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Dec 2016 | Vol 21 Issue 12 Jan 2017 | Vol 22 Issue 1







The Essence of Perfection For Retina, Cataract and Glaucoma Surgery • HDC Control for maximum precision, safety and surgery control • Newly developed vacuum and flow tri-pump system • SPEEP® mode for very precise maneuvers • Active and gravity infusion • Up to 10’000 cuts with the Continuous Flow-Cutter • Double light source with color adjustable LED technology • Fully integrated 532 nm green endo laser • Brand new phaco engine for even more efficiency and safety • Wireless, dual linear all-in-one foot switch • Intuitive user interface with Direct Access® • Embedded Controller Technology for utmost system performance

Ecknauer+Schoch ASW. Not available for sales in the US. ID1002.E-2015.09


Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Lara Fitzgibbon Designer Monica De Iscar 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: Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983



SPECIAL FOCUS CATARACT & REFRACTIVE 4 Cover Story: New biometric devices – the quest for optimum outcomes

8 Everything you ever wanted to know about small pupil phacoemulsification – Part 1

10 Why is there no growth in LASIK volume?

11 ‘FLACS provides

better visual outcomes compared to conventional cataract surgery’

12 Reducing effective

phaco time to zero

13 JCRS Highlights

FEATURES CORNEA 16 Intraoperative OCT helpful for complex lamellar surgery

17 ‘New approaches urgently needed to address the management of the ocular surface’

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.

18 Cultivated limbal

stem cell grafts – exciting potential

RETINA 21 Trials evaluating gene therapy for Leber’s hereditary optic neuropathy

22 ‘Office-based vitrectomy set to become a reality’

23 Ophthalmologica Update

GLAUCOMA 24 Glaucoma monitoring

– mean deviation versus visual field index


25 Individual modulation of stimuli used in standard automated perimetry


26 ‘One type of testing

31 ESCRS News

can be better than two’

32 Hospital Diary


33 Industry News

27 Flicker test could

35 Book Reviews

provide simple screening tool for Alzheimer’s

36 Calendar

28 Measuring ophthalmic quality of life with greater precision


treatment approach for congenital cataracts? CME Monograph

Supplement Dec 2016/Jan 2017

Included with this issue... ESCRS Education Forum and MedEdicus supplements



Visit for online testing and instant CME certificate.

Surgical Management of Astigmatism for Cataract Patients: Pre, Intra, and Post-Operative Protocols for Success

FACULTY: Andrea Leonardi, MD (Chair and Moderator) Francisco C. Figueiredo, MD, PhD, FRCOphth Elisabeth M. Messmer, MD, FEBO Terrence P. O’Brien, MD Stephen C. Pflugfelder, MD

ORIGINAL RELEASE: December 1, 2016 LAST REVIEW: September 19, 2016 EXPIRATION: December 31, 2017


Distributed with This continuing medical education activity is jointly provided by New York Eye and Ear Infirmary of Mount Sinai and MedEdicus LLC.

This continuing medical education activity is supported through an unrestricted educational grant from Santen Pharmaceutical Co, Ltd.





The ESCRS is using new technologies to produce better educational and training resources for its members


e should never be slaves to technology, but The Young Ophthalmologists Programme on Friday, 10 February we must always be prepared to consider new will once again feature the very popular “Learning from the approaches in our practices. This month’s learners” interactive session on cataract surgery for trainees, where cover story looks at new biometry instruments young ophthalmologists can present their own video cases. that measure ocular dimensions (see Page 4). As always, I am very grateful to my co-chairpersons Simonetta As I have pointed out in the article, Morselli and Kaarina Vannas the accuracy of modern biometry instrumentation in and our distinguished speakers When I attended my first measuring the eye’s dimensions and the postoperative Richard Packard and Khiun Tjia, position of the intraocular lens (IOL) in relation to the who will discuss these cases with ESCRS Congress, the majority intraocular anatomy, mean that the term ‘effective lens the trainees and also present of delegates attending position’ is out-of-date. their own pearls of wisdom. lectures and instructional We relied on formulas because, 15 or 20 years ago, the Finally, a quick reminder to technology was not as advanced as it is today. Now, with all of our YOs that the very courses would rely on printed even mobile phones having more computational power popular John Henahan Writing handouts to help them than the largest computers at that time, we can do the Prize is now open for entries understand some of the direct calculation of the optics of the individual eye using for 2017. The topic for the ray tracing without approximations and simplifications. essay is ‘How does commercial complex procedures... I believe this will be a game changer for IOL power interest affect my career?’, a calculation in the future. subject which we expect will When I attended my first ESCRS Congress, the majority of generate a lot of interest from our trainees. delegates attending lectures and instructional courses would The winner will receive a €1,000 travel bursary to the XXXV rely on printed handouts to help them understand some of the Congress of the ESCRS in Lisbon, Portugal. Further information complex procedures that were being highlighted. Now almost is available on: every delegate will have a phone or a tablet to help them process Finally, as we look back on the old year and look forward to the information in real-time. next 12 months, I would like to wish all readers of EuroTimes a As chairperson of the Young Ophthalmologists Committee, I am very happy and prosperous 2017. pleased to see that we are not only following the latest technological advancements but that we are using these technologies to produce better educational and training resources for our members. The new ESCRS Player now has a special section featuring videos from previous YO Programmes. The best videos have been selected and tagged with keywords which makes them easy to navigate. YOs will also benefit from studying the ESCRS Video of the Month and the EuroTimes Eye Contact video interviews with key opinion leaders. I am also glad to note that the YO programme at the annual Dr Oliver Findl is Secretary of the ESCRS, Chairperson ESCRS Congress in Copenhagen was very well received by of the ESCRS Young Ophthalmologists Committee, Chief of delegates and that it continues to go from strength to strength. the Department of Ophthalmology in Hanusch Hospital, and We are now looking forward to the 21st ESCRS Winter founder of the Vienna Institute for Research in Ocular Meeting which will be held in Maastricht, The Netherlands, from Surgery (VIROS), both in Vienna, Austria 10-12 February 2017.


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)


It‘s time to start Laser Cataract Surgery. 2


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cts. st catara o m r fo LS. d IAL CEL Standar DOTHEL TO EN GENTLE

chine. ry I/A ma e v e h it IDE Works w ORLD W IS A W LASER ENT TREATM D E T P E ACC

Bessemerstr. 14 90411 Nürnberg Germany  +49 (0) 911 217 79 -0





New biometric devices and data analysis techniques combine in the quest for optimum outcomes in cataract surgery. Roibeard O’hEineachain reports EUROTIMES | DECEMBER 2016/JANUARY 2017

NEW MACHINES IOL calculation formulas include a range of measurements, keratometry and axial length (AL) being essential to all, and anterior chamber depth (ACD) included in most, with lens thickness and corneal diameter measurements included in some. Originally these types of measurements required several tests with several machines. In more recent years there has been a trend towards allin-one biometers that can provide all of those measurements and more in a single short test. One example is optical biometry, which, almost from its launch in1999 in the form of the IOLMaster® (Zeiss), emerged as the gold standard for obtaining AL measurements. However, its precision based on partial coherence interferometry (PCI), was more limited when measuring ACD, and lens thickness. A drawback of the multimode laser used with PCI is its spectral side maxima,


Courtesy of Oliver Findl MD


ew biometry instruments that measure ocular dimensions with micron precision and intraocular lens (IOL) calculation formulas using increasingly sophisticated methodology are showing promise in providing much-needed improvements in the predictability of the IOL power in the eyes of cataract surgery patients. The sophistication of IOL designs has also increased with the potential for precise correction of astigmatism and presbyopia, as well as an enhanced quality of vision. However, much of the benefit of the newer lens designs is lost where there is only slight residual refractive error. Currently, on average around threequarters of eyes undergoing cataract surgery achieve the requisite accuracy of being within plus or minus half of one dioptre of emmetropia. But there remain around 25% of patients who are not within that range and around 10% of patients who are more than 1.0D outside of predicted refraction, said David J Spalton FRCS, FRCP, FRCOphth, President of the ESCRS. “We now realise that with our presbyopia-correcting lenses or toric lenses, the biometry has to be a lot better than it has been up until now if these lenses are going to work properly. And since 95% of refractive error is sphere and cylinder, the benefits of asphericity get lost in the noise unless your biometry and IOL calculation is really spot on,” he told EuroTimes in an interview. “I also think we are entering a new era with regard to IOL calculation because the newer formulas, such as the Olsen, Barrett Universal II and Warren Hill’s Radial Basis Function formula, are all becoming much more accurate in offering a greater chance of achieving emmetropia,” he added.


Screening for macular disease with swept-source OCT biometry (left) compared to retinal OCT (right)

which might lead to secondary interference maxima of the retinal peak, resulting in misinterpretation of the retinal signal in some cases. This, however, was addressed by a software upgrade (IOLMaster Version 5). This software allows averaging of consecutive optical scans, resulting in a composite scan. The new algorithm has been useful in 30% of cases that could not be measured with the previous software version. A new non-contact optical biometer (Lenstar, Haag-Streit AG) using optical low-coherence reflectometry (OLCR) was commercially introduced in 2008. The technique was developed in the 1980s in the telecommunication industry for reflection measurements. “With this new piece of technology, for the first time we were truly able to measure the ACD and for the first time were able to truly measure the lens thickness, and also get better measurements in the eyes with very dense cataracts and posterior subcapsular cataracts,” said Sathish Srinivasan FRCSEd, FRCOphth, FACS, University Hospital Ayr, Scotland, UK. The new IOLMaster 700 (Zeiss) uses swept-source optical coherence tomography (SS-OCT) which enables more accurate ACD, measuring lens thickness and still better measurements of the cornea. It also provides more accurate keratometry and may eliminate the need for corneal topography in eyes with irregular corneas. “The IOLMaster 700 is quite different and it is a game changer because it uses SS-OCT. That means we get a proper twodimensional cross-sectional image of the entire eye. You also have a pachymetry map of the cornea. Software updates to actually give the posterior corneal curvature data will be coming out soon,” said Oliver Findl MD, Hanusch Hospital, Vienna, Austria. The posterior corneal curvature is generally not an important factor in most cataract patients, but can be crucial in toric IOL calculations, and for eyes that have undergone previous corneal refractive

surgery or keratoplasty procedures. Corneal topographers have been the device of choice for anterior and posterior curvature mapping, although the Barrett Toric IOL Calculator uses a fudge factor.

OPTICAL ELEMENTS The values measured by ocular biometry in cataract patients make up the optical elements of the eye. Keratometry provides the refractive power, the AL provides the eye’s overall focal length, and the ACD provides an idea of where the lens is and therefore the power of the IOL needed to provide the eye with desired refraction. However, the different formulas vary in terms of what parameters they include. All require AL and K, including several early formulas that required only those two parameters, such as the Hoffer Q, Holladay 1, SRK/T, and T2. The Haigis formula adds ACD, but does not use the K. Further parameters in other formulas include lens thickness, corneal diameter, age and preoperative refraction. Since not all biometers can provide all of the measurements necessary for some thirdand fourth-generation formulas, results with the different formulas will differ with different devices. At the same time, some formulas with fewer inputs perform as well or better than those with more inputs. A recently published study (Cooke et al, Cataract Refract Surg, 2016; 42:1157–1164) showed that, in a retrospective series of 1,450 eyes implanted with the Acrysof SN60WF IOL (Alcon), the Olsen formula performed the best out of nine formulas at all ALs when Lenstar values were used, but performed the worst of all nine formulas at all ALs when PCI measurements were used and the lens thickness values were not included. That may indicate the importance of lens thickness in the formula. However, when PCI measurements were used, the Barrett Universal II formula achieved the best results at all ALs, despite the formula’s requirement for unavailable lens thickness values. EUROTIMES | DECEMBER 2016/JANUARY 2017

COVER STORY: CATARACT & REFRACTIVE Moreover, the Barrett formula performed almost as well as the Olsen formula when using Lenstar measurements, even though, unlike the latter formula, its inputs do not include patients’ age or central corneal thickness. Another finding of the study was that the Holladay 2 formula performed better when the preoperative refraction data was omitted.

