pressure gradient is calculated by subtracting intracranial CSF pressure from intraocular pressure (IOP).

In a theoretical model, when the two pressures are equal, the translaminar pressure gradient would be zero. Whereas when CSF pressure exceeds IOP, the gradient will have a negative value and the papilloedema might occur, and if IOP exceeds intracranial CSF, the gradient will have a positive value and glaucoma might occur.

However, the optic nerve’s subarachnoid space has a complex anatomy. For example, the area where CSF would be applying pressure to the lamina cribrosa has an annular shape, segmented into many tiny compartments, each with different amounts of compliance to pressure. In addition, scanning electron microscopy shows that the subarachnoid space right behind the lamina cribrosa is filled with trabeculae unlike a Bernoulli tube.

CSF is not homogenous at different sites. Unlike a Newtonian fluid, it contains up to 20,000 peptides with a variety of biochemical functions.

“What we need is hyperbolic geometry so that we can actually model to the formation of this area behind the lamina cribrosa, and then we could get more accurate measurement of actual CSF pressure,” Dr Killer said.

One way to calculate the dynamics of the ocular pressure within the optic nerve is to use Alan Turing’s reaction diffusion equation.

Using partial differential equations, it calculates the surface area of a torus composed of segments of varying diameter.

NEW TECHNOLOGY Dr Killer noted that, to obtain the measurements necessary to perform EUROTIMES | OCTOBER 2016

The concept is still in the Platonic and infancy stage and really needs to be refined in order to fulfil the laws of physics and mathematics Hanspeter Esriel Killer MD

Subarachnoid space of the optic nerve with trabeculae between arachnoid and pia layer

those calculations in patients, he and his associates are in the process of creating a three-dimensional reconstruction of the whole optic nerve subarachnoid space.

Another problem they are working on overcoming is the actual measurement of CSF pressure in the optic nerve subarachnoid space. The conventional means of measuring CSF pressure is to use a lumbar puncture. That approach assumes that CSF pressure is equal throughout the body in a manner akin to a Bernoulli tube.

In fact, studies using computed tomography (CT) cisternography show herniations and blockages to the flow of CSF in different parts of the spinal canal and the subarachnoid space of the optic nerve, as well as different concentrations of contrast-loaded CSF and in different parts around the optic nerve. (HE Killer et al, Br J Ophthalmol 2012; 96:544-548; HE Killer et al, The optic nerve: a new window into cerebrospinal fluid composition. Brain 2006; 129:1027-1030; HE Killer et al, Cerebrospinal fluid dynamics between the intracranial – and the subarachnoid space of the optic nerve. Is it always bidirectional?; Brain 2007 129(4):1027-1030) “The reason is simply because the anatomy throughout the optic nerve is not the same in every location. If you are behind the lamina cribrosa or in the middle portion, or if you are in the connector portion, the size of the subarachnoid space is variable,” Dr Killer said.

To help determine the contribution of CSF to the translaminar pressure, he and his associates have developed a technique for measuring the velocity of the CSF in different positions in the subarachnoid space surrounding the optic nerve, using an MRI diffusion sequence, he said.

He added that in order to accurately measure translaminar pressure, the measurements of IOP and CSF need to be simultaneous, whereas currently they are generally performed at separate times. Moreover, account has to be taken of the fact that IOP and CSF have independent cycles of peaks and troughs that do not coincide.

Hanspeter Esriel Killer: killer@ksa.ch

GLAUCOMA

POPULATION SCREENING Remote case-finding for angleclosure glaucoma – new technology needed. Roibeard O’hEineachain reports

P

rimary angle-closure glaucoma would be an ideal candidate for population screening using a telemedicine approach, were it not for the lack of a remote means of diagnosing the condition by non-clinicians, according to Gus Gazzard MD, FRCOphth, Moorfields Eye Hospital, London, UK. “We have a spectrum of disease which is eminently treatable, and at various stages preventable, but we’ve got far too few ophthalmologists to screen such a large population by any traditional form of examination,” Dr Gazzard told the 12th European Glaucoma Society Congress in Prague.

He noted that, although it is much less common, angle-closure glaucoma outstrips primary open-angle glaucoma in terms of global blindness. That is despite the availability of safe, proven interventions that can prevent the disease from occurring and can also prevent the early stages of disease from proceeding on to further visual loss once it has become established.

The potential benefit of a preventive approach has been demonstrated in a paired-eye trial carried out in Singapore, which showed that only 20 primary angle-closure suspects would need to undergo prophylactic iridotomy in order to reduce by half the number progressing on to more advanced disease.

Similarly, the EAGLE trial has shown that lens extraction in patients with angle-closure or angle-closure glaucoma can reduce the need for subsequent glaucoma surgery and medication.

The optimal balance between smaller 27-gauge incision surgery and instrument capability.

GONIOSCOPY PROBLEM The problem with applying these findings to population screening is that the diagnosis of angle-closure depends on the detection of iridotrabecular contact through gonioscopic examination. Gonioscopy is unsuited as a technique for remote examination, as it requires training and experience and an expensive clinician.

“We need an accurate, trained technician-based test that can detect iridotrabecular contact, so we can go out and find those individuals who need gonioscopy,” Dr Gazzard said.

He noted that studies conducted in public optometric practices in the UK, China and Mongolia have shown that traditional techniques, such as the oblique flashlight test and limbal anterior chamber depth measurements, have too low a specificity for screening large populations on a systematic basis. The same has been shown to be true with more advanced technologies like Scheimpflug and ultrasound biomicroscopy, and anterior segment optical coherence tomography imaging.

However, many companies are working on developing technologies that can detect the presence and extent of iridotrabecular contact in an automated fashion. Research has identified novel parameters in angle-closure disease such as lens vaulting and anterior chamber volume, which may have predictive value for angle-closure.

“Through the use of complex computer algorithms that are currently being developed, it may be possible to combine those measurements to identify cases for referral for gonioscopic examination,” Dr Gazzard said.

