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VOLUME 18 ISSUE 12 december 2013 | VOLUME 19 ISSUE 1 january 2014

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ESCRS

EUROTIMES

december 2013/january 2014 Volume 18/19 | Issue 12/1 This ISSUE... Newsmaker Interview 4

Newsmaker interview with incoming ESCRS president Roberto Bellucci

Special Focus: Cornea

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Study looks at corneal transplantation options

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New CXL technique may enable patients to avoid epithelial debridement

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Pros and cons with femto lasers and keratoplasty discussed

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Corneal graft survival a complex issue

Cataract & Refractive 10 All-FS refractive surgery shows better results than conventional LASIK in studies 11 Hong Kong cataract surgeon adopts intracameral cefuroxime 12 Understanding corneal ablation may improve outcomes 13 Emanuel Rosen receives UKISCRS Lifetime Achievement Award 14 Posterior capsule tear can lead to many other complications 15 Further studies needed to understand scope of posterior capsular opacification 16 Excellent results found with iFS incisions for cataract surgery 17 Imaging tool provides valuable information across range of procedures

Glaucoma 18

A look at the first consensus statement on childhood glaucoma

19 Glaucoma can negatively affect many areas of a patient’s quality of life 20 Should cataract surgery be combined when treating glaucoma patients?

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21 Expert believes glaucoma research should use more quality of life data

Retina 24 Radiotherapy and its progress in treating ocular tumours 25 Predicting visual outcomes in patients with neovascular AMD

Ocular 26 A look at the present state of Irish ophthalmology

Paediatric Ophthalmology 28 Study finds laser ablation has no effect on endothelial cells

News 29 AMD Dublin congress organised by ESASO a success 30 The E-DMEK technique can be very beneficial to the DMEK surgeon

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36 editorial staff

ESCRS

EUROTIMES

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Advertising Executive Mairin Condon Senior Designer Janice Robb

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

31 ESCRS Clinical Research Awards aim to support worthy projects 32 Call for entries to 2014 John Henahan writing competition

Features 33 35 36 37 39

Resident’s Diary Ophthalmologica highlights Outlook on Industry Book Review Eye on Travel

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

Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

40 41 43 44

Industry News Eye on History JCRS Highlights Calendar

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2012 and 31 December 2012 is 37,563.

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EUROTIMES

Editorial

ESCRS

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EDITORIAL

Medical Editors

Volume 18/19 | Issue 12/1

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

A GOOD YEAR FOR EUCORNEA The society is having a major impact on exchanging scientific knowledge and practical skills among corneal specialists

by José Güell

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia

I

am very grateful for this opportunity to write the editorial in this issue of EuroTimes which has cornea as its Special Focus. These are exciting times for corneal specialists and also for EuCornea, the society established four years ago, to promote personal relationships and exchange of scientific knowledge and practical skills among specialists in Europe. When the society was established we knew that it would take time for us to achieve our objectives which were to encourage, support and register scientific research in the field of cornea and ocular surface disease in Europe and to promote the dissemination of the highest level of knowledge in the field of ophthalmology and specifically in cornea. Thanks to the hard work of our Board and our ordinary members, I am very pleased to see that the society has had a major impact and that EuCornea continues to grow as well as an increasing working relationship with other supranational societies focused on Cornea such as the Cornea Society, the Asian Cornea Society and the South American Cornea Society. The 4th EuCornea Congress in Amsterdam, The Netherlands was attended by over 700 delegates and was a major success thanks to the high-calibre of the scientific programme with world leaders in the field of cornea and ocular surface disease speaking across 12 symposia, six courses and 12 free paper sessions. This included a joint ESCRS/EuCornea symposium on Refractive Surgery in Risky Cornea chaired by Beatrice Cochener and Rudy Nuijts with co-chairperson Roberto Bellucci.

Building relationships As we all know, it is not possible to attend every major ophthalmological congress held in Europe and in other major centres so we have to choose carefully which congresses we attend. That is why it is very rewarding for me, as president of EuCornea, to see that EuCornea is now regarded as one of the major events in the ophthalmological calendar for corneal specialists.

EUROTIMES | Volume 18/19 | Issue 12/1

Bekir Aslan TURKEY As one congress finishes, work begins on the next congress. In September 2014, EuCornea will be partnered with the ESCRS and EURETINA congresses in London and we hope that this alliance of related meetings will be highly beneficial for members and delegates from all organisations. As a past president of ESCRS, I realise the importance of building relationships between specialists in all fields of ophthalmology and our meeting next year will give us the opportunity to discuss areas of common interests and future areas for collaboration. As a medical editor of EuroTimes, I am glad to see that the magazine has an increasing focus on cornea and this issue includes some excellent articles on the role of HLA matching in corneal graft survival, corneal transplantation, femtosecond lasers and keratoplasty and a new iontophoresis technique. Finally, on behalf of all the medical editors and our International Editorial Board, I would like to thank all of our readers for continuing to support EuroTimes. This issue is a double issue covering December 2013 and January 2014 so it is also a good time to say goodbye to the old year and welcome in the new year. We have exciting plans for EuroTimes over the next 12 months and as always if you have any ideas on how we can improve the magazine, we would like to hear from you. Happy New Year!

Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Béatrice Cochener france Hiroko Bissen-Miyajima JAPAN John Chang CHINA Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY

* José Güell is president of EuCornea and a medical editor of EuroTimes

Roberto Zaldivar ARGENTINA Oliver Zeitz germany


Abstract submission deadline: 1 March 2014

14th EURETINA Congress

LONDON 11-14 September 2014

www.euretina.org


contact

Newsmaker Interview

escrs

Roberto Bellucci – robbell@tin.it

AN EXPANDING ROLE

Incoming president of ESCRS believes that the difficulties as a result of the current economic climate can enhance the role of a leading society of surgeons by Roibeard O’hEineachain

Roberto Bellucci MD is the incoming president of the ESCRS. He spoke with EuroTimes contributing editor Roibeard O’hEineachain about the evolving role of the ESCRS in promoting the advancement of ophthalmology in Europe and throughout the world. My involvement with the ESCRS dates back to the very early days of the organisation. I remember wanting to go to the meeting of the society in 1986 because I had started implanting intraocular lenses, but at that time I was so young I had to stay in the hospital working while other doctors went to the meeting. So my first presentation was in Zürich in 1989. Then in 1990 I had three presentations at the meeting in Dublin, and attended all the meetings thereafter. Then I joined the ESCRS Board as a co-opted member early in the year 2000. After a few years I became an elected member of the Board of ESCRS and a few years later I became secretary and now I am president of the society. Over the years, the role of ESCRS in ophthalmology has changed a lot. It started as a society for ophthalmic surgeons who were helping each other achieve a better understanding of surgical procedures and refining our techniques. Then the ESCRS began to adopt an educational role and the educational activities at meetings and on the Internet have been so effective that our society has become what I believe is the leading ophthalmological subspecialty society in the world. More recently, the ESCRS has become involved in research. First there

ophthalmology as a comprehensive speciality. Although we may focus on anterior segment surgery and on cataract and refractive surgery, we must also be aware that the needs of an eye, like the needs of a patient, are not restricted to anterior segment surgery.

Roberto Bellucci

was the Endophthalmitis Study led by our president Peter Barry and then the recently started Cystoid Macular Oedema research under Rudy Nuijts' direction. On top of that there is the EUREQUO system led by Mats Lundstrom and similar registry-based research initiatives which are providing helpful data to clinicians. The ESCRS has also been expanding its activities to include other areas of ophthalmology. We are accomplishing this by holding our meetings in conjunction with those of other sister societies like the World Society of Paediatric Ophthalmology and Strabismus, EURETINA, EuCornea and the European Glaucoma Society. In this way we can encourage our members to regard

EUROTIMES

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INDIA

www.eurotimesindia.org EUROTIMES | Volume 18/19 | Issue 12/1

Another role I think that the ESCRS can play is to use the Internet to provide patients with reliable information about cataract and refractive surgery. The Internet is not controlled and contains a lot of misinformation about all branches of medicine. At present pubmed.com is the only reliable source of information available to doctors and to patients. Our society could do a great service by providing our patients with a freely accessible place online where they could find information that is valid from a scientific point of view about their eye conditions and the procedures they may undergo. During the years of my participation in the ESCRS, techniques and technology have likewise changed. Like many others of my generation I went through all the techniques of cataract surgery from intracapsular, to ECCE, to phaco. I started doing phaco in 1991 when I joined the hospital of Verona where I am the chief today, because Verona had the machine and the facility my previous hospital had not. I began to use topical anaesthesia around 1995 and I began doing MICS as early as 2006 and we began using femtosecond laser cataract surgery in 2012. In the long-term, femtosecond laserassisted cataract surgery will probably take

over from MICS, although in the shortterm cost will be the barrier to its broader use. But once a technology demonstrates better results or safer results or an easier technique than previously available techniques it stays with us. This presents a special challenge to us as surgeons, because we will need to learn new techniques but must do so without forgetting the old ones. Another challenge we face is the problem of increasing demands and decreasing resources to deal with them. The difficult economic period that Europe is currently going through poses some restrictions on our work as ophthalmologists. Reimbursement is decreasing in public hospitals, and patients have less and less money to pay out-of-pocket for specific procedures. At the same time the number of conditions we can treat is increasing but the number of ophthalmologists to treat them is decreasing. These difficulties enhance the role of a leading society of surgeons. In the meantime, the ESCRS is in very good health and is seen as a model of efficiency and organisation by other ophthalmic subspecialty societies. During my tenure as president I would like the society to continue in its role as the leading ophthalmic society in this part of the world, and to continue to expand its educational activities through better videos (including 3-D videos) and better activities in order to deliver the benefits of the society into the homes of its members.

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See your success in the eyes of your patients

Defining the standard of care in RVO* LUCENTIS® (ranibizumab) ABBREVIATED UK PRESCRIBING INFORMATION Please refer to the SmPC before prescribing LUCENTIS 10mg/ml solution for injection. Presentation: A glass single-use vial containing 0.23ml solution containing 2.3mg of ranibizumab (10mg/ml). Indications: The treatment in adults of neovascular (wet) age-related macular degeneration (AMD), the treatment of visual impairment due to diabetic macular oedema (DMO), the treatment of visual impairment due to macular oedema secondary to retinal vein occlusion (branch RVO or central RVO), and the treatment of visual impairment due to choroidal neovascularisation (CNV) secondary to pathologic myopia (PM). Administration and Dosage: Single-use vial for intravitreal use only. LUCENTIS must be administered by a qualified ophthalmologist experienced in intravitreal injections under aseptic conditions. The recommended dose is 0.5 mg (0.05ml). For treatment of wet AMD: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. The patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to wet AMD. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. For treatment of visual impairment due to either DMO or macular oedema secondary to RVO: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. the patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab treatment. If there is no improvement in visual acuity over the course of the first three injections, continued treatment is not recommended. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to DMO or to macular oedema secondary to RVO. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. LUCENTIS and laser photocoagulation in DMO and in macular oedema secondary to BRVO: When given on the same day, LUCENTIS should be administered at least 30 minutes after laser photocoagulation. LUCENTIS can be administered in patients who have received previous laser photocoagulation. For treatment of visual impairment due to CNV secondary to PM: Treatment is initiated with a single injection. If monitoring reveals signs of disease activity, e.g. reduced visual acuity and/or signs of lesion activity, further treatment is recommended. Monitoring for disease activity may include clinical examination, optical coherence tomography (OCT) or fluorescein angiography (FA). While many patients may only need one or two injections during the first year, some patients may need more frequent treatment. Therefore, monitoring is recommended monthly for the first two months and at least every three months thereafter during the first year. After the first year, the frequency of monitoring should be determined by the treating physician. The interval between two doses should not be shorter than one month. LUCENTIS and Visudyne photodynamic therapy in CNV secondary to PM: There is no experience of concomitant administration of LUCENTIS and Visudyne. Before treatment, evaluate the patient’s medical history for hypersensitivity. The

patient should also be instructed to self-administer antimicrobial drops, 4 times daily for 3 days before and following each injection. Children and adolescents: Not recommended for use in children and adolescents due to a lack of data. Elderly: No dose adjustment is required in the elderly. There is limited experience in patients older than 75 years with DMO Hepatic and renal impairment: Dose adjustment is not needed in these populations. Contraindications: Hypersensitivity to the active substance or excipients. Patients with active or suspected ocular or periocular infections. Patients with active severe intraocular inflammation. Special warnings and precautions for use: LUCENTIS is for intravitreal injection only. Intravitreal injections have been associated with endophthalmitis, intraocular inflammation, rhegmatogenous retinal detachment, retinal tear and iatrogenic traumatic cataract. Monitor during week following injection for infections. Patients should be instructed to report symptoms suggestive of any of the above without delay. Transient increases in intraocular pressure (IOP) within 1 hour of injection and sustained IOP increases have been identified. Both IOP and perfusion of the optic nerve head should be monitored and managed appropriately. Concurrent use in both eyes has not been studied and could lead to an increased systemic exposure. There is a potential for immunogenicity with LUCENTIS which may be greater in subjects with DMO. Patients should report an increase in severity of intraocular inflammation. LUCENTIS should not be administered concurrently with other anti-VEGF agents (systemic or ocular). Withhold dose and do not resume treatment earlier than the next scheduled treatment in the event of the following: a decrease in best corrected visual acuity (BCVA) of ≥30 letters compared with the last assessment of visual acuity; an intraocular pressure of ≥30 mmHg; a retinal break; a subretinal haemorrhage involving the centre of the fovea, or if the size of the haemorrhage is ≥50% of the total lesion area; performed or planned intraocular surgery within the previous or next 28 days. Risk factors associated with the development of a retinal pigment epithelial (RPE) tear after anti-VEGF therapy for wet AMD include a large and/or high pigment epithelial retinal detachment. When initiating LUCENTIS therapy, caution should be used in patients with these risk factors for RPE tears. Discontinue treatment in cases of rhegmatogenous retinal detachment or stage 3 or 4 macular holes. There is only limited experience in the treatment of subjects with DMO due to type I diabetes. LUCENTIS has not been studied in patients who have previously received intravitreal injections, in patients with active systemic infections, proliferative diabetic retinopathy, or in patients with concurrent eye conditions such as retinal detachment or macular hole. There is also no experience of treatment with LUCENTIS in diabetic patients with an HbA1c over 12% and uncontrolled hypertension. In PM patients there are no data on the use of LUCENTIS in patients with extrafoveal lesions and only limited data on its use in those who have had previous unsuccessful therapy with verteporfin photodynamic therapy. Systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events have been reported following intravitreal injection of VEGF inhibitors. There are limited data on safety in the treatment of DMO, macular oedema due to RVO and CNV secondary to PM patients with prior history of stroke or transient ischaemic attacks. Caution should be exercised when treating such patients. There is limited experience with treatment of patients with prior episodes of RVO and of patients with ischaemic BRVO and CRVO. Treatment is not recommended in RVO patients presenting with clinical signs of irreversible ischaemic visual function loss. Interactions: No formal interaction

studies have been performed. In DMO and BRVO adjunctive use of laser therapy and LUCENTIS was not associated with any new ocular or non-ocular safety findings. Pregnancy and lactation: Women of childbearing potential should use effective contraception during treatment. No clinical data on exposed pregnancies are available. Ranibizumab should not be used during pregnancy unless the expected benefit outweighs the potential risk to the foetus. For women who wish to become pregnant and have been treated with ranibizumab, it is recommended to wait at least 3 months after the last dose of ranibizumab before conceiving. Breast-feeding is not recommended during the use of LUCENTIS. Driving and using machines: The treatment procedure may induce temporary visual disturbances and patients who experience these signs must not drive or use machines until these disturbances subside. Undesirable effects: Most adverse events are related to the injection procedure. Serious adverse events reported include endophthalmitis, blindness, retinal detachment, retinal tear and iatrogenic traumatic cataract. The safety data below include adverse events experienced following the use of LUCENTIS in the entire clinical trial population. Those marked * were only seen in the DMO population. Very Common: Intraocular pressure increased, headache, vitritis, vitreous detachment, retinal haemorrhage, visual disturbance, eye pain, vitreous floaters, conjunctival haemorrhage, eye irritation, foreign body sensation in eyes, lacrimation increased, blepharitis, dry eye, ocular hyperaemia, eye pruritus, arthralgia, nasopharyngitis. Common: Urinary tract infection*, anaemia, retinal degeneration, retinal disorder, retinal detachment, retinal tear, detachment of the retinal pigment epithelium, retinal pigment epithelium tear, visual acuity reduced, vitreous haemorrhage, vitreous disorder, uveitis, iritis, iridocyclitis, cataract, cataract subcapsular, posterior capsule opacification, punctuate keratitis, corneal abrasion, anterior chamber flare, vision blurred, injection site haemorrhage, eye haemorrhage, conjunctivitis, conjunctivitis allergic, eye discharge, photopsia, photophobia, ocular discomfort, eyelid oedema, eyelid pain, conjunctival hyperaemia, cough, nausea, allergic reactions, hypersensitivity, anxiety. Product-class-related adverse reactions: There is a theoretical risk of arterial thromboembolic events, including stroke and myocardial infarction, following intravitreal use of VEGF inhibitors. A low incidence rate of arterial thromboembolic events was observed in the LUCENTIS clinical trials in patients with AMD, DMO, RVO and PM and there were no major differences between the groups treated with ranibizumab compared to control. Please refer to the SmPC for full listing of all undesirable effects.

For UK: Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Novartis Pharmaceuticals UK Ltd on (01276) 698370 or medinfo.uk@novartis.com Legal category: POM, UK Basic NHS cost: £742.17. Marketing authorisation number: EU/1/06/374/001. Marketing authorisation holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Full prescribing information, including SmPC, is available from: Novartis Pharmaceuticals, Frimley Business Park, Frimley, Camberley, Surrey, GU16 7SR. Telephone: 01276 692255. Fax: 01276 692508. Prepared July 2013.

* Visual impairment due to macular edema secondary to retinal vein occlusion (branch RVO or central RVO)

Lucentis Indications may vary from country to country. Physicians should refer to their National Prescribing Information. Novartis Pharma AG CH-4002 Basel, Switzerland

©2013 Novartis Pharma AG

October 2013

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LUC13-C166b


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Special Focus

CORNEA

Iva Dekaris – iva.svjetlost@gmail.com

transplantation

Faster visual recovery with ultra-thin DSAEK? by Dermot McGrath in Copenhagen

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hinner lamellar endothelial grafts result in better visual outcomes sooner after surgery compared to thick lamellar grafts or penetrating keratoplasty (PKP), according to a study presented at the 2013 Congress of the European Society of Ophthalmology. “According to our results on a relatively small number of eyes, the thinner lamellar endothelial grafts obtained using ultra-thin Descemet’s stripping automated endothelial keratoplasty (UT-DSAEK) provides faster and more complete visual rehabilitation as compared to conventional DSAEK,” Iva Dekaris MD, PhD told delegates. While corneas with thicker grafts do eventually improve in terms of visual results, they do not, however, attain the level of best-corrected vision obtained with ultra-thin grafts, noted Prof Dekaris, and the advantage of quicker visual recovery is lost. Although PKP has been the mainstay of treatment for corneal diseases for the best part of a century, lamellar surgery has become increasingly popular in recent years, said Prof Dekaris, and now makes up about half of all corneal transplants in the US and approximately 25 per cent of those in Europe, with DSAEK the most commonly used lamellar technique.

Don’t Miss Industry News, see page 40 EUROTIMES | Volume 18/19 | Issue 12/1

The advantages of DSAEK have already been well established in the scientific literature, said Prof Dekaris, highlighting the fact that it is safe and technically straightforward compared to more complex surgical procedures such as Descemet’s membrane endothelial keratoplasty (DMEK), in which only Descemet’s membrane is transplanted. Although technically more difficult, the principal advantage of DMEK over DSAEK is its superior visual outcomes, said Prof Dekaris. “There are pros and cons to every medical procedure and the biggest drawback of DSAEK is the fact that many patients do not obtain postoperative vision of 20/20, and in DMEK we know that they do,” she said. Understanding why DMEK patients obtain better visual results prompted Prof Dekaris and other researchers to explore possible links between graft thickness and postoperative outcomes. “When we started to prospectively follow our DSAEK cases we asked ourselves whether graft thickness matters, but at the time in 2010 there were only two scientific papers with small patient numbers that sought to address this issue. We knew for sure that DMEK patients do better regarding vision and perhaps it was not just coincidence that the thinnest graft is that produced in DMEK procedures,” she said. To test the hypothesis, Prof Dekaris and co-workers carried out a prospective case study of 20 eyes that underwent UT DSAEK (group 1) and 30 eyes that had conventional DSAEK (group 2), all for the treatment of pseudophakic bullous keratopathy (Figure 1). Both surgeon-cut and “pre-cut” tissue obtained from certified eye banks was used and all patients underwent serial central graft thickness measurements with non-contact optical coherence tomography (Zeiss Visante™ AS-OCT) at various time points after surgery. The eyes in the conventional DSAEK group were further subdivided into three subgroups based on first day postoperative endothelial graft thickness, said Prof Dekaris: thin grafts with a lamellar thickness less than180 μm, medium-thick grafts of between 180 and 250 μm and thick grafts over 250 μm. The differences between the groups regarding best spectacle-corrected visual acuity (BSCVA) and endothelial cells density loss were recorded. Noting that there was no statistically significant difference in age, sex, or preoperative BSCVA between groups, Prof Dekaris said that the median postoperative graft thickness in group 1 was 78 μm and 190 μm for group 2, with a follow-up of between three and 36 months. In terms of visual outcomes, the UT DSAEK group achieved better postoperative BCVA both in quantity and speed of recovery (mean BCVA of 0.75 and 0.8 at one and three months, respectively), compared to all conventional DSAEK groups, said Prof Dekaris. The thin DSAEK grafts of less than 180 microns recorded the best visual acuity among

Courtesy of Iva Dekaris MD, PhD

6

the three DSAEK subgroups and attained a mean BCVA of 0.6 at six months postoperatively. By contrast, thick grafts never reached the same BCVA score of either ultra-thin or thin DSAEK grafts, she said (Figure 2). To illustrate the difference in visual recovery, Prof Dekaris showed one case study of a patient who had PKP in one eye and ultra-thin DSAEK in his fellow eye. At three months he had BCVA of 0.35 in PKP and 0.95 in the UT-DSAEK eye (Figure 3). “We can see that the speed of visual recovery is drastically different between the PKP and UT-DSAEK eyes. The tempo of visual recovery between conventional DSAEK and ultrathin DSAEK in different eyes of the same patients was objectively better in UT-DSAEK, reaching BCVA of 0.9 at one month, as compared to 0.7 in conventional DSAEK. However, patient observations were that they do not see much difference between the two operated eyes,” she said. Summing up, Prof Dekaris said that the study showed that only lamellar grafts of 180 microns and less obtain good visual quality in conventional DSAEK with results superior to PK eyes over the long term. Furthermore, ultra-thin DSAEK provides faster and more complete visual rehabilitation compared to conventional DSAEK. “I would echo Dr Melles’ saying that 'not only one road leads to Rome' and at this time the range of different endothelial keratoplasty procedures allow us to manage each case based on the patient's individual needs. We would emphasise, however, that DMEK is safer regarding graft rejection and we do need more data going forward to see how ultra-thin DSAEK performs in this respect,” she concluded.