FORMULA EVALUATION PROTOCOLS Among the difficulties encountered when collating data for use in evaluating and comparing IOL formulas are the discrepancies in data collection and errors in methodology, according to an editorial by the IOL Power Club, a group of well-known creators of IOL calculation formulas and a respected statistician, in the March 2015 issue of the American Journal of Ophthalmology. They point out, for example, that ACD is variously defined as the distance between the corneal epithelium and the anterior surface of the lens, and as the distance between the corneal endothelium and the lens. While the latter may be the original definition of ACD, they suggest that the endothelium-to-lens distance should instead be termed the ‘aqueous depth’ and ACD be used for the epithelium-to-lens distance. Even the term ‘target refraction’ can be confusing and contradictory, since some authors define it as the desired refraction, whereas it is more appropriately defined as the refraction achievable with a given lens in a given eye according to the formula used. Speaking with EuroTimes in an interview, Kenneth J Hoffer MD, one of the co-authors of the editorial, said that the use of the term 'average' for biometric values also needs to be better qualified. He pointed out that his own research indicates that biometric averages vary by gender and race. “We did a study collecting data in 250,000 eyes published over the past 20 years and discovered that men have an AL a half millimetre longer than women when you adjust for height and weight, and a half a dioptre flatter cornea,” said Dr Hoffer, Stein Eye Institute, University of California, Los Angeles, USA. He noted that average values are an important component of the Holladay 2 formula. In a retrospective, study involving 2,707 eyes, he was able to show that adjusting the average values in the Holladay 2 to the average values for the patient’s gender and race resulted in a 30-40 % better median absolute error prediction accuracy

Courtesy of Oliver Findl MD


Predicting post-op IOL tilt using swept-source OCT biometry

compared to the Hoffer Q, the Holladay 1 and the SRK/T formulas. The new formula, called the Hoffer H-5 (H for Holladay; 5 for 5th generation), would have resulted in 84% of eyes being within ±0.20D of predicted refraction, he said. The H-5 formula will soon be available on the IOLMaster 700, the Lenstar and the Aladdin.

THE END OF FORMULAS? Meanwhile, new research tools such as artificial intelligence are making inroads into IOL calculation with the introduction of Warren Hill’s Radial Basis Function software. Using pattern recognition software and an ever-growing database, the software detects correlations between postoperative outcomes and three IOL calculation inputs, such as AL, ACD, and steep and flat keratotomy values, and on that basis determines the best IOL for a particular patient. “They’ve done both a prospective and retrospective analysis to show that it works not only in the retrospective database but also when you enter prospective data. So they have been incredibly thorough about it,” Prof Spalton told EuroTimes. The Hill-RBF Calculator has been launched in 2016 and it is available for free online. Surgeons using the calculator

...we should be moving away from only formulas and moving more towards ray tracing Oliver Findl MD EUROTIMES | DECEMBER 2016/JANUARY 2017

are encouraged to enter optional values such as lens thickness and corneal diameter measurements, to provide data for future versions of the calculator. One limitation of the radial basis function IOL power calculator in its present form online is that it is based on data obtained with only one optical biometer, the Lenstar LS 900, and only one type of IOL. And, though the user enters the type of biometer used and the A constant of the lens to be implanted, the website cautions users of the calculator that for optimal results the same biometer/lens as that of the original dataset should be used. Dr Findl told EuroTimes that he also questions whether the traditional formulas of the past are the way forward. He noted that the accuracy of modern biometry instrumentation in measuring the eye’s dimensions and the IOL’s postoperative position in relation to the intraocular anatomy, mean that the term ‘effective lens position’ is out-of-date. “I think we should replace the term ‘effective lens position’ with ‘anatomic lens position’. And I personally believe we should be moving away from only formulas and moving more towards ray tracing. We had formulas because, 15 or 20 years ago, our computers lacked the necessary speed. Today, with any smartphone we can do the calculation in a very short time,” Dr Findl added. David J Spalton: Sathish Srinivasan: Oliver Findl: Kenneth J Hoffer:



FIL – Feira Internacional de Lisboa, Portugal

Abstract Submission Deadline: 15 March 2017 /ESCRS @ESCRSOfficial ESCRS




Everything you ever wanted to know about small pupil phacoemulsification – Part 1.


small pupil, either a poorly dilating one or one that constricts intraoperatively, can create difficulty in each step of phacoemulsification and result in a downward spiralling sequence of events. A pupil smaller than 5mm may result in a smaller-sized rhexis than desired. Difficult manoeuvring can cause accidental iris aspiration, iris damage, bleeding, unintentional anterior capsular tears, difficulty in nucleus and cortical removal and in-the-bag intraocular lens (IOL) insertion and IOL rotation in case of toric IOLs. Difficult surgery can result in unwanted complications such as iridodialysis, zonulodialysis, hyphema, nucleus drop, IOL drop etc. Postoperatively, prolonged and difficult surgery can result in striate keratopathy, anterior chamber inflammation, secondary glaucoma, irregular tied down pupil, iris defects/atrophic patches, cystoid macular oedema etc. A small rhexis can also result in future complications such as capsular phimosis, IOL decentration etc. It is therefore important to be prepared.

PREOPERATIVE CONSIDERATIONS: Pupillary dynamics and dilated pupil size should be noted preoperatively. A thorough history and examination reveals any underlying aetiology, such as longterm topical miotics, rigid pupil, posterior synechiae, pseudoexfoliation syndrome, diabetic and post-uveitic patients and those on alpha-1 antagonists such as tamsulosin (FLOMAXÂŽ, Boehringer Ingelheim) for prostatic hypertrophy. Mydriatic and non-steroidal antiinflammatory drug (NSAID) drops should be used preoperatively on the day of surgery. Inadequate preoperative mydriatics can result in poor dilatation or intraoperative constriction. EUROTIMES | DECEMBER 2016/JANUARY 2017

Dr Soosan Jacob reports INTRAOPERATIVE CONSIDERATIONS: Intracameral pharmacological mydriasis: Shugarcaine (1cc preservative-free 4% lidocaine and 3cc BSS plus, created by the late Dr Joel Shugar) is a well-tolerated, neutral pH intracameral anaesthetic which paralyses the pupil sphincter. Epinephrine is especially useful in intraoperative floppy iris syndrome (IFIS) as it reduces iris prolapse and billowing. Intracameral phenylephrine 1.5% may also be used together with lidocaine 2%. Epi-Shugarcaine (3cc preservative-free 4% lidocaine, 4cc bisulfite free 1:1000 epinephrine and 9cc BSS plus) increases pupil dilatation and iris rigidity by increasing dilator smooth muscle tone. Toxic anterior segment syndrome (TASS), especially with improper dilution and systemic hypertensive spikes, though rare, may occur. Mechanical mydriasis: High molecular weight cohesive viscoelastics such as Healon-5/ Healon GV can be injected into the centre of the pupil for pupillary dilatation in some cases. Repeated instillation may be required. Surgical mydriasis: Synechiolysis, if required, may be done with viscoelastic

Iris stretch

or a blunt spatula. Pupillary membranes may be cut and removed using intraocular micro-instruments. Any bleeding can generally be tamponaded with air. Small, less than 1mm mini-sphincterotomy cuts on the iris that are limited to sphincter tissue can be made with Vannas scissors or vitreoretinal scissors. Pupillary stretching, as described by Dr Luther Fry, can also be performed. Under viscoelastic cover, the pupil is stretched gently in one or more axes using two Kuglen Hooks, taking care to avoid large sphincter tears. Two-, threeand four-pronged pupil stretchers are also available. Pupil stretch has the disadvantages of creating large sphincter tears and making the iris flaccid which can cause repeated iris prolapse through phaco incisions, especially in poorly constructed, short tunnels. They can also increase postoperative inflammation. A combination of mini-sphincterotomies/ gentle stretch with viscoexpansion may be employed. Pupil expander devices may be used for phaco in patients with small pupil (these will be discussed in Part 2).

Tri-pronged pupil stretcher


PHACO CONSIDERATIONS: Phaco incisions need to be self-sealing and sufficiently long. Too short or leaking tunnels can allow repeated iris prolapse and iris trauma. Viscoelastic may be used to expand the pupil. The rhexis should be done through a partial entry to avoid the ophthalmic viscosurgical device (OVD) from escaping, which can allow the pupil to constrict again. Capsular dye may be used for better visualisation. It is possible to carry the rhexis just outside the pupillary margin by keeping the anterior capsular flap flat and by repeatedly redirecting it. With sufficient experience, it is often possible to carefully perform phaco through a 4-4.5mm pupil, provided the iris is not atonic or floppy. As a smaller rhexis can increase chances of a capsular blowout, only gentle multi-quadrant hydrodissection is done. Blind manoeuvres under the iris should be avoided and vertical chop can be used for nuclear disassembly. Soft nuclei may be hydrodelineated well and then gently hydroprolapsed out. The phaco tip should remain only in the centre of the pupil to avoid iris aspiration. Once aspirated, there is a tendency for repeated aspiration at same site. The second instrument may be used to hold the iris margin away during intraoperative manoeuvres. Irrigation/aspiration (I/A) is easier with the bimanual technique. Capsule polishing mode can often be helpful to grasp and bring sub-incisional cortex centrally, following which vacuum can be increased for aspiration. A slow expanding IOL may be easier to insert, making sure both haptics enter the capsular bag. More intensive postoperative steroids may be required for controlling inflammation. In situations which do not allow adequate visualisation or if the surgeon


Vertical chop

feels the need for it, one or more of the previously mentioned techniques/devices may be used to expand the pupil.

with a 5.0mm pupil, there is risk of accidental iris injury. Laser application itself can cause pupillary miosis and lenticular fragmentation may become more difficult or cause iris trauma. Pre-treatment with a topical NSAID may be done to decrease prostaglandin induced miosis.

IFIS: Described by Chang and Campbell, this presents with progressive intraoperative pupillary constriction, along with billowing of a flaccid iris and iris prolapse into the phaco incisions. These may be tackled using pharmacological strategies (described earlier), bimanual microincision phacoemulsification, gentle hydrodissection, a highly viscous or viscoadaptive OVD, low flow parameters, directing irrigating currents away from the pupillary margin and mechanical pupillary dilators such as iris hooks and expansion rings. Minisphincterotomies and pupillary stretch are ineffective and may worsen iris flaccidity.

Soosan Jacob MS, FRCS, DNB 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

FEMTOSECOND LASER-ASSISTED CATARACT SURGERY (FLACS): A pupil less than 6mm in diameter is a relative contraindication to FLACS. Though possible to perform an anterior capsulotomy

Scan this QR code to view the live surgery


Glaucom� Day 2017 Friday 6 October FIL – International Fair of Lisbon, Portugal Scientific Programme organised by





NO GROWTH IN LASIK Despite better outcomes than ever, volume has not recovered to its 2007 peak. Howard Larkin reports


ith advanced diagnostics, femtosecond laser flap cutters, and wavefrontand topography-guided treatment, LASIK refractive outcomes and safety have never been better. Yet global LASIK volume peaked at about 3.8 million procedures in 2007, and has struggled to break 3.6 million since. In the USA, the picture is even worse. Volume peaked at 1.4 million procedures in 2000, and has bumped along around 600,000 for the last five years, according to Market Scope data presented by Richard L Lindstrom MD at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. “We are in a no-growth market globally and in the USA. The question is, why is that?” asked Dr Lindstrom, founder of Minnesota Eye Consultants in Bloomington, Minnesota, USA.