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Gus Gazzard: gusgazzard@gmail.com EUROTIMES | OCTOBER 2016

29

MAASTRICHT 2017 21ST ESCRS WINTER MEETING

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OCULAR

ALZHEIMER’S EYE TEST RNFL thickness may correlate with AD risk. Pippa Wysong reports

M

onitoring retinal nerve fibre layer (RNFL) thickness may have a role in helping screen, and possibly diagnose, conditions such as Alzheimer’s disease (AD). This is according to research which found an association between thinner RNFL and poorer cognition.

Details were presented at the 2016 Alzheimer’s Association International Conference in Toronto, Canada, by Fang Ko MD. She was at Moorfields Eye Hospital in London, UK, when conducting the research. This work was sponsored by the National Institute of Health Biomedical Research Centre of Moorfields Eye Hospital.

Retinal thickness, detection of amyloid plaques (characteristic of AD) on the retina, and retinal vessel behaviour are all being investigated as ways to help screen for neurodegenerative diseases, which may put ophthalmologists at the forefront of screening efforts.

The study used data from the UK Biobank, a project that includes medical and health details of 500,000 volunteers aged between 40 to 69 years from across England. Of these, 67,000 underwent eye exams, which included spectral-domain optical coherence tomography (SD-OCT) imaging. For the study, a large number were excluded, including Fang Ko those with poor image quality, any known ocular disease, elevated intraocular pressure, extreme refractive error, poor vision, neurologic disease or diabetes.

This left a total of 33,000 participants.

Some 32,000 also completed four different tests relating to cognition, including prospective memory, episodic memory, reasoning and reaction time. After three years, 1,251 participants repeated the cognitive tests.

Researchers found that people with thinner RNFL tended to perform worse on each of the cognitive tests than people with thicker RNFL. The differences in cognition between thick and thin RNFL were statistically significant.

Generally, it was found that the thinner the layers, the more poorly individuals performed. For instance, in the prospective memory test, the mean RNFL thickness was 53.3um for those who were able to recall details in the test correctly on the first attempt. For those who recalled details on a second attempt, the mean thickness was 52.5um, while those who did not succeed in recalling details had a mean thickness of 51.9um. “It may be that the nerve fibre layer could be a biomarker,” Dr Ko said.

When it came to the 1,251 people who did follow-up cognitive tests, it was found that those who had thinner RNFL at baseline performed worse after three years. In other words, it may be possible to use thin RNFL as a predictor of cognitive decline, she said.

However, various things “can influence someone’s nerve fibre layer or their cognitive function”, she said. Glaucoma and other retinal diseases can affect RNFL thickness, and other factors can cause cognitive decline. “Because of its availability and presence of OCT in most ophthalmology offices, its potential for clinical use (as a screening tool) is quite high,” Dr Ko added.

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PAEDIATRIC OPHTHALMOLOGY

MYOPIA IN TEENS School-based cohort study documents rates and progression.

4 TH

Cheryl Guttman Krader reports

N

ew analyses of data collected in the Singapore Cohort Study of the Risk Factors for Myopia (SCORM) provide insight about the prevalence, incidence, and progression of myopia among teenagers in Singapore. Seang-Mei Saw MD, PhD presented the findings from the longitudinal epidemiologic study during the 2016 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Seattle, USA. She reported that the prevalence of myopia (SE<-0.5D) and of high myopia (SE<-5.0D) among the Singapore teens aged 11-18 years was 69.1 per cent and 12.6 per cent, respectively.

The myopia progression rate was slower among myopic teens than in children aged seven to nine years, -0.32D/year versus -0.95D, but among the teens it was faster in high myopes than in those with lower myopia.

“The high prevalence of myopia and high myopia among the Singapore teens is worth noting because the final prevalence of myopia and of visually-disabling pathologic myopia will be even higher in adults. Moreover, although myopia progression slows down during the teenage years, it does not cease, and the teens who already have high myopia have a higher risk of developing extreme myopia and visually disabling complications,” said Prof Saw, SCORM Principal Investigator, Head, Myopia Unit, Singapore Eye Research Institute, and Professor, SSH School of Public Health, National University of Singapore.

“We also think the age of cessation of myopia progression is likely later in young adulthood in Singapore. This information has clinical implications for determining when to start therapy and how long to continue it,” she said.

SCORM is an 18-year cohort study implemented in 1999 that recruited 1,979 children aged seven to nine years at three schools. Participants initially underwent yearly comprehensive eye examinations that included cycloplegic autorefraction. The analyses of myopia in teens were based on data from 1,246 participants examined in 2006 and 1,037 participants examined in 2007.

Prof Saw also reported that the total annual incidence rate of “adolescentonset” myopia in the 11-18 year-olds was 17.6 per cent in males, 9.6 per cent in females, and 13.7 per cent overall, which was lower than the 21.6 per cent annual incidence rate found in SCORM among children aged seven to nine years.

Consistent with other studies, myopia among Singaporean teens was more common among those of Chinese descent than in Indians and Malays.

Seang-Mei Saw: seang_mei_saw@ nuhs.edu.sg

...although myopia progression slows down during the teenage years, it does not cease...

World Congress of Paediatric Ophthalmology and Strabismus

1-3 December 2017 www.wspos.org

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Seang-Mei Saw MD, PhD EUROTIMES | OCTOBER 2016

33

YOUNG OPHTHALMOLOGISTS

Manish Mahabir receives the John Henahan Prize from ESCRS President David J Spalton at the XXXIV Congress

A GLOBAL VILLAGE won the 2016 John Henahan Prize for Young Ophthalmologists for this essay on the theme of ‘Why Should I Publish?’

Manish Mahabir

I

t was late at night. With droopy eyes and a bag in my hand heavy with papers, my legs could barely carry me. I was walking towards my home. There was no soul around. Dimly lit streets and occasional barking from stray dogs were my only company. I was dead tired from a long day's work. The only thing on my mind was crashing on my bed so that I could get up early in the morning to finish my pending works.

‘Cling, Cling’… ‘Cling, Cling’…

‘Cling, Cling’...

It took me a while to figure out that phone in my lab coat was ringing. It was from my colleague Dr Bhagabat.

‘Heeellloooo’...

My speech slurred as I put the phone to my ears. What followed was one of the sweetest voices I had heard in a long while.

“The paper we had been working on for the past year has been published in Nature.”