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Special Focus

CORNEA

New OCULUS Keratograph 5M

EPI-ON CXL

New iontophoresis technique enhances penetration of riboflavin through intact epithelium by Roibeard O’hEineachain in Verona

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new collagen cross-linking technique (CXL) that uses iontophoresis to enhance penetration of riboflavin through epithelial tissue may enable patients to undergo the procedure without the need for epithelial debridement, said Francois Malecaze MD, CHU de Toulouse-Hôpital Purpan, Toulouse, France, at Femto 2013, an international meeting on anterior segment surgery. “The iontophoresis technique could allow intrastromal riboflavin diffusion, while keeping the corneal epithelium on, combining the efficiency of the standard procedure without the side effects of epithelial debridement,” noted Dr Malecaze.

The iontophoresis technique could allow intrastromal riboflavin diffusion, while keeping the corneal epithelium on, combining the efficiency of the standard procedure without the side effects of epithelial debridement Francois Malecaze MD

Less pain

He presented results from a rabbit eye study which indicated that the new and as yet experimental “epi-on” crosslinking technique allows penetration of riboflavin into the corneal stroma for CXL. He also reported that preliminary results from a clinical study show that it causes patients much less pain than is the case with conventional “epi-off” techniques. The current CXL technique requires the debridement of the epithelium to allow the penetration of riboflavin into the cornea. That causes patients significant pain during the first two postoperative days and results in some loss of visual acuity for the first three postoperative months. It also creates the risk of more serious complications such as infection and stromal opacity due to corneal scarring. The new technique proposed by Dr Malecaze and his associates involves iontophoresis, a technique that has been developed for enhancing the diffusion of ionised molecules through living tissue using a small electric charge. It also involves the use of special formulations of riboflavin Ricrolin TE (Sooft Italia) that has been modified to enhance penetration through the epithelium. “Riboflavin is a perfect candidate for delivery through iontophoresis because it has a small molecular weight, is negatively charged at physiologic pH, is soluble in water and has minimal buffer content,” Dr Malecaze said. The iontophoretic CXL technique involves placement of two electrodes, one on the forehead and the other inside a reservoir cup EUROTIMES | Volume 18/19 | Issue 12/1

Topography and advanced external imaging for dry eye assessment

fixed to the cornea by means of suction ring. The generator applies a constant current of 1mA for a preset period of five minutes allowing riboflavin in the reservoir to diffuse through the anterior stromal tissue. Afterwards the cornea is irradiated with UVA in the usual manner. In an animal study involving rabbits that underwent the iontophoretic CXL procedure HPLC biochemical analysis and two-photon microscopy showed that although riboflavin only penetrated to half the depth of that achieved with the conventional epi-off technique, the diffusion of the agent was sufficient to achieve adequate cross-linking in the anterior two-thirds of the stroma.

Resolved in 24 hours The preliminary results of an ongoing multicentre clinical study that has so far involved 30 patients undergoing iontophoretic CXL show that all patients had a punctate keratitis postoperatively similar to photokeratitis, and around half of patients had pain five hours after the procedure, but it resolved within 24 hours. In addition, the cornea had a normal appearance under slit-lamp examination. “Since we have only two months’ work it is too early to draw any conclusions about the efficacy of the technique,” Dr Malecaze added.

contact Francois Malecaze – malecaze.fr@chu-toulouse.fr

High-resolution colour camera

Imaging of the upper and lower meibomian glands

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

Assessment of the lipid layer and tear film particles

Grading of the bulbar redness

Image and video documentation

www.oculus.de


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Special Focus

CORNEA

FEMTO LASERS

New technology offers some advantages but is it worth it? by Roibeard O’hEineachain in Verona

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emtosecond lasers are finding a diverse range of uses in keratoplasty procedures, although the expense of the instruments must be weighed against the relatively modest benefits, if any, that they provide in terms of visual outcomes, according to several presenters speaking at Femto 2013, an international meeting on anterior segment surgery. “Femtosecond lasers provide customised corneal patterns, cut very precisely and with a perfect correspondence between the donor and recipient cornea, maximising the surface area of the wound and providing greater wound stability and increased resistance to wound leakage,” said Romina Fasciani MD. She noted that because of the precision of the femtosecond trephination it could theoretically make the penetrating keratoplasty procedure into a more repeatable technique that could result in faster visual rehabilitation, less postoperative astigmatism and greater wound strength

Femtosecond lasers provide customised corneal patterns, cut very precisely and with a perfect correspondence between the donor and recipient cornea... Romina Fasciani MD

with less risk of wound dehiscence during suture removal. In the Eye Clinic of Catholic University of “Sacro Cuore” in Rome with Prof Emilio Balestrazzi and Dr Luigi Mosca, we have experienced the effectiveness of lamellar and penetrating keratoplasty assisted by femtosecond laser.

MILOS EYE HOSPITAL - BELGRADE, SERBIA

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EUROTIMES | Volume 18/19 | Issue 12/1

Research conducted to date indicate that with current technology femtosecond laserassisted penetrating keratoplasty results in better wound adhesion and more rapid improvement in acuity and permits earlier suture removal than is the case with standard penetrating keratoplasty, Dr Fasciani said. However, the lasers provide little if any advantage over penetrating keratoplasty in terms of postoperative astigmatism in the long term and the rates of endothelial cell loss with the lasers has ranged very widely, from under five per cent to over 30 per cent. Moreover, the newer technology is also more expensive, takes longer, and generally entails the use of general anaesthesia. There are a number of trephination profiles that are possible with the femtosecond laser, such as the mushroom, the top hat, the zigzag and the Christmas tree. There are also several new trephination profiles that are coming into clinical use, including the dovetail, the bolt and decagonal shapes. Future trends to watch out for include the use of anterior segment OCT to precisely guide the trephination, and the use of fibrin glue or laser corneal welding to seal and secure the shaped opposing wound edges, Dr Fasciani added.

Femto DALK In eyes where the pathology affects only the anterior cornea, deep anterior lamellar keratoplasty (DALK) is a useful option since it spares the recipient’s endothelium and greatly reduces the risk of corneal rejection. The use of femtosecond laser in such cases has the same potential benefits as it does with penetrating keratoplasty, said Elisabetta Böhm MD, Ospedale dell'Angelo, Venice-Mestre, Italy. “Femtosecond DALK provides simplicity and also safety because of the larger scar, which should grant a stronger graft. Its learning curve is also short,” she said. Cases particularly suited to femtosecond laser-assisted DALK include young patients, because the tighter wound apposition they afford would offer better protection against ocular trauma. DALK may be useful in eyes with vascularised corneas, because the perfect smoothness of the laser cut, very seldom followed by any inflammation, may inhibit vascular re-growth. Cases unsuited to the procedure include those where a suction ring cannot be applied, such as in eyes with conjunctival oedema. Also unsuited are eyes with thin and damaged corneas, as in the case of corneal hydrops, where the pressure exerted by the cone could be harmful. She noted that she and her associates use mainly the mushroom and diamond profiles when performing femtosecond-laserassisted DALK procedure, and each have their advantages. The mushroom profile has the greatest effect on the anterior cornea

Romina Fasciani – romina.fasciani@gmail.com Elisabetta Bohm – elisabetta.bohm@ulss12.ve.it Mor M Dickman – Mor.dickman@mumc.nl

Preparation of the donor posterior lamellar disc with a femtosecond laser enables the creation of planar grafts with micrometer precision, independent of the limitations of microkeratome mechanics Mor M Dickman MD

and requires only a small bubble to cleave the residual stroma from the Descemet’s membrane. The diamond profile makes it easier for the surgeon to perform the final cutting of the stroma from the periphery of the denuded Descemet’s membrane.

Femto DSEK Endothelial keratoplasty has the opposite advantage from DALK in that it leaves the anterior cornea intact and replaces only the host endothelium with as little of donor stroma attached to it as possible. Preparation of the donor posterior lamellar disc with a femtosecond laser enables the creation of planar grafts with micrometer precision, independent of the limitations of microkeratome mechanics, said Mor M Dickman MD, University Eye clinic Maastricht, the Netherlands, Maastricht. However, the results of the Dutch Lamellar Corneal Transplantation Study (DLCTS), indicate that femtosecond laserassisted Descemet’s-stripping endothelial keratoplasty produces results inferior to those of penetrating keratoplasty in terms of visual acuity and endothelial cell survival, he said. As part of the prospective randomised multicentre study, Dr Nuijts and his associates compared the results achieved in 36 eyes that underwent a laser assisted procedure with 40 eyes that underwent penetrating keratoplasty. At one year’s follow-up, mean BCVA was 20/70 lines in the femtosecond laser-assisted DSEK group and 20/44 in the penetrating keratoplasty group (P < .001) despite significant improvement in both refractive and topographic astigmatism in the DSEK group. The main factor limiting visual acuity was interface wound healing. In addition, endothelial cell counts fell to around 1,000 cells/mm2 in the DSEK group compared to 2,000 cells/mm2 in the penetrating keratoplasty group. "This finding is likely related to the learning curve of different surgeons, as preliminary in vitro studies have shown that femtosecond laser assisted endothelial graft dissection is not associated with significant endothelial cell loss," Dr Dickman said.


9

Special Focus

CORNEA

CORNEAL GRAFT

Unravelling the complex role of HLA matching in corneal graft survival by Dermot McGrath in Copenhagen

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dvanced tissue typing techniques such as human leukocyte antigen (HLA) matching deserve greater attention as a potential means of increasing the survival of corneal grafts over the long term, according to John Armitage PhD, director of tissue banking at the University of Bristol, UK. “HLA matching in corneal transplantation remains a controversial issue, although I think it is now reasonably accepted, at least in Europe, that HLA class I matching is beneficial for the survival of grafts in penetrating keratoplasty procedures,” he told delegates attending the 2013 Congress of the Society of European Ophthalmology (SOE). He added that a lot more research was needed to resolve questions relating to possible benefits or otherwise of HLA class II matching and understand more about the way HLA responses are modulated in the anterior chamber. A wide range of factors have been invoked over the years to explain the cornea’s immune-privileged status, including the absence of lymphatic and blood vessels in the corneal graft bed, the expression of Fas ligand on corneal cells, low-level expression of HLA antigens, the paucity of mature antigen-presenting macrophages or Langerhans cells, and the presence of immunomodulatory cytokines such as α-melanocyte–stimulating hormone and transforming growth factor in aqueous humour, among other reasons. “Despite this relative immune privilege, I think what we know now is that all of these factors can be overridden by inflammatory responses, leading to rejection and graft failure,” he said. Prof Armitage said that there is actually little evidence to justify the oft-repeated mantra that corneal transplantation is the most successful of all organ transplants. “If you look at penetrating keratoplasty data from the United Kingdom and compare it with first renal transplants, the first year survivals are very similar, but by the time we reach five years then corneal transplant survival at 73 per cent is worse than renal which had an 83 per cent survival rate,” he said. Around 34 per cent of these penetrating keratoplasty failures are caused by allograft rejection, said Prof Armitage. EUROTIMES | Volume 18/19 | Issue 12/1

“A more recent study in the UK found that matching for HLA class I antigens in bullous keratopathy patients reduced the risk of graft failure at five years by two-and-a-half-fold, which is quite a big impact” “Even if the surgeons are able to control and reverse the rejection episodes, long-term survival is compromised, as shown by data from the Australian corneal graft registry. For grafts that have suffered one or more rejection episodes, the survival rate after 10 years is halved. Probably the reason for that is that with each rejection episode we tend to lose corneal endothelial cells and these cells can continue to be lost at an accelerated rate many years after the transplant,” he said. Prof Armitage said that there are several studies in the scientific literature showing that HLA class I matching reduces the risk of graft rejection. “A more recent study in the UK found that matching for HLA class I antigens in bullous keratopathy patients reduced the risk of graft failure at five years by twoand-a-half-fold, which is quite a big impact. And Prof Thomas Reinhard’s group in Freiburg, Germany, has also shown that HLA matching reduced the risk of rejection even in apparently low-risk grafts,” he said. Prof Armitage said that while contradictory results on the benefits of HLA matching have been obtained in previous trials, ongoing studies using modern DNA typing techniques should help to demonstrate that HLA typing has a positive role in reducing the rate of allograft rejection in both high- and low-risk patients.

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contact John Armitage – w.j.armitage@bristol.ac.uk 109-1166 ADV-Masterpiece-120x300.indd 1

27-11-13 16:29


Update

Cataract & refractive

FS-surgery

Small-incision lenticule extraction results similar to LASIK at one year

Courtesy of Osama Ibrahim MD

by Howard Larkin in San Francisco

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ll-femtosecond laser refractive surgery produces good visual outcomes with greater stability and fewer side effects than conventional LASIK, according to a series of studies presented at the annual meeting of American Society of Cataract and Refractive Surgery. Known as ReLEx SMILE, for small-incision lenticule extraction, the procedure uses a Carl Zeiss Meditec VisuMax femtosecond laser to cut a refractive lenticule in stromal tissues along with a 3.0mm to 4.0mm incision through the corneal epithelium and Bowman’s membrane. The lenticule interfaces are then separated manually using a flap dissector and the lenticule is removed in one piece through the small incision. An earlier ReLEx procedure known as FLEX is similar except the lenticule is removed through a flap instead of a small incision. “This all-femtosecond laser refractive surgery is a flapless procedure which permits minimally invasive refractive correction,” said Jean-Francois Faure MD, Espace Nouvelle Vision, Paris, France.

Don’t Miss Eye on History, see page 41 EUROTIMES | Volume 18/19 | Issue 12/1

Unlike LASIK, his HRT and OCT exams of post-op SMILE eyes showed no degradation of corneal nerves, which Dr Faure believes promotes quicker recovery. In the largest series reported at the ASCRS conference, Osama Ibrahim MD, Alexandria University, Egypt, found SMILE refractions extremely stable. From a preoperative mean spherical equivalent of -5.92 +/- 2.13 D, he reported postoperative SE means ranging from -0.09 +/- 0.39 D for 975 eyes at one month to -0.07 +/- 0.37 D for 266 eyes followed to 12 months. “These patients maintained vision at one month, three months, six months and one year. The patients followed up to two years showed exactly the same results,” he reported. At one year, 95 per cent of SMILE patients were within 1.0 D of the target refraction, and 73 per cent were within 0.25 D, Dr Ibrahim reported. About five per cent lost one line of corrected distance vision, while 26 per cent gained one line and seven per cent gained two lines. Over time, patients tended to recover lost vision, he added. Arturo J Ramirez-Miranda MD, Instituto de Oftalmologia “Conde de Valenciana,” Mexico City, reported similar results in a prospective interventional case series involving 113 eyes in 58 patients with a mean preoperative SE of -5.0 D, ranging from -1.25 to -7.88 D. Between three and 12 months after surgery, only four per cent of patients saw refractions change more than 0.5 D. “At one year, 97 per cent were 20/20 or better uncorrected, with two per cent losing one line of corrected distance visual acuity while 27 per cent gained one line and seven per cent gained two lines,” Dr Ramirez-Miranda said. Mean SE measured -0.21. Predictability was 98 per cent, with 94 per cent within 1.0 D SE of intended correction and 81 per cent within 0.5 D. For astigmatism, 90 per cent were within 1.0 D, and 54 per cent within 0.5. Igor Solomatin MD, Riga, Latvia, one of the earliest SMILE researchers, presented a series of 60 eyes in 30 patients with a preoperative SE of -4.53 +/- 1.29 D. He reported 95 per cent predictability, with all eyes within 1.0 D of intended refraction, 92 per cent within 0.5 and 40 per cent within 0.13 at one year. Also, 98 per cent achieved 20/25 or better uncorrected, 86 per cent 20/20 and 54 per cent 20/16 or better. About 12 per cent lost one line of corrected distance vision while 34 per cent gained one to two lines. A contralateral eye study involving 20 patients comparing SMILE and femto-LASIK, also done at Conde de Valenciana in Mexico City, found no statistical significance in refractive outcomes, said Angie De La Mota MD. Predictability was 97 per cent in both groups, with 79 per cent of LASIK and 93 per cent of SMILE eyes within 1.0 D, and 64 and 71 per cent, respectively, within 0.5 D of the intended refraction. No significant differences were found in postoperative tear film breakup time, Schirmer test or corneal

contacts

10

Jean-Francois Faure – jf.faure@espace-nouvelle-vision.com Arturo J Ramirez-Miranda – arturorammir@gmail.com Osama Ibrahim– ibrosama@gmail.com Igor Solomatin– contacts@acucentrs.lv

At one year, 97 per cent were 20/20 or better uncorrected, with two per cent losing one line of corrected distance visual acuity while 27 per cent gained one line and seven per cent gained two lines Arturo J Ramirez-Miranda MD

aesthesiometry, Dr De La Mota said. Patient satisfaction also was similar, with a slight trend toward SMILE. However, in his study of 110 eyes evaluating postoperative corneal interfaces, Dr Faure noted that 2/3 had stopped artificial tears one month after surgery, more than he typically sees after LASIK. Microscopic examinations revealed less inflammation in the corneal epithelium, Bowman’s membrane, and mid-stroma beyond the lenticule in SMILE eyes than in LASIK eyes. Similar levels of inflammatory cells were seen in the area of lenticule extraction in SMILE patients as in the anterior stroma of LASIK patients, though with unidentified hyperreflective particles in the SMILE eyes. This, along with maintaining corneal nerves, may account for less dry eye after surgery.


add_december_ok.pdf

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11/25/13

11

Update

Cataract & refractive

Endophthalmitis

Prospective audit finds no infections in 11,500+ cases over three years by Cheryl Guttman Krader in Singapore

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ong Kong cataract surgeon Kendrick Shih MD was “delighted” to have no cases of endophthalmitis at his highvolume cataract surgery centre over a three year period after changing to intracameral cefuroxime to prevent postoperative endophthalmitis. A high-volume surgery centre was established as a pilot programme at the Grantham Hospital, Hong Kong, in November, 2009. Routine use of intracameral cefuroxime 1 mg/0.1 ml BSS, except in patients with known beta-lactam antibiotic allergy, was incorporated into the surgical protocol from the outset. Patients also underwent disinfection on the operating table with five per cent povidone iodine, but they received no topical or systemic antibiotics preoperatively. Postoperative treatment consisted of fixed combination dexamethasone/neomycin, one drop every four hours for four weeks. Speaking at the 26th Asia-Pacific Association of Cataract & Refractive Surgeons Annual Meeting, Dr Shih reported that between November 1, 2009, and December 31, 2012, a total of 11,537 cataract surgeries were performed by 31 surgeons at the surgical centre. The majority of patients were aged 70 years or older, and 94 per cent of cases involved phacoemulsification through a clear corneal incision (2.2 or 2.75mm) with implantation of a single-piece hydrophobic acrylic IOL. Routine practice was to leave the incision unsutured.