NEW GENERATION, NEW ATTITUDES It’s not lack of candidates, Dr Lindstrom said. In the USA, just 12% of the more than 120 million candidate eyes have been treated – and the pool grows by one million eyes every year for myopia alone. Nor is it poor outcomes. More than 95% of commercial LASIK patients and 98% of military patients were at least somewhat satisfied, with well over 90% completely or very satisfied, according to an FDA quality-of-life survey. Nearly 80% had 20/20 or better vision, and 99% had 20/40, 12 months after surgery. What hasn’t kept up is public awareness and doctor interest, Dr Lindstrom said. Many patients have outdated impressions of LASIK, such as that it can’t correct

astigmatism. And while marketing and advertising expenses per procedure have remained steady, total budgets have fallen. Some practices may find they get a better return marketing refractive lens exchange or premium intraocular lenses, he said. A similar dynamic may be driving a decline in ‘refractive only’ surgeons – since 2007 the proportion of US surgeons identifying as ‘refractive only’ dropped 84%, while those doing both cataract and refractive climbed. With the population ageing, some may feel there’s no need to fight for LASIK patients when there


Social media may be one way to reach Millennials, said Eric Donnenfeld MD, of New York University, USA. Outcomes are good, making outreach to friends a natural. “When people start talking about this on social media forums, the overwhelming message will be: ‘Wow, this is the best thing I’ve ever done’. We have to really encourage our patients to get involved in social media,” he said. Market research in conjunction with the ASCRS shows that there is big disconnect between what p a t i e n t s , particularly younger patients, want to hear and what surgeons think is important, Dr Lindstrom said. “They don’t care if it’s wavefront-guided or topography-guided, they want to know if it will help them see better when they go to the beach – and how big the risks are, and what the process is like, and later what it costs,” he added. Emphasising the excellent outcomes of modern LASIK may also help, said Steven Dell MD, Austin, Texas, USA. Patients treated with current wavefront and femtosecond laser technology often end up with better than 20/20 uncorrected vision. In fact, three-quarters of patients treated in the PROWL-1 study of US military personnel were 20/12.5 or better six months after LASIK, he noted. Dysphotopsias and dry eye were also reduced from preop levels, so emphasising the minor and temporary nature of most complications may also help. LASIK patient satisfaction also compares favourably to other elective surgical procedures, Dr Dell said. “The only adjective I can come up with that describes current LASIK outcomes is superb,” he concluded.


are plenty of cataract, glaucoma, diabetic retinopathy etc. cases, Dr Lindstrom said. Alternatives are also improving, Dr Lindstrom said. Extended wear and new materials have made contact lenses more convenient and comfortable. Even so, about three million patients give up contacts annually, but only 10% transition to LASIK. Many go back to spectacles. Thinner lenses and stylish-frame spectacles are not only attractive, they can be a fashion statement. “Perhaps there’s something wrong with our message,” Dr Lindstrom said. He pointed out that current surgeons started out marketing to their friends and colleagues and now are marketing to their children. “The messages I respond to are very different from the messages my children respond to,” Dr Lindstrom added. He suggested more focus on Millennials, now in their 20s, who are on their way to prime LASIK age in their 30s.

When people start talking about this on social media forums, the overwhelming message will be: ‘Wow, this is the best thing I’ve ever done’ Eric Donnenfeld MD


Richard L Lindstrom: Eric Donnenfeld: Steven Dell:


LASER OR ULTRASOUND? Meta-analysis suggests better visual outcomes and safety with FLACS. Roibeard O’hEineachain reports


emtosecond laser-assisted cataract surgery (FLACS) provides better visual outcomes with less trauma to the eye compared to conventional cataract surgery, according to a meta-analysis of peer-reviewed studies presented at the XXXIV Congress of the ESCRS in Copenhagen, Denmark. The analysis showed that FLACS performed significantly better than conventional surgery in terms of uncorrected visual acuity, corneal endothelial cell loss and effective phaco time (EPT), and that it posed no additional dangers to the eye apart from a slightly but significantly higher incidence of anterior capsule rupture, reported Thomas Kohnen MD, PhD, Goethe University, Frankfurt, Germany. “FLACS has a comparable advantage and disadvantage profile to conventional cataract surgery. However, FLACS appears to be superior overall,” he added. Prof Kohnen and his associates included in their meta-analysis 38 peer-reviewed prospective and retrospective studies published from April 2015 to March 2016. The studies were identified through a systematic review of MEDLINE, The Cochrane Library and Embase. In total, the studies included 8,198 eyes that underwent FLACS and 7,684 eyes that underwent Thomas Kohnen conventional cataract surgery with ultrasound phacoemulsification and manual incisions and capsulotomies. All of the studies compared the two cataract surgery approaches, each recording their own sets of parameters. The researchers found that mean uncorrected visual acuity was significantly better in FLACS-treated eyes than in conventionally treated eyes, both overall and in five of seven studies involving a total of 2,215 eyes (p<0.01). Best corrected visual acuity was also better during the first week (p=0.001), but not after the first month. Furthermore, in most of the trials, mean EPT was several times lower in the FLACS groups. That is, in 11 trials involving a total of 609 eyes, mean EPT ranged from 0 seconds to 5.6 seconds among FLACS-treated eyes, and from 0.12 seconds to 14.24 among conventionally treated eyes.

LOWER CENTRAL CORNEAL THICKNESS Endothelial cell loss after six months was significantly lower in the FLACS-treated patients, both overall and in five of seven trials, which together involved a total of 833 eyes. The FLACS-treated eyes also had significantly lower central corneal thickness one day and one month after surgery compared to conventionally treated eyes. FLACS also did not appear to endanger the posterior segment to any greater extent than conventional cataract surgery. For example, posterior capsule rupture occurred with similar frequency with the two treatments, as was the case with macular oedema and increased intraocular pressure within the first 24 hours of surgery.

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Thomas Kohnen: EUROTIMES | DECEMBER 2016/JANUARY 2017



ZERO PHACO FLACS Effective phaco time can be reduced to zero with femtosecond laser-assisted cataract surgery. Roibeard O’hEineachain reports


o ultrasound is necessary when using femtosecond laser-assisted cataract surgery (FLACS) in most cataract patients, provided the correct nuclear fragmentation grid pattern is used, said Zsolt Biro MD, PhD, Head, Department of Ophthalmology, Medical University of Pécs, Hungary, and OPTIMUM Laser Centre, Budapest, Hungary. “We postulate that, with the routine use of zero phaco, we can further reduce the damage to the endothelial cells and the macula, which results in better postoperative visual acuity and quicker rehabilitation of our patients,” Dr Biro told the XXXIV Congress of the ESCRS in Copenhagen, Denmark. He noted that FLACS is gaining in popularity, not only because most of the important surgical steps can be performed with superb accuracy and repeatability. Furthermore, the perfectly circular and centred capsulotomies the laser provides allows for a more predictable and stable positioning of the intraocular lens (IOL), which is especially important for premium (multifocal and toric) IOLs. Moreover, research has shown that the simpler nucleotomy patterns, such as the cross pattern or the so-called called “pizza pattern”, reduces the amount of phaco energy used by up to 50%. That in turn improves safety for the endothelium, reducing endothelial cell loss by up to 40%. Furthermore, he noted that his own recent experience in a series of 20 patients shows that use of the cubicle grid nucleotomy pattern available with the VICTUS® (Bausch + Lomb) femtosecond laser platform can eliminate the need for ultrasound phacoemulsification completely in most patients. “Zero phaco FLACS should result in clearer corneas on the first day,” added Dr Biro, President of the Hungarian Ophthalmological Society. The cubicle grid pattern fragments the

nucleus into tiny 400µm or 500µm cubes. After nucleofractis the small pieces can be successfully removed with the Bausch + Lomb 20-gauge zero phaco irrigation and aspiration handpiece through a 1.82.75mm clear corneal incision.

THE ROAD TO ZERO EPT Dr Biro pointed out that effective phaco time (EPT) with standard ultrasound phacoemulsification can be as high as 10 to 12 seconds. With the earlier FLACS, EPT could be reduced to one second for grade I cataracts, between one second and two seconds for grade II cataracts, and between five seconds and six seconds for grade III cataracts. He noted that his experience has shown that, with the cubicle grid nucleotomy pattern, zero phaco FLACS surgery is easy for grade I cataracts, a little bit difficult for grade II cataracts, a little bit more difficult still for grade III, and not successful for grade IV (LOCS III). He added that the learning curve is minimal. When performing the zero phaco procedures, Dr Biro first locks the eye to the femtosecond laser and commences the nuclear fragmentation, using 500-micron cubicles in most cases. He noted that the fragmentation can be clearly observed in real time on both the surgical microscope and on the Victus system’s optical coherence tomography. Following nucleofractis, he moves the patient a few feet over to the phacoemulsification suite. Dr Biro then creates a 2.2mm clear corneal incision using a disposable knife. He then performs a hydrodissection and inserts the irrigation and aspiration handpiece and, with the vacuum set to 600mmHg, using a dual linear foot switch, and with the infusion bottle at 110-130cm, he extracts the fragmented nucleus and the cortex. He cautioned that, although ultrasound is eliminated, the laser energy use can lead to bubble formation which might potentially lead to possible

We postulate that, with the routine use of zero phaco, we can further reduce the damage to the endothelial cells and the macula... Zsolt Biro MD, PhD EUROTIMES | DECEMBER 2016/JANUARY 2017

Lens nucleus after grid pattern fragmentation with the VICTUS (Bausch + Lomb) femtosecond laser

Courtesy of Zsolt Biro MD, PhD


The 500µm cubes can be successfully removed with the Bausch + Lomb 20-gauge zero phaco irrigation and aspiration handpiece through a 1.8-2.75mm clear corneal incision

capsular rupture, increased levels of prostaglandin E2, intraoperative miosis, and potentially an increased inflammatory response. The surgeon must also be careful to maintain anterior chamber stability while removing the cataract, he noted. Fluid consumption with zero phaco can be 2.3 times higher on average than it is with conventional FLACS. The higher fluid consumption causes fluid streams in the anterior chamber which has the potential to damage endothelial cells and send small lens particles into the vitreous. “This was a descriptive analysis on a series of 20 cases without a research hypothesis. Further randomised trials are required to confirm the safety and efficacy of the zero-phaco technique of cataract removal,” Dr Biro concluded. Zsolt Biro:




TORIC IOL CALCULATION CHALLENGES The influence of posterior corneal astigmatism on total corneal astigmatism is known to differs between eyes with with-therule astigmatism and eyes with against-the-rule astigmatism. No prospective long-term study has assessed the influence of preoperative corneal astigmatism axis on prediction error after toric intraocular lens (IOL) implantation. In particular, the influence of oblique astigmatism has not been well addressed. Japanese researchers now report a prospective study that assessed the one-year clinical outcomes of toric IOL implantation in 218 eyes, including the influence of the preoperative astigmatism axis orientation, postoperative contrast sensitivity, higher order aberrations (HOAs), and rotational stability of toric IOLs. Overall, the study found that the toric IOLs were rotationally stable and highly effective in correcting pre-existing corneal astigmatism. However, cases of against-the-rule and oblique astigmatism remained slightly under-corrected with the current toric calculation system based on anterior corneal curvature data alone. Ocular HOAs and contrast sensitivity were not significantly influenced by toric IOL implantation. Y Ninomiya et al, JCRS, “Toric intraocular lenses in eyes with with-the-rule, against-the-rule, and oblique astigmatism: Oneyear results”, Volume 42, Issue 10, 1431-1440.

Controversies in Anterior Segment Surgery Monday, May 8, 2017 1:00–2:30 PM

IMPROVING TORIC IOL OUTCOMES Recent research suggests that calculating the cylinder power for toric IOLs could become more accurate when allowing for the effect of posterior corneal astigmatism. Australian researchers compared the absolute value of the prediction error of the toric IOL cylinder power effect in consecutive eyes with preoperative anterior keratometric cylinder values of 1.0 dioptre or more with the absolute value of the prediction error in a historical control group. The anteriorly measured keratometric cylinder values were altered by two coefficients of adjustment, one for with-the-rule eyes and one for against-the-rule eyes, before calculation of the IOL cylinder power to be implanted. In the controls, unadjusted keratometric cylinder values were used. In this case series of 31 eyes of 29 patients and a control group of 65 eyes, the absolute error in prediction of the toric IOL cylinder power effect was reduced from a median of 0.45D (95% confidence interval [CI], 0.33-0.58) in the controls to a median of 0.23D (95% CI, 0.13-0.35) in the adjusted eyes (P = .004). Toric IOLs of 2.0D cylinder power or less were prone to an error in refractive astigmatic outcome due to the relationship between the anterior and posterior keratometric rule. The researchers conclude that adjustment of toric IOL cylinder power by application of a coefficient of adjustment to anteriorly measured keratometric cylinder values based on the keratometric rule of the eye led to a clinically and statistically significant improvement in refractive astigmatic outcome. M Goggin et al, JCRS, “Outcome of adjustment for posterior corneal curvature in toric intraocular lens calculation and selection”, Volume 42, Issue 10, 1441-1448.