“Oh my god!” I cried out loud.

My eyes lit up with joy and there was a EUROTIMES | OCTOBER 2016

chord with me. It was a topic alluded to many times, but had never been discussed explicitly. I was intrigued and discussed it with my colleagues.

Still there was an itch to know what others felt about it. I created an online survey and leveraged email lists and

large smile on my face. I felt lighter with an overwhelming sense of pride, fulfilment and accomplishment. All the hard work, sleepless nights and sacrifices we had made had finally come to fruition.

A few days later, when a click in my Gmail unveiled this topic, it struck a

CHART 1: RESPONSE TO THE QUESTION ‘WHY SHOULD I PUBLISH?’ Immortality Regulatory compulsion Overcome fear Response

34

Leadership Collaboration opportunity Sense of fulfilment Personal recognition Contributing to knowledge base Professional growth Self-learning 0

10

20

30

40

50

60

Percentage agree (%)

70

80

90

100

YOUNG OPHTHALMOLOGISTS

TABLE 1: PROFILE OF THE RESPONDENTS Population Characteristics, N=71

N

Percentage (%)

>50

8

11.3

30-50

30

42.2

<30

33

46.5

Male

49

69

Female

22

31

Yes

53

74.6

No

18

25.4

Doctoral

9

12.7

Masters

52

73.2

Age (Years)

Gender

Published

Highest Qualification

TABLE 1: PROFILE OF THE RESPONDENTS Graduate

6

8.5

Population Characteristics, N=71 Undergraduate

N4

Percentage 5.6 (%)

>50

8

11.3

30-50

30

42.2

Age (Years)

social media to share it with the medical consisted of non-identifying <30 33 46.5 data about community. The first page of the respondent. It included age, gender, Gender the questionnaire consisted of 10 highest educational qualification and Malereasons cited for why we should 49 the respondent had 69 already common whether publish, based on literature review and published.

Dual responses31were Female 22 personal discussions. prevented using a browser cookie so Published TheTABLE reasons included personal the survey could *be taken only once 2: RESPONSE TO THE QUESTION ‘WHYthat SHOULD I PUBLISH?’ Yes 74.6 of the survey, recognition, growth,Percent agree (%)from53a Mean±SD browser. At Coeff the .end Response,professional N=76 of variation (%) No 18 25.4a live display self-learning, contributing to the respondents were taken to Self-learning collaboration 90.8 4.43±0.74results. (1, 2) 17 knowledge of the survey Highest base, Qualification opportunity, sense of fulfilment, Professional 90.8 Doctoral growth 9 4.38±0.83 12.719 regulatory compulsion, immortality, SELF-LEARNING Contributing knowledge base fear.

90.8 Mastersandtoto 52 4.36±0.93 73.221 leadership overcome A total of 76 people voluntarily chose to Graduate 6 8.519 These options appeared in a random Personal recognition 88.2 take the4.32±0.80 survey. Among them, five chose order for each respondent.

It had to Undergraduate 5.618details. not to4 disclose Sense of fulfilment 90.8 4.29±0.78 their personal be graded on a five-point Likert scale Among the 71 respondents, 11.3 per cent Collaboration opportunity agree (score 82.9 4.09±0.69 17 ranging from strongly (eight) belonged to >50 years age group; of 5) to strongly disagree (score of Leadership 77.6 42.2 per3.95±0.93 cent (30) were in the2430-50 age 1). There was a comment box where group; and 46.5 per cent (33)31belonged to Overcome fear 3.41±1.06 respondents could share their opinion.53.9 the age group <30 years.

The second of the questionnaire 42.1 Regulatorypage compulsion 3.38±0.93 28 Immortality

48.7

3.33±1.18

36

* Response measured on a 5-point likert scale ranging from strongly agree (5) to strongly disagree (1)

TABLE 2: RESPONSE TO THE QUESTION ‘WHY SHOULD I PUBLISH?’ * Percent agree (%)

Mean±SD

Coeff. of variation (%)

Self-learning

Response, N=76

90.8

4.43±0.74

17

Professional growth

90.8

4.38±0.83

19

Contributing to knowledge base

90.8

4.36±0.93

21

Personal recognition

88.2

4.32±0.80

19

Sense of fulfilment

90.8

4.29±0.78

18

Collaboration opportunity

82.9

4.09±0.69

17

Leadership

77.6

3.95±0.93

24

Overcome fear

53.9

3.41±1.06

31

Regulatory compulsion

42.1

3.38±0.93

28

Immortality

48.7

3.33±1.18

36

* Response measured on a 5-point likert scale ranging from strongly agree (5) to strongly disagree (1)

Some 69 per cent (49) of our respondents were male, and only 31 per cent (22) were female. The majority of our respondents (74.6 per cent; 53) had a publication in their name. While 73.2 per cent (52) had completed their Masters or postgraduate, 12.7 per cent (nine) held a doctoral degree.

Some 8.5 per cent (six) had completed their graduation, and 5.6 per cent (four) were undergraduate students.

Self-learning, professional growth, contributing to the knowledge base, personal recognition and sense of fulfilment were among the most common reasons respondents agreed with.

Immortality, regulatory compulsion and overcoming fear were among the least favoured reasons.

There was ambiguity about immortality, with the coefficient of variation being highest at 36 per cent.

One of the respondents wrote that it was important to share knowledge - even negative results were important. Another commented that research without publication was a waste of time, effort and money, and hence unethical.

We learn the most when we try to teach. We discover the gaps in our own knowledge. Things we did not know that we did not know, gradually come to light and reveal themselves.

We live in interesting times. The whole world is a global village. When we publish, the whole world is our audience. This is the era of artificial intelligence, crowdsourcing and democratisation of processes.

Strong technical insights can launch innovative new products, or a company, or a whole new industry. It is all within reach of a common man and not just the purview of industry or governments.

There is no better time to publish and manifest the unlimited potential already within us. (3–5) 1. Einstein A. Writing and publishing a scientific paper: Facts, Myths and Realities. Med J Armed Forces India.