No adverse events Intracameral cefuroxime was used in 99.4 per cent of cases. Nearly all patients (98.0 per cent) completed all scheduled follow-up visits at one day, one week, and one month. In this very large, multi-surgeon series, there were no cases of postsurgical endophthalmitis, allergic reactions to cefuroxime, or other adverse events associated with its intracameral use. “We are delighted with our results using intracameral cefuroxime, and while we recognise that the lack of a comparator group is a major limitation of our analysis, our experience compares well with historical data from other studies in Hong Kong for which the quoted incidence of postcataract surgery endophthalmitis ranges from 0.11 per cent to 0.20 per cent,” said EUROTIMES | Volume 18/19 | Issue 12/1

2:31 PM

“Private surgeons in Hong Kong do not have the advantage of having access to material prepared under controlled sterile conditions, and for that reason, most private surgeons are not using intracameral cefuroxime” C

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Dr Shih, clinical assistant professor of ophthalmology, University of Hong Kong. He added, “We do not expect that the incidence of post-cataract surgery endophthalmitis will be maintained at zero forever. However, we hope this prospective audit will facilitate ongoing quality assurance and be a method for future risk factor identification for our centre.” Dr Shih said that based on accumulating evidence, he looks forward to seeing more centres adopt intracameral cefuroxime for postoperative endophthalmitis prophylaxis. However, he recognised that concerns relating to cefuroxime reconstitution remain a barrier. At the Grantham Hospital centre, the cefuroxime used for intracameral administration is prepared in the sterile environment of the pharmacy’s total parenteral nutrition laboratory. Twice a week, on Monday and Thursday, reconstituted cefuroxime for intravenous injection is drawn up into 1.0ml syringes that are sealed in sterile packaging and stored at 4° C for up to one week. “Private surgeons in Hong Kong do not have the advantage of having access to material prepared under controlled sterile conditions, and for that reason, most private surgeons are not using intracameral cefuroxime,” Dr Shih said.

contact Kendrick Shih – kcshih@hku.hk

Strawinskylaan 1265, 1077 XX Amsterdam - The Netherlands www.vsybiotechnology.com


Cataract & refractive

THE ABLATED CORNEA

ESCRS Binkhorst lecturer says understanding how ablation affects the cornea may improve outcomes by Howard Larkin in Amsterdam

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growing understanding of the anatomical and optical changes induced by corneal ablation is leading to treatment refinements that may further improve visual outcomes in refractive ablation procedures and postablation implantation of the intraocular lens (IOL), Douglas D Koch MD told the XXXI Congress of the ESCRS in the Binkhorst Medal Lecture 2013. He acknowledged his co-investigators Li Wang MD, PhD, Mitchell P Weikert MD and Bruna Ventura MD. Improved measurements of the posterior corneal surface, post-ablation epithelial thickness and anterior topography can help plan and monitor corneal changes in patients undergoing ablation procedures. This could also allow predictable manipulation of some aberrations to optimise depth of focus while minimising visually disturbing aberrations, said Dr Koch, Allen, Mosbacher and Law Chair in Ophthalmology at Baylor College of Medicine, Houston, US. For post-refractive surgery patients undergoing cataract procedures, better measurements will help improve calculation of IOL power, added Dr Koch, who is also editor emeritus of the Journal of Cataract and Refractive Surgery.

Anatomical changes Corneal ablation achieves its intended refractive effect by removing anterior stromal tissue. But it also stimulates remodelling of the corneal epithelial profile, producing unintended refractive changes, Dr Koch said.

EUROTIMES | Volume 18/19 | Issue 12/1

Recent optical coherence tomography studies confirm high-frequency ultrasound studies that show that central epithelial thickness progressively increases for about three months following myopic LASIK, adding up to 13 microns at the central cornea, resulting in a myopic shift of about -0.38 D (see figure below). Conversely, hyperopic LASIK results in central epithelial thinning of up to 8.0 microns with annular thickening of up to 24 microns, Dr Koch noted (Reinstein DZ et al. J Refract Surg, 2012;28(3):195-201. Ma XJ, Wang L and Koch DD. Cornea, in press). Ablation changes corneal biomechanical properties, producing central flattening, peripheral corneal thickening, and an inward shift of the posterior cornea that can appear to be central steepening. This tends to regress during the first year, (Grzybowski DM et al. J Cataract Refract Surg. 2005;31:72-81. Smadja D et al. J Cataract Refract Surg. 2012;38:1222-1231). Dr Koch’s OCT data showed a minimal curvature change in the central 3.0mm zone with a mean power of -0.02 D. While these changes are small, monitoring and modulating them could improve refractive predictability and

stability, and increase the accuracy and effectiveness of retreatment, Dr Koch said.

Altering optics Altering anterior corneal curvature also changes the size of the effective optical zone. Based on anterior corneal refractive maps, standard LASIK ablations reduce this zone by about 4.9mm2, while wavefront-guided ablations actually increase it by about 3.9mm2 (Racine L Et Al. Am J Ophthalmol. 2006;142:227-232). But when higher order aberrations and the entire optical system are accounted for, only 65 per cent of patients maintain wavefront quality equivalent to 20/20 across a 6.0mm zone after ablation, compared with 99 per cent before, though nearly 100 per cent maintain zones of 4.0mm, Dr Koch said. “Some reduction is inevitable due to transition to unablated tissue. We need to better understand correlation with visual function and what is the minimal zone needed to prevent haloes and other unintended visual issues.” Changing corneal curvature also induces higher order aberrations, with spherical aberration being the most significant. With myopic PRK, corneal SA rises from about +0.27 microns in the normal eye to a mean of about +0.47, Dr Koch said. This

contact

Update

Courtesy of Douglas D Koch MD

12

Douglas Koch – dkoch@bcm.edu

creates defocus but does not appear to reduce contrast sensitivity. On the upside, it increases depth of focus (Yeu E et al. Am J Ophthalmol. 2012;153:972-981).

IOL selection IOL selection is affected in at least three ways: 1. Changing corneal spherical aberration complicates IOL selection for post-ablation cataract surgery patients, Dr Koch said. To achieve maximum polychromatic modulation transfer function performance, the amount of SA in the lens should be matched to the corneal asphericity of the patient. For those corneas with high amounts of positive SA (> 0.4 microns), this is not feasible and may not be desirable due to high sensitivity to decentration. Also, the optimal postoperative SA will depend on the refractive error. For 0.0 defocus, optical quality is optimal with no SA, whereas with -0.5 D of myopia, total SA of +0.2 microns provides sharpest uncorrected vision. 2. As all cataract surgeons have now found, post-ablation anterior corneal curvature changes have a major impact on selecting the spherical power for IOLs, Dr Koch noted. Current formulas (such as those on the ASCRS postrefractive surgery IOL calculator) are based on regression. They are at best highly educated guesses. Ideally, surgeons will apply one or more of these three options: 1) accurately measure total power preoperatively, 2) calculate IOL power intraoperatively, and 3) adjust IOL power postoperatively. Using fourier-domain OCT measurements of posterior and anterior cornea and a new formula, IOL power prediction matches the best available conventional formulae (see figure above). Dr Koch expects its accuracy will improve with further development. 3. Measurement is also critical for astigmatic correction and particularly selecting toric IOLs in post-ablation patients, Dr Koch said. In normal eyes, anterior curvature suggests the direction of the cylinder on the posterior corneal surface, allowing use of a nomogram to select toric lens power. Patients displaying with-the-rule astigmatism on the anterior surface are overcorrected by a mean of 0.5 D while those displaying against-the-rule anteriorly are undercorrected by 0.3 D. But this correlation is lost in post-ablation patients, requiring examination anterior and posterior corneal curvature to determine the power and axis of toric lenses. Dr Koch is confident that these issues will be worked out. “We are making great progress and I am optimistic about where we are going and how we are improving what we do for patients. The field has a tremendous future ahead.”


13

Update

Cataract & refractive

EMANUEL ROSEN

ESCRS pioneer reflects on 50 years in ophthalmic practice and also looks to the future by Priscilla Lynch in Manchester

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r Emanuel Rosen FRCS, FRCOphth, was the joint recipient of the inaugural UKISCRS Lifetime Achievement Awards at the XXXVI UKISCRS Congress in Manchester, and was praised for his innovative and visionary career, which included setting up the specialist cataract treatment centre in Manchester and a prestigious record in ophthalmology photography and academia. Dr Rosen, a past president of the ESCRS and chair of the society's Publications Committee, gave a fascinating perspective on his half a century in active ophthalmic clinical practice.

Early days

His first exposure to ophthalmology was as a medical student in 1958 when he undertook an anaesthetic rotation. Back then the ophthalmologist in his hospital was attired in a pinstripe suit and wore a magnifying headband loupe, and there was an open fire in theatre. Dr Rosen became an SHO in 1964, at a time when ophthalmology was “crude” with poor tools and limited pharmacopeia for glaucoma, for example, and no microscopes for surgery. He said he had a hunch that ophthalmology could be a land of opportunity, not knowing what the future held. ¨Ophthalmology was a Cinderella specialty in 1964,” he noted, adding that a “surgical and ophthalmic apprenticeship with lots of practical experience” best described the training he received.

Photography Dr Rosen spoke in depth about his other great love – photography, which he combined to great success in his ophthalmic career. His entry into ophthalmology immediately attracted him to photographic applications in retinal disorders, which he said was fortunate timing because of imaging developments in the field in the 1960s. Dr Rosen became custodian of the retinal camera at his hospital and adapted it for the then newly described technique of fundus fluorescein angiography (FFA), thus allowing him to utilise his growing interest in retinal disorders through photographic applications developing fast systems for angiography many years before the digital age EUROTIMES | Volume 18/19 | Issue 12/1

It was fascinating revealing the detail of vascular pathology in diabetic retinopathy, for example, the clarity of the pathology, seeing the thickening of arterial walls with narrowing of caliber and nonperfusion of the retina

Emanuel Rosen FRCS, FRCOphth “It was fascinating revealing the detail of vascular pathology in diabetic retinopathy, for example, the clarity of the pathology, seeing the thickening of arterial walls with narrowing of caliber and non-perfusion of the retina,” he explained, showing the audience some of his original images. In 1968 having collected an extensive portfolio of retinal disorders photographed through the medium of angiography, he produced the first English language textbook on FFA, entitled Fluorescence Photography of the Eye.

Evolution Dr Rosen described the evolution of various ophthalmic procedures and technologies over his career, including vitrectomy, the development of cataract surgery and IOLs, which he described as a “career changer” for him personally, and eventually phacoemulsification surgery. Concluding, Dr Rosen said the evolution of ophthalmic practice between 1964 and 2013 “has seen a progress beyond science fiction, it has been phenomenal”. Clinicians now practice evidencebased ophthalmology, there are multiple ophthalmic expert sub-specialties and the standard of ophthalmic care is outstanding, he stated, praising the development of various technologies like the latest IOLs, tomography, topography and femtosecond laser: “Looking to 2063; can the next 50 years be as productive?”

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10.01.13 10:05


14

Update

Cataract & refractive

Explore

NEW

FRONTIERS

Posterior capsule tear

Timing of the complication guides management decisions By Cheryl Guttman Krader in Singapore

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

Visit www.escrs.org to apply

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ear of the posterior capsule during cataract surgery opens the door to a host of further complications, including vitreous loss, retained lens material, cystoid macular oedema, retinal detachment and endophthalmitis. However, if faced with this event, cataract surgeons should maintain their composure and focus on the primary objectives of cataract surgery, ie, removing the soft lens material and achieving safe implantation of a posterior chamber IOL, said Peter Barry MD, speaking during the Combined Symposium of Cataract and Refractive Surgery Societies at the 26th Asia-Pacific Association of Cataract and Refractive Surgeons Annual Meeting. The decision to perform other manoeuvres is guided by when during the case the posterior capsule rupture occurs. If the complication developed during irrigation/aspiration, which is the most common scenario, surgeons can perform a controlled two-port trans-limbal anterior vitrectomy. However, if the capsule tears during phacoemulsification and the nucleus or nuclear material drops, they should resist the urge to go after the dropped nucleus and call a retinal colleague instead, according to Dr Barry, head, Department of Ophthalmology, St Vincent’s University Hospital, Dublin, Ireland. “I strongly suggest that only a three-port pars plana vitrectomy will allow safe removal of dropped nucleus and retained lens fragments in the posterior segment, and it will also enable preservation of the posterior capsule and successful posterior chamber IOL implantation,” he said.

Retinal breaks Reminding cataract surgeons that vitreous surgeons remove the vitreous first and then perform phaco with a fragmatome, he cautioned that cataract surgeons should never use a phaco probe in the vitreous cavity or in the anterior chamber if vitreous is present in the anterior chamber. He also warned against using infusion or a vectis in the vitreous cavity to elevate lens material. “These attempts to remove lens material in the posterior chamber cause vitreoretinal traction that can lead to retinal breaks. Retinal detachment is the ultimate insult to complicated cataract surgery because it inevitably leaves the eye worse off,” Dr Barry explained. Outlining the steps for managing posterior capsule rupture during irrigation/aspiration, Dr Barry explained that he advocates a two-port translimbal vitrectomy using two sideport incisions (not the cataract incision) over a pars plana approach as the latter takes cataract surgeons out of their comfort zone. “I know some people say pars plana vitrectomy is better, but because of the need to put infusion through the pars plana in a soft eye and the risks of uveal effusion and iris prolapse, pars plana vitrectomy creates apprehension for cataract surgeons,” Dr Barry said. In performing the translimbal vitrectomy, surgeons should dissociate the infusion from the cutter so that the cutter can be turned on or off at the touch of the EUROTIMES | Volume 18/19 | Issue 12/1

If vitrectomy is performed with the cutter in the anterior chamber, vitreous will be pulled forward and the posterior capsule tear will increase Peter Barry MD

footswitch. In addition, they should lower the infusion so that it is just enough to preserve anterior chamber depth and increase the cutting rate to the maximum the machine permits. Vitreous should be removed to a plane behind the torn posterior capsule, and surgeons may consider using preservative-free triamcinolone acetonide for staining. “If vitrectomy is performed with the cutter in the anterior chamber, vitreous will be pulled forward and the posterior capsule tear will increase. Having the cutter in the right place behind the torn posterior capsule pulls the vitreous back to its normal anatomic position to minimise stress on the vitreous base, and keeping the flow of infusion in front of the iris towards the vitreous cavity helps push the vitreous back toward the cutter if it is in the correct position,” Dr Barry explained. “Above all, take maximum care to preserve the posterior capsule remnants and do not further damage an already compromised capsule, which is a very common mistake. Surgeons have to slow down, not speed up,” he added. To avoid causing a retinal break, Dr Barry also cautioned that surgeons should never pull the cutter when the vitreous is engaged and never use cellulose sponges to protect the wound or to test for vitreous. Once vitrectomy is finished successfully without causing extension of the posterior capsule tear, the case can be completed with IOL implantation. While implantation in the bag is ideal, in these cases, the IOL will more likely need to be placed in the sulcus, Dr Barry said. Posterior capsule tear after both phacoemulsification and irrigation/aspiration are finished represents a minimal problem. Importantly, however, surgeons should be careful to keep their instruments inside the eye. “If you remove the instrument, the eye will soften, the vitreous will prolapse and a small tear will become a big one,” Dr Barry explained. When a small tear is noticed at the end of the case, surgeons can use viscoelastic as a tamponade over the break to prevent vitreous prolapse and finish the case as planned by implanting the IOL in the capsular bag. “Need of a posterior capsulorhexis is unlikely,” Dr Barry said.

contact

Peter Barry – peterbarryfrcs@theeyeclinic.ie


contact

Oliver Findl – oliver@findl.at

Update

Cataract & refractive

Posterior capsule opacification

A multifactorial problem yet to be solved By Cheryl Guttman Krader in Singapore

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esearch to identify factors influencing posterior capsular opacification (PCO) has led to surgical techniques and IOL designs that have limited the development of this complication after cataract surgery. However, the problem of PCO has not been eliminated, and further study is needed to understand its true scope and the efficacy of novel strategies to prevent its occurrence, according to Oliver Findl MD. “Current data for otherwise healthy eyes implanted with modern IOLs show that Nd:YAG capsulotomy rates are only about three per cent at two to three years postoperatively. Still, longer follow-up to five years and beyond is needed because there is some evidence that PCO is increasing over time,” said Dr Findl, director, Vienna Institute for Research in Ocular Surgery, Hanusch Hospital, Vienna, Austria. Speaking at the 26th Asia-Pacific Association of Cataract & Refractive Surgeons Annual Meeting, Dr Findl reviewed principles for PCO, which provides a basis for understanding how various factors limit or allow its development, and he discussed the effect of specific IOL features on PCO, including the relatively new idea that a design able to keep the bag open may be beneficial. Dr Findl explained that there are two types of lens epithelial cells (LECs) in the eye – anterior capsule LECs and equatorial LECs. The anterior capsule LECs, which transdifferentiate into myofibroblasts after surgery, modulate capsular fibrosis leading to capsular collapse, sealing of the anterior and posterior capsules and “shrink wrapping”

of the optic. PCO develops when the equatorial LECs, which are regeneratory cells programmed to regrow the lens, are able to migrate behind the IOL.

IOL design factors A sharp posterior optic edge that indents the posterior capsule and causes capsular bending provides an augmented mechanical barrier to LEC migration. This explains why PCO is seen less with sharp edge versus round edge IOLs, noted Dr Findl, reviewing results from a meta-analysis he conducted investigating interventions for preventing PCO [Cochrane Database Syst Rev 2010 Feb 17(2):CD003738]. “Ideally, the anterior and posterior capsules should be firmly sealed and there should be a good bend of the posterior capsule over the optic edge because months to years later, the regeneratory LECs will reopen the capsular bag if it is not permanently ‘glued’,” he said. Haptic configuration may also play a role in PCO since it affects whether there is contact between the optic and the posterior capsule and also the quality of the posterior capsule bend. Even though single-piece IOLs are now available with a 360-degree square posterior optic edge, Dr Findl pointed out the haptic of these implants is relatively thick. This bulk may limit total fusion of the anterior and posterior capsules and thereby also interfere with complete shrink wrapping of the IOL optic and an optimal capsular bend. Dr Findl noted that in the meta-analysis he conducted, PCO scores were not

ESCRS

EUROTIMES

PCO risk. More time is needed to tell, and for now the jury is still out,” Dr Findl said.

An open capsular bag allows continuous flow of aqueous that may contain or remove factors affecting the development of PCO Oliver Findl MD

significantly different comparing singlepiece and three-piece IOLs. However, results from a clinical trial he conducted comparing the two implant styles showed a tendency for more PCO after three years in eyes implanted with the single-piece technology. “While there is no proof today, we believe that with longer follow-up, the single-piece IOLs may do worse,” said Dr Findl, who is also a consultant ophthalmic surgeon at Moorfields Eye Hospital, London, UK. The effect of IOL material on PCO development also remains unclear. In the meta-analysis, hydrophilic acrylic IOLs had more PCO than implants made of hydrophobic acrylic or silicone. However, optic edge configuration may be a confounding factor in the outcomes because the hydrophilic acrylics included a mix of round- and sharp-edge IOLs. Furthermore, as a consequence of the production process, the sharp edge of hydrophilic acrylic IOLs remains somewhat round. “A modern hydrophilic material IOL with a sharp edge may have good performance for

Future strategies The surprising finding of minimal PCO in eyes implanted with the dual optic accommodating IOL (Synchrony, Visiogen) has turned attention to the idea that keeping the capsular bag open may be useful. Further support for this concept comes from a study Dr Findl conducted of a prototype silicone IOL that kept the capsular bag open by virtue of its circular tripod design. He noted there was no evidence of PCO in patients followed to three years post-implantation. Currently, the explanation for these findings is unclear, but Dr Findl put forth a few ideas. “An open capsular bag allows continuous flow of aqueous that may contain or remove factors affecting the development of PCO. In addition, this prototype IOL featured ring modules exerting pressure at the equator that may have prohibited proliferation of the regeneratory LECs.” Meanwhile research is continuing to identify effective strategies to prevent PCO by completely removing or destroying LECs during surgery. “The hope for the future is to refill the capsular bag with an injectable material after the crystalline lens is removed. However, the viability of this approach depends on eliminating PCO,” Dr Findl told EuroTimes. “Unfortunately, nothing available now or on the horizon appears capable of doing this job.”

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EUROTIMES | Volume 18/19 | Issue 12/1

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Update

Cataract & refractive

iFS CATARACT INCISIONS

The main thing we did notice was the importance of marking the patient’s eyes prior to performing incision creation in order to locate the exact location of the incisions

Tri-planar clear corneal incisions reliably cut with iFS laser by Howard Larkin in San Francisco

Shamik Bafna MD

Courtesy of Shamik Bafna MD

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he femtosecond laser can be used to create precise clear corneal incisions for cataract surgery using a proprietary software algorithm, Shamik Bafna MD, of the Cleveland Eye Clinic, Ohio, US, told the 2013 American Society of Cataract and Refractive Surgery annual symposium. In a prospective trial, the device cut true tri-planar main and paracentesis incisions that measured on average less than 0.1mm of intended size, and were watertight immediately after surgery and the next day. The IRB-approved study involved 37 patients at two centres who received tri-planar main and single-plane paracentesis incisions cut with an iFS femtosecond laser (Abbott Medical Optics). The device was approved last year for arcuate incisions for astigmatism treatment with cataract surgery, and some surgeons have used it off-label for cataract entry incisions, Dr Bafna noted. This trial was a test of an AMO incision programme for accuracy and wound sealing. All patients underwent cataract removal and intraocular lens placement surgery the same day incisions were made. Some 19 patients received incisions and surgery in the same centre, while another 18 had incisions cut at one centre and were transported to another about three kilometres away for surgery. Between incisions and surgery, patients were examined at the slit lamp and by OCT. Seidel tests for aqueous leakage

Shamik Bafna – drbafna@clevelandeyeclinic.com

iFS tri-planar corneal incision

were performed immediately after incisions and one day after cataract surgery, Dr Bafna said. In all cases, both clear corneal entry and paracentesis incisions were observed at the slit lamp immediately after cataract surgery, Dr Bafna reported. All eyes were negative for aqueous leakage after incisions and the next day. 100 per cent of incisions were intact. Cataract removal and IOL placement were successful in all cases, and no adverse events were observed. In terms of accuracy, the results were excellent. For clear corneal incisions, the average programmed anterior

width was 2.74mm and the average achieved 2.75mm, a difference of just 0.01mm. Posterior CCI widths were nearly as good, with an average difference of just 0.04mm. Anterior paracentesis widths differed an average of 0.10mm while posterior width differences averaged 0.01mm. “Pretty much what you programmed was what you got,” Dr Bafna said. OCT images confirmed that tri-planar main incisions were achieved in all cases, Dr Bafna said. “You can clearly define how the incisions go down vertically, and then horizontally in three planes.”