THOMAS KOHNEN European editor of JCRS

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Management of Residual Refractive Errors After Cataract Surgery Best Refractive Procedure for Moderate to High Myopia Intraocular Antibiotics for Cataract Surgery Moderators: Nick Mamalis, MD Sathish Srinivasan, MD During the ASCRS Symposium on Cataract, IOL and Refractive Surgery Los Angeles, California, USA




The Netherlands

In conjunction with the Netherlands Intra Ocular Implant Club & the Belgian Society of Cataract & Refractive Surgery

10–12 February

At the MECC Maastricht Main Symposia Friday 10 February

Saturday 11 February

Corneal Cross-Linking Update

Minimally Invasive Glaucoma Surgery (MIGS) for Cataract Surgeons

17.00 – 18.30

Chairpersons: D. Epstein SWITZERLAND J. Vryghem BELGIUM

16.30 – 18.00

Chairpersons: M.J Tassignon BELGIUM C. Webers THE NETHERLANDS

Saturday 11 February

Sunday 12 February

11.30 – 13.00

09.00 – 10.30

Long-term Complications of Refractive Surgery

The Usual Suspects: How to Handle Your First Complications

Chairpersons: A. Behndig SWEDEN R. Nuijts THE NETHERLANDS

Chairpersons: M. Severinsen DENMARK N. Visser THE NETHERLANDS /ESCRS @ESCRSOfficial ESCRS

Other Highlights Friday 10 February

Sunday 12 February

l Basic Optics Course

l NIOIC and BSCRS Symposium

l Cataract Surgery Didactic Course Part 1 l ESCRS/EuCornea Cornea Day l Moderated Poster Session l Refractive Surgery Didactic Course Part 1 l Young Ophthalmologists Programme Learning from the Learners: Interactive Video Session on Cataract Surgery for Trainees

Saturday 11 February l Cataract Surgery Didactic Course Part 2

25 l

Surgical Skills

Training Courses

Book early to avoid disappointment

l Cornea Didactic Course l Live Surgery (Organised by the Netherlands Intra Ocular Implant Club & the Belgian Society of Cataract & Refractive Surgery)

l Moderated Poster Sessions l Refractive Surgery Didactic Course Part 2

Programme, Registration and Hotels available online




MAASTRICHT Friday 10 February Lunchtime Symposium 13.00 Alcon Satellite Symposium Sponsored by

Saturday 11 February Lunchtime Symposia 13.00 My Best Case Reports from Premium Cataract and Refractive Practice Supported by an unrestricted educational grant from

Shaping Tomorrow’s Vision – ZEISS Innovative Refractive Solutions Moderator: B. Şener THE NETHERLANDS

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Intraoperative OCT helpful for complex lamellar surgery. Dermot McGrath reports


ntraoperative optical coherence tomography (iOCT) provides very useful but not indispensable guidance in the majority of lamellar corneal procedures, according to a study presented at the 2016 French Implant and Refractive Surgery Association annual meeting in Paris. “While OCT is certainly a useful tool to have for lamellar surgery, it is not absolutely vital in the majority of cases. Its utility varies according to the type of procedure being employed. Our study showed that it was very useful in Descemet’s membrane endothelial keratoplasty (DMEK), moderately useful in deep anterior lamellar keratoplasty (DALK), and less useful in Descemet’s stripping automated endothelial keratoplasty (DSAEK) procedures,” said Eric Gabison MD, PhD. However, OCT is particularly helpful when performing modified intrastromal lamellar sclero-keratoplasty for cases such as advanced pellucid marginal degeneration, he added. The technique was conceived based on iOCT technology. (Guindolet D, Petrovic A, Doan S, Cochereau I, Gabison EE. Sclerocorneal Intrastromal Lamellar Keratoplasty for Pellucid Marginal Degeneration. Cornea. 2016 Jun;35(6):900-3) Prof Gabison tested the real-time iOCT device (RESCAN 700 OCT, Carl Zeiss Meditec) in a variety of corneal lamellar procedures. The OCT is fully integrated into the OPMI LUMERA 700 microscope, with key functions controlled from the microscope’s foot pedal, enabling the surgeon to take videos and 3D OCT images without looking up or stopping the surgery.

STROMAL WHITENING In 20 DALK cases, no difference was seen in terms of “big bubble” achievement, however the visibility of the needle or cannula with OCT was safer and more reproducible, particularly for thin corneas. The visibility of the “big bubble” was also the same in routine cases, although OCT did prove useful in rare cases of stromal whitening, said Prof Gabison, Professor of Ophthalmology, Hôpital Bichat and Fondation Ophtalmologique Adolphe de Rothschild, Paris, France. In 10 DSAEK cases, there was no clear advantage using OCT to verify the graft orientation or the position of the cannula before air injection, said Prof Gabison. The device was, however, more useful in the 50 DMEK cases in order to determine the graft orientation before air injection, especially in the case of severe stromal oedema. For challenging cases of corneal disease where sclerocorneal intrastromal lamellar keratoplasty (“SILK”) might be indicated, the OCT proved indispensable for stromal lamellar dissection to correct both corneal thinning and induced corneal astigmatism, said Prof Gabison. (Guindolet D et al. Sclerocorneal Intrastromal Lamellar Keratoplasty for Pellucid Marginal Degeneration. Cornea. 2016 Jun;35(6):900-3; Guindolet D, Gabison EE. AAO 2016, Chicago) In this approach, corneal thinning was first mapped using OCT and then an intrastromal pocket was created by stromal lamellar dissection under OCT guidance. A 300μm-thick stromal lamellar graft was then inserted in the intrastromal pocket before closing the sclera to increase vertical median keratometry. Eric Gabison:



TAKING A NEW APPROACH Management of the ocular surface before and after refractive surgery. Leigh Spielberg MD reports

A Masterpiece of Dry Eye Diagnostics


ew approaches are urgently needed to address the management of the ocular surface before and after refractive surgery, according to Alexandre Denoyer MD, PhD, who discussed the way forward in a major symposium at the XXXIV Congress of the ESCRS in Copenhagen, Denmark. “We need new tools in order to better detect, treat and understand this problem, and to be able to objectively quantify disease severity and assess its impact on both quality of life and quality of vision. We also need these tools to help us to identify new pathological pathways,” said Prof Denoyer, University Hospital Robert Debré, Reims, and Quinze-Vingts National Ophthalmology Hospital, Paris, France. The new tools must have a high degree of validity to be useful to clinicians. They must be routinely usable, quantitative, predictive, objective, specific and sensitive while being able to immediately give the surgeon information, he said. In order to demonstrate the importance of the problem, he highlighted dedicated questionnaires, such as the Ocular Surface Disease Index (OSDI) and the Impact of Dry Eye on Everyday Life (IDEEL), that seek to quantify the effect of dry eye disease on the quality of life and its impairment of activities of daily living. Prof Denoyer further illustrated a strategy for preoperative detection of high-risk patients, selection of the correct procedure to minimise risk and administration of specific prophylactic and therapeutic treatments.

TEAR FILM AND THE OCULAR SURFACE The tear film can currently be visualised on high-definition optical coherence tomography, and conjunctival imprints might allow evaluation of the health of the ocular surface, he said. Imprints can be used for histopathology, immunostaining, flow cytometry, polymerase chain reaction and proteomics. “Thanks to the work of Prof Christophe Baudouin and his team, HLA-DRII is today the validated marker for inflammation in dry eye disease, but tear proteome and protein network analysis have also revealed a novel panel for tear film or ocular surface characterisation in dry eye and Meibomian gland dysfunction. For now, new biomarkers have been identified when comparing dry eye and control individuals. The question remains as to what can be done with all this new information,” said Prof Denoyer. Prof Denoyer called into question the tests currently on the market, such as those testing tear film osmolarity and tear film MMP9 levels, asking whether such tests were accurate and sensitive enough to be reliable tools to guide surgical decision-making. Lastly, objective tests also include ocular surface imaging such as confocal microscopy, which can demonstrate the changes in corneal innervation and cell trafficking that occur after corneal refractive surgery, and optical analysis of the cornea such as dynamic aberrometry, which provides a progression index for higher order aberrations directly related to ocular dryness.

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Alexandre Denoyer: EUROTIMES | DECEMBER 2016/JANUARY 2017




STEM CELL GRAFTS Exciting potential for ocular surface reconstruction. Dermot McGrath reports utologous cultivated limbal stem cell grafts give good and stable longterm clinical results and have several advantages in the reconstruction of compromised ocular surface due to disease or severe trauma, according to Paolo Rama MD. “Stem cells can be cultured under appropriate culture conditions and can be implanted and remain viable and functional in the long-term. Furthermore, the surgical procedure is simple and reproducible, and cells on fibrin can easily be handled and transported,” Dr Rama said in his EuCornea Medal Lecture at the 7th EuCornea Congress in Copenhagen, Denmark. Dr Rama explained that ocular surface diseases are challenging and complex and that corneal transparency is the final goal of treatment. “A healthy ocular surface is absolutely necessary for the preservation of corneal transparency. Traditional corneal transplants cannot be successful when the ocular surface is impaired,” he said. Much of Dr Rama’s research has focused on limbal stem cell deficiency (LSCD), a disorder often caused by chemical or thermal injury, multiple surgeries, severe infections, or immunologically mediated diseases such as Stevens-Johnson syndrome and atopic keratoconjunctivitis. As early as 1960, pioneering work by Strampelli and Barraquer, and later refined by Kenyon, showed that autologous limbal transplantation was effective for treatment of unilateral LSCD. In 2012, Sangwan et al revised the technique with simple limbal epithelial transplantation (SLET), which required less donor tissue than conventional autografting and which did not require a specialist laboratory for cell expansion. Despite the advantages of the technique, limbal autografts remained a limited option for treating LSCD, said Dr Rama. “There are potential risks for the healthy donor eye, it is not repeatable in case of EUROTIMES | DECEMBER 2016/JANUARY 2017

Total corneal conjunctivalization after burn and after a failed traditional autologous limbal transplantation

failure and it is only possible in cases of unilateral LSCD. Furthermore, patients are often fearful about the procedure and surgeons carry a heavy responsibility in the presence of complications,” he said. The revised version of the technique, SLET, also falls short of the optimal solution for LSCD, said Dr Rama. “Studies by Li et al have shown that outgrowths from human limbal explants show a rapid decline in proliferative potential, with transient amplifying cells rather than stem cells migrating on to the surface. There was also a progressive decline in the number of epithelial progenitor cells observed during culture on amniotic membrane. So we need more studies to determine the long-term survival of this procedure,” he said.