2015;71(107):e111 2. SurveyMonkey Analyze - Why should I publish? [Internet]. SurveyMonkey Inc. [cited 2016 May 27]. Available from: https://www.surveymonkey.com/ analyze/lDcY99nGZ_2BK58vWas6W06 3sACFo9_2FcYtZMmlrPwM8Ks_3D 3. Chen Y, Elenee Argentinis J, Weber G. IBM Watson: How Cognitive Computing Can Be Applied to Big Data Challenges in Life Sciences Research. Clin Ther.

2016 Apr;38(4):688–701 4. Silver D, Huang A, Maddison CJ, Guez A, Sifre L, van den Driessche G, et al.

Mastering the game of Go with deep neural networks and tree search. Nature.

2016 Jan 27;529(7587):484–9 5. Diamandis PH, Kotler S. Bold: How to Go Big, Create Wealth and Impact the World. Simon and Schuster 2015 EUROTIMES | OCTOBER 2016

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JCRS

JCRS HIGHLIGHTS

VOL: 42 ISSUE: 8 MONTH: AUGUST 2016

MULTIFOCALS AND ASTIGMATISM Unhappy multifocal intraocular lens (IOL) patients report such problems as glare, halos and reduced contrast. Patients also complain of substandard near or intermediate vision, where uncorrected astigmatism could play a role. A new rotationally asymmetric multifocal IOL appears to provide good visual acuity, even in the presence of varying amounts of residual refractive astigmatism or corneal astigmatism. McNeely and colleagues report a retrospective comparative case series in which 117 patients had been implanted with the Lentis Mplus LS-312 MF30 IOL. They evaluated the postoperative degree of tolerance towards different magnitudes of residual refractive astigmatism and corneal astigmatism, and the angles of corneal astigmatism in these patients. While there was a significant difference in uncorrected distance visual acuity (UDVA), refractive sphere, and defocus equivalent between the residual refractive astigmatism groups, there was no difference in quality of vision. Similarly, no difference was found for corneal astigmatism with UDVA and quality of vision. Overall, the angle of the residual corneal astigmatism in relation to the position of the multifocal IOL did not affect objective outcomes or the overall patient satisfaction rates.

RN McNeely et al, JCRS, “Threshold limit of postoperative astigmatism for patient satisfaction after refractive lens exchange and multifocal intraocular lens implantation”, Volume 42, Issue 8, 1126-1134.

NINE IOL FORMULAS COMPARED A new comparison study of nine IOL power calculation formulas confirms significant differences in their predictive ability. The formulas gave different results depending on which machine measurements were used. The Olsen formula was the most accurate, with optical low-coherence reflectometry (OLCR) measurements significantly better than the best formula with partial coherence interferometry (PCI) measurements. The Olsen was better, regardless of axial length. If only PCI measurements (without lens thickness) were available, the Barrett Universal II performed the best and the Olsen formula performed the worst. The pre-installed version of Olsen was not as good as the standalone version. DL Cooke et al, JCRS, “Comparison of 9 intraocular lens power calculation forumulas”, Volume 42, Issue 8, 1157-1164.

LASIK OUTCOMES: PATIENT SATISFACTION More than 16 million LASIK procedures have been performed globally. A massive literature review of LASIK outcomes supports the safety and efficacy of the procedure and suggests improvement in patient satisfaction over time. The review included the as yet unpublished PROWL study conducted by the US FDA. The researchers note that patient selection has improved greatly over the past two decades. Candidacy criteria include sufficient corneal bed thickness following flap formation and corneal ablation, and a healthy tear film. HP Sandoval, JCRS, “Modern laser in situ keratomileusis outcomes”, Volume 42, Issue 8, 1224-1234.

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EUROTIMES | OCTOBER 2016

37

INDUSTRY NEWS

INDUSTRY

NEWS

PRELOADED IOL INSERTS Rayner launched the RayOne®, their fully preloaded intraocular lens (IOL) injection system, at the XXXIV Congress of the ESCRS in Copenhagen.

Designed from the outset to work together, the RayOne lens and injector makes micro-incision cataract surgery (MICS) quicker and easier with the smallest-tipped preloaded IOL system currently on the market, said CEO Tim Clover.

Ease of use and safety were RayOne design priorities, Clover added. Patented “Lock & Roll” technology rolls the lens tightly before pushing it forward in the fully enclosed cartridge, enabling smooth, consistent injection with minimum force and maximum control. The 1.65mm nozzle is parallel-sided for minimal stretch, supporting wound-in lens injection through sub-2.2mm incisions. www.rayner.com

Watch the latest video content from ESCRS and EuroTimes, FREE on the ESCRS Player l Eye Contact Interviews l Video of the Month l Video Journal of Cataract

NEW CEO APPOINTED

James V Mazzo

FDA APPROVAL The Medical Technology Business Group of Zeiss has announced FDA approval of the VisuMax® small incision lenticule extraction (SMILE) procedure.

“I thank the surgeons and clinics who have paved the way for Zeiss to be able to bring this new innovative technology to refractive practices throughout the US,” said James V Mazzo, Global President of Ophthalmic Devices, and President and CEO of the company’s US organisation. www.zeiss.com

Avedro, Inc. has announced the appointment of Reza Zadno, medical device entrepreneur, as the company’s CEO. “We are very pleased to have Reza join Avedro’s senior executive team as CEO,” said Gil Kliman, Managing Director at InterWest Partners, and a member of the Avedro Board of Directors.

“His entrepreneurial skills and proven leadership will help assure the successful commercialisation of our recently FDAapproved crosslinking device and drugs in the US, and speed our clinical development of PiXL, a first-incategory, non-surgical procedure for the correction of myopia.” www.avedro.com

& Refractive Surgery

l Young Ophthalmologists

Videos: “My Early Surgeries”

player.escrs.org EUROTIMES | OCTOBER 2016

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40

REVIEW

SUBLUXATED CATARACT Everything you ever wanted to know about subluxated cataract surgery â&#x20AC;&#x201C; Part 3. Dr Soosan Jacob reports

P

ROGRESSIVE SUBLUXATION:

In-the-bag intraocular lens (IOL) with sutured scleral fixation of a segment or ring or the glued capsular hook technique is an option for subluxated cataract.