No complications OCT and Seidel tests after incisions took time, so the average lag between incision creation and surgery was 91 minutes overall, Dr Bafna noted. However, the time for patients treated at the centre that required transport between the incision and surgery were on average 29 minutes longer than the 77 minutes averaged at the facility with both laser and surgery suite in-house. No incidents of complications were noted with transport, though AMO recommends placement of an eye shield, which was done for this study, Dr Bafna said. “The main thing we did notice was the importance of marking the patient’s eyes prior to performing incision creation in order to locate the exact location of the incisions.”

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Türkiye

TURKISH LANGUAGE EDITION NOW ONLINE EUROTIMES | Volume 18/19 | Issue 12/1

Visit: www.eurotimesturkey.org


Update

17

Cataract & refractive

Courtesy of Soumya Nanaiah MS

contact

Soumya Nanaiah – soumya.kaveri@yahoo.com

HANDHELD SD-OCT

Refractive surgeons find non-invasive, real-time imaging tool provides valuable information across a range of procedures by Cheryl Guttman in Singapore

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xperience using a handheld high-resolution spectral domain OCT (SD-OCT) platform (Envisu, Bioptigen) for intraoperative imaging indicates it has a range of applications that should make it a helpful tool in clinical research and daily practice, reported Soumya Nanaiah MS, at the 26th Asia-Pacific Association of Cataract & Refractive Surgeons Annual Meeting. Speaking in a free paper session on refractive surgery, Dr Nanaiah reviewed findings from evaluations performed with the imaging system in cases of LASIK, corneal collagen crosslinking (CXL), intracorneal ring segment (ICRS) implantation and cataract refractive surgery. “This SD-OCT machine comes with a handheld probe that enables intraoperative measurements with patients

EUROTIMES | Volume 18/19 | Issue 12/1

in the supine position,” said Dr Nanaiah, a cataract and refractive surgery fellow at the Narayana Nethralaya Eye Hospital, Bangalore, India. She noted that the instrument is useful in assessing treatment depths in various refractive procedures as well as to determine anatomic changes and responses of ocular tissues to treatments. During LASIK, the device was used to evaluate stromal bed characteristics and flap thickness in groups of 50 eyes each where either a mechanical microkeratome or a femtosecond laser was used for flap creation. The intraoperative images clearly showed differences in edge architecture and stromal bed smoothness between the two techniques. In addition, analysis of data collected using the calipers available with the

device to measure flap thickness demonstrated significantly better predictability was achieved using the femtosecond laser. Images from eyes that underwent ICRS placement into femtosecond laser-created channels were analysed to determine placement depth. The investigators found no tendency for any part of the segments to be more superficial than another, and there was no statistically significant difference comparing the planned segment depth and that achieved postoperatively. In CXL, the handheld SD-OCT device was used to evaluate depth of riboflavin penetration in eyes that underwent complete or only partial (grid pattern) removal of the epithelium. In serial imaging of eyes in which the epithelium was completely removed, a homogenous hyperreflective band denoting soakage was observed after 30 and 60 minutes at mean depths of 54.2 µm and 72.4 µm, respectively. Similar depths of riboflavin penetration were measured after 30 and 60 minutes in the partial removal group in areas where the epithelium was off (56.9 and 74.2 microns, respectively), but the depth of penetration at both time points was significantly less at sites corresponding to areas where the epithelium was still intact (18.9 and 24.7 microns, respectively). “In patients who had LASIK with CXL, we observed a pseudo-Bowman’s membrane at the interface between the flap and the bed,” Dr Nanaiah reported. Most recently, the investigators are applying the imaging tool to compare the features of cataract surgery clear corneal and sideport incisions created using a manual technique versus with a femtosecond laser and to confirm whether or not free-floating caps were achieved after femtosecond laser capsulotomy.


contacts

18

Update

GLAUCOMA

Allen Beck – abeck@emory.edu Peng Tee Khaw – p.khaw@ucl.ac.uk John Brookes – john.brookes@moorfields.nhs.uk

care needed

Consensus statement defines disease and treatment

Courtesy of John Brookes FRCOphth Clinical photograph of a child with primary congenital glaucoma

EUROTIMES | Volume 18/19 | Issue 12/1

said. The statement also addresses glaucoma which develops after cataract surgery. Surgical treatment is controversial, and a survey was performed of paediatric glaucoma surgeons worldwide to determine common practices, said Peng T Khaw MD, PhD, professor of glaucoma and ocular healing, UCL Institute of Ophthalmology, and consultant ophthalmic surgeon at Moorfields Eye Hospital, London UK. Survey results were based on feedback from 78 surgeons. Results showed that, for primary congenital glaucoma, goniotomy is performed by 28.6 per cent of surgeons, and 27.3 per cent perform trabeculectomy with metal trabeculotome. "There are 360 degree trabeculectomies as well, with 13 per cent saying they do this”, Prof Khaw said. The statement confirms that surgery is critical in managing childhood glaucoma, but there was a strong sense that “glaucoma surgery should be performed by a trained surgeon in centres where there is sufficient volume to ensure surgical expertise and skill, and safe anaesthesia,” he said. "A longer-term surgical strategy, including the choice of procedures, should be based on training, experience, logistics and the surgeon’s preference. The first chance for surgery is often the best chance, and it is important to choose the most appropriate operation," he said. Glaucoma surgery in children has a higher failure and complication rate than in adults. However, among consensus experts, angle surgery is the preferred option for primary congenital glaucoma. The exact choice should be dictated by corneal clarity and the surgeon’s experience and preference. The results for non-primary congenital glaucoma cases are not as good, he said. “There was consensus that trabeculectomy done by an experienced paediatric surgeon can be associated with satisfactory and good outcomes in appropriate cases," Prof Khaw said. As for long-term IOP control, aqueous drainage devices were often deemed the most effective, especially in cases refractory to other surgical treatments. The statement notes that cyclophotocoagulation has limited long-term success. “Other glaucoma procedures have not been widely adopted because of the technical challenges in buphthalmic eyes,

A shunt device placement in a child

Courtesy of Peng T Khaw MD

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ttendees of the 5th World Glaucoma Congress were given a glimpse of the first consensus statement on childhood glaucoma. Publication is expected soon. This first consensus statement defines childhood glaucoma somewhat differently than the way we define it in adults, according to Allen Beck MD, professor of ophthalmology at Emory University. While childhood glaucoma is defined as intraocular pressure (IOP)-related damage to the eye, the optic nerve is not the only factor. The disc appearance is important as are fields. Elevated IOP can affect various ocular structures in infancy, and in turn, interpretation of IOP can be influenced by various factors. Also, physicians need to consider other possible indicators of glaucoma, such as ocular enlargement, Haab striae and increased cup-to-disc ratio. The statement classifies childhood glaucoma as primary or secondary, but secondary glaucoma is sub-classified according to whether the condition is acquired after birth or is present at birth (non-acquired). Terms such as developmental, congenital or infantile glaucoma lack clear definition and are falling out of favour as terms, he said. In children, other conditions can mimic glaucoma, so extra care is needed for the diagnosis. The statement includes "categories of definitions for glaucoma, and we have criteria that include both optic nerve changes and the effects of ocular stretching such as progressive myopia,” he

Courtesy of Allen Beck MD

by Pippa Wysong in Vancouver

The consensus suggested that procedures involving angle surgery were preferred for primary congenital glaucoma. This image shows a goniotomy using a specially adapted wideview direct gonioscopy lens used at Moorfields Eye Hospital

or because they are yet to be proven efficacious or safe in children," he said. Visual development needs to be evaluated as children undergo treatment, and how treatment and repetitive surgery on the problem eye may affect the other eye. "With childhood glaucoma, one needs to carefully consider the risks and benefits of each intervention," he said. John Brookes FRCOphth from the Moorfields Eye Hospital addressed the management of primary congenital glaucoma and juvenile open-angle glaucoma. Primary congenital glaucoma is the most common non-syndromic glaucoma in infancy, he said. It occurs worldwide though the incidence is higher in consanguineous populations. A family history is reported in 10 to 40 per cent of cases. The actual pathogenesis of primary congenital glaucoma is still uncertain but thought to be isolated trabeculodysgenesis. The consensus group considers primary congenital glaucoma a surgical condition. First line surgery should usually be angle

surgery (goniotomy or trabeculectomy), and there are high rates of success reported for both of these types of surgery. Some experts prefer combined trabeculectomytrabeculotomy as an initial procedure, however there are no prospective comparisons in the medical literature to support this. If an angle surgery fails, the statement suggests the next procedure of choice be either trabeculectomy or a glaucoma drainage device. Juvenile open-angle glaucoma is discussed too. It is rare but usually presents after four years of age with a normal angle appearance and no signs of other ocular anomalies or systemic disease. Evidence is weak for the best interventions for this but experts concurred that depending on age, medical therapy be the first-line treatment, although surgery is often required, Dr Brookes said. The consensus report will have more details on these and other topics once it is published.


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GLAUCOMA .org scrs e . w ww

www.e

uro tim es. or g

FUNCTIONAL BURDEN

Late detection of glaucoma weighs heavily on patients and health systems By Dermot McGrath in Copenhagen

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laucoma is not only widely under-diagnosed, it also directly limits the quality of life and life expectancy of affected individuals, according to Roger Hitchings MD, who gave a keynote lecture at the 2013 Congress of the European Society of Ophthalmology. “In looking at the functional burden of glaucoma we see that it is under-diagnosed, has a significant effect on quality of life, is extremely costly to treat, especially if it presents late, and results in a significant reduction in social status as well as a reduction in life expectancy," said Prof Hitchings, an honorary consultant ophthalmologist at Moorfields Eye Hospital, London, and Professor Emeritus in Glaucoma and Allied studies at the University of London. The impact of the disease is particularly deleterious in poorer regions, said Prof Hitchings. “When someone becomes blind, and particularly with late presentation, and especially in the so-called developing world, they cannot work. Their life expectancy falls and they experience a loss of social standing. Women who have lost vision as a result of chronic glaucoma suffer a loss of authority in their households because they are now dependent on others,” he said. Looking at the epidemiological data from 39 countries, Prof Hitchings said that an estimated 285 million people are visually impaired in the world, with 39 million classified as legally blind. Of those blind patients, 43 per cent are due to uncorrected refractive errors, 33 per cent due to cataract, and 12.3 per cent due to glaucoma. “This makes it the commonest irreversible cause of blindness in the world today,” he said. The majority of patients in the major population studies were unaware that they had glaucoma when the condition was diagnosed, said Prof Hitchings. This figure was as high as 90 per cent in the Aravind Eye Study in India, and around 50 per cent or so in the Rotterdam and Blue Mountains eye studies. “No matter which study we look at, the message to emerge is how common it is for glaucoma patients in population screening to be discovered when they were unaware of the problem, so late presentation is a major problem,” he said. Socioeconomic status plays a major role in late presentation, with those from poorer backgrounds, living in rental accommodation, with no access to a car and who left full-time occupation at a young age more likely to present late. In the UK, the time to the last visit to an optometrist was identified as a factor, while other studies identified the failure of the optometrist to diagnose glaucoma and a negative family history of glaucoma as also playing a role in late presentation. There are also other less apparent reasons for late presentation, said Prof Hitchings. “Glaucoma tends to occur in the elderly who think that declining eyesight is part of growing old and so ignore it. The elderly also have other systemic and social problems which are to them more important,” he said, EUROTIMES | Volume 18/19 | Issue 12/1

“When someone becomes blind, and particularly with late presentation, and especially in the so-called developing world, they cannot work” Late presentation also results in increasing costs to the health system, said Prof Hitchings, with at least two studies showing that the more the disease progresses the more costly it is to society. Looking at possible reasons why glaucoma patients do not notice the visual loss, Prof Hitchings said that binocular field loss seems to be one of the most critical factors involved. “If binocular field loss is a disability, we need to ask what effect it has on a patient’s quality of life. We can use a range of questionnaires – generic health related, vision-specific or glaucoma specific – and the patient’s response gives us an idea of how we can assess the effect on the patient’s quality of life,” he said. Glaucoma has the potential to negatively affect many aspects of a patient’s quality of life, said Prof Hitchings, with one composite analysis of several quality of life studies showing that binocular field loss had a negative impact on activities such as reading, routine household tasks, mobility and driving. “A study by Haymes et al showed that glaucoma patients had a threefold increase in the risk of falls over the previous 12-month period and a sixfold increase in the risk of car accidents over the previous five years compared to agematched controls,” he said. Another study cited by Prof Hitchings showed that automated visual field screening of 10,000 volunteers showed the incidence of visual field loss was three per cent to 3.5 per cent for persons aged 16 to 60 but was approximately 13 per cent for those older than 65 years. The most common causes of visual field loss were glaucoma, retinal disorders and cataracts. “Drivers with binocular visual field loss had accident and conviction rates twice as high as those with normal visual fields, whereas drivers with monocular visual field loss had accident and conviction rates equivalent to those of a control group,” he said. A study by Keltner and Johnson in 1983 showed that half of the people with abnormal visual fields were previously unaware of any problem with peripheral vision. “This is probably due to a combination of factors such as denial, a function of the slow rate of change, and also perhaps a compensatory function in the brain,” concluded Prof Hitchings.

contact

Roger Hitchings – roger.hitchings@virgin.net

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Update

GLAUCOMA

CATARACT AND GLAUCOMA

In coming years, the question of when and how to perform combined surgery will have a different answer by Pippa Wysong in Vancouver

I

n the ongoing discussion of whether to perform cataract surgery alone or in combination in glaucoma patients, a Canadian glaucoma specialist says the choice depends on the features of the disease in individual patients, but adds there is scientific evidence that supports some of the current options. In brief, cataract surgery alone can be considered for the patient who has ocular hypertension or early damage, but who has well-controlled intraocular pressure (IOP). And combined surgery can be the preferred choice if there is advanced damage or IOP is unlikely to reach targets with the modest IOP-lowering effects of cataract surgery alone, said Jamie Taylor MD, clinical assistant professor of ophthalmology at Canada’s University of Victoria. He spoke at the recent 5th World Glaucoma Congress where he gave an overview on cataract surgery in the glaucoma patient. When it comes to patients with pseudoexfoliation who do not yet have glaucoma, several studies in the medical literature show there are mild pressurelowering effects with cataract removal. One study by Damji et al, from 2006, found that phacoemulsification alone produced greater IOP-lowering at two years in pseudoexfoliation patients than those without PEX, in both suspect and glaucoma populations. Degree of IOP lowering correlated positively with irrigation volume used.

Reducing bias Another study, by Shingleton, from 2008, found a 1.0 to 2.0 mmHg reduction in IOP out to seven years in pseudoexfoliation patients without glaucoma. People needing glaucoma surgery were excluded. However, those pseudoexfoliation glaucoma suspects had a 17 per cent risk of IOP spike over 30.0 mmHg on the first day post surgery. Dr Taylor notes that a number of studies in the literature have methodological problems, but the Ocular Hypertension Treatment Study (OHTS) overcame some of that by including significant data on patients prior to cataract surgery, reducing bias from regression to the mean and medication impact.

“Taking various studies into account, it appears we may be able to discontinue a medication early on after surgery, but three or four years later they’re back on their prostaglandin” OHTS results showed a significant IOP drop in patients who had cataracts removed, but no change in IOP in the controls who did not have cataracts removed. Plus, over time, pressure tended to increase gradually in the months after the surgery. The IOP-lowering effect was strongest in patients with higher IOP prior to surgery. Also, some patients actually had an increase

Don’t Miss Resident’s Diary, see page 33 EUROTIMES | Volume 18/19 | Issue 12/1

in IOP. An increase can also happen in patients with uveitis and those with previous filtering surgery, he said. "Taking various studies into account, it appears we may be able to discontinue a medication early on after surgery, but three or four years later they’re back on their prostaglandin," Dr Taylor said. As for performing cataract surgery as a glaucoma treatment, the evidence doesn't yet support that in the open-angle glaucoma population. There have been no randomised trials comparing surgery to medication in this group, he said. However, with the angle-closure population it’s been shown that cataract surgery alone can lead to substantially lower IOP. There are a number of prospective studies on this, Dr Taylor said. Generally though, various guidelines, including those from the Canadian Ophthalmological Society, note there is a risk of an IOP spike with cataract surgery alone. As for other surgeries, the guidelines note that often trabeculectomy can worsen cataract, more so than medication alone.

Jamie Taylor –drainsurg@gmail.com

“And with the combined procedures, if you’re looking at someone with markedly elevated intraocular pressure, the combined procedure phacotrabeculectomy is a few millimetres of mercury less effective than trabeculectomy alone”

Courtesy of Jamie Taylor MD

20

“And with the combined procedures, if you’re looking at someone with markedly elevated intraocular pressure, the combined procedure phacotrabeculectomy is a few millimetres of mercury less effective than trabeculectomy alone," he said. But the field is changing. In 2013, trabeculectomy rates are lower than before the introduction of prostaglandins. And there are improved glaucoma surgery options, including trabeculectomy with mitomycin C, minimally invasive glaucoma surgery such as trabectome, tube shunts, non-penetrating surgeries and more.

Key factors A crucial factor, too, is where the patient is on the glaucoma (not cataract) disease spectrum. When choosing which surgery to perform, key factors to take into account include the degree of optic nerve damage, what the IOP target is, how many medications a patient is on and the surgeon's comfort and experience with specific procedures. Individual patients should be treated according to the degree of severity of their disease. In early glaucoma where IOP is controlled with one or two medications, most guidelines recommend phaco alone. In advanced glaucoma, patients need a glaucoma procedure added, usually phacotrabeculectomy with MMC. In moderate or advanced glaucoma with a markedly elevated IOP, evidence suggests trabeculectomy MMC first, then phaco later. It’s a rapidly evolving field and there are an ever increasing number of glaucoma surgery options. In the coming years, “the question of when and how to perform combined surgery will have a different answer,” Dr Taylor said.


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Update

GLAUCOMA

GLAUCOMA RESEARCH

Observational glaucoma studies need to move beyond IOP endpoints

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EUROTIMES | Volume 18/19 | Issue 12/1

World Society of Paediatric Ophthalmology & Strabismus

PAEDIATRIC SUB SPECIALTY DAY

by Dermot McGrath in Copenhagen

here is a compelling need to incorporate more quality of life data in glaucoma research and to move beyond using intraocular pressure (IOP) as the only significant endpoint in observational clinical trials, according to Norbert Pfeiffer MD. “IOP is a very poor endpoint for glaucoma studies and we use it primarily because it is straightforward and simple and we can obtain it very easily. Visual fields are subjective and cumbersome and optic disc progression is an extremely difficult endpoint for observational studies. Our own studies show that glaucoma affects quality of life and we need to see more account taken of quality of life in observational glaucoma studies going forward,” he said. “Quality of life may be affected by visual loss but also by side effects of treatment such as ocular surface disease.” Addressing delegates attending the 2013 Congress of the European Society of Ophthalmology, Prof Pfeiffer, head, Department of Ophthalmology, Johannes Gutenberg University, Mainz, Germany, said that because long-term observation studies are difficult to achieve, there may be increasing scope for model simulations based on real data to be used in the future. “The problem is that you need to observe many patients for a very long time, and we estimated it would ideally need to be about 20 years. So if you start a study now and want to have the results in 10 years, by the time you have the results nobody is interested because the medications are perhaps no longer available or other new treatments are on the market,” he said. Reviewing the endpoints used in major observational studies conducted to date, Prof Pfeiffer noted that it was perhaps not surprising that IOP was so frequently cited. “This is because the other end points that relate to visual function are so difficult to look at and take such a long time. Two older studies from Jay and Allen and Jay and Murdoch reported that the estimated progression from detectable to end stage of primary open angle glaucoma if treatment is optimal was 38 years. This becomes 10 years in the case of unsatisfactory treatment and 3.6 years if left untreated,” he said. Two more recent observational studies, the Early Manifest Glaucoma Trial (EMGT) and the Collaborative Initial Glaucoma Treatment Study (CIGTS), looked at visual field progress in glaucoma patients, said Prof Pfeiffer. In the EMGT, the loss over five years in mean deviation was a mean of 3.9 decibels if untreated and 2.2 decibels if treated. The data for CIGTS showed a loss of 0.3 decibels in medically treated eyes and zero in surgically treated eyes. “The point is that glaucoma progresses very slowly, and if we look at a group of patients for just five years we may find nothing or just a tiny little bit of difference in that time-frame,” said Prof Pfeiffer. He added that other observational trials with non-IOP endpoints had also underscored the difficulty of using visual field and optic disc progression as viable endpoints in observational studies.