EFFECTIVE TREATMENT Dr Rama said that ex-vivo expanded cultured stem cells may offer the most viable and effective treatment for LSCD, following

One year after cultivated limbal stem cell transplantation obtained, for ex-vivo expansion, from a small biopsy in the fellow eye

on from the pioneering work by Dr Howard Green at Harvard Medical School, who developed the first therapeutic application of cultured cells using keratinocytes for the regeneration of epidermis on severely burned patients. “Thousands of third-degree burned patients have now been grafted in many countries with permanent epidermal

Fellow healthy eye with limbal biopsy for the first limbal transplantation and small biopsy for ex-vivo limbal stem cell expansion

Six years after penetrating keratoplasty

stem cells for ocular surface repair and regeneration has been recently approved by the European Commission (Holoclar™) as a commercially available stem cell therapy for use in cases of blindness caused by burning. While autologous cultivated limbal stem cell grafts offer clear advantages over many current methods of ocular surface reconstruction, the complexity and costs of the procedure may inhibit its initial uptake, said Dr Rama. Nevertheless, he said that Holoclar™offers

The reality is that innovative procedures are often not convincing and convenient in the beginning...

too many advantages not to gain more widespread use in clinical practice over the long-term. He compared the situation to that which existed in cataract surgery over 20 years ago, before the advent of phacoemulsification. “Phacoemulsification took more than 20 years of research and development to become a routine and safe procedure for cataract surgery. So you should ask your colleagues in cataract if they consider as misguided the early efforts and investment and initial high costs of the phacoemulsification procedure. The reality is that innovative procedures are often not convincing and convenient in the beginning, but later may show clear advantages before becoming routine,” he said.

Paolo Rama MD

Paolo Rama:







regeneration over more than a 20-year period,” said Dr Rama. He noted that the wide variation in the results achieved, ranging from 0% to 100% success rates, depended on a factors such as the properties of the cultured graft, surgical technique to prepare the wound surface and control of postoperative infections. In ophthalmology, the first application of the technique by Pellegrini et al successfully restored damaged corneal surfaces with autologous cultivated corneal epithelium in three patients. The autologous limbal cells were cultured on fibrin and clinical-grade 3T3-J2 feeder cells. In a study published in 2010, Dr Rama and co-workers used autologous limbal stem cells cultivated on fibrin to treat 112 patients with corneal damage, most of whom had burn-dependent LSCD. Permanent restoration of a transparent, renewing corneal epithelium was attained in 76.6% of eyes, with failures occurring within the first year. Restored eyes remained stable over time, with up to 10 years of follow-up, said Dr Rama. Buoyed by these positive results, the technique to use autologous limbal


C o r n

8th EuCornea Congress


European Society of Cornea and Ocular Surface Disease Specialists


Courtesy of Paolo Rama MD


6–7 October

FIL – International Fair of Lisbon, Portugal


17th EURETINA Congress 7â&#x20AC;&#x201C;10 September 2017 CCIB, Barcelona, Spain


LHON: GENE THERAPY Pivotal efficacy studies under way evaluating novel platform that restores mitochondrial function. Cheryl Guttman Krader reports


hase III trials are now under way evaluating gene therapy for Leber’s hereditary optic neuropathy (LHON) due to the G11778A mitochondrial ND4 DNA mutation, said Scott Uretsky MD at the 2016 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Seattle, USA. The investigational therapy, GS010 (GenSight Biologics, SIGHT.PA), is administered by intravitreal injection. It is a recombinant adeno-associated viral vector serotype 2 carrying the wild-type mitochondrial ND4 gene (rAAV2/ND4) and uses novel proprietary technology that allows localisation of the wild-type protein to the mitochondrion in order to restore mitochondrial function. The double-masked phase III trials, RESCUE and REVERSE, each plan to enrol 36 patients at sites in Europe and the USA. Patients will receive a single injection of GS010 (dose 9E10 viral genomes/90 μL) in one randomly selected eye and sham procedure in the contralateral fellow eye. RESCUE is enrolling patients with vision loss duration of up to six months, and patients eligible for REVERSE will have vision loss duration ranging from >six months to one year. The primary outcome measure in both studies is change in ETDRS visual acuity (VA) from baseline to week 48. “ND4 is the most common mutation in LHON and carries the worst clinical prognosis. We hope that treatment with rAAV2/ ND4 can halt, reverse, or even prevent further vision loss in patients with LHON caused by the ND4 mutation,” said Dr Uretsky, Medical Director, GenSight Biologics, Paris, France. “Results from a phase I/IIA trial showed that intravitreal GS010 had a good safety and tolerability profile. The study was not powered for efficacy, but the preliminary findings were encouraging, and not surprisingly showed that shorter vision loss duration and better baseline status impacted the magnitude of the treatment effect. This information supports the protocol strategy of the phase III programme based on the notion that time is vision,” he added. The single-centre phase I/IIA safety and tolerability study had an open-label dose-escalating design. Eligible patients had VA worse than 20/200 and received a single intravitreal injection of rAAV2/ND4 in the worse-functioning eye. No systemic or serious adverse events related to the gene therapy were recorded. The most common ocular adverse events were intraocular pressure (IOP) elevation and ocular inflammation. “Despite anterior chamber paracentesis pre-injection, IOP elevation was not unexpected considering the injection volume of 180μL is two to three times the volume administered for most intravitreous medications. We have lowered injection volume in the phase III studies that will reduce the occurrence of IOP elevations, of which all have been fully reversed and controlled,” Dr Uretsky said. Elevated IOP levels ranged from 23 to 38mmHg, but the elevations were transient and either resolved spontaneously or were reversible with topical IOP-lowering treatment. No patient required paracentesis post-injection. Ocular inflammation, manifesting in the anterior chamber or vitreous, was also expected, based on findings in preclinical studies. It was mostly mild, and in two patients the reaction was severe and oral corticosteroid treatment was given. Other patients received topical anti-inflammatory therapy, and there were no visual or ocular sequelae related to the inflammatory events. Immunogenicity was also assessed through assays of AAV2

neutralising antibodies in the serum. Ten patients had an increased titre post-injection that neither correlated with the baseline antibody level or GS010 dose. “Importantly, there was no consistent correlation between the occurrence or severity of ocular inflammation with either baseline immune status or change of immune status after injection,” Dr Uretsky said.

TIME IS VISION Analyses of logMAR VA data from patients who had reached week 48 of follow-up showed that in eyes with vision loss of less than two years, there was a three-line difference in mean change from baseline comparing the treated and untreated eyes. Visual field and colour vision outcomes were also better when duration of vision loss was less than two years. “These outcomes are consistent with LHON being a neurodegenerative disease. In stroke patients, we say ‘time is brain’. In LHON, we think time is vision,” Dr Uretsky said. “Now we will see if these promising efficacy findings are sustained when data from all the phase I/IIA patients are analysed and in the ongoing phase III trials.” Scott Uretsky:





VITRECTOMY EVOLUTION Elements in place to support shift into the office-based setting. Cheryl Guttman Krader reports


ffice-based vitrectomy is poised for making the transition from concept to reality, according to Tarek S Hassan MD, speaking at the 16th EURETINA Congress in Copenhagen, Denmark. Dr Hassan noted that the idea of performing vitrectomy in the office setting was first proposed 25 years ago. In the interim, the procedure followed a protracted course in moving from being done exclusively in hospital operating rooms (ORs) into ambulatory surgery centres. Compared with other surgical specialists, the vitreoretinal community has been particularly slow in taking the next evolutionary step, bringing vitrectomy into the office. However, thanks to a number of developments, the foundation for officebased vitrectomy is set, and the future is now. “There have been limitations in technology, safety, and the perception of safety that restricted the movement to office-based vitrectomy. Now the arguments have changed. What is needed is the willingness to break from old dogma and look to the inevitability of change in our surgical world,” said Dr Hassan, Professor of Ophthalmology, Oakland University, Michigan, USA. Arguments against office-based vitrectomy have cited inability to fully achieve surgical goals, insufficiency of technology, limited

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surgical indications, lack of sterility, inability to handle operative emergencies, and the lack of regulation and reimbursement. In his talk, Dr Hassan explained why all of those arguments are no longer valid.

SURGICAL GOALS The idea that vitrectomy in the office cannot be done to achieve surgical goals was proven wrong almost 15 years ago by a published paper describing space and media clearing procedures performed safely and effectively in a series of 225 eyes. Subsequently, multiple reports have established the feasibility of office-based vitrectomy for an expanding list of indications. The idea that technology is insufficient for office-based vitrectomy is also wrong, as current platforms, including small, portable units as well as full-sized consoles, can be used in the office, Dr Hassan said. Moreover, he predicted that future advancements – including smaller instrumentation providing faster cutting, enzymatic adjuncts, heads-up visualisation systems, and even wearable headsets with 3D visualisation – will deliver even better functionality and safety to optimise attainment of surgical goals. The idea that insufficient sterility is a barrier to office-based vitrectomy is negated by consideration of the fact that many office treatment rooms are likely more sterile than hospital ORs in third world countries, where surgery is done with infection rates comparable to those in the Western world despite conditions that include open windows, Tarek S Hassan unmasked staff, and reuse of “disposable” instrumentation. Further evidence of safety in terms of sterility derives from a prospective study of 37 office-based microincision vitrectomy surgeries in which the rate of vitreous contamination was only 2.7%, which is lower than the 22% to 32% rate that was reported for 25-gauge standard vitrectomy in the OR, Dr Hassan said. In addition, new laminar flow technology has emerged that is allowing any room to achieve OR-like sterile conditions. Inability to handle medical emergencies in an office-based setting is also not a concern. With the use of peribulbar anaesthesia and with appropriate supplies on hand, such situations can be addressed by a trained office-based staff, although some office settings even have anaesthesia support. Furthermore, office-based vitrectomy can be performed under general anaesthesia if there is an anaesthesiologist on staff, and operative retinal emergencies can be addressed when surgeons are using either the small footprint or full-sized consoles that are capable of being used in the office setting. Dr Hassan pointed out there are ongoing efforts focusing on regulatory oversight and reimbursement that are relevant for office-based vitrectomy. At least in the USA, there is now much greater oversight and accreditation or registration of office-based surgery practices coming from boards of medicine, departments of health, specialty societies, and other medical organisations. In addition, a manual presenting standards for office-based surgery practices was published by the Joint Commission in 2016. Tarek S Hassan:




CLOT-BUSTER EFFECTIVE IN SUBRETINAL HAEMORRHAGES Vitrectomy combined with subretinal rtPA injection and gas or air tamponade can improve vision and reduce lesion size in eyes with subretinal haemorrhages (SRHs) alone and with combined subretinal and subpigment epithelial haemorrhages (SPHs). The treatment also seems to slightly improve the anatomical outcome in eyes with SPH alone, an observational study suggests. It showed that among 19 eyes with SRH and 53 eyes with combined haemorrhages, the mean best corrected visual acuity (BCVA) improved significantly following treatment. There were also significant reductions in maximal haemorrhage diameter (MHD), and central macular thickness (CMT) (p<0.05). M Waizel et al, “Efficacy of Vitrectomy Combined with Subretinal Recombinant Tissue Plasminogen Activator for Subretinal versus Subpigment Epithelial versus Combined Haemorrhages”; Ophthalmologica 2016, Volume 236, Issue 3.

HIGH INTRAVITREAL VEGF LEVELS PREDICT WORSE VITRECTOMY OUTCOMES Patients with proliferative diabetic retinopathy (PDR) who have higher levels of intravitreal vascular endothelial growth factor (VEGF) have a significantly worse postoperative visual acuity following vitrectomy than those with lower levels, a new study suggests. It showed that, among 136 eyes of 114 PDR patients vitrectomised between 2006 and 2008, corrected visual acuity six months after surgery was significantly worse in those with intravitreal VEGF levels 5,000 pg/mL or higher than it was in those with higher levels of the growth factor (p=0.02). Reoperations were also significantly less common among those with low VEGF levels. Y Suzuki et al, “Level of Vascular Endothelial Growth Factor in the Vitreous Fluid of Proliferative Diabetic Retinopathy Patients and Prognosis after Vitrectomy”; Ophthalmologica 2016, Volume 236, Issue 3.

HYPHAEMA FOLLOWING VITRECTOMY High myopia and scleral buckling procedures combined with vitrectomy are risk factors for postoperative hyphaema following surgery for primary rhegmatogenous retinal detachment (RRD), a new study suggests. Among 1,011 consecutive eyes that underwent surgery for RRD, 32 had postoperative hyphaema. A comparison between eyes with and without the complication indicated that the likelihood of hyphaema was over three times higher among high myopes (odds ratio 3.396; p=0.003), and over 20 times higher among those who underwent a combined scleral buckling-vitrectomy procedure (OR 21.266; p<0.001), than among the patients overall. Y Kung et al, “Risk Factors for Hyphema following Surgeries for Primary Rhegmatogenous Retinal Detachment”; Ophthalmologica 2016, Volume 236, Issue 3.

