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ESCRS convenes 14th ESCRS Winter Meeting in Budapest

Editorial February

Medical Editors

Zsolt Biro MD, PhD José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins


Bekir Aslan


Bill Aylward Peter Barry



Roberto Bellucci


Hiroko Bissen-Miyajima John Chang


Joseph Colin


Alaa El Danasoury Oliver Findl



I Howard Fine Jack Holladay


Vikentia Katsanevaki Thomas Kohnen



Anastasios Konstas Dennis Lam



Boris Malyugin


Marguerite McDonald Cyres Mehta Gisbert Richard Robert Stegmann



Thomas Neuhann

Ulf Stenevi





Emrullah Tasindi


Marie-Jose Tassignon Manfred Tetz



Carlo Enrico Traverso Roberto Zaldivar



Guest Editorial

Hungarian ophthalmologists welcome ESCRS Winter Meeting to Budapest In February 2010, for the first time in its history, the ESCRS will hold its Winter Meeting in Budapest, Hungary, together with the Hungarian Society of Cataract and Refractive Surgeons (SHIOL). On behalf of the local organisers and the Board of the SHIOL, I would like to welcome friends and colleagues from Europe and around the world. The Hungarian Ophthalmological Society is more than 100 years old and the SHIOL celebrated its 20th birthday in 2008. It is a great honour for all Hungarian ophthalmologists to host the 14th ESCRS Winter Meeting in our capital, Budapest. Hungarian ophthalmology can be proud of the achievements of some of its internationally acclaimed members. Just to mention a few of them, we may remember Janos Fabini, who already in 1840 performed extracapsular cataract surgeries in 70 per cent of his cases, and in 1823 wrote the university textbook in Latin on ophthalmology “Doctrina de Morbus Oculorum”, which was later translated into Hungarian, German and Dutch. Vilmos Schulek at the end of the 19th century was dealing with “protective spectacles against ultraviolet radiation” and for his achievements he was awarded the Great Gold Medal at the Paris World Exhibition in 1900. Jozsef Imre became famous worldwide because of the “arched plasty” of the eyelids named after him (also called “Hungarian plasty”). He excelled in keratoplasty and plastic surgery and it was his opinion that: “Plastic operations can be placed somewhere between surgical knowledge and art”. We are also proud of the Hungarian Ophthalmological Society, founded in 1904, which is one of the oldest European opthalmological societies. Szemészet, the official journal of Hungarian ophthalmology was established in 1864. As my very good friend, the president of ESCRS Jose Güell has written: “Budapest, as a venue, is a direct result of the society’s strategy to engage more directly with ophthalmologists in the new independent states in eastern Europe”. The 14th Winter Congress of the ESCRS has an exciting programme, including Main Symposia on Keratoconus, Imaging, Complications of Cataract Surgery and Secondary IOL Implantation. The Cornea Day will discuss Penetrating and Lamellar Keratoplasty and Ocular Surface Reconstruction. There will be several courses such as the

Basic Optic Course, Cataract and Refractive Surgery Didactic Courses, Cornea Didactic Course and Surgical Skills Training Course. The Free Papers and Posters will focus on Cataract and Cornea, Refractive and Visual Optics and Quality of Vision, and there will be a session for Cornea Case Presentations. A prize of €1000 is awarded to the best Cataract and Refractive Poster Presentations of the Congress. I hope the Live Surgery, which is sponsored by Alcon and Bausch & Lomb, will be very successful and will attract a lot of people. Live Surgery will be transmitted from the newly renovated 100-year-old Ophthalmology Department of the Semmelweis University at Maria Street. The venue of the congress is the elegant Corinthia Hotel, in the very centre of the city. Budapest is a beautiful city, lying on both sides of the river Danube, in the centre of Hungary and in the centre of Europe as well. It is easy to access by plane, train, and on road as well. I hope those who are visiting the city for the first time will enjoy its charm; the historic buildings, the picturesque panorama of the illuminated bridges by night, and the castle on the Buda side and the Houses of Parliament on the Pest side. Those who already have visited the city will enjoy again the Hungarian hospitality, the cultural heritage of Budapest, which has many museums, theatres, the opera and the Hungarian Ballet to offer unforgettable hours. Beside the “Chain Bridge” which was opened in 1870 and is one of the landmarks of Budapest, there are several other bridges connecting Buda and Pest to make the unique, wonderful capital of Hungary. I do hope that as the bridges connect the different parts of the city, the Winter ESCRS Meeting in February 2010 will connect people from eastern and western Europe, including young participants and residents attending the congress. On behalf of all Hungarian ophthalmologists I wish all of you a very warm welcome and a successful and memorable congress. Welcome to Budapest! Zsolt Biro is professor of