WSPOS

The recognised glaucoma guidelines state that we should look at the visual function and related quality of life, because this is important for the patient who, of course, does not know about his optic disc and visual field and will usually not pick up early change Norbert Pfeiffer MD

This is where quality of life metrics can play an important role, said Prof Pfeiffer. “The recognised glaucoma guidelines state that we should look at the visual function and related quality of life, because this is important for the patient who, of course, does not know about his optic disc and visual field and will usually not pick up early change,” he said. In terms of quality of life studies and glaucoma treatments, Prof Pfeiffer said that it was possible to derive significant information from well-designed studies. He cited a recent multicentre open-label study of 158 patients in Finland, Sweden and Germany which set out to determine if Latanoprost or the preservative-free Tafluprost was better tolerated. After 12 weeks of treatment with Latanoprost, the patients who switched to Tafluprost experienced reduced ocular symptoms such as irritation, burning, stinging, foreign body sensation and dry eye sensation. “We can look at aspects of quality of life for these studies and learn more about our treatments just by asking patients,” said Prof Pfeiffer. To measure specific signs of quality of life, Prof Pfeiffer cited the health utility index (HUI3), a questionnaire focusing on general health that allows comparison between different diseases, or a more specific vision-related questionnaire such as the National Eye Institute 25-item Visual Function Questionnaire (NEI-VQF-25) looking at global vision rating, difficulties with near vision, distance vision, social function, levels of independence, general mental health, driving and limitations for peripheral and colour vision and also ocular pain. Prof Pfeiffer noted that such questionnaires could be used effectively in assessing treatments. He cited a longterm quality of life study of 154 patients which his own team conducted and which showed for the first time that the mean health utility index related very well to the visual field. The questionnaires are also useful in identifying the domains most affected by the loss in quality of life, he said.

contact Norbert Pfeiffer – pfeiffer@augen.klinik.uni-mainz.de

FRIDAY 12 SEPTEMBER 2014

Preceeding the XXXII Congress of the ESCRS 13 – 17 September 2014 London, UK

www.wspos.org


18TH

ESCRS Winter Meeting In conjunction with the Slovenian Society of Cataract & Refractive Surgery

Ljubljana, Slovenia

14-16 February 2014

A Meeting not to be missed!

Main Symposia Friday 14 February

Enhancements in Pseudophakia Chairpersons:

J. Güell SPAIN V. Pfeifer SLOVENIA

Saturday 15 February

Applications of the Femtosecond Laser Chairpersons:

R. Bellucci ITALY K. Mikek SLOVENIA

Update on Endophthalmitis Chairpersons:

P. Barry IRELAND M. Globočnik Petrovič SLOVENIA

Sunday 16 February The Perfect Phaco

Organised by the Young Ophthalmologists Committee Chairpersons:

A. Crnej SLOVENIA D. Kook GERMANY S. Manning IRELAND M. Morral SPAIN


Other Highlights Friday 14 February

Saturday 15 February

Chairpersons:

Chairpersons:

Basic Optics Course

Cataract Surgery Didactic Course Part 2

I. Pallikaris GREECE M.J. Tassignon BELGIUM

Cataract Surgery Didactic Course Part 1 Chairpersons:

Cornea Didactic Course

R. Packard UK P. Rosen UK

Live Surgery Organised by the Slovenian Society of Cataract & Refractive Surgeons

Cornea Day

Organiser: V. Pfeifer SLOVENIA

Organised by ESCRS and EuCornea Chairpersons:

R. Packard UK P. Rosen UK

J. Güell SPAIN (PRESIDENT, EuCornea) R. Nuijts THE NETHERLANDS (CHAIRPERSON,

Refractive Surgery Didactic Course Part 2

ESCRS CORNEA COMMITTEE)

Sunday 16 February

Refractive Surgery Didactic Course Part 1

Slovenian Society of Cataract & Refractive Surgeons Symposium

Young Ophthalmologists Programme

Chairperson:

Learning from the learners: Interactive Session on Cataract Surgery for Trainees Video cases presented by Young Ophthalmologists and discussed with the audience

V. Pfeifer SLOVENIA M. Hawlina SLOVENIA

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24

Update

RETINA

Frankfurt Retina Meeting Live Surgery · Lectures Video Presentations

March 15th - 16th 2014 Dear colleagues and friends, it is my great pleasure to invite you to the next Frankfurt Retina Meeting, March 15th - 16th, 2014. As usual the meeting will include live surgery, presentations, panel discussions and videos from invited guests and participants. We look forward to welcoming you to the Frankfurt Retina Meeting 2014. Claus Eckardt, MD

Faculty

Ahmed Bedda - Egypt Ferdinando Bottoni - Italy Donald D’Amico - USA Morten de la Cour - Denmark Claus Eckardt - Germany Tillmann Eckert - Germany Ehab El Rayes - Egypt Marta Figueroa - Spain Heinrich Heimann - Great Britain Frank Holz - Germany Birgit Lorenz - Germany Tamer Mahmoud - USA Carlos Mateo - Spain

Frankfurt Retina Meeting March 15th - 16th 2014

Andreas Mohr - Germany Marco Mura - Netherlands Sengul Ozdek - Turkey Grazia Pertile - Italy Stanislao Rizzo - Italy Ursula Schmidt-Erfurth - Austria Peter Stalmans - Belgium Peter Szurman - Germany Ramin Tadayoni - France Asheesh Tewari - USA Marc Veckeneer - Netherlands Wei-Chi Wu - Taiwan David Wong - China

Congress Centrum Mainz Gutenbergsaal · Rheinstraße 66 55116 Mainz · Germany

For further information & registration please visit:

www.eckardt-frankfurt.de

OCULAR TUMOURS

Key moments in the history of radiotherapy development for ocular tumours discussed

by Dermot McGrath in Hamburg

R

adiotherapy has made major advances in recent years in offering a viable treatment modality to patients with ocular tumours that were once deemed inoperable, according to Leonidas Zografos, who delivered this year’s EURETINA Medal Lecture as part of the official Opening Ceremony at the 13th EURETINA Congress. In a broad overview of the past, present and future of radiotherapy treatments in ocular oncology, Prof Zografos, Honorary Professor of Ophthalmology and consultant at the Jules-Gonin Eye Hospital, Lausanne, Switzerland, told delegates that technology has come a long way since the pioneering German ophthalmologist Richard Deutschmann’s first successful treatment of uveal melanoma in 1915 with seven episcleral applications of filtered mesothorium. While the earliest treatment for uveal melanoma was removal of the eye, this has now been supplanted by radiotherapy as the standard of care for patients with uveal melanoma, offering preservation of an intact eye and, in many cases, preservation of visual function, said Prof Zografos. Discussing other key moments in the history of the development of radiotherapy for ocular tumours, Prof Zografos highlighted the research of R Foster Moore, H B Stallard, and Martin and Reese, among others, in ushering in the modern treatment of ocular tumours. While ocular brachytherapy has made major strides in recent years, there are still treatment limitations in terms of tumour height, position and shape, said Prof Zografos. Much of Prof Zografos’ lecture focussed on the breakthrough provided by proton beam irradiation of intraocular tumours. At present there are more than 10 major units worldwide performing this type of therapy, with an estimated 25,000 to 30,000 cases of uveal melanoma now performed. Over 6,000 cases have now been carried out at the Swiss treatment centres alone, said Prof Zografos. Survival rates with this type of therapy are excellent. After 10 years, local tumour control is 98.8 per cent and eye retention probability around 95.6 per cent, he said.

The key challenges are the reduction of tumour-related mortality rate, the reduction of the irradiation-induced side-effects and the preservation of a low tumour recurrence rate Leonidas Zografos

The broad aim of the treatment is to prevent the recurrence of the tumour, said Prof Zografos. “If the recurrence occurs during the first two years, the mortality rate is almost 75 per cent, and if the recurrence occurs after the first two years the mortality rate is about 40 per cent, much more than the normal mortality rate without recurrence. So recurrence of the tumour is an extremely serious complication. With proton beam irradiation we have succeeded in reducing the recurrence rate to 1.2 per cent which is extremely low,” he said. While proton beam irradiation represents a step forward in the treatment of uveal melanoma, there is always scope for further progress, said Prof Zografos. “The key challenges are the reduction of tumour-related mortality rate, the reduction of the irradiation-induced side-effects and the preservation of a low tumour recurrence rate,” he said. Putting the evolution of radiotherapy in the treatment of ocular tumours over the past century into context, Prof Zografos quoted the Greek statesman and orator Demosthenes: “Bad things of the past benefit the future and this applies to our patients as well,” he concluded.

contact Leonidas Zografos – leonidas.zografos@fa2.ch

Don’t Miss Ophthalmologica, see page 35 EUROTIMES | Volume 18/19 | Issue 12/1


25

Update

RETINA

IMAGING AMD

OCT can reveal retinal and vitreomacular features related to visual outcomes by Roibeard O’hEineachain in Hamburg

O

CT can be a highly useful tool for predicting visual outcomes in patients with neovascular AMD, according to Sebastian M Waldstein MD, Medical University of Vienna, Vienna, Austria. “OCT is the most valuable tool in our hands. We know that it gives the highest resolution, is able to quantify changes in terms of progression and it certainly has the strongest predictive value,” Dr Waldstein told the 13th EURETINA Congress. He presented the findings of a post hoc analysis of the VIEW II, EXCITE and MONT BLANC studies, which respectively involved comparison between aflibercept vs. ranibizumab, monthly vs quarterly ranibizumab injections and PDT with ranibizumab vs ranibizumab alone. In all three studies patients underwent monthly OCT examination and masked grading of retinal morphology at the Vienna Reading Centre. Their analysis showed that OCTdetected features such as intra-retinal cysts, pigment epithelial detachments (PEDs) and vitreomacular configurations all have a bearing on the outcomes of anti-VEGF treatment and could be important factors in treatment decisions, he noted. One of their findings was that patients with higher visual acuity at baseline tended to have a gain of around 10 letters following treatment regardless of retinal morphology. However, in eyes with low visual acuity of around 40 letters at baseline, those without cysts or PED will gain nearly 20 letters. The improvements among those with intra-retinal cysts were much lower. Patients whose intra-retinal cysts disappear during the first three months generally don’t have a recurrence during the first year of treatment, and patients maintain a steady gain of around seven letters. Eyes where cysts are present at 12 weeks of treatment tend to show persistence even with an intensive anti-VEGF regimen, a condition called degenerative cysts. In such cases the ETDRS letter score was three letters lower on average than in eyes where the cysts resolved during the first 12 weeks. In eyes with PED but without cysts, Dr Waldstein noted that patients generally gained about two letters less than those without PED or intra-retinal cysts.

EUROTIMES | Volume 18/19 | Issue 12/1

The ability to predict disease outcome can be useful for the patient and the ophthalmologist because it can enable to treat as much as required without over treating

Sebastian M Waldstein MD However, when cysts appeared in these patients during a PRN regimen, vision began to decline towards baseline values during the second year of treatment. Meanwhile, the presence of subretinal fluid had only a very limited prognostic value, and patients with subretinal fluid in the absence of intraretinal cysts or PED had excellent visual gains during anti-VEGF therapy. “As regards retinal morphology, intraretinal cysts are the strongest predictive factor both for baseline vision and for visual gain and patients with degenerative cysts show the worst outcomes,” Dr Waldstein said. In terms of the vitreomacular interface, he noted that patients with posterior vitreous detachment appeared to do equally well with six injections per year as with 12 injections per year. Those with vitreomacular adhesions on the other hand required monthly injections for optimum outcomes. “The ability to predict disease outcome can be useful for the patient and the ophthalmologist because it can enable to treat as much as required without over treating,” Dr Waldstein added.

contacts Sebastian M Waldstein – sebastian.waldstein@meduniwien.ac.at


contacts

26

Update

OCULAR

Peter Barry – peterbarryfrcs@theeyeclinic.ie Arthur Cummings – abc@wellingtoneyeclinic.com

UNDER PRESSURE

In a continuing series looking at how the recession is affecting European eye care, EuroTimes looks at the present state of Irish ophthalmology by Roibeard O’hEineachain in Dublin

A

collapsed economy and an ageing population are putting a lot of pressure on ophthalmologists in Ireland, and patients with eye diseases are finding it increasingly difficult to obtain treatment through the public health system. The Irish health system is caught in a situation where it has ever dwindling funds and a dwindling workforce to deal with an ever-increasing number of patients requiring treatment for an increasing number of indications. The proportion of the population over 65 years of age has been steadily increasing in Ireland over the past decade, rising from 11.1 per cent in 2002 to 11.7 per cent in 2011, and it is predicted to reach 16 per cent by 2026. The ageing of the population brings with it an increasing prevalence of eye diseases such as cataract, age-related macular degeneration and glaucoma.

“Since their income or their pension is either not going up or is actually being reduced, many elderly patients can no longer afford to pay their insurance premiums and must resort to the public health system,” said Peter Barry FRCS, St Vincent’s University Hospital and Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

More patients, fewer doctors

Ireland has a total of 120 ophthalmologists to serve a population of around 4.6 million. A report from the Irish College of Ophthalmologists estimated that an additional 19 consultant ophthalmologists and 14 community ophthalmologists would be necessary to achieve best practice patient ratios. Moreover, as things currently stand new appointments are not being made to replace consultant eye doctors who retire. As of December 2012, 4,266 people were on waiting lists for cataract surgery, and 19

ESCRS

Board Election Following on from the 2013 ESCRS Board Election, the following people have been elected to the Board:

per cent of patients were waiting for over six months. That was after an average sixmonth wait from the time they get a referral from their family doctor to the time they are actually seen by an ophthalmologist. Adding to the caseload are those patients with many retinal conditions which are now treatable by medical means, but on a chronic basis for the lifetime of the patient. For example the indications for anti-VEGF injections now include exudative macular degeneration, diabetic macular oedema, retinal vein occlusion and choroidal neovascularisation from pathological myopia. “The exponential growth in the number of patients presenting with these medical retinal conditions is really causing the system to shudder because once they are with you, they are with you indefinitely,” Dr Barry said. The cumulative effect of the increasing demands and decreasing returns has been a very disillusioned generation of trainee ophthalmologists who feel that their best options for pursuing their career will be in other, more prosperous countries. In fact, half of doctors trained in Ireland are now working abroad and half of doctors in Ireland received their training in other countries. “I think that doctors have to do everything that they can to ensure and preserve the teaching and training of the next generation. This next generation needs to have something to look forward to in order to prevent them from voting with their feet and moving to countries like the US, Canada and Australia which are currently draining hordes of young Irish medical trainees,” Dr Barry said.

Fewer opting for elective procedures Refractive surgery is also

Massimo Busin Italy

Dan Epstein Switzerland

Thomas Kohnen Germany

Jérôme Vryghem Belgium

EUROTIMES | Volume 18/19 | Issue 12/1

Beatrice Cochener France

feeling the brunt of Ireland’s straitened economic circumstances, since it is almost entirely made up of elective procedures generally not covered by insurance, said Arthur Cummings FRCS, Wellington Eye Clinic and UPMC Beacon Hospital, Dublin, Ireland. “The volume of LASIK absolutely mimics and reflects the consumer confidence grid. If consumers are confident and have expendable income, they will find LASIK more affordable, otherwise they simply don't have it done until later,” he told EuroTimes. He noted that several refractive surgery

The volume of LASIK absolutely mimics and reflects the consumer confidence grid. If consumers are confident and have expendable income, they will find LASIK more affordable, otherwise they simply don’t have it done until later Arthur Cummings FRCS

centres in Ireland have closed over the last five years, especially the last year or two. "The Irish market was over-saturated during the boom years. At one point there were some 14 laser clinics in the greater Dublin area. The population of this catchment area is only about 1.5 million," he said. One or two of the centres have gone into administration and some have consolidated in recent times. "Some of the remaining refractive surgery centres have adopted a range of strategies to attract patients, including reducing fees and offering alternative treatments. Some of the centres are still reportedly struggling," he added. Dr Cummings said that the Wellington Eye Clinic had a decline in LASIK patients in 2008-2009, but that since that time business has remained stable. He attributed the stability to the decreased competition as well as a policy that insures that all patients receive the best available treatment at a competitive price representing value to the patient. The option of femtosecond laser-created flaps has been the sole addon optional expense. Another of their policies, which they introduced in 2004, was to provide refractive laser enhancements without charge, giving patients greater security in their investment. “There are pressures on us, but for the time being we've been holding our own because we absolutely focus on quality service provision and compete on that basis,” he added.


See your success in the eyes of your patients

Defining the standard of care in myopic CNV* LUCENTIS® (ranibizumab) ABBREVIATED UK PRESCRIBING INFORMATION Please refer to the SmPC before prescribing LUCENTIS 10mg/ml solution for injection. Presentation: A glass single-use vial containing 0.23ml solution containing 2.3mg of ranibizumab (10mg/ml). Indications: The treatment in adults of neovascular (wet) age-related macular degeneration (AMD), the treatment of visual impairment due to diabetic macular oedema (DMO), the treatment of visual impairment due to macular oedema secondary to retinal vein occlusion (branch RVO or central RVO), and the treatment of visual impairment due to choroidal neovascularisation (CNV) secondary to pathologic myopia (PM). Administration and Dosage: Single-use vial for intravitreal use only. LUCENTIS must be administered by a qualified ophthalmologist experienced in intravitreal injections under aseptic conditions. The recommended dose is 0.5 mg (0.05ml). For treatment of wet AMD: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. The patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to wet AMD. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. For treatment of visual impairment due to either DMO or macular oedema secondary to RVO: Treatment is given monthly and continued until maximum visual acuity is achieved i.e. the patient’s visual acuity is stable for three consecutive monthly assessments performed while on ranibizumab treatment. If there is no improvement in visual acuity over the course of the first three injections, continued treatment is not recommended. Thereafter patients should be monitored monthly for visual acuity. Treatment is resumed when monitoring indicates loss of visual acuity due to DMO or to macular oedema secondary to RVO. Monthly injections should then be administered until stable visual acuity is reached again for three consecutive monthly assessments (implying a minimum of two injections). The interval between two doses should not be shorter than 1 month. LUCENTIS and laser photocoagulation in DMO and in macular oedema secondary to BRVO: When given on the same day, LUCENTIS should be administered at least 30 minutes after laser photocoagulation. LUCENTIS can be administered in patients who have received previous laser photocoagulation. For treatment of visual impairment due to CNV secondary to PM: Treatment is initiated with a single injection. If monitoring reveals signs of disease activity, e.g. reduced visual acuity and/or signs of lesion activity, further treatment is recommended. Monitoring for disease activity may include clinical examination, optical coherence tomography (OCT) or fluorescein angiography (FA). While many patients may only need one or two injections during the first year, some patients may need more frequent treatment. Therefore, monitoring is recommended monthly for the first two months and at least every three months thereafter during the first year. After the first year, the frequency of monitoring should be determined by the treating physician. The interval between two doses should not be shorter than one month. LUCENTIS and Visudyne photodynamic therapy in CNV secondary to PM: There is no experience of concomitant administration of LUCENTIS and Visudyne. Before treatment, evaluate the patient’s medical history for hypersensitivity. The

patient should also be instructed to self-administer antimicrobial drops, 4 times daily for 3 days before and following each injection. Children and adolescents: Not recommended for use in children and adolescents due to a lack of data. Elderly: No dose adjustment is required in the elderly. There is limited experience in patients older than 75 years with DMO Hepatic and renal impairment: Dose adjustment is not needed in these populations. Contraindications: Hypersensitivity to the active substance or excipients. Patients with active or suspected ocular or periocular infections. Patients with active severe intraocular inflammation. Special warnings and precautions for use: LUCENTIS is for intravitreal injection only. Intravitreal injections have been associated with endophthalmitis, intraocular inflammation, rhegmatogenous retinal detachment, retinal tear and iatrogenic traumatic cataract. Monitor during week following injection for infections. Patients should be instructed to report symptoms suggestive of any of the above without delay. Transient increases in intraocular pressure (IOP) within 1 hour of injection and sustained IOP increases have been identified. Both IOP and perfusion of the optic nerve head should be monitored and managed appropriately. Concurrent use in both eyes has not been studied and could lead to an increased systemic exposure. There is a potential for immunogenicity with LUCENTIS which may be greater in subjects with DMO. Patients should report an increase in severity of intraocular inflammation. LUCENTIS should not be administered concurrently with other anti-VEGF agents (systemic or ocular). Withhold dose and do not resume treatment earlier than the next scheduled treatment in the event of the following: a decrease in best corrected visual acuity (BCVA) of ≥30 letters compared with the last assessment of visual acuity; an intraocular pressure of ≥30 mmHg; a retinal break; a subretinal haemorrhage involving the centre of the fovea, or if the size of the haemorrhage is ≥50% of the total lesion area; performed or planned intraocular surgery within the previous or next 28 days. Risk factors associated with the development of a retinal pigment epithelial (RPE) tear after anti-VEGF therapy for wet AMD include a large and/or high pigment epithelial retinal detachment. When initiating LUCENTIS therapy, caution should be used in patients with these risk factors for RPE tears. Discontinue treatment in cases of rhegmatogenous retinal detachment or stage 3 or 4 macular holes. There is only limited experience in the treatment of subjects with DMO due to type I diabetes. LUCENTIS has not been studied in patients who have previously received intravitreal injections, in patients with active systemic infections, proliferative diabetic retinopathy, or in patients with concurrent eye conditions such as retinal detachment or macular hole. There is also no experience of treatment with LUCENTIS in diabetic patients with an HbA1c over 12% and uncontrolled hypertension. In PM patients there are no data on the use of LUCENTIS in patients with extrafoveal lesions and only limited data on its use in those who have had previous unsuccessful therapy with verteporfin photodynamic therapy. Systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events have been reported following intravitreal injection of VEGF inhibitors. There are limited data on safety in the treatment of DMO, macular oedema due to RVO and CNV secondary to PM patients with prior history of stroke or transient ischaemic attacks. Caution should be exercised when treating such patients. There is limited experience with treatment of patients with prior episodes of RVO and of patients with ischaemic BRVO and CRVO. Treatment is not recommended in RVO patients presenting with clinical signs of irreversible ischaemic visual function loss. Interactions: No formal interaction

studies have been performed. In DMO and BRVO adjunctive use of laser therapy and LUCENTIS was not associated with any new ocular or non-ocular safety findings. Pregnancy and lactation: Women of childbearing potential should use effective contraception during treatment. No clinical data on exposed pregnancies are available. Ranibizumab should not be used during pregnancy unless the expected benefit outweighs the potential risk to the foetus. For women who wish to become pregnant and have been treated with ranibizumab, it is recommended to wait at least 3 months after the last dose of ranibizumab before conceiving. Breast-feeding is not recommended during the use of LUCENTIS. Driving and using machines: The treatment procedure may induce temporary visual disturbances and patients who experience these signs must not drive or use machines until these disturbances subside. Undesirable effects: Most adverse events are related to the injection procedure. Serious adverse events reported include endophthalmitis, blindness, retinal detachment, retinal tear and iatrogenic traumatic cataract. The safety data below include adverse events experienced following the use of LUCENTIS in the entire clinical trial population. Those marked * were only seen in the DMO population. Very Common: Intraocular pressure increased, headache, vitritis, vitreous detachment, retinal haemorrhage, visual disturbance, eye pain, vitreous floaters, conjunctival haemorrhage, eye irritation, foreign body sensation in eyes, lacrimation increased, blepharitis, dry eye, ocular hyperaemia, eye pruritus, arthralgia, nasopharyngitis. Common: Urinary tract infection*, anaemia, retinal degeneration, retinal disorder, retinal detachment, retinal tear, detachment of the retinal pigment epithelium, retinal pigment epithelium tear, visual acuity reduced, vitreous haemorrhage, vitreous disorder, uveitis, iritis, iridocyclitis, cataract, cataract subcapsular, posterior capsule opacification, punctuate keratitis, corneal abrasion, anterior chamber flare, vision blurred, injection site haemorrhage, eye haemorrhage, conjunctivitis, conjunctivitis allergic, eye discharge, photopsia, photophobia, ocular discomfort, eyelid oedema, eyelid pain, conjunctival hyperaemia, cough, nausea, allergic reactions, hypersensitivity, anxiety. Product-class-related adverse reactions: There is a theoretical risk of arterial thromboembolic events, including stroke and myocardial infarction, following intravitreal use of VEGF inhibitors. A low incidence rate of arterial thromboembolic events was observed in the LUCENTIS clinical trials in patients with AMD, DMO, RVO and PM and there were no major differences between the groups treated with ranibizumab compared to control. Please refer to the SmPC for full listing of all undesirable effects.