However, in progressive zonulopathy secondary to pseudoexfoliation, high myopia, aniridia, Marfanâ&#x20AC;&#x2122;s syndrome etc, a two- or three-point fixation is preferable to avoid late subluxation of the unsupported side. Lensectomy with vitrectomy and anterior chamber (AC) IOL, iris or glued scleral fixated IOL, provides long-term fixation but loss of posterior capsule, disturbance of anterior hyaloid face and vitreous can increase the risk of posterior segment complications.

The supracapsular glued IOL technique has advantages of retaining an intact posterior capsule and hyaloid face; avoiding vitreous disturbance; decreasing the incidence of posterior segment complications such as retinal detachment and cystoid macular oedema; maintaining bicamerality of the eye while providing stable long-term fixation of the IOL.

bent 23-gauge needle. The sclerotomies are made without entering the vitreous cavity by going ab-interno via the AC in a supracapsular plane parallel to the iris to come out under the scleral flap.

Loosening the capsular hooks to allow the bag to fall slightly backwards and ballooning the iris upwards by injecting a cohesive viscoelastic under the iris in the quadrant of the scleral flap creates space to help pass the needle easily. After again expanding the retroiridal space with viscoelastic, the haptics of a three-piece foldable IOL are sequentially externalised above the anterior capsule using endgripping microforceps introduced through the sclerotomies.

The use of high molecular weight viscoelastic allows these manoeuvres

to be performed easily. Intra-scleral haptic tuck is then utilised for stabilizing the glued IOL as conventionally done and scleral flaps and conjunctiva are closed with fibrin glue. Retention of the capsulo-zonular barrier maintains complete bicamerality of the eye, separating posterior chamber from vitreous cavity, thus leading to lesser endophthalmodonesis and pseudophacodenesis, especially important in eyes already predisposed to a higher incidence of retinal complications.

Postoperative phimosis, if it occurs, can be prevented/ tackled in a more controlled manner with relaxing cuts on the anterior capsule, either at the time of surgery or postoperatively with the YAG laser.

SUPRACAPSULAR GLUED IOL: Phacoemulsification is started after making two partial thickness lamellar flaps 180 degrees apart. Capsular hooks engage the rhexis and support the bag during phacoemulsification. An AC maintainer is used to allow slow infusion into the eye when required, to prevent shallowing of the AC and extension of dialysis while removing phaco and irrigation/aspiration probes.

Good but gentle cortical cleaving hydrodissection allows complete cortex aspiration. After cortex removal, glued IOL implantation is done above the intact capsular bag. Two ab-interno sclerotomies are created under the scleral flaps with a EUROTIMES | OCTOBER 2016

Supracapsular glued IOL - A: Phacoemulsification and cortex aspiration; B: Haptics of a three-piece IOL are sequentially exteriorised over an intact capsular bag and anterior hyaloid face; C and D: Well-centred, stable IOL

REVIEW

DANGLING SUBLUXATION: These are difficult to stabilise for performing phacoemulsification, and trying to do so often results in prolonged and complicated surgery, with eventual loss of any remaining area of zonular support as well. Therefore, a better option in such cases is to extract the cataract with bag and perform AC IOL, iris-fixated or sutured/sutureless glued scleral fixated IOL.

LENSECTOMY WITH VITRECTOMY WITH IOL FIXATION: This may be performed in soft cataracts where the vitrectomy probe is used in aspiration mode. Though the commonly performed technique is to use the vitrectomy probe to cut and aspirate the crystalline lens from end to end, care needs to be taken to avoid lens fragment drop as well as accidental vitreous aspiration.

In my opinion, an ideal and better way to prevent lens material drop into the vitreous is to create a small opening in the capsular bag using the vitrector in cutting mode, followed by peeling and aspirating all the soft lens material through this opening with the vitrector in suction mode.

This prevents fragment drop, admixture of vitreous with lens material and inadvertent aspiration of vitreous. After

removal of all the soft lens material in this manner, the empty capsular bag is removed using vitrector in cutting mode.

The visual axis is cleared and an anterior vitrectomy is performed followed by IOL implantation using the surgeon’s preferred choice. The glued IOL scaffold technique (described below) can also be used for these soft, dangling cataracts.

falling into the vitreous. For higher grades of nuclear sclerosis, after bringing the nucleus into the AC, a corneoscleral incision is made and the cataract is removed in toto using a vectis. In all cases where vitrectomy is done, preservative free intravitreal triamcinolone acetonide should be used to identify and remove any vitreous in the AC.

INTRACAPSULAR CATARACT EXTRACTION AND SECONDARY IOL FIXATION:

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India. She has a patent pending for the Glued Capsular Hook

This is done in cataracts with nuclear sclerosis which a vitrectomy probe will not be able to remove. Glued IOL flaps and sclerotomies are created. Posterior assisted levitation is performed through the sclerotomy to bring the dangling cataract up into the AC. An anterior vitrectomy is then done through the sclerotomy.

With nuclear sclerosis of grade 1 to 2, a glued IOL scaffold technique can then be used to position a glued IOL behind the iris. Here, the haptics of a three-piece IOL are carefully exteriorised sequentially under the nucleus as a glued IOL, and the haptics are tucked into intra-scleral Scharioth tunnels. If required, intracameral miochol may be used to constrict the pupil. The phaco probe is then used to emulsify the nucleus.