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





GLAUCOMA MONITORING Mean deviation better for detecting early diffuse visual loss; visual field index more centrally weighted and resistant to increasing cataract. Roibeard O’hEineachain reports


n experienced clinician and one of best pioneers in the modern statistical analysis of visual field testing debated the relative merits of mean deviation (MD) and visual field index (VFI) in the detection of glaucomatous progression, at the 12th European Glaucoma Society Congress in Prague, Czech Republic. Francisco Javier Goñi MD, Barcelona, Spain, said that he prefers MD, a value derived from the total deviation which represents the overall mean departure from the age-corrected norm. That is because MD is better at detecting diffuse loss in early glaucoma, he said. He noted that 15% of eyes with early glaucoma will have a VFI value of 99% or more, meaning almost perfectly normal vision for a patient’s age. “With VFI we are missing some glaucoma, at least for 15% of our patients with early damage,” Dr Goñi said. Moreover, diffuse retinal nerve fibre loss corresponds to diffuse sensitivity loss on preserved hemifields of glaucoma eyes. In addition, pattern deviation analyses, like VFI, classify 15% fewer glaucomatous eyes more progressive than would be classified as such with total deviation analyses, like MD. “So that means that mean defect is better at detecting this diffuse loss,” he said. He added that although only 4.4% of patients present with only diffuse vision loss, focal visual field loss is usually associated with a diffuse component. For example, most of the eyes that developed glaucomatous endpoints in the Ocular Hypertension Treatment Study (OHTS) showed both diffuse and focal visual field changes. One often cited potential disadvantage of MD is that it is less sensitive than VFI to central vision loss-threatening fixation. However, Dr Goñi questioned whether that is relevant when assessing progression and predicting future vision loss.

...we think that the most central part of the visual field is more important than the periphery Boel Bengtsson MD

He noted that a study conducted in Sweden showed that eyes with glaucomatous fixation-threatening visual field loss within the innermost points had significantly worse MD values than those without any macular threat.

EVENTUAL BLINDNESS RATES Moreover, with regard to survival curves, there was no significance difference between the eventual blindness rates of eyes with and without a threat to fixation, once adjusted for MD values. On that basis, the study’s authors concluded that the risk of blindness can be based solely on MD, Dr Goñi pointed out. MD also has the advantage of providing a more precisely graded assessment of visual function that is the same across the entire standard automated perimetry range. In contrast, VFI is calculated from the pattern deviation (PD) probability map when MD is better than 20dB, and from the total deviation (TD) map when MD is worse than 20dB. That means if MD is going across the 20dB threshold, the VFI value can vary up to 15% with the change of just one decibel in MD. Boel Bengtsson MD, Lund University, Malmo, Sweden, who developed the VFI with Anders Heijl MD, countered Dr Goñi’s argument by pointing out that the VFI was designed to measure the rate of progression of glaucoma visual field loss in eyes with manifest glaucoma. It was not designed for detection of visual field defects nor was it designed to detect

With VFI we are missing some glaucoma, at least for 15% of our patients with early damage Francisco Javier Goñi MD EUROTIMES | DECEMBER 2016/JANUARY 2017

progression. Event analysis is designed for those purposes. Trend analysis is not sensitive at all early scatter in proceeding repeatable visual field defects. She added that VFI values are usually similar to MD, but not always. One exception is in glaucomatous eyes with paracentral visual field defects. “VFI is much more heavily weighted towards the centre of the visual field, because, even where there is not such a great risk for blindness, we think that the most central part of the visual field is more important than the periphery,” Dr Bengtsson said. Another exception is in glaucomatous eyes with concomitant cataract. VFI is considerably less affected by cataracts than MD. As an illustration, she described a study she and her associates conducted which compared visual fields of glaucoma patients with and without (pseudophakic eyes) increasing cataract. It showed that the mean annual rate of progression was 3.6% using MD values versus only 2.1% using VFI in eyes with increasing cataract, and 2.7% and 2.6% respectively in eyes without increasing cataract. Similarly, a glaucomatous cataract patient’s MD values will typically have a pronounced recovery towards normal values, but there will only be a slight change in VFI values. Dr Bengtsson said that she also prefers VFI’s graphical display of the rate of progression to that of MD. She noted that the purpose of trend analysis is to identify patients who are at risk of developing field defects that will reduce their quality of life during their expected lifetime. Plotting MD over several visits can provide an estimate of the rate of progression, but since (unlike VFI) it does not plot change against time or age, it provides a less clear picture of a patient’s lifetime risk of severe visual impairment or blindness. Francisco Javier Goñi: Boel Bengtsson:


SAP TESTING Adjustment of perimetric stimuli can improve sensitivity and decrease variability of visual field testing. Roibeard O’hEineachain reports


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ndividual modulation of the size, duration and luminance of stimuli used in standard automated perimetry (SAP) may enhance the monitoring of glaucomatous visual loss at different stages of the disease, according to Roger S Anderson PhD, DSc, FCOptom, University of Ulster, Coleraine, Northern Ireland. “In the future, instead of modulating the stimulus just in terms of luminance and size, we might modulate in terms of luminance, size and duration and in so doing increase the glaucoma signal, increase the dynamic range and possibly reduce the variability at the same time,” Prof Anderson told the 12th European Glaucoma Society Congress in Prague, Czech Republic. He noted that testing patients with SAP typically involves the use of a stimulus with a fixed size and duration and varying luminance. The stimulus targets, called the Goldmann sizes, are derived from kinetic perimetry. However, the stimulus duration and area of conventional SAP may be inadequate for identifying subtler types of visual field loss. “SAP has low sensitivity in early glaucoma, high variability in moderate glaucoma and insufficient dynamic range to monitor advanced visual field loss in advanced glaucoma,” he added.

SPATIAL SUMMATION When presented with a Goldmann III stimulus, an eye with glaucoma will have one log unit change in the retinal ganglion cell number in the peripheral retina for every one log unit change in luminance threshold in the peripheral visual field. There will also be a three-to-four log unit of change in the retinal ganglion cell number in the central retina for every one log unit change in luminance threshold in the central visual field, Prof Anderson explained. He noted that, for a set of small stimulus areas there will be an inverse relationship between luminance and stimulus size at the threshold of visibility. That is, one log unit of change in area of the stimulus will have the same effect on its visibility as

one log unit of change in luminance. The largest stimulus areas for which this holds true is called the area of complete spatial summation, or Ricco’s area. Prof Anderson noted that research he and his associates have conducted has shown that there is an increase in the Ricco’s area in eyes with early glaucoma. “We explained this by the visual system changing the area of complete spatial summation in response to glaucomatous damage, in order to maintain the number of retinal ganglion cells in that perceptive field. You start with a healthy eye, you lose ganglion cells and the visual system enlarges the perceptive field in order to maintain a constant number of ganglion cells in an attempt to preserve the signal-to-noise ratio,” he said. He added that when they used a stimulus in the central retina that is larger than the Ricco’s area like a Goldman III stimulus, there was only be a small glaucoma signal, whereas when using a smaller area stimulus, within Ricco’s area, the glaucoma signal will be much more pronounced.

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TEMPORAL SUMMATION Glaucomatous damage also appears to affect the temporal processing of visual stimuli, Prof Anderson noted. Similarly to spatial summation, when stimulus duration is plotted against luminance threshold there is a set of durations where duration and luminance have an inverse relationship, the limit of which is called the critical duration. He added that, in studies he and his associates have conducted, they found that when they used a Goldman III stimulus there was a small-to-moderate but significant increase in the critical duration or change in temporal summation in eyes with early glaucoma, and that the critical duration of the stimulus increased in tandem with total deviation values. Another finding was that when using a 200ms stimulus, as is typically used in SAP, there was little difference in luminance thresholds between normal and glaucomatous eyes. Roger S Anderson:

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You start with a healthy eye, you lose ganglion cells and the visual system enlarges the perceptive field... Roger S Anderson PhD, DSc, FCOptom EUROTIMES | DECEMBER 2016/JANUARY 2017




MORE INFORMATION One type of testing can be better than two, with quality of data the key. Roibeard O’hEineachain reports


erforming either structural or functional tests more frequently can provide more information about an eye’s glaucoma status than performing both types of test less frequently. Furthermore, performing both tests more frequently could show less discrepancy between the two types of test, but agreement between the two tests increases the redundancy of one of them, said Balwantray C Chauhan PhD, Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia, Canada. “The most important point is that if you’re not going to use a test for clinical decision-making, then don’t do it. Instead, do something that you’re comfortable with and do it more frequently and do a good quality exam,” he told the 12th European Glaucoma Society Congress in Prague, Czech Republic. Dr Chauhan noted that, with current diagnostic testing, changes in the optic nerve might become evident before visual field changes appear, or the opposite may occur. Numerous factors can play a role in the discrepancies. The type of testing to detect glaucoma most sensitively may also depend on the stage of the patient’s disease. One technique might be better at detecting early visual loss and another might be better at detecting later loss.

“These measurements are a surrogate that are far away removed from what we really want to measure at the individual retinal ganglion cell level, at which point there should be a perfect correlation between the two,” he added. The stringency of the criteria used can contribute to discrepancies between the two types of measurement. A study he and his associates conducted showed that when using intermediate criteria, glaucoma progression was detected in 28% of eyes with structural tests and in 27% of eyes with functional tests, but in only 10% of eyes with both structural and functional tests. When more conservative criteria were applied, only 14% had structural evidence of progression, only 14% had functional evidence, and only 3% had both structural and functional evidence of progression. Another contributor to the often poor agreement between structural and functional tests is signal processing errors, or noise, he said. He cited a study by Prof David Crabb, City University London, UK, who modelled structural change and functional change and simulated different degrees of noise. It showed that, in an eye where there was a good overlap when there was little noise, the simulated addition of noise progressively distorted the association between the results of the two types of testing. “This is depressingly like what we see in our data. I would like to be more optimistic and think that we are not measuring noise and independent indicators of disease progression,” Dr Chauhan said.

Position of fellowship available in Paediatric and Refractive Ophthalmology

Infrequent testing can also reduce the reliability of either type of test. A recently published US study showed that during the first two years after diagnosis of glaucoma, only 70% underwent perimetry, only 60% underwent testing with an imaging modality, and 20% underwent disc photography. “Quite staggeringly, around 10% of patients with a diagnosis of glaucoma have had no diagnostic testing done during those two years and that suggests that the diagnosis was made purely on the basis of intraocular pressure,” he pointed out. Dr Chauhan noted that one approach to integrating the findings from structural and functional testing is a Bayesian method, whereby one could use prior information from structural measurement as a prior probability, and convert that into a visual field map, using that, in turn, to model the rate of visual field loss. Studies using this approach show that the method improves results over using only one type of testing or the other, but also that the more frequently both types of testing are performed, the less of a difference there is between their findings. “This shows that, once you have a large amount of data, integrating this information may not be as valuable as having just one method of testing,” he added.

Under the Direction of Professor Michael O’Keeffe FRCS At the Mater Private Hospital and The Children’s University Hospital, Temple Street, Dublin. Fellowship for one year commencing 1st January 2017 Candidates must have at least 3 years experience FRCS or equivalent in clinical ophthalmology and have surgical experience. Candidates must be registered with the Irish Medical Council.