For UK: Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Novartis Pharmaceuticals UK Ltd on (01276) 698370 or medinfo.uk@novartis.com Legal category: POM, UK Basic NHS cost: £742.17. Marketing authorisation number: EU/1/06/374/001. Marketing authorisation holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Full prescribing information, including SmPC, is available from: Novartis Pharmaceuticals, Frimley Business Park, Frimley, Camberley, Surrey, GU16 7SR. Telephone: 01276 692255. Fax: 01276 692508. Prepared July 2013.

* Visual impairment due to choroidal neovascularisation (CNV) secondary to pathologic myopia (PM)

Lucentis Indications may vary from country to country. Physicians should refer to their National Prescribing Information. Novartis Pharma AG CH-4002 Basel, Switzerland

©2013 Novartis Pharma AG

October 2013

146879

LUC13-C166c


28

Update

PAEDIATRIC OPHTHALMOLOGY

LASEK SAFETY

Study finds laser ablation has no effect on endothelial cells

NürNberg 2014 27 th international Congress of

gerMaN oPHTHaLMiC SurgeoNS

May 15th - 17th, 2014 NürnbergConvention Center e DeaDndlin 2014 april 2 ,

Video LiVe Surgery May 16th aNd 17th, 2014 MaiN ToPiCS

(Simultaneous translation english - german)

➤ doC – iSrS/aao Symposium ➤ award ceremonies and Honorary lectures ➤ glaucoma surgery ➤ Corneal surgery ➤ Cataract surgery ➤ Vitreoretinal surgery ➤ orbita, lacrimal and lid surgery ➤Forum eye surgery in the developing countries

Free PaPer SeSSioN SCieNTiFiC PoSTerS SurgiCaL FiLMS SubMiSSioN deadLiNe MarCH 11th, 2014)

You are invited to visit a comprehensive industry exhibition with exhibits and information on medical equipment and pharmaceuticals. The exhibition will take place during the congress in Hall 7a as well as transition and entrance hall.

27th International Congress of German Ophthalmic Surgeons, NürnbergConvention Center, May 15th - 17th, 2014 Please send me: $ a Preliminary Program MCN Medizinische Congressorganisation Nürnberg AG Neuwieder Str. 9 90411 Nürnberg, Germany Z ++49/(0)911/3931646 hi ++49/(0)911/3931620 E-Mail: doc@mcnag.info

Name

Street

Country/Zip Code/City

Z

E-Mail

www.doc-nuernberg.de EUROTIMES | Volume 18/19 | Issue 12/1

hi

by Howard Larkin in Amsterdam

A

s with adults, excimer laser energy in children undergoing laser subepithelial keratomileusis, or LASEK, has no apparent effect on endothelial cell density or morphology, Adam K Muzychuk MD told the XXXI Congress of the ESCRS. His study suggests that LASEK, which has been shown effective for treating refractive amblyopia unresponsive to standard therapy, is safe and unlikely to increase long-term risks of corneal oedema or other problems related to endothelial cell damage. The result was hardly surprising, said Dr Muzychuk, of the University of Calgary, Alberta, Canada, who is a resident under the supervision of William F Astle MD, FRCSC, Dipl ABO, at the Alberta Children’s Hospital, University of Calgary, Canada. He pointed to studies in adults, showing that 200 microns of residual stroma protects endothelial cells (Kim et al. 1997; Advances in Corneal Research, Springer:329-342), and that refractive surgery shows no effect on endothelial cell density or morphology long term (Woodward et el. J Cataract Refract Surg. 2011; 37(4):767-777). Also, the safety and efficacy of PRK and LASEK for treating amblyopia in a subset of children not responsive to glasses, contact lenses, eye patches or atropine has been demonstrated in follow-up studies ranging up to 15 years with Dr Astle’s patients at the Alberta Children’s Hospital, in Calgary, Canada (Astle et al. J Cataract Refractive Surg. 2008; 34(3):411-6), Dr Muzychuk said. “We anticipated there would be no effect on the endothelium from excimer laser treatment.” Still, no paediatric studies existed, Dr Muzychuk said. It could be because assessing endothelial cell condition involves confocal microscopy, requiring several seconds of absolute stillness. This is difficult with any paediatric population let alone this subset of amblyopia patients, who usually have poor vision and often neurodevelopmental deficits. But given the potential for devastating long-term complications if endothelial cells are damaged by laser refractive surgery in children, Dr Astle and his colleague, Dr Peter T Huang, felt a study was warranted. Dr Muzychuk explained: “The concern has been raised in the literature over the years and has yet gone unanswered.” (Paysse,

We anticipated there would be no effect on the endothelium from excimer laser treatment Adam K Muzychuk MD

E. A., L. Tychsen, et al. (2012.) 'Paediatric refractive surgery: corneal and intraocular techniques and beyond.' J AAPOS 16(3): 291-297.) The retrospective study involved 15 eyes of 11 patients under age 18 receiving LASEK for amblyopia. The group included five males and six females with a mean age of 12.2 +/- 3.7 years, ranging from 6.8 to 17.1. Refractive error ranged from -17 D to +6.9 D with four hyperopic, five astigmatic and six myopic corrections. No complications were observed in any patient, and there were no signs of endothelial cell dysfunction. Endothelial cell density and morphology were analysed manually and automatically using confocal microscopy before surgery and at a mean 145 days after surgery, ranging from 62 days to 302 days. Mean density fell by 25 cells per square mm from 3,493 to 3,468 measured manually, and by 32 from 2,954 to 2,922 measured automatically, neither of which was statistically significant, Dr Muzychuk reported. No correlation between change in cell density and spherical equivalent correction was found. Similarly, no significant differences were found in cell area or percentages of cells with polymorphism or polymegathism by either manual or automated analysis. Dr Muzychuk acknowledged that the study’s retrospective nature, small sample, single follow-up and difficulties imaging patients limit its power. However, its consistency with adult studies and longterm observations of patients operated as children lend credence to the conclusion that LASEK does not harm the endothelium in paediatric patients.

contacts William F Astle – William.astle@albertahealthservices.ca Adam Muzychuk – muzychuk@gmail.com


29

News

esaso

AMD CONGRESS

International meeting provides update on retinal disease therapy by Roibeard O' hEineachain in Dublin

T

he 13th International AMD and Retina Congress organised by European School for Advanced Studies in Ophthalmology (ESASO) took place in Dublin in October 2013. With around 1,200 international eye doctors and surgeons from 45 countries in attendance, the meeting highlighted the rapidly changing nature of the treatment of retinal disease. “This is the fifth year that the congress has been conducted under the umbrella of the ESASO school and we are introducing some new educational modalities. We have master classes and clinical cases and we're trying to make this meeting a bit more interactive than before,” said Francesco Bandello MD, FEBO, chairman of the ESASO Scientific Committee, at the Opening Ceremony of the congress. Also speaking at the Opening Ceremony, Dr Marie Hickey Dwyer, president of The Irish College of Ophthalmologists and member of the meeting's Scientific Board said the meeting had been organised by collaborating with people from five continents of the world. Borja Corcostegui MD, a member of the meeting's organising committee, said highlights of the meeting included discussions about the use of anti-VEGF agents in an ever-broadening range of indications, and the insights gained from clinical experience in terms of their appropriate dosage and regimens and safety. Also under discussion was the place of enzymatic vitreolysis in vitreoretinal surgery. “AMD is a very important disease. It affects a huge number of patients all over the world and we need to determine the optimum regimen for anti-VEGF injections to keep their visual acuity at a good level. We are also focusing on the treatment of diabetic macular oedema which is becoming an increasingly important cause of loss of vision because the incidence of diabetes is increasing around the world. With regard to enzymatic vitreolysis we need to find out which patients are likely to benefit from this kind treatment,” said Dr Corcostegui, who is medical director of IMO Institut Microcirurgia Ocular, Barcelona, Spain. Other topics included the latest research into practical application of once purely futuristic concepts including artificial vision, stem cell implantation and gene

EUROTIMES | Volume 18/19 | Issue 12/1

This is the fifth year that the congress has been conducted under the umbrella of the ESASO school and we are introducing some new educational modalities

Francesco Bandello MD, FEBO therapy, as they make their way from the laboratory to the clinic. Anat Lowenstein MD, Tel Aviv Medical Centre, Israel, noted that the ESASO congresses represent one of three important aspects of the organisation's educational activities. The society's primary efforts are concentrated at their school based within the Campus of the Universita della Svizzera Italiana (USI), Lugano, Switzerland. There, young ophthalmologists can take intensive courses in all fields of ophthalmology from some of the world's greatest experts, she told EuroTimes. “The courses require dedication from those taking part and each of the teachers gives a whole morning to a specific subject. For example, somebody may talk about retinal vein occlusion or diabetes, starting with the pathogenesis and then it goes into the various treatment options for surgery and case presentations, and the doctor comes out with very extensive knowledge,” she said. ESASO also organises courses in different parts of the world where advanced ophthalmic training is non-existent and physicians are unable to travel to the Lugano centre. The ESASO congresses provide another way of disseminating expert knowledge throughout the global community, she noted. “This meeting is becoming one of the most important meetings of retinal disease in the world and covers all areas of the topic in a very good manner,” she added.

contacts Francesco Bandello – bandello.francesco@hsr.it Anat Lowenstein – anatlow@tasmc.health.gov.il Borja Corcostegui – corcostegui@imo.es 08_1312_18 ESASO_Anz_EUT_120x300_Dez_RZ.indd 1

03.12.13 16:11


News

EYE ON TECHNOLOGY

new technique

The E-DMEK procedure can make a world of difference to the DMEK surgeon by Dr Soosan Jacob

D

escemet's membrane endothelial keratoplasty (DMEK) is a new type of endothelial transplantation described first by Gerrit Melles in 2006. It comprises the transplantation of only the donor Descemet's membrane with endothelium unlike Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) which also transplants donor stroma. DMEK has major advantages over DSAEK in that it provides better vision as well as very low rates of graft rejection. As there is no stroma transplanted, there is also no induced hyperopia. However, it has still not become a widely practised technique the world over mainly due to the steep learning curve associated with it. The DMEK graft is thin and flimsy and is difficult to handle with ease in the anterior chamber. It is vital to correctly identify the Descemetic side of the graft in order to orient the graft with Descemet's side up. Since the Descemet's membrane is an elastic structure, the graft always curls towards the Descemetic side. During surgery, the final graft orientation should be such that its edges curl upwards. The graft can be stained with Trypan blue dye to enhance visibility, however wash-off of dye can occur during surgery, especially with longer surgical times. Even with a well-stained graft, it is often difficult to identify the Descemetic side as the microscope light falling vertically on the graft passes through the transparent graft without giving much additional information about the graft morphology, orientation or direction of curling. A purely vertical view affects three-dimensional perception and makes surgical decisions difficult. One technique to determine edge curl is by passing a cannula into the anterior chamber to see if the cannula lies below or above the blue stained graft. However, this is a touch technique, can lead to shallowing of the anterior chamber and can disturb an oriented graft. The hand-held slit lamp may also be used very effectively but this gives only a slit view and not a view of the entire graft simultaneously. It therefore needs to be scanned across the graft and surgical manoeuvres cannot be done simultaneously with slit viewing. Hence, for rapid, easy and successful surgery, it is important to be able to determine in an easy, non-touch manner, without confusion, the way the EUROTIMES | Volume 18/19 | Issue 12/1

graft lies within the anterior chamber. It is also important to be able to see and comprehend clearly the graft dynamics as it is attempted to be unfolded so that the surgeon is sure that he/she is doing the right manoeuvre. The entire scenario is worsened by corneal oedema which often co-exists in such patients or increases with increasing duration of surgery.

New technique A new technique that I have described for making DMEK easier and less dependent on guesses is the Endoilluminator assisted DMEK or E-DMEK. An endoilluminator or light pipe that is used for vitreo-retinal surgeries is used for this purpose. The DMEK graft is prepared and stained. The host Descemet's membrane is scored and stripped and the DMEK graft is injected into the anterior chamber. The microscope light is then switched off and the endoilluminator is held obliquely at the limbus in such a manner that the light is shone into the anterior chamber and onto the DMEK graft. The tangential light from the endoilluminator is used to comprehend details of the DMEK graft, its position, folds in the graft and orientation of Descemet's membrane versus endothelium with respect to overlying stroma. The angle of incident light can be changed and the probe may be moved around the limbus to help comprehend the entire graft morphology. As the light is incident from an angle and not vertical, striking three-dimensional depth perception is obtained secondary to reflexes from the light bouncing off the edges of the graft as well as by seeing the movement induced in the graft by fluid currents/gentle tapping. The direction of curvature of graft edges, and thereby graft orientation is confirmed by tapping the host cornea gently and appreciating light reflexes (see figures; Video file). As and when required, the surgeon may switch between working with either the endoilluminator or the microscope light or both. However, best three-dimensionality is obtained with only the endoilluminator light alone. The endoilluminator probe may be held by the surgeon or the assistant. Using E-DMEK, the graft is thus oriented the right way up, unfolded and centred following which it is floated up with air. Surgery is finished by checking IOP and light perception and the patient is asked to

Courtesy of Soosan Jacob MS, FRCS, DNB

30

Figure A: With E-DMEK, graft edges are seen clearly highlighted and three-dimensionally. Gentle tapping allows identification of direction of curve. Figure B: Rolled up DMEK graft as seen under microscope light. Figure C: With E-DMEK, light reflexes created by obliquely incident light from endoilluminator (arrowhead) provides excellent detail with regards to scrolling, folds and edges of graft as well as greatly enhanced three-dimensionality thus giving better comprehension of graft position, orientation and morphology

maintain a supine position for 24 hours. The major advantage that E-DMEK gives is that the entire extent of the graft can be easily visualised three-dimensionally, thus clearing any doubts in the mind of the surgeon regarding orientation, morphology, position etc. Graft dynamics can be better comprehended leading to easier and faster surgery. This has the advantage of decreasing graft damage secondary to prolonged surgery, excessive fluidics and unnecessary manipulation. Though the increased visibility and three-dimensional depth perception that is obtained is very useful in DMEK with relatively clear corneas, it becomes even more invaluable when visibility is already compromised secondary to corneal oedema or dye washout. Graft orientation can be checked by seeing the reflexes bouncing off the edge of the graft on very gently tapping the cornea thus helping the surgeon to conclusively determine whether or not the graft is flipped. This is done while maintaining a no-touch technique, thus decreasing cell loss in the graft. Surgery can be sped up because of better visualisation of the whole graft, thereby decreasing graft damage. The E-DMEK technique can also be

translated into the latest form of endothelial keratoplasty â&#x20AC;&#x201C; Pre-Descemetic endothelial keratoplasty (PDEK) as Endoilluminator assisted PDEK or E-PDEK. Prof Agarwal, who brought out the technique of PDEK which includes transplantation of the Pre-Descemetic or Dua's layer with the Descemet's membrane and endothelium says, "The E-DMEK technique makes a world of difference to the DMEK surgeon. It is extremely helpful in all the intracameral steps of surgery. I use it in every single case of both DMEK and PDEK as I know it will make all the difference to the surgery and the postoperative outcomes." n Dr

Soosan Jacob is a senior consultant ophthalmologist at Dr Agarwal's Eye Hospital, Chennai, India and can be reached at: dr_soosanj@hotmail.com

Scan this QR code to go to video link for surgery: http://www.youtube.com/ watch?v=K3SmgJ2exWY


31

News

RESEARCH

escrs launches 2014 research awards by Dermot McGrath

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uropean-based clinicians and researchers are being encouraged to craft imaginative proposals in the field of cataract and refractive surgery for the 2014 ESCRS Clinical Research Awards. With the final deadline for Expressions of Interest set for 31 January 2014, the ESCRS sees the Clinical Research Awards as the ideal opportunity to support worthy projects in cataract and refractive surgery. “The awards were instituted in order to support, encourage and fund individuals that actively conduct clinical research in the field of cataract and refractive surgery,” explained Prof Rudy Nuijts MD, PhD, current treasurer of the ESCRS and chair of the ESCRS Research Committee. “One of the aims of the ESCRS is to facilitate and support an independent culture of clinical study for the ultimate benefit of patients with cataract and refractive disorders, and to engage and encourage the networking potential of the ophthalmic clinical community across the EU to improve both patient care and outcomes in Europe,” he added. As Prof Nuijts noted, the ESCRS is the ideal platform for initiating clinical multicentre studies that seek to provide evidence-based responses to important research questions that have implications for most health systems in Europe. “Having such data also facilitates discussions with national health authorities and governmental decision-makers,” said Prof Nuijts. Prof Nuijts, whose own research group at the Maastricht University Medical Centre, Netherlands, received funding from the ESCRS for its ground-breaking PREMED study on cystoid macular oedema after cataract surgery, said that the ESCRS is fully committed to supporting innovation and creativity in European clinical research. “The ESCRS is prepared to invest substantial funding in the right project with suitable infrastructure and experience. We want to see how passion and curiosity can be applied to a significant clinical problem and are keen to support the best and brightest clinical research ideas with the capacity to change how we manage and treat our patients in the field of ophthalmology,” he said.

EUROTIMES | Volume 18/19 | Issue 12/1

One of the aims of the ESCRS is to facilitate and support an independent culture of clinical study for the ultimate benefit of patients with cataract and refractive disorders

FOR REFRACTIVE AND CATARACT SURGERY Reaching a new level in corneal tomography Patented Dual Scheimpflug system provides highly accurate pachymetry and ray-tracing, even when the measurement is decentred.

Rudy Nuijts MD, PhD

Scope of possibilities As Prof Nuijts emphasised, the scope of possibilities for clinical research proposals is very wide indeed. The Judging Panel will consider ideas ranging from clinical research into the use of specific medical treatments or surgeries, or from the application of qualityadjusted life years (QALYs) in clinical care, to the management of national and global healthcare systems in ophthalmology or clinical research on the pharmaco-economic analysis of particular treatments. He added that the ESCRS Clinical Research Awards are as much to do with good clinical science and medicine as they are to do with the capability to execute a solid research project creating near-term clinical impact. The combination of clinical science and clinical research expertise is the key to convincing the external Judging Panel of a credible and attractive clinical research programme. All Expressions of Interest will be evaluated by the ESCRS Research Committee, from which short-listed entries will be invited to make a full proposal. The awards are open to clinicians and researchers holding a full-time clinical/ research post at an EU-based clinical or academic centre and all proposed projects must be in the field of cataract or refractive surgery.