The constricted pupil, together with the glued IOL scaffold, prevents any fragment

Soosan Jacob: dr_soosanj@hotmail.com

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42

ESASO

NEW CENTRE FOR TRAINING Important milestone on 28 October: ESASO to open new state-of-the-art training centre and innovation lab

W

ESASO Preliminary Programme 2017 Oculoplastic Surgery Surgical Retina Medical Retina Basic Surgical Retina Surgical Retina Medical Retina Cornea & Corneal Refractive Surgery Glaucoma Cataract & Intraocular Refractive Surgery Cataract & Intraocular Refractive Surgery

23 – 26.01.17, La Valletta 06 – 10.02.17, Lugano 20 – 24.02.17, Rome 20 – 24.03.17, Lugano 29.05 – 02.06.17, Lugano 05 – 09.06.17, Lugano 04 – 08.09.17, Lugano 18 – 22.09.17, Lugano 16 – 20.10.17, Lugano 20 – 24.11.17, Lugano

Asia Courses Singapore Medical & Surgical Retina 3 planned for 2017

ESASO Programme 2016 NEW Cataract and Intraocular Refractive Surgery

24 – 28.10.16, Lugano

NEW Cataract and Intraocular Refractive Surgery

21 – 25.11.16, Lugano

Medical & Surgical Retina 27 – 30.11.16, Hanoi Medical & Surgical Retina 03 – 07.12.16, Kuwait

www.esaso.org

EUROTIMES | OCTOBER 2016

hen ESASO was founded in 2008 with the mission to further and support advanced education of young ophthalmologists, nobody was able to anticipate the quick evolution and international attractiveness of this initiative. In 2011, in light of the rapid and continuous growth, ideas emerged to establish ESASO’s own lab and training centre in Lugano, Switzerland.

The following years saw strong joint efforts of all stakeholders towards realising a centre of excellence in Lugano. The new ESASO training centre (ETC) is conceived as the main campus for ESASO’s educational programme. The spacious ETC offers excellent equipment, with plenty of opportunities for didactical training and hands-on education of ophthalmologists.

The ESASO Training Centre contains: l A classroom for approximately 60 people, equipped with cutting-edge technological devices l A 200m2 wet laboratory, which was built to host ophthalmic courses, but can also be adapted to a wide range of situations and needs l A dry laboratory equipped with ophthalmology simulators l An eye tech centre to expose innovations l Modular space for small meetings l A fully equipped control room, thanks to which a wide range of activities can effectively be managed Currently, ESASO trains its participants at the university campus of the Università della Svizzera italiana (USI). The two institutions have shared a long and strong partnership. The available space and times are, however, restricted due to the university’s own needs. Thus, ESASO’s constantly increasing demand fostered the need to build its own training facilities.

While ESASO searched for ideal educational facilities, it was the idea of Dr Fabrizio Barazzoni, Medical Director and then responsible for the development, research and innovation of the Association of the Public Cantonal Hospitals in Ticino, to construct it on the top of the Regional Hospital in Lugano.

In a close collaboration with the director of the hospital, Ing Luca Jelmoni, ESASO passed all the necessary bureaucratic steps that led to the new construction of its school. The new centre fits well with Lugano’s and Canton Ticino’s economical development objectives. Traditionally a city of banking, Lugano is now dedicated to also becoming a city of science and advanced learning.

Together the involved partners will create new bonds for the city, not only for the soon-to-come medical faculty but also with selected medical devices and pharma industry partners.

As a centre of excellence with international faculty and delegates, the ETC will thus contribute to Lugano’s increasing attractiveness as a centre of science, technology and education.

Giuseppe Guarnaccia, the Global Executive Director of ESASO, notes: “When we founded ESASO, we had a vision of collaboration. I hope that our project will continue growing, so physicians come to Lugano to teach and learn from each other. I hope they will grow into the next generation of skilled experts for the benefit of their patients.”

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 236 ISSUE: 2

VITRECTOMISED EYES HAVE SLOWER BUT EQUAL RESPONSE TO INTRAVITREAL ANTI-VEGF A history of vitrectomy is not a contraindication for antiVEGF therapy in eyes with diabetic macular oedema (DME), new research suggests. In a prospective study, there were no statistically significant differences between the safety and efficacy of intravitreal ranibizumab in 10 vitrectomised and 15 non-vitrectomised eyes with DME. After six months of treatment, the non-vitrectomised eyes had significant improvement in terms of both mean best corrected visual acuity (BCVA) and mean central macular thickness (CMT). The vitrectomised eyes also had a significant improvement in mean CMT, although their improvement in BCVA did not reach statistical significance. In addition, the treatment response was slower in the vitrectomised eyes. However, at six months there was no significant difference between the groups in terms of improvement in either BCVA or CMT. Y Koyanagi et al, “Comparison of the Effectiveness of Intravitreal Ranibizumab for Diabetic Macular Edema in Vitrectomized and Nonvitrectomized Eyes”; Ophthalmologica 2016, Volume 236, Issue 2.

FRAGMENTED DEXAMETHASONE INTRAVITREAL IMPLANTS STILL AS EFFECTIVE Fragmentation of the Ozurdex® (Allergan) dexamethasone intravitreal implant does not influence the implant’s efficacy or safety in eyes with macular oedema (ME) secondary to branch retinal vein occlusion (BRVO), a new study indicates. It showed that the implants were broken in six (8.8 per cent) of 68 consecutive patients undergoing treatment for BRVO-induced ME. However, the two groups did not differ in BCVA at any time point (all p>0.05). There were also no differences in the ME recurrence rate, frequency of intraocular pressure elevation, or cataract progression between the two groups (p>0.05). JC Im et al, “Does Intravitreal Dexamethasone Implant Fragmentation Affect Clinical Outcomes in Macular Edema from Branch Retinal Vein Occlusion”; Ophthalmologica 2016, Volume 236, Issue 2.

True innovation comes from sharing knowledge.

With ESCRS On Demand, you can view the presentations from as many conferences as you want.

Catch up on all the sessions from the Copenhagen congress.

CFH VARIANTS A DETERMINANT OF TREATMENT RESPONSE The variant of CFH haplotype a patient has can significantly influence their response to ranibizumab in the treatment of neovascular age-related macular degeneration (nAMD), a prospective cohort study suggests. Seventy treatment-naive nAMD patients were included in the study. All were genotyped for CFH haplotypes, single nucleotide polymorphisms (SNPs) in the C3 chromosome, the ARMS2 gene, and mitochondrial DNA genes. After six months of treatment with intravitreal ranibizumab, patients expressing protective CFH haplotypes were more likely to have gained 15 or more letters of visual acuity compared to those expressing the high risk CFH haplotypes (OR 6.58). V Chaudhary et al, ”Genetic Risk Evaluation in Wet Age-Related Macular Degeneration Treatment Response”; Ophthalmologica 2016, Volume 236, Issue 2.