For further information contact: Helen Murphy Suite 5 Mater Private Hospital, Eccles Street, Dublin 7 Tel: 00353 1 8858626 Email:



Balwantray C Chauhan:

...if you’re not going to use a test for clinical decision-making, then don’t do it... do something that you’re comfortable with... Balwantray C Chauhan PhD



ALZHEIMER’S SCREENING Flicker test could provide simple screening tool for AD. Pippa Wysong reports


MAXIMAL ARTERIAL DILATION Retinal arterial and venous reactions to 20-second flicker stimulation of 12.5Hz were measured with the Dynamic Vessel Analyzer (IMEDOS Systems). In AD patients, the maximal arterial dilation was on average 6.6%, whereas in the MCI group it amounted to 3.8%, and in healthy controls it was 2.7%. Dilation was delayed in AD, with 30% of the maximal dilation being reached in seven seconds, whereas in MCI and in the control group this level occurred two seconds earlier, he said. Maximal venous dilation to flicker was notably different between the groups too – being 3.7% in the control group, 4.7% in the MCI group, and 5.4% in the AD group. This reaction occurred in AD and MCI one second later than in the control group. Generally, the reactivity of retinal vessels was a surprise to the researchers. “The reactivity of retinal vessels was a surprise, because in other diseases of vascular origin we see an impaired reaction. We believe

Courtesy of Konstantin Kotliar PhD

flickering light exam of the retinal vessels is showing promise as a way to help screen for Alzheimer’s disease (AD), early research suggests. Because of so-called neurovascular coupling in the retina, the application of flickering light can evoke immediate dilation of both retinal arteries and veins in healthy people. But in the elderly as well as in eye diseases with vascular involvement such as glaucoma or age-related macula degeneration, and in systemic diseases like arterial hypertension or diabetes mellitus, retinal vessel dilation is diminished and sometimes delayed, said Konstantin Kotliar PhD, a biomedical engineer at the Aachen University of Applied Sciences, Germany. “In people with AD, retinal arteries and veins have a delayed reaction to a flickering light test too, but they dilate surprisingly more than those in people without the disease,” he told the 2016 Alzheimer’s Association International Conference in Toronto, Canada. He presented a study measuring and comparing retinal vessel reactions to flickering light in groups of elderly people of the same age: 15 patients with mild-to-moderate dementia due to probable AD; 24 patients with mild cognitive impairment (MCI) due to AD; and 15 healthy controls without any cognitive impairment. An example of retinal arterial (red) and venous (blue) diameter changes in response to flickering light (530-600nm, 12.5Hz, 20s) in a young healthy person. In the elderly and in diseases with vascular involvement, retinal vessel dilation is diminished and sometimes delayed. In AD it was also delayed but much more emphasised

this fascinating finding reflects a peculiar failure of the retinal autoregulation in AD,” said Dr Kotliar. Being able to distinguish AD in the study also had a good level of sensitivity and specificity, making the use of retinal vessel reaction a promising tool for diagnostic purposes. As well as having potential to help screen for AD, the test may also help reveal the role of vascular factors in this disease. More research is needed to find the reason for such an enhanced vessel reaction in AD and also in its early stage, MCI, he stressed. Konstantin Kotliar:





POWERFUL NEW TOOL Novel system measures ophthalmic quality of life with greater precision. Dermot McGrath reports


WINTER MEETING Medical University Vienna, Austria

Saturday 28 January 2017


new testing system for quality of life (QoL) patient-reported outcome measures will give ophthalmologists a powerful new tool to test for all major eye diseases across all population groups, according to Konrad Pesudovs PhD. “The Eye-tem Bank project is a large project that develops a third-generation approach to the measurement of ophthalmic QoL across 13 different disease groups. We have made tremendous progress in the last year or so and have now completed phase I for 10 disease groups,” he told delegates at the XXXIV Congress of the ESCRS in Copenhagen, Denmark. Dr Pesudovs, Foundation Chair of Optometry and Vision Science at Flinders University in Adelaide, South Australia, said that Eye-tem will eventually be made available for wider use via an Internet-based ophthalmic QoL measurement system to provide online testing, real-time scoring and data storage across a range of digital formats. Although a wide variety of patientreported outcomes (PROs) already exist in ophthalmology, they are not all the same in terms of technology or content, said Dr Pesudovs. Invalid scoring is the main issue with first-generation PROs which use summary scoring, where ordinal values are applied to response categories, he explained. “They are not really suitable for statistical analysis of Konrad Pesudovs correlation or change,” he said. While Rasch analysis solves this problem in second-generation instruments, allowing them to be used for statistical analysis, these PROs also have limitations, said Dr Pesudovs. “The content of a questionnaire may not suit the population and may be too easy or too difficult. There is a trade-off of length versus applicability, they are not adaptable to change and they use a paper-based format, so are not very convenient or efficient to use,” he said. The approach of the Eye-tem Bank system is to use item banking combined with advanced information technology to overcome the handicaps of first- and second-generation PROs. “Item banking uses a very large collection of questions or items and these items are calibrated on a single measurement scale using Rasch analysis. The advantage of having many items is that you can suit all patients’ abilities and therefore all populations. It is dynamic, new questions can be added to keep the content current, and measurements can be made very quickly using computer adaptive testing (CAT),” he said. Studies thus far show that new domains of QoL should perhaps also be considered, such as “coping” and “driving”, said Dr Pesudovs. “We may also need to consider splitting groups further in vitreoretinal into hereditary and acquired diseases, and we have shown the clear importance of disease-specificity, with only 20% of items common across all groups,” he added. Konrad Pesudovs:



CONGENITAL CATARACTS Controversy continues on best treatment approach. Sean Henahan reports


ongenital cataracts account for as much as 20% of childhood blindness around the world, with half of these cases being unilateral. So, is it better to do the cataract surgery as early as possible, or wait? The Infant Aphakia Treatment Study (IATS), a clinical study designed to answer that question, produced results that remain controversial. EuroTimes met with Ken Nischal MD to discuss the controversy at the 2016 WSPOS Subspecialty Day in Copenhagen, Denmark. IATS sought to determine which treatment for aphakia is better for infants between the ages of four weeks and seven months who were born with a unilateral cataract. Specifically, it compared implantation with a primary lens implant with leaving the child aphakic and using a contact lens, looking at visual outcomes, surgical complications, or complications after the surgery was done. The study included 114 patients from centres around the world. The five-year outcomes came out recently, with numerous publications reporting and discussing the results. The primary finding was that patients who received an implant had the same visual outcome as those who remained aphakic, but were more likely to require additional surgery, and to have more complications such as anterior membranes, membranes behind the implant, and glaucoma. “This was the first prospective, randomised controlled trial of paediatric cataract surgery. It used the best methodology possible, since this is not a common disease. To enrol a sufficient number of patients they had to involve a large number of centres. This can make it difficult to get a consensus. Moreover, the study tried to answer an important question, but it did it in a way that tried to create a perfect situation, not matching real-world conditions,” said Dr Nischal, Chief, Paediatric Ophthalmology and Strabismus, Children’s Hospital of Pittsburgh, USA. Consensus was challenging because of a diverse range of approaches around the world. “In many ways IATS has not affected my practice in a big way because I already had very tight criteria as to when I would put an implant in an infant and when I would not,” added Dr Nischal. He explained that the most common cause of unilateral congenital cataract he sees involves persistent foetal vasculature. These are challenging cases with a number of pros and cons. The decision needs to be based on the particular anatomy and other factors for each patient. The personal and economic circumstances of the patient can also affect the decisionmaking process. If a child comes to his US clinic with inadequate insurance coverage, that patient may only be covered for one contact lens per year, or may not have access to an optometrist. “I have to very careful not to leave that child aphakic even in one eye. I don’t want to put a contact lens in, only to find that it has been chewed by the dog, and they can't afford another contact lens. I have to avoid creating a case of Ken Nischal MD

My decisionmaking has served my population well. Nothing that IATS added has changed my decision-making for the children I look after

deprivation amblyopia. You have to make this decision based on the circumstances of the child, and the eye itself,” he said. “My decision-making has served my population well. Nothing that IATS added has changed my decision-making for the children I look after. It is not as if every child who walks in with unilateral congenital cataract gets an implant. They all get carefully vetted and evaluated. Even in those where I thought we could put a implant in, 43% don’t get an implant. IATS hasn’t changed that.” In IATS, the rate of putting an implant in was 80% in a randomised group. While IATS reported complication rates as high as 78%, other series have reported rates as low as 25%. “What IATS has done is to raise doubts among people who were considering doing implantations. My concern is that there may be children in parts of the world who may end up severely visually disabled, because they didn’t get an implant when perhaps they should have,” emphasised Dr Nischal. Ken Nischal: Dr Nischal discusses issues raised by IATS in an Eye Contact video interview with Sean Henahan on the ESCRS Player. To view the video, go to:

AbstrAct submission DeADline: 27 FebruAry 2017 eArly registrAtion DeADline: 15 April 2017







ESCRS Academy members (from left) Sathish Srinivasan, Thomas Kohnen, Ewa Mrukwa-Kominek, Boris Malyugin, Simonetta Morselli, Bekir Sitki Aslan, Roberto Bellucci, Vladimir Pfeifer and Zoltan Nagy

ESCRS ACADEMY IN MOSCOW Ophthalmologists from Russia and surrounding countries gathered in Moscow for the XVII National Cataract and Refractive Surgery Congress, which was attended by more than 1,500 delegates. The congress was held at the S. Fyodorov Eye Microsurgery Federal State Institution. The meeting programme included a broad range of topics including femtosecond laser assisted cataract surgery, refractive corrections in complicated cases, and small incision lenticule extraction. One of the major highlights of the meeting was the ESCRS Academy, organised jointly by the ESCRS and the Russian Ophthalmology Society on Friday, 28 October. The Academy featured a half-day programme on ‘Difficult and Challenging Cases in Cataract Surgery’, with lectures on topics including combined cataract and glaucoma, lens subluxation, uveitis, high astigmatism and cataract surgery in patients after corneal refractive procedures. The Academy was co-chaired by ESCRS past president Roberto Bellucci, Chief of the ESCRS Academy Programme, and Boris Malyugin, President of the Russian Ophthalmological Society.



All completed applications should be sent by email to Danielle Maher at: The deadline for submission of all applications is: 30 April 2017 See also: ESCRS-Peter-Barry-Fellowship.asp

For further information visit:

To apply, please submit the following: A detailed, up-to-date CV l A letter of intent of 1-2 pages, outlining your choice of centre for undertaking the fellowship, and the reasons why you feel you would benefit from the fellowship l A letter of recommendation from your head of department l A letter from your potential host institution, agreeing to accept you on the fellowship (if successful) l

The ESCRS has announced details of the annual fellowship set up to honour the immense contribution of Peter Barry FRCS to European and global ophthalmology. Dr Barry, who served as ESCRS President in 2012 and 2013, died after a short illness in May 2016. The fellowship of €50,000 will enable a trainee ophthalmologist from Europe to study at a centre of excellence anywhere in the world.

Videos should be submitted to:

Entries are now being invited for the 2017 John Henahan Writing Prize. The topic for the essay is ‘How does commercial interest affect my career?’ The judges will draw up an initial shortlist of the five best essays submitted and will then decide on the winning essay. The shortlisted essays and the winning essay will be published in EuroTimes. The competition is open to ophthalmologists who are members of the ESCRS and aged 40 years or under on 1 January 2017. The winner of the prize will receive a €1,000 travel bursary to the XXXV Congress of the ESCRS in Lisbon, Portugal, and will be presented with a specially-commissioned trophy during the ESCRS Video Competition Awards ceremony. Entries should be 850 words and should be sent to Colin Kerr, EuroTimes Executive Editor, in Microsoft Word document format to: The closing date for entries is Friday, 31 March 2017.

Applicants for the fellowship must meet the following criteria: l Be a European trainee ophthalmologist l Be 35 years of age or under on the closing date for applications (30 April 2017) l Have been an ESCRS member for three years at the time of taking up the fellowship (if successful)

Peter Barry

The ESCRS has launched an online museum which shows historic videos from some of the great innovators in ophthalmology. The videos, which are submitted by ophthalmologists, are studied, verified and curated by Dr Richard Packard and Prof Andrzej Grzybowski and date back to the 1930s. The videos are featured on the ESCRS Player at: category/online-muesum By viewing these videos, ophthalmologists can gain an insight into the rich history of the profession, learning from those who have gone before. The online museum includes the first LASIK procedure in 1990 by Prof Ioannis Pallikaris, a video of the logbook from 1949 showing a summary of Sir Harold Ridley’s operations from 1949 and 1950, and a video from Prof HJM Weve showing an intracapsular extraction in the late 1930s. All the videos that we receive and publish will be fully credited, downloaded by users, and the originals will be returned to their authors.





With a little technical advantage, a trainee can see what the trainer misses. Dr Leigh Spielberg reports


o, Dr Spielberg, fitting it under someone’s brow.” did you see the I wondered whether it was time lesion?” asked to upgrade my own lens set. I Jean-Baptiste hadn’t previously given much W i l l e m o t thought to my lenses. What’s after I had funny is that I obsessively research examined his patient. other, arguably less important, “No, actually. I didn’t notice purchases ahead of time. I’ve spent anything unusual,” I answered. whole evenings online looking for I had taken my time and had a perfect pair of skis, a rugged new performed a thorough fundus mountain bike, top-notch openexamination, but I had seen back headphones, and a sharp nothing out of the ordinary. Jeancamera lens to capture it all for Baptiste always performs a very later… But fundus lenses? No. thorough and deliberate retinal I decided then to approach the examination. Like most first-year topic like I research my leisureresidents, he doesn’t want to miss time toys. After all, I spend more anything, not even in the extreme time with my lenses than with my periphery of the retina, especially outdoor gear and electronics, so I when he knows I’ll be doublemight as well select what I think is checking the patient afterwards. best. The High Resolution Wide “That little pigmented lesion Field: no-distortion, with a 165° at 6 o’clock?…” he asked, with dynamic view of the periphery an insistent tone in his voice, despite a tiny profile. Excellent. suggesting that he would prefer As for the Digital Wide Field: me to look once again, just to it increases the field of view at the be certain. same dioptre power as the 90D, I knew for sure that there which enables me to see more was nothing of importance to anatomy in one glimpse. This be seen. The rest of the fundus allows the exam to proceed more So, a year after the completion of my was normal, there was no quickly while reaching out into vitreoretinal surgery fellowship, tobacco dust in the vitreous, the periphery. I felt I had to step it up no haemorrhage, no subretinal What I had been thinking fluid, no schisis. about a lot was my examination But I was curious to find out technique. “Wow, you’re really what he might have seen. I was also interested in helping him making it difficult on yourself,” Marc Veckeneer had said to me learn the difference between clinically significant and insignificant recently, while I performed an exam in a room with the blinds open. findings. He stood in my doorway with his new shiny blue fundus The patient had a highly atypical, bilateral foveoschisis. I hadn’t lens in his hand. expected Dr Veckeneer, a consultant in my university hospital, an expert diagnostician, and my other vitreoretinal mentor, to require such a strictly controlled environment in which to work. FANCY EQUIIPMENT So, a year after the completion of my vitreoretinal surgery “Let me take a look with that blue diamond,” I said, teasing him fellowship, I felt I had to step it up. It seems we have the tendency a bit for having such fancy equipment. I put down my SuperField to stick to what we’re used to. lens, and he handed me his Volk Digital Wide Field as I summoned After having done my research, I obtained the two lenses at the the patient from the waiting room. EURETINA/ESCRS Congresses in Copenhagen and have been Once the patient had settled into position behind the slit lamp, I using them ever since. The Wide Field lens instantly became my asked him to “Please look down as far as possible”, while I looked go-to lens for examination of the periphery, particularly for an for anything abnormal. I caught a glimpse of an unusually large overview of retinal detachments or when I suspect a retinal tear. ora bay that I had missed with my SuperField. The Digital Wide Field has also replaced my SuperField. It not Jean-Baptiste had been correct in noticing the physiologic only has a wider field of view, but it also produces a higher quality abnormality. Fortunately, I had also been correct in not having image. The image quality is comparable to the difference between missed anything that required treatment, follow-up, or even regular and high-definition TV. documentation in the patient’s file. So, now that I’ve got these two wide-angle lenses, what’s next? This experience mirrored one that I had had several weeks I’ll soon test the Digital High-Mag, which I suspect will sharpen earlier. My colleague and one of my vitreoretinal surgery mentors, my view of the posterior pole. I would hate to miss something that Fanny Nerinckx, had been speaking highly of the Volk High a trainee might see! Resolution Wide Field lens that she had purchased at the last international conference. Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent “The wide-angle view is just like the SuperQuad, but without University Hospital in Belgium the distortion. And it’s tiny, so you never have the problem of IIllustration by Eoin Coveney





PRIZE 2017



GOLD STANDARD Laboratoires Théa says a new approach to aid cataract surgery is set to become the gold standard following evidence that it simplifies the procedure and dramatically cuts time spent at the hospital by patients. Mydrane® is intended for patients who have demonstrated a satisfactory pupil dilation with topical mydriatic therapy during their preoperative visit. The company says this new alternative to eye drops for mydriasis offers a major step forward. Prof Béatrice Cochener, Chair of Ophthalmology at Brest University, France, and President of the French Academy of Ophthalmology, said Mydrane® will save time, optimise organisation of the fast-track process through its e fficacy, and reduce the risk of systemic and local side effects seen with the topical drugs. Calculations based on the UK model of cataract surgery have revealed that the intracameral approach also cuts costs, through the time it saves for nurses in preoperative preparation and the time taken to perform the surgery, Prof Cochener said.


ENTRIES Young ophthalmologists are invited to write a 900-word essay on

“How does commercial interest affect my career?” First prize is a €1,000 travel bursary to the XXXV Congress of the ESCRS in Lisbon, Portugal.

Closing date Friday 31 march 2017 NEW LASER

UNIVERSAL TRIAL FRAME OCULUS says its new Universal Trial Frame is lighter, trendier, simpler and more comfortable. “For the new generation of the OCULUS Trial Frame, many suggestions from users were taken into consideration in order to create an even more comfortable method of subjective refraction for customers and optometrists,” said a spokeswoman for the company. “All 166 individual parts of the new Trial Frame are carefully crafted by hand with the highest attention to detail, for guaranteed quality,” she added.

Optotek Medical has announced that its newest laser, the OptoSLT nano, has received CE mark approval and is now commercially available. “This is a notable achievement for Optotek Medical that will help to make the treatment of glaucoma safer and more effective for patients worldwide. At Optotek, we are proud to be known for our eye care innovations and the OptoSLT nano is a great example of this,” said Klemen Kunstelj, sales and marketing manager for Optotek Medical.

Entries to be sent to: For further information visit:







• Learn directly from the world’s thought leaders


• Broaden your networking connections


• Return with the practical tools needed to improve your practice




IMAGING TECHNIQUE Optical coherence tomography angiography (OCTA) has generated an enormous amount of interest at international conferences and in journals since it was introduced several years ago. And yet, I hadn’t yet had the chance to really dive into this new imaging technique. PUBLICATION So I was very pleased when I OCT ANGIOGRAPHY IN RETINAL AND received a review copy of OCT MACULAR DISEASES Angiography in Retinal and EDITORS Macular Diseases (Karger). F BANDELLO, EH SOUIED & G QUERQUES OCTA is still in its infancy, and the editors preface the PUBLISHED BY KARGER book with an admission that “we all are still trying to interpret the information, and many of the images… still require great effort to be understood.” And yet, many influential retinal specialists seem convinced that OCTA will change diagnostics and follow-up of retinal disease. This 180-page book contains 24 chapters, starting with the technical aspects of the technology and then moving on to descriptions of the images generated in healthy subjects. Commonly seen diseases, such as neovascular age-related macular degeneration, diabetic retinopathy and retinal vein occlusion are covered first. Rarer diseases are also described. Each chapter starts with an abstract, which helps orient the reader. The text is supplemented by high-quality OCTA images next to more recognisable images of standard fluorescein angiography, colour photographs and “normal” OCTs. This allows the reader to more efficiently understand OCTA imaging and how it might complement the current standard imaging modalities. This book is intended for anyone who is involved with OCTA, particularly retina fellows, retinal specialists and general ophthalmologists who are considering incorporating OCTA into their own practice.



RETINAL DISORDERS Also from Karger, Retinal Pharmacotherapeutics, edited by QD Nguyen et al, is a large 400-page overview of the current knowledge regarding medical treatment of retinal disorders. Anti-VEGF is the first thing that comes to mind, but this book casts its net much wider. Well-established pharmacologic treatment regimens of posterior uveitis and endophthalmitis are reviewed, but research-oriented treatments are also considered. Basic sciences in the retina are discussed first, followed by animal models, routes for retinal drug delivery, mechanisms of individual drugs, and regulatory and economic considerations of retinal drugs. The last chapter is dedicated to future perspectives and agents on the horizon. This text-dense book is primarily appropriate for clinical and laboratory researchers in retinal pharmacology, as well as retina fellows who are interested in gaining detailed insight into the treatments they administer on a daily basis.

€50,000 Peter Barry Fellowship The ESCRS has launched an annual Fellowship to commemorate the immense contribution made by the late Peter Barry to European and global ophthalmology, and to the ESCRS. The Fellowship of €50,000 is to allow a trainee to work abroad at a centre of excellence for clinical experience or research in the field of cataract and refractive surgery, anywhere in the world, for 1 year. Applicants must be a European trainee ophthalmologist, 35 years of age or under on the closing date for applications and have been an ESCRS member for 3 years by the time of starting the Fellowship. The Fellowship will be awarded at the ESCRS Annual Congress in Lisbon in September 2017, to start in 2018.

To apply, please submit the following: l l



A detailed up-to-date CV A letter of intent of 1-2 pages, outlining which centre you wish to attend and why A letter of recommendation from your current Head of Department A letter from your potential host institution, indicating that they will accept you if successful

Closing date for applications: 30 April 2017 Applications and queries should be sent to Danielle Maher at:


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





Vienna, host city of the 7th EURETINA Winter Meeting




8th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery 11–13 January Vienna, Austria

7th EURETINA Winter Meeting

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

21st ESCRS Winter Meeting

28 January Vienna, Austria

10–12 February Maastricht, The Netherlands

Retina World Congress

23–26 February Fort Lauderdale, USA


31st International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 2–5 March Athens, Greece

NEW 3rd OCT San Raffaele Forum 17–18 March Milan, Italy

8th World Congress on Controversies in Ophthalmology (COPHy)

30 March –1 April Madrid, Spain 2017/default.aspx


AAPOS Annual Meeting

2–6 April Nashville, USA annual_meeting_future_dates

FLOREtina 2017 Paris, host city of SFO in May 2017


27–30 April Florence, Italy


ASCRS 2017

5–9 May Los Angeles, USA

SFO 2017

6–9 May Paris, France

ARVO Annual Meeting 2017 7–11 May Baltimore, USA

MediterRetina Club International Meeting 11–13 May Parma, Italy


30th APACRS Annual Meeting

1–4 June Hangzhou, China

SOE 2017

10–13 June Barcelona, Spain

World Glaucoma Congress

28 June–1 July Helsinki, Finland


NEW MaculArt Meeting

2–4 July Paris, France


ASRS Annual Meeting 2017 12–16 August Boston, USA annual-meeting

7–10 September Barcelona, Spain

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

DOG 2017

28 September–1 October Berlin, Germany


8th EuCornea Congress 6–7 October Lisbon, Portugal


XXXV Congress of the ESCRS 7–11 October Lisbon, Portugal




18th EURETINA Congress


20–23 September Vienna, Austria

NEW WOC 2018

16–19 June Barcelona, Spain

9th EuCornea Congress

AAO 2017

11–14 November New Orleans, USA annual-meeting


21–22 September Vienna, Austria


17th EURETINA Congress

XXXVI Congress of the ESCRS 22–26 September Vienna, Austria

4th World Congress of Paediatric Ophthalmology and Strabismus 1–3 December Hyderabad, India

4 TH

World Congress of Paediatric Ophthalmology and Strabismus See You in Hyderabad

India 1-3 December 2017


EuroTimes Vol. 21 - Issue 12 - Vol22 - Issue 1  
EuroTimes Vol. 21 - Issue 12 - Vol22 - Issue 1