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n Final

decision of award winner(s) will be made at the XXXII ESCRS Congress in London to be held from 13-17 September 2014. EuroTimes_dez2013_jan2014_GALILEI_G4_ad_120x300.indd 1

01.11.13 08:45


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EUROTIMES | Volume 18/19 | Issue 12/1

News

young ophthalmologists

Call for entries

Writing prize open to ESCRS members who are aged 40 or under before January 1, 2014

E

ntrants to the John Henahan Prize are invited to write a 900-word essay on the topic of, “How do I see cataract surgery in 30 years?” The essays will be judged by Emanuel Rosen, chairman ESCRS Publications Committee; Jose Guell, former president ESCRS; Oliver Findl, chairman ESCRS Young Ophthalmologists’ Forum; Sean Henahan, editor EuroTimes; Paul McGinn, editor EuroTimes; and Robert Henahan, contributing editor EuroTimes. The two main criteria for consideration by the judges are the clinical content of the story and the writing style, including punctuation and grammar, which should reflect the high standard of material published in EuroTimes. The winner will receive a travel bursary worth €1,000 to attend the XXXII Congress of the ESCRS in London, UK and a special trophy which will be presented at the Young Ophthalmologists' Programme.

2013 Winner The 2013 John Henahan Prize winner was Dr Nicole Tsim whose winning essay was on the theme of, Recollections of My First Intraocular Surgery. Dr Tsim received her prize from ESCRS president Peter Barry at the XXXI ESCRS Congress Video Awards Session in Amsterdam, The Netherlands After the ceremony, Dr Rosen, chairman of the John Henahan Prize Judging Panel, congratulated Dr Tsim and said her essay was outstanding. “In Nicole Tsim’s award-winning essay she liked drawing analogies with several sports where errors can easily creep in if composure is not maintained,” said Dr Rosen. “She also likens her first ECCE experience to a pilot flying solo for the first time where, as she admits, disaster is always just around the corner. Her determination to control her hands and her breathing help us all to recall those first steps in undertaking intraocular surgery trying to banish negative thoughts and concentrate on having a positive attitude.” Dr Tsim graduated from the University College London Medical School and became interested in ophthalmology as a specialty while working as a summer intern, fundraising with the Project ORBIS and during her Basic Surgical Training, while working in the Accidents and Emergency

Nicole Tsim receives the 2013 John Henahan prize from Peter Barry, president of ESCRS

Department in England. She is a member of the Royal College of Surgeons of Edinburgh and is currently in her third year of ophthalmology training at the Prince of Wales Hospital in Hong Kong. She is also an honorary staff member of the Chinese University of Hong Kong.

Entry forms The prize is named in honour of John Henahan, who edited EuroTimes from 1996 to 2001. “John’s work has inspired a generation of young doctors and journalists, many of whom continue to work for EuroTimes. The prize will not only bring satisfaction to the winner and credit to all the contributors but may enhance all their prospects of pursuing a medical writing aspect to their future careers. We look to their further contributions to EuroTimes and the Journal of Cataract & Refractive Surgery,” said Dr Rosen. n Entry

forms are available from Colin Kerr, executive editor, EuroTimes at: henprize@eurotimes.org.The closing date for entries is Friday 6 June, 2014. For further information see www.escrs.org.


Feature

33

RESIDENT’s DIARY

MOMENT OF TRUST

Confidence from attending ophthalmologist helps build confidence in self

T

here comes a time when a senior ophthalmologist decides to place his or her trust in a resident’s judgment and skills even without a formal teaching moment, without an official evaluation. There is a transfer of trust: “I think you can do this on your own, even though you’ve never done it.” There is an acknowledgement of maturation and of the inevitability of competence: “Within a year or two, your legal status as a certified ophthalmologist will equal mine, so let’s get on with it.” And there comes a time when it simply becomes more practical to allow a resident to do it him- or herself. By 'it' I mean small surgical procedures that senior ophthalmologists do regularly, but what we residents have to earn the right to do outside the traditional training plan. As residents, our surgical training occurs within a highly structured framework. The interventional learning process starts off slowly, step-by-step. We’re taught how to laser the retina to treat tears, laser the posterior capsule to eliminate opacities and laser the iris to relieve acute angle closure. We remove sutures from corneal transplants, excochleate chalazia and epilate distichiatic cilia. We perform strabismus surgery, suture scleral buckles and extract cataracts. We revitalise upper eyelids, tighten lower eyelids and eviscerate or enucleate all that which cannot be saved. But there are surgical interventions that are excluded from the official training modules because of their infrequent and unpredictable presentation. Their need usually arises unexpectedly, often as a complication of a prior surgical procedure. Yet once the decision has been made to perform the intervention, the question arises: who will do it? I had one of these moments recently. I presented a case to a senior glaucoma specialist, Dr de Waard, during his clinic: “Mrs Suykerbuyk has been vomiting since she returned to the inpatient ward after her glaucoma drain operation this morning. Her IOP is 66. I don’t think topical treatment will help much here. What would you like to do?” “Drain it,” he replied. “Ok, I’ll get her prepared and I’ll call you when she’s ready,” I said. “No, I mean you drain it,” he countered.

EUROTIMES | Volume 18/19 | Issue 12/1

“Pardon?” “Drain the anterior chamber. The temporal paracentesis incision is fresh and will open easily. Indent the posterior lip of the incision and the pressure will be relieved.” I hadn’t expected him to request such an invasive manoeuvre, and my surprise was probably obvious. “You’ve done intraocular surgery before, haven’t you?” he prodded. Yes, of course, I thought. In fact, Dr de Waard had been the first staff ophthalmologist to allow me to perform an intraocular manoeuvre when he let me insert an IOL at the end of a standard cataract operation. This he had surely forgotten long ago. “Yes,” I answered, with more confidence. I had since successfully completed my surgical cataract rotation. He said: “Well, get it done. It’ll be fine,” and he turned to examine his next patient. “Let me know how it goes.” So I returned to Mrs Suykerbuyk to explain the plan. “The specialist recommended we release the pressure,” I said, while contemplating all the possible complications of such a manoeuvre. “Sure,” she said, without requesting further details. A patient with extremely high IOP will agree to nearly anything to be relieved of the discomfort. I performed the paracentesis, the IOP dropped and the patient felt better soon thereafter. Dr de Waard was happy to hear that it went well. And he was pleased to have been able to continue with his clinic essentially undisturbed. The moment that trust is transferred to a resident occurs with each resident and each staff ophthalmologist at specific and unpredictable moments. An important factor seems to be the senior doctor’s confidence in his or her own skills. Dr de Waard is not lacking in confidence. He seems quite assured that if we were to mess something up, he could probably fix it. Another factor is confidence in the residents themselves. Dr van Meurs, a senior retinal surgeon and director of residency training, has this to an unprecedented degree, despite his profound, near-philosophical deliberations about nearly every case. “Dr van Meurs, I have a pseudophakic patient with gas in his anterior chamber a

Illustration: Eoin Coveney

by Leigh Spielberg

few days after vitrectomy. The pressure is in the 50s and he’s quite uncomfortable.” “Hmm… that gas isn’t too useful there. No sense in keeping gas in the anterior chamber. Use a 30-gauge needle,” he replied, as he continued with his retinal laser clinic. Off I went. An anterior chamber gas paracentesis makes a distinctive “pppfffttt” sound, and it’s surprisingly effective. I called Dr van Meurs to tell him that it went well. “Goed. Goed gedaan.” Well done. I had thus performed two anterior chamber paracenteses and felt like a pro. This was fortunate, because a few days later, during the Avastin clinic, a patient experienced amaurosis after an intravitreal injection. “Did the lights go out? I can’t see anything at all,” he said. “Not your hand, not the lights, nothing.” In this situation, there’s no time to consult with a senior doctor. I turned to

the nurse, requested new sterile gloves, a fine needle, extra anesthetic drops and antisepsis. “I’m going to release some pressure from your eye, sir.” I flattened the patient’s chair to horizontal, stabilised my hands on his face and penetrated the temporal cornea with the needle. One drop of aqueous oozed out of the end of the needle. Done. “Yes, it’s coming back! I can see the light again!” I could see the light as well. New skill: paracentesis. New feeling: confidence.

Leigh Spielberg is an ophthalmology resident at the Rotterdam Eye Hospital in The Netherlands


SYMPOSIUM & CONGRESS

2014

APRIL 25–29 BOSTON

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

REGISTER TODAY EARLY BIRD DEADLINE—WEDNESDAY, JANUARY 8 A R AC T A N D R E F R CAT AC

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www.ascrs.org www.asoa.org The Only U.S. Meeting Dedicated to the Anterior Segment Specialist & The Leading Practice Management Program in Ophthalmology Follow @ASCRStweets on Twitter. #ASCRSASOA2014


35

Review

OPHTHALMOLOgica

Spectral domain findings match structure to function

SD-OCT detected retinal layer degradation

The amount of reduction in central retinal thickness detected by spectral-domain optical coherence tomography (SD-OCT) corresponds well with improvements in visual acuity among patients undergoing intravitreal ranibizumab therapy for diabetic macular oedema, according to a new study involving 59 eyes monitored over six months of therapy with the antiVEGF agent. At six months’ follow-up, BCVA had improved by 10.3 letters in 26 eyes where SD-OCT showed a decrease in central retinal thickness of 20 per cent. That compared to a gain of only 1.8 letters among 33 eyes where SD-OCT showed a decrease in central retinal thickness of less than 20 per cent.

Changes in the volume of retinal and subretinal spaces detected by SD-OCT correlate with visual acuity in eyes with neovascular AMD, according to the findings of a retrospective study. A quantitative analysis SD-OCT and visual acuity measurements in 64 treatment-naïve eyes showed that a lower baseline visual acuity correlated with an increased volume of subretinal hyperreflective material ( p < 0.001) and with decreased volume of the photoreceptor layer. At one year’s followup, lower visual acuity correlated with decreased volume of the retina ( p < 0.001), outer nuclear layer (p < 0.05) and PRL (p < 0.001) and photoreceptor layer (p < 0.05).

n Santos

A R et al Ophthalmologica, “Degree of Decrease in Central Retinal Thickness Predicts Visual Acuity Response to Intravitreal Ranibizumab in Diabetic Macular Edema”, 2014 (DOI:10.1159/000355487)

Nonmydriatic SLO for diagnosing diabetic retinopathy Nonmydriatic ultra wide-field 2000 scanning laser ophthalmoscopy offers the potential of a better differentiation of diabetic retinopathy lesions than is possible with standard stereoscopic 45° colour fundus photography, although in its current form it may not be as diagnostically accurate as the older technology, researchers have reported. In a study involving 143 consecutive eyes of patients with varying levels of diabetic retinopathy, the correlation was strongest for grading clinically significant macular oedema, with a statistical kappa value of 0.77, and was fair-to-moderate for grading macular oedema in general, with a statistical kappa value of 0.39 (p < 0.001).

n Ristau

T et al, Ophthalmologica “Relationship between Visual Acuity and Spectral Domain Optical Coherence Tomography Retinal Parameters in Neovascular AgeRelated Macular Degeneration” 2014 (DOI:10.1159/000354551) .

Myopic foveoschisis study results In a retrospective study involving 56 eyes of 39 consecutive patients with myopic foveoschisis, optical coherence tomography at baseline showed an isolated foveoschisis in 62.5 per cent, foveal detachment in 21.4 per cent and a lamellar hole in 16.1 per cent of the eyes. After a mean follow-up period of 15.7 months, 1.8 per cent of the eyes developed a full-thickness macular hole and 28.5 per cent of the eyes required surgery. n Rey

A. • Ophthalmologica, “Natural Course and Surgical Management of High Myopic Foveoschisis” 2014 (DOI:10.1159/000355324).

n Liegl

R et al, Ophthalmologica, “Nonmydriatic Ultra-Wide-Field Scanning Laser Ophthalmoscopy (Optomap) versus Two-Field Fundus Photography in Diabetic Retinopathy” 2014 (DOI:10.1159/000355092).

José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA EUROTIMES | Volume 18/19 | Issue 12/1

4TH EURETINA WINTER MEETING

ROME INNOVATION IN MANAGEMENT OF RETINAL DISEASE

25 JANUARY 2014 ROME CAVALIERI WALDORF ASTORIA HOTEL, ITALY

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Feature

OUTLOOK ON INDUSTRY

contact

36

Kristy Guerra – kristy.guerra@bausch.com

MAJOR ACQUISITION

Valeant acquires Bausch+Lomb and says it is committed to continuing aggressive product research and development by Howard Larkin

B

ausch+Lomb (B+L), the 160-yearold giant of eye care is now part of Valeant Pharmaceuticals International Inc, a publicly traded multinational company that specialises in dermatology, eye health, neurology and branded generics. Completed in early August, the cash transaction totalled $8.7bn, or about €6.4bn at current exchange rates. Cashing in on the brand cachet of its latest addition, Valeant will integrate its existing ophthalmology businesses into a newly established B+L division. With 2013 projected pro forma net revenue of more than $5.7bn, or about €4.19bn, the unit will nearly double Valeant’s annual sales, which totalled $1.5bn, or about €1.11bn, in the third quarter of 2013. That quarterly figure represents a 74 per cent increase from the same period in 2012. Organic sales growth accounted for four per cent of the increase in developed markets and 14 per cent in emerging markets. Reflecting Valeant’s aggressive acquisition strategy, revenues from newly acquired products contributed the rest, according to the firm’s financial filings. As with many acquisitions, Valeant hopes to increase its returns by reducing overhead at B+L, including a 10 per cent to 15 per cent reduction in staffing. Moves to achieve this include transferring B+L’s historic headquarters in Rochester, New York, to consolidated division offices in New Jersey.

Integrating distribution Valeant also hopes to halve B+L’s operating expenses, which reportedly reached 40 per cent in recent years, according to published accounts. This may be done by integrating distribution with other Valeant products and renegotiating distribution agreements. The firm also hopes to leverage B+L’s established presence in emerging markets, particularly the Far East, to promote its other products, including its oral care and aesthetic skincare and topical acne franchises, which have seen strong sales growth in recent quarters. So far, financiers have embraced Valeant’s growth and consolidation strategy. From announcement of the B+L acquisition in May

through early October, Valeant’s stock price jumped from about $75 to more than $110, continuing an upward trend dating from late 2008, when the price dipped below $10. Analysts have pegged the stock’s target price as high as $115 to $130 in recent weeks, following second quarter earnings of $1.30 per share, which beat the consensus estimate by $0.08. One thing the merger won’t alter is B+L’s historic focus on cutting-edge ophthalmic products, promises Calvin Roberts MD, Valeant’s chief medical officer for ophthalmology and eye health. “Valeant shares Bausch+Lomb’s commitment to providing exceptional service to customers and patients, and it is strongly committed to building a sustainable eye health business.” Valeant plans to rapidly expand B+L’s global presence with new or added products in several categories, Dr Roberts says. “These next few months will be exciting both for Bausch+Lomb and for doctors as we launch PureVision 2 for presbyopia contact lenses in Europe and Asia, and xpand Biotrue ONE Day contact lenses to Russia and France. In the Asia Pacific region, we recently launched Biotrue Multipurpose Solution in Taiwan, Naturelle contact lenses in Singapore, and Ocuvite 50+, PreserVision and PreserVision with Lutein in Australia.” Cataract and cataract refractive surgeons can look forward to advanced intraocular lenses from Valeant, according to Dr Roberts. “We continue to grow our IOL global business with enVista and enVista Toric, our PhysIOL line of IOLs, plus Trulign, our newest toric IOL.” Retinal surgeons around the world will soon have an integrated laser in Stellaris PC, along with new valved cannulas, he adds. Valeant is also committed to B+L’s pharmaceutical development programme, Dr Roberts says. “Building the pipeline, which already includes a novel glaucoma drug and a first in category antiinflammatory drug, is a high priority. In July, we acquired an option to secure an exclusive global license for an investigational compound currently in Phase 2 development for the treatment of dry eye syndrome.”

Don’t Miss Eye on Travel, see page 39 EUROTIMES | Volume 18/19 | Issue 12/1

The TRULIGN Toric intraocular lens

The dry eye compound, called MIMD3 and developed by Mimetogen, has the potential to be the first in a new class of agents called TrkA agonists. Currently available dry eye therapies work to increase tear production, but do not address tear quality. MIM-D3 stimulates the production of mucins, which are essential for ocular lubrication as well as removal of allergens, pathogens and debris, and corneal epithelial healing. MIM-D3 may also improve neural function, which may improve corneal sensitivity and integrity. A Phase 3 trial is slated for late this year. Valeant also will strengthen B+L’s close relationships with surgeons, Dr Roberts predicts. “We will continue to listen and value the input from our doctors as we continue to strive to improve eye health all over the world.”

Featuring multifocal lens technology, PureVision2 for Presbyopia contact lenses are designed to deliver clear, crisp vision


37

Feature

Book REVIEW

Authors: Dr Kenneth Fong Choong Sian & Goo Chui Hoong PUBLISHED BY Star Publications If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

12-13 September 2014

Corn

Abstract submission deadline: 1 March 2014

a

a

EUROTIMES | Volume 18/19 | Issue 12/1

PUBLICATION Food for Your Eyes

LONDON e

Dietary alternatives Against that background, this book provides dietary alternatives to the AREDS supplements in a bid to include many of the same beneficial vitamins, minerals, carotenoids and omega3 fatty acids. But tables and lists are bland and difficult to incorporate into daily life.

BOOKS EDITOR Leigh Spielberg

5th EuCornea Congress

Eu

C o r n

e

Food for Your Eyes opens with a question that ophthalmologists frequently hear from their patients: “Doctor, is there anything I should eat or avoid to maintain or improve my eyesight?” We usually answer something like, “Eat as healthily as possible and your eyes will get everything they need.” Of course, what we should say is, “I don’t really know.” The authors of this book try to change that. Dr Sian, a UK-trained ophthalmologist currently living and working in Malaysia, wrote this book with his wife, Goo Chui Hoong, who is a professional dietician. Published by Star Publications, this book “aims to educate the public about the prevention of age-related macular degeneration through diet.” However, given the scope of the book, it may be useful for all health professionals who look after the eye. In addition to covering AMD, the book looks at the role of diet and dry eye and meibomian gland dysfunction, cataract, diabetic retinopathy, floaters, glaucoma, myopia, retinal detachment and strabismus. The answers here are clear: with the exception of a healthy diet for diabetics, no evidence (yet) exists to link what we eat with our eyes. “There is no supplement or diet that you can take to remove cataracts,” the authors note. Similarly, “there is no clear evidence that supplements are helpful for glaucoma.” In fact, very little information exists linking particular diets, nutrients or supplements to ocular disease. The Age-Related Eye Disease Study (AREDS), a landmark trial completed in 2006, looked at the effect of nutrient supplementation in preventing AMD and delaying its progression in more than 4,000 patients. AREDS found that patients at high risk of developing wet AMD benefitted from taking various supplements. However, the authors caution that some of the high-dose nutrients in the AREDS formulation might have adverse effects, especially for elderly patients with concomitant medications and co-morbidities.

The authors realise that patients want their medical advice packaged into simple, colorful, easy-to-digest bytes. Thus, this book gently flows into a concise, beautifully photographed set of recipes, each of which is packed with the nutrients our patients “should” be ingesting. The recipes reflect the fact that Food for Your Eyes is written for both an Eastern and a Western audience. This introduces an international flavour, which manages to seem both familiar and exotic at the same time. For Western readers, “homemade granola” is quite obvious. “Vietnamese spring roll” is recognisable enough. “Nai pak choi cooked with taro and dried prawns” will require some adventurous shopping, while “cucur jagung” would require a moment or two on Google Translate if the book weren’t bilingual – in English & Chinese. The recipes are short and sweet and do not seem to require extensive cooking experience or expensive equipment. And the expert photographs make it all seem so lusciously delectable that the reader is motivated not only to prepare the meals, but also to keep seeing clearly enough to enjoy the pictures. “While this book has been written with AMD patients and their caregivers, and the prevention of AMD, in mind, it would also serve the public as a healthy-eating book,” the authors tell us. The book would make a nice gift to an ophthalmologist and patients with AMD.

Eu

Taste and see

European Society of Cornea and Ocular Surface Disease Specialists

www.eucornea.org


Physicians Program (subject to change)

Faculty Brock K. Bakewell, MD John D. Banja, PhD Clara C. Chan, MD Robert J. Cionni, MD Nick Mamalis, MD Nancey McCann Brendan J. Moriarty, FRCS, FRCOphth, MD Robert H. Osher, MD E. Ann Rose, MD Thomas W. Samuelson, MD Steven R. Sarkisian Jr, MD Kerry D. Solomon, MD Doyle Stulting Jr, MD, PhD Elizabeth Yeu, MD …More to come

Program Topics

EL CONQUISTADOR a Waldorf Astoria Property

The Premier Innovative Educational Retreat for Anterior Segment Surgeons and Administrators

REGISTER BY MONDAY, JANUARY 13 FOR EARLY BIRD SAVINGS www.WinterUpdate.org

• Cataract: Challenging Cases & Complications Management • Ethics Interactive • Glaucoma • Interactive Cornea • Legislative Update • Medicare Update • Patients with Retinal Disease • Rapid F-Eye-R: You Make the Call • Refractive Surgery • Top Pearls • Video Presentations Highlight • What’s New in Technology

Program Chairs Edward J. Holland, MD Stephen S. Lane, MD Roger F. Steinert, MD

Program Planning Committee David F. Chang, MD Eric D. Donnenfeld, MD Richard A. Lewis, MD Keith A. Warren, MD


Feature

EYE ON TRAVEL

EXPLORING SLOVENIA

Delegates attending the Winter ESCRS meeting have the opportunity to enjoy four unique travel experiences, each only an hour’s drive from Ljubljana by Maryalicia Post

famous "yard", the mansion and Velbanca, the oldest stable in Lipica. The tour takes about 50 minutes and includes a visit to the Lipicum, a fascinating interactive museum. Experienced riders who meet certain criteria can pre-book a trail ride. For tour times at the stud or to book a trail ride, visit the website: http://www.lipica.org/

Time stands still In a ‘deserted’ castle

Explore a cave Some 10,000 caves are listed on the official register in Slovenia. Two of the most spectacular – Postojna and Skocjan – are open to visitors. Don't leave Slovenia without seeing one... but which one? Postojna is the most popular (and the most commercialised). An open electric train transports you through the first two and last three kilometres of underground caverns. In between there's a steep up and down one kilometre walk which begins in the incredible five-storey high cavern that, when used as a concert hall, holds 10,000 people. The tour takes about an hour and a half. (See website http://www.postojnska-jama.eu) The Skocjan caves receive only one fifth as many visitors as Postojna although they contain the largest underground cavern in Europe. They are a UNESCO heritage site and are explored on foot. It's three kilometres of demanding walking after you cover the 500 metres downhill to the cave mouth. I visited the Skocjan caves in February. It was zero degrees celsius and there were treacherous patches of black ice on the steep road down to the cave mouth. At the entrance a sign warns people with heart problems not to enter. That may be because, in addition to the 3km walk you read about, there are 580 steps you don't read about. The cave is lit in sections... on my visit an attendant ran ahead switching on the lights for the next stretch as we, two Italians and EUROTIMES | Volume 18/19 | Issue 12/1

two English-speaking tourists, clustered around the guide at the occasional halts. The cave temperature is a constant 12 degrees and humid. The stops give you a chance to catch your breath, contemplate the surreal underworld scenery and see what lies ahead... the narrow pathway clinging to the cave wall and, eventually, the fragilelooking Cerkvenik Bridge spanning the cavern. Crossing this bridge, suspended 50 metres above the thundering Reka River, is an unforgettable experience. Once outside the cave, a climb with dramatic views leads to a funicular which hauls you up the last bit of the uphill journey. Skocjan cave visits in February are at 10 and 13:00 MondaySaturday with an additional tour at 15:00 on Sundays.The visit lasts about 90 minutes. No photography is allowed in the cave. See website: http://www.park-skocjanske-jame.si

Visit the lipizzaners Because the climate and soil of Lipica is similar to that of Spain, this is where the Hapsburg Archduke Charles established the royal stud farm in 1581. He planned to propagate the Spanish horse, considered at the time the ideal breed. In 1583, 24 broodmares and six stallions were brought over from Spain to Lipica; the famous white horses got their name from the town. Over four centuries later, despite the vicissitudes of two world wars, the stud farm flourishes. Visitors can walk through the

Tour a deserted castle Castle Sneznic, the only surviving, fully-furnished castle in Slovenia, was home to a succession of German nobles until 1832, when it was won in a lottery by a Hungarian blacksmith. The castle was eventually purchased by Prince Oton Vktor Schoenburg-Waldenburg whose son, the last resident, died in 1943. During WWII, the castle caretaker guarded the estate, repelling looters; as a consequence, the interior furnishing of the Schoenburgs survive intact. In 2008, after a complete restoration, the castle reopened to the public. A tour takes you through four floors of rooms frozen in time as they were on the day they were 'abandoned'. To visit, join a castle tour (cca. 40 min).Tour times in winter (October 1 - March 31) every day, except Mondays, from 10.00 to 16.00 on the hour; last admission at 16.00. http://www.nms.si/ A former dairy building on the estate houses the Dormouse Hunting Museum (April-October). Dormouse night, in late September, is open season on dormice, prized for the pot and for their fur. Row across a glacier lake Lake Bled is beautiful and the most visited tourist attraction in Slovenia. The Assumption of Mary Pilgrimage Church rises in the centre of the lake on the site of a former pagan temple. Nine hundred steps lead to the chapel; grooms carry their brides up to the church to be wed. Row yourself over to the island or be ferried in a Pletna, the traditional flat-bottomed boat. Visitors are invited to ring the church bell and make a wish. Bled Castle, high on a rock on the lake shore, contains a museum, forge, printing press and a wine cellar where you can try your hand at bottling wine. Open 08:00 to 18:00. For a spectacular experience, particularly in winter, drift over the area in a hot air balloon.http://freeweb.siol.net Directions to these destinations are on the relevant websites or arrange a tour through Roundabout, www.travel-slovenia.com

Reka river tumbling out of the Skocjan cave

Castle Sneznic in the snow

39


40

Feature

industry news

Recent developments in the vision care industry

Automated cutting process

One-step cannula system

Gebauer Medizintechnik has rolled out the Doc Assistant which enables users to experience a hands-free cutting process. “The Gebauer SLc Doc Assistant eliminates the possibility of any complications caused by irregular hand movements that may occur during the cutting process from a downward pressure or rotational pressure on the donated cornea,” said a company spokeswoman. “The Doc Assistant is connected to the Artificial Anterior Chamber (AAC) and serves as a solid base for the Gebauer SLc Handpiece during the pass. This new safeguard feature ensures a precise and repeatable result on every pass, and makes the process truly user independent,” said the spokeswoman.

DORC has introduced its one-step MVR Cannula System for 23, 25 and 27 Gauge. “The revolutionary new MVR blade will reduce the insertion pressure needed with more than 50 per cent less,” said a company spokeswoman. “By lowering the insertion pressure the wound closure will improve. Furthermore DORC integrated in the MVR Cannula System new translucent closure valves for enhanced visibility when entering instruments,” said the spokeswoman.

n www.gebauermedical.com

n www.DORC.eu

New phaco device

Optical coherence tomography NIDEK has released the upgraded unit of optical coherence tomography, RS-3000 Advance, with new features including 12 x 9mm wide area scan, tracing HD plus, torsion eye tracer and multi-functional follow-up. “The 12mm wide horizontal scan allows detailed observation of the vitreous body, retina and choroid from the macula to optic disc in a single image,” said a company spokesman. “The tracing HD plus function traces involuntary eye movements to maintain the same scan location on the SLO image for accurate image capture. The torsion eye tracer corrects ocular cyclotorsion and fundus tilt, and ensures accurate image capture. The multifunctional follow-up allows assessment of change over time combined with other examination results,” he said. n www.nidek.com

EUROTIMES | Volume 18/19 | Issue 12/1

Oertli launched the CataRhex 3 phaco device at the XXXI Congress of the ESCRS in Amsterdam, The Netherlands. "Weighing as little as 5kg and fitting in any pilot case, CataRhex 3® can be mounted on any IV pole with a click – it is thus the epitome of portable equipment," said a company spokeswoman. "A device that takes up so little space and is so easy to handle is becoming increasingly attractive in both outpatient and high-volume clinics," she said. "Efficiency and safety start with ease of operation. Displays and tactile keys are visible at a glance, all connections can be operated from the front, with the ergonomic multi-function pedal immediately responding to any foot movement. CataRhex 3 is a power pack with cutting-edge technology," said the spokeswoman. n www.oertli-catarhex3.com

Wide angle viewing system OCULUS has developed a single-use wide angle viewing system. The company launched the OCULUS BIOM ready at the 2013 AAO Congress in New Orleans. “The BIOM ready provides the retinal surgeon the same unparalleled view that they have come to expect from the OCULUS BIOM brand,” said a spokeswoman. “It combines the perfect balance between flexibility and high optical quality, meeting the demands of both the retinal surgeon and the operating room staff. The new BIOM ready is adaptable to most ophthalmic microscopes,” said the spokeswoman. n www.oculus.de

Exclusive partnership SCHWIND eye-tech-solutions, Germany, has announced an exclusive partnership with ALPHAEON Corporation, US. SCHWIND has granted ALPHAEON the exclusive license to market SCHWIND AMARIS technology in the US. As part of the relationship, ALPHAEON will oversee and finance the US Food and Drug Administration (FDA) clinical trial required to market the product in the US. ALPHAEON, a wholly-owned subsidiary of Strathspey Crown Holdings LLC, closely cooperates with American eye surgeons to bring highly developed technologies to the US market. SCHWIND chief executive officer Rolf Schwind (pictured) said: “This cooperation is a historical milestone in the SCHWIND company history and for us, as a medium-sized family company, the best possible strategy to establish our cutting-edge technology in North America without entrepreneurial risks. We strongly believe that our partnership with ALPHAEON will build customer confidence and significantly impact the growth of patient procedures.” n www.eye-tech-solutions.com


Feature

Eye on history

FORGOTTEN GIANT

Slovenian inventor, Anton Banko, was behind the success story of phacoemulsification that started with Charles Kelman by Marko Hawlina, Eye Hospital, University Medical Centre, Ljubljana, Slovenia

A

nton Banko was born in a Slovenian family in Istria on 26 August 1927. He studied engineering and electronics in Ljubljana and later moved to the US where he worked in the field of ultrasound instruments for dental use with the Cavitron company as director of research and development. Charles Kelman turned to him with a request to construct an ultrasound device for cataract removal and their first joint US patent No.3589363 was filed on 25 July 1967. The patent described an instrument designed for "breaking apart and removal of unwanted material", especially cataracts, using a handheld tip operating in the "ultrasonic range with an amplitude controllable up to several thousandths of an inch". Their pioneering work was described in Charles Kelman's book, Through My Eyes: The Story of a Surgeon Who Dared to Take on the Medical World. (New York: Crown Publishers, 1985).

Closed vitrectomy In 1968, Anton Banko established his own company in New York, Surgical Design, committed solely to innovation in the design and development of ophthalmic instruments. The company soon started to produce and market a series of very reliable and successful phaco machines that are still used worldwide. He followed up his invention for cataract surgery by not only inventing instruments for phacoemulsification but also patenting

Anton Banko

the first surgical procedure for closed vitrectomy (Apparatus for Performing Surgical Procedures On the Eye. U.S. Patent No. 3,528,425; filed on September 16,1968 and patented September 15, 1970). The vitreoretinal surgical work was performed with Charles L Schepens, MD, the founder of the Retina Foundation of Boston and is described in his book, quoting Banko's primacy before Robert Machemer. Extensive courses were given by the Retina Foundation of Boston and Surgical Design to surgeons throughout the world, teaching them the

techniques of vitreoretinal surgery. These courses were also attended by Richard Mackool and Buol Heslin with whom, in 1980, Anton Banko presented the first combined computerised instrument for phacoemulsification and vitrectomy named 'Mackool/Heslin Ocusystem', one of the most successful surgical consoles of its time. As Richard Mackool described in his paper: Closed Vitrectomy and Intraocular Implant, (Ophthalmology 88:414-424, 1981): "Closed vitrectomy instrumentation that permits simultaneous cutting, aspiration, and replacement of the vitreous was first developed in 1968 by Banko, but was not reported in the ophthalmic literature until 1971 by Machemer." Sadly, soon after the success of his company, Anton Banko died of an incurable disease. Slavi Banko, his widow, recalls: “Anton Banko was always very healthy and a dynamic person. In April 1986 he felt for the first time that he gets tired quickly. 16 of April he went to the hospital and he died of severe autoimmune disease in four weeks despite all medical efforts. He died on 16 May 1986 at the age of 58. This was a tragedy for the family with two young children.” After the death of Anton Banko, his company was led by his son William. William Banko received his MD in 1987. Dr Banko also holds several patents on surgical and medical instrumentation. He has co-authored 20 publications in ophthalmic and general surgery and co-edited a book entitled Phacoemulsification Surgery,

From the Archive Microincision phaco safe for hard cataracts

W

ith the right technology, even the hardest of cataracts is no obstacle to safe and effective removal using bimanual microincision phacoemulsification, according to Richard Packard MD. "My own odyssey with microincision surgery has included various iterations of technique and instrumentation, but

EUROTIMES | Volume 18/19 | Issue 12/1

along the way I certainly have been able to do all cataracts, and I have found that mature cataract surgery can be performed as safely using microincision surgical techniques as it can with conventional phaco, he told a session of the XXI Congress of the ESCRS. The essentials for carrying out microincision surgery on very hard

cataracts include an ultra-sound system offering excellent fluidics combined with micropulse technology, as well as the appropriate instrumentation. n From EuroTimes, Volume 8, Issue 11,

November 2003

Friderik Pregl

F

riderik (Fritz) Pregl (1869–1930), biochemist and ophthalmologist, was awarded the 1923 Nobel Prize in chemistry for developing techniques in the microanalysis of organic compounds. Pregl is the only Nobel prize winner of Slovenian origin. He was born in Ljubljana (at that time a town in the Austro-Hungarian empire, now the capital of Slovenia) and attended the local grammar school before studying medicine at the University of Graz. After becoming a medical doctor he established a practice in ophthalmology, but was also appointed as a lecturer in histology and physiology at Graz University. He chose analytical chemistry and did not pursue a career in ophthalmology. He was awarded the Nobel Prize for novel techniques in the study of microchemistry, particularly reducing the size of samples for experimentation that paved the way for modern biochemistry.

Pergamon Press, (now McGraw Hill), 1991. Altogether, Surgical Design holds more than 40 patents for the instruments used in their surgical consoles which are still produced today. Anton Banko’s wish to donate one of the machines to the University Eye Hospital in Ljubljana was conveyed by his family. Due to his legacy, surgeons from Slovenia started to use phacoemulsification as early as 1989 after training in the wetlab of Surgical Design company. Anton Banko remains one of the (largely forgotten) giants of instrumentation in ocular surgery with Slovenian origins.

41


43

Review

JCRS HIGHLIGHTS

Journal of Cataract and Refractive Surgery

IOL calculation Optimal calculation of intraocular lens (IOL) power in patients who have undergone myopic refractive surgery is an ongoing challenge. Problems include inaccurate measurement of the anterior corneal curvature by automated and manual keratometry or computerised videokeratography, inaccurate value of the keratometric index resulting from the modified relationship between the anterior and posterior corneal surface and incorrect estimation of the effective lens position resulting from these modifications. Korean researchers compare the results of IOL power calculation methods using different keratometry values after myopic refractive surgery. They calculated IOL power of 53 patients who had cataract surgery after refractive surgery using the SRK/T formula with true net power (TNP) and the equivalent K using the Pentacam Scheimpflug system. They calculated the simulated K, 2.0mm zone of total mean power (TMP 2.0mm) maps, and 4.0mm zone of total optical power (TOP 4.0mm) maps using the Orbscan II scanningslit topographer and keratometer of the IOLMaster partial coherence interferometer. They also calculated IOL power using the Haigis-L method with the corneal radius using the PCI system. The PCI axial length was used with all methods. The prediction error and absolute prediction error measured with the Haigis-L, TNP, TMP 2.0mm, and TOP 4.0mm were lower than the equivalent K, simulated K and PCI K. The percentages of correct refraction predictions within ±0.50 D, ±1.00 D and ±2.00 D in the Haigis-L method were the highest of all methods. The Haigis-L using corneal radius with the PCI measurement was the most predictable method for IOL calculation after corneal refractive laser surgery in patients without a clinical history. n E

Kim et al., JCRS, “Intraocular lens prediction accuracy after corneal refractive surgery using K values from 3 devices”, Volume 39, No. 11, 1640-1646.

were phacoemulsification. Complications occurred in six of 244 cases in which phacoemulsification was performed by a beginner resident primary surgeon and in seven of 172 cases in which ECCE was used (P=.40). Posterior chamber IOLs were placed in all but two phacoemulsification cases and four ECCE cases (P=.24). Three cases in the phacoemulsification group and one case in the ECCE group required a reoperation within 90 days (P=.65). The researchers conclude that phacoemulsification cataract extraction can be taught effectively to residents with no cataract surgery experience as a primary surgeon.

EYE CHAT Exclusive interviews Up to date information Problem solving

n LA

Meeks et al., JCRS, “Outcomes of manual extra capsular versus phacoemulsification cataract extraction by beginner resident surgeons”, Landen et al Volume 39, No. 11, 1698 -1701

Wet lab vs. simulator Investigators compared the operating room performance of ophthalmology residents trained by traditional wet-lab versus surgical simulation on the continuous curvilinear capsulorhexis portion of cataract surgery. The prospective randomised study compared 10 residents trained in the wet lab and 11 on the simulator. There was no significant difference in overall scores of initial surgery performance between the two groups. There was no significant difference in any individual score except time, with the wet-lab group being slightly faster than simulator group (P=.038). The time to pass the simulator curriculum was predictive of the time and overall performance in the OR. n MK

Daly et al., JCRS, “Efficacy of surgical simulator training versus traditional wet-lab training on operating room performance of ophthalmology residents during capsulorhexis in cataract surgery”, Volume 39, No. 11, 1734-1741.

The Dua Layer Dr Oliver Findl talks with Professor Harminder Dua about how he discovered a hitherto undescribed layer of the cornea anterior to Descemet’s membrane.

Beginning surgeons ECCE or phaco, which technique should residents learn first? Some argue that ECCE be given before phacoemulsification experience to establish the fundamental skills of ophthalmic surgery. Others argue that ECCE is best taught to more experienced residents and used only when necessary to optimise patients' visual outcomes and recovery. US researchers compared data collected for cases performed over a sixyear period during which initially the first primary surgeon cases were ECCE and later, the first primary surgeon cases EUROTIMES | Volume 18/19 | Issue 12/1

Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

podcast

www.eurotimes.org

Also available on iTunes

Scan this QR code to gain access to EuroTimes podcasts


44

Reference

CALENDAR OF EVENTs

Dates for your Diary

2014

JANUARY

5th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery 8-10 January Vienna, Austria www.ophthalmictrainings.com

FEBRUARY 12th International Ocular Inflammation Society Congress 27 February – 1 March Valencia, Spain http://ioisvalencia.org/

MARCH

4th EURETINA Winter Meeting 25 January Rome, Italy www.euretina.org

FEBRUARY 18th ESCRS Winter Meeting 14-16 February Ljubljana, Slovenia www.escrs.org

28th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 20-23 February Athens, Greece http://www.hsioirs.org/index.php/en/

Frankfurt Retina Meeting 2014 15-16 March Frankfurt, Germany www.eckardt-frankfurt.de

The 5th World Congress on Controversies in Ophthalmology (COPHy) 20-23 March Lisbon, Portugal http://www.comtecmed.com/cophy

APRIL NEW ENTRY XIII International Congress of Cataract and Refractive Surgery 2-5 April Rio de Janeiro, Brazil http://www.cataratarefrativa2014.com.br/

APRIL World Ophthalmology Congress

ESCRS Glaucoma Day

NEW ENTRY International Symposium on Cornea: Clinical Approach

WSPOS Paediatric Sub Speciality Day

2-6 April Tokyo, Japan www.woc2014.org

11 April Belgrade, Serbia www.cornea-belgrade2014.org

ASCRS•ASOA Symposium and Congress 25-29 April Boston, USA www.ascrs.org

Excellent session rate and hours/sessions to suit

MAY NEW ENTRY ARVO

4–8 May Orlando, Florida, USA www.arvo.org

JUNE 7-11 June Nice, France http://www.eugs.org/eng/default.asp

AUGUST

The Practice, the largest independent provider of community based ophthalmology services to the NHS, has recently experienced significant growth as a result of our being awarded a number of NHS contracts. Consequently we are seeking to recruit Ophthalmologists at Consultant, Associate Specialist and Staff Grade level to deliver a mixture of clinical leadership and/or clinical care. From £250 to £350 per 4 hour session. Various national locations from Salford through to the Midlands, Home Counties and The South Coast. Please contact John (07595 200787) or Nick (07581 471916), to discuss your individual needs.

www.thepracticeplc.com

12 September London, UK www.escrs.org

12 September London, UK www.wspos.org

5th EuCornea Congress 12-13 September London, UK www.eucornea.org

XXXII Congress of the ESCRS

11th EGS Congress

Sessional Ophthalmic Clinicians

SEPTEMBER

Nordic Congress of Ophthalmology (NOK 2014) 20-23 August Stockholm, Sweden http://www.nok2014.se/Default.aspx

SEPTEMBER 14th EURETINA Congress

13-17 September London, UK www.escrs.org

NEW ENTRY 2nd Asia-Pacific Glaucoma Congress 10th International Symposium of Ophthalmology 26-28 September Hong Kong http://www.apgc-isohk-2014.org/

OCTOBER NEW ENTRY AAO Annual Meeting 18-21 October Chicago, Illinois, USA www.aao.org

NOVEMBER NEW ENTRY 27th APACRS Annual Meeting 13-16 November Jaipur, India www.apacrs2014.org

11-14 September London, UK www.euretina.org

Advertising Directory: ASCRS/Eyeworld: Pages: 34, 38, 42; Croma-Pharma GmbH: Page: 13; DOC: Page: 28; D.O.R.C. International BV: Page: 9; ESASO: Page: 29; Frankfurt Retina Meeting: Page: 24; International Symposium on Cornea: Page: 8; Nidek: Page: 25; Novartis: Pages: 5, 27; Oculus Optikgerate GmbH: Page: 7; Oertli Instruments AG: Page: IFC; The Practice: Page: 44; VSY Biotechnology: Page: 11; Ziemer Ophthalmic Systems: Page: 31

If you would like to see your classified ad here, please contact Mairin Condon: mairin.condon@escrs.org.


E

E R IP FR EA SH ES 3 Y BER INE A EM R M RT FO

ESCRS


13-17 September

2014

London XXXII Congress of the ESCRS

Free paper, poster and video abstracts submission deadline:

15 March 2014

www.escrs.org

Vol. 18 - Issue 12 / Vol. 19 - Issue 1  

A European Outlook on the World of Ophthalmology

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