Belong to something powerful. Join us. www.escrs.org

SEBASTIAN WOLF Editor of Ophthalmologica The peer-reviewed journal of EURETINA

EUROTIMES | OCTOBER 2016

43

ATTEND THE LARGEST U.S. MEETING DEDICATED EXCLUSIVELY TO THE NEEDS OF THE ANTERIOR SEGMENT SPECIALIST. • Learn directly from the world’s thought leaders

ADDITIONAL PROGRAMS

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ASCRS REFRACTIVE DAY • MAY 5 ASCRS GLAUCOMA DAY • MAY 5 CORNEA DAY • MAY 5 ASOA WORKSHOPS • MAY 5 T&N TECH TALKS | ATPO TRAIN THE TRAINER • MAY 5 TECHNICIANS AND NURSES PROGRAM • MAY 6–8

• Return with the practical tools needed to improve your practice

BOOK HOUSING TODAY AnnualMeeting.ascrs.org A JOINT MEETING WITH

HOSPITAL DIARY

A LITTLE THOUGHT If only there were a micro-assistant for the really tricky bits. Dr Leigh Spielberg reports

W

Illustration by Eoin Coveney

i t h o u t “I wish I had a tiny little assistant a pretty who could go check it out for us,” I significant said aloud while contemplating my zonular options. “She could go stand next to defect, the optic disc and look under the tuft it would to let me know what’s underneath. be tricky to get our little microIs there a massive vessel attached to assistant into the posterior the disc? Or is it harmless?” segment,” said Elke Kreps, the Elke didn’t miss a beat. “Yeah, fourth-year resident helping me that would be useful,” she said. “But in the operating room that day. if it did happen to bleed, you’d have “I know,” I replied. “Not ideal. But to get her out quickly before you hey, I can live with an intentional, raised the intraocular pressure to iatrogenic zonular defect if it serves 60mmHg. She might have trouble the greater good.” breathing under those conditions.”

“Me too,” she agreed.

“Yeah, and she’d get the bends “Good,” I concluded. when she came back out,” I added.

“But how would she lower I decided to remove the tuft herself down into the retina?” she with forceps and, as expected, asked. “Attach a fine suture to it bled a bit. But the optic disc some intact zonulae and rappel was undamaged. I increased the herself down?” intraocular pressure and waited “Well, now that we’ve destroyed patiently for the bleeding to stop. some zonulae, I don’t think we As I was performing panretinal can really risk damaging more. endolaser, Elke continued with I think we’d have to run a nylon our intraocular assistant musings.

10.0 through the primary incision “How would we get her into the at the limbus and anchor it to the posterior segment in the first conjunctiva,” I said. place?” she asked.

“Nylon?! Wouldn’t that be “Um, maybe inject her like an way too slippery for her to rappel Ozurdex?” I blurted out, without down? She wouldn’t have any thinking it through.

“Well, now that we’ve destroyed some grip at all,” she said.

“That would be efficient but zonulae, I don’t think we can really “Well, that depends. Would intense,” said Elke. “What if she the posterior segment be filled ended up stuck inside a choroidal risk damaging more” with air?” I asked. I had been detachment? Or a choroidal imagining a slow, aqueous haemorrhage? Doesn’t that descent from just under the iris to the posterior pole, but Elke had occasionally happen with intravitreal steroid implants?” something else in mind.

Ha! Elke had clearly been doing her homework for her “Of course. How would she breathe if it were filled with VR surgery rotation. “Not in my hands,” I countered, with a BSS?” asked Elke. vitreoretinal surgeon’s typical braggadocio.

“Hmm… Scuba equipment? Yeah, very small scuba But she was right. Injecting our micro-assistant through the equipment,” I replied. sclera wouldn’t work. That would require a custom-made injection It was time to go back to the OR. We had started this absurd, yet capsule for her to fit into. And as long as we were operating, there instructive, thought experiment during the previous procedure, a would be enough entry ports: like the limbal incision of the vitrectomy for vitreous hemorrhage in an eye with proliferative cataract surgery, or the vitrectomy ports. diabetic retinopathy.

Our thought experiment had borne its fruits. We had, in an It had been my most difficult PDRP case since I had amusing fashion, thought intelligently, if somewhat irreverently, completed my advanced VR fellowship in Ghent. I had cleared about the challenges facing VR surgeons: visualisation of, the haemorrhage and had safely dissected all vitreoretinal and and access to, the posterior chamber, including anatomical membranous adhesions. However, there remained a rather large considerations and the risks of complications. fibrovascular tuft adherent to the optic disc, and it wasn’t I started thinking of other useful things a micro-assistant could immediately clear how I should best deal with it. do, like gently dislodge vitreomacular traction or make sure that Use the cutter to shave it as closely as possible to the disc? there’s no posterior hyaloid left on the retinal surface after I Or the forceps to remove it? How vascular was it? Was the had induced a posterior vitreous detachment. But it was time to neovascularisation active? Fluorescein angiography had been operate, and we had to concentrate. The micro-assistant would impossible, so I had to rely on my instinct and experience. have to wait until a later date.

On the one hand, I wanted to remove it entirely. On the other Dr Leigh Spielberg is a vitreoretinal and cataract surgeon hand, I wasn’t enthusiastic about the possibility of a massive at Ghent University Hospital in Belgium haemorrhage covering the posterior pole or a sectorial avulsion of a quarter million retinal nerve fibres.

Leigh Spielberg: leigh.spielberg@gmail.com EUROTIMES | OCTOBER 2016

45

BOOK REVIEWS

SMALLER! SMALLER! Ask any vitreoretinal surgeon what the future holds, and the answer is always the same: “Smaller!” Smaller gauge, that is, and its promise of smaller incisions, shorter surgical times, fewer scleral sutures, less inflammation, and hopefully a faster and smoother recovery.

But how and when should PUBLICATION each surgeon decide to transition 27-GAUGE VITRECTOMY from 23G? Which points must be AUTHORS taken into consideration? How ULRICH SPANDAU does one get started? & MITROFANIS PAVLIDIS The textbook 27-Gauge Vitrectomy (Springer), by PUBLISHED BY SPRINGER Ulrich Spandau and Mitrofanis Pavlidis, is a great place to start.

As promised, it provides “step-by-step instructions on how to operate with 27G instrumentation in a wide range of surgical indications… and a meticulous description of preparation and performance with supporting photographs, drawings and videos.” In doing so, it does a thorough job of preparing a surgeon for the upgrade to 27G surgery.

But this book is not simply a tribute to 27G. Instead, it is a rather comprehensive handbook of surgical technique, offering experienced insight into the instruments, procedures and principles of vitreoretinal surgery as it is currently practised.

While watching many of the 103 videos (convenient to download, with titles such as ‘Anterior dislocated IOL and macular hole with 27G’), reading all 101 surgical pearls (such as 'Difficult IOL extraction from posterior pole'), and contemplating the 35 case reports, I had the pleasant feeling that I was back in my fellowship, being actively coached through an operation.

This book is most appropriate for vitreoretinal surgeons planning a switch to smaller-gauge instrumentation, as well as for VR fellows and early-career VR surgeons.

BOOK

REVIEWS

Corn

e

Eu

a

a

Eu

C o r n

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European Society of Cornea and Ocular Surface Disease Specialists

8th EuCornea Congress

2017

LISBON 6–7 October

FIL – International Fair of Lisbon, Portugal

www.eucornea.org

27G CHALLENGES Once the switch to 27G has been made, several challenges will arise. One of these is the management of difficult diabetic retinopathy cases. Ever since the development of smallergauge techniques, surgeons have expressed reservations about the ability of these much thinner instruments to handle long, complex procedures involving a great deal of manipulation of the globe. Is the vitrectome rigid enough? Is the aspiration powerful enough? Will my surgery take forever?

Small-Gauge Vitrectomy for Diabetic Retinopathy (Springer), by Ulrich Spandau and Zoran Tomic, puts these concerns to rest. “All gauges from 20G to 27G can be used.

The main limitation of 25 or 27-gauge is the limited product range of vitreoretinal instruments. This will most likely change in the future,” the book states. The text then proceeds to share the surgeons’ experience and insight regarding the step-by-step treatment of every classification of proliferative diabetic retinopathy. Intended readers are the same as for 27-Gauge Vitrectomy.

DR LEIGH SPIELBERG Books Editor

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 | OCTOBER 2016

CALENDER

NOVEMBER

BEAVRS 2016

10–11 November Southampton, UK www.beavrs.org

↙

IMO – Trends in Glaucoma: Surgical & Medical Meeting

LAST CALL

OCTOBER 2016 The European Association for Vision and Eye Research (EVER) Congress 2016

18–19 November Barcelona, Spain www.imo.es/ glaucoma2016

DECEMBER

ISOPT Clinical 2016 1–3 December Rome, Italy www.isoptclinical.com

Joint Irish and UKISCRS Refractive Surgery Meeting 2 December Dublin, Ireland Email: hmurphy@materprivate.ie

5–8 October Nice, France www.ever.be

2017

AAO 2016

8th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

15–18 October Chicago, USA www.aao.org

The XXXX Anniversary of UKISCRS – Annual Meeting

20–21 October London, UK www.ukiscrs.org.uk/events

JANUARY

11–13 January Vienna, Austria www.ophthalmictrainings.com/ workshops

7th EURETINA Winter Meeting 28 January Vienna, Austria www.euretina.org

FEBRUARY

3rd Asia-Australia Congress on Controversies in Ophthalmology (COPHy AA) 9–12 February Seoul, South Korea www.comtecmed.com/ cophy/aa/2017/ default.aspx

21st ESCRS Winter Meeting

10–12 February Maastricht, The Netherlands www.escrs.org

FEBRUARY

Retina World Congress

23–26 February Fort Lauderdale, USA www.retinaworldcongress.org

MARCH

NEW 31st International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 2–5 March Athens, Greece www.hsioirs.org/index.php/en

8th World Congress on Controversies in Ophthalmology (COPHy)

30 March –1 April Madrid, Spain www.comtecmed.com/cophy/ 2017/default.aspx

APRIL

AAPOS Annual Meeting

2–6 April Nashville, USA www.aapos.org/meeting/ annual_meeting_future_dates

FLOREtina 2017 27–30 April Florence, Italy www.floretina.it

MAY

ASCRS 2017

5–9 May Los Angeles, USA www.ascrs.org

ARVO Annual Meeting 2017 7–11 May Baltimore, USA www.arvo.org

MediterRetina Club International Meeting 11–13 May Parma, Italy www.mediterretina.com

JUNE

30th APACRS Annual Meeting

1–4 June Hangzhou, China www.apacrs2017.org

SOE 2017

10–13 June Barcelona, Spain www.soe2017.org

World Glaucoma Congress

28 June–1 July Helsinki, Finland www.worldglaucoma.org

EUROTIMES | OCTOBER 2016

47

CALENDAR

AUGUST

ASRS Annual Meeting 2017 12–16 August Boston, USA www.asrs.org/ annual-meeting

SEPTEMBER

17th EURETINA Congress 7–10 September Barcelona, Spain www.euretina.org

EVER – European Association for Vision and Eye Research Congress 2017 27–30 September Nice, France www.ever.be

Berlin

DOG 2017

28 September–1 October Berlin, Germany www.dog.org

8th EuCornea Congress

11–14 November New Orleans, USA www.aao.org/ annual-meeting

XXXV Congress of the ESCRS

4th World Congress of Paediatric Ophthalmology and Strabismus

OCTOBER

6–7 October Lisbon, Portugal www.eucornea.org

7–11 October Lisbon, Portugal www.escrs.org

2018

NOVEMBER

AAO 2017

DECEMBER

SEPTEMBER

↙

48

1–3 December New Delhi, India wspos.org/india-2017

EURETINA WINTER MEETING Medical University Vienna, Austria

Saturday 28 January 2017 Programme available online www.euretina.org EUROTIMES | OCTOBER 2016

18th EURETINA Congress 20–23 September Vienna, Austria www.euretina.org

9th EuCornea Congress 21–22 September Vienna, Austria www.eucornea.org

XXXVI Congress of the ESCRS 22–26 September Vienna, Austria www.escrs.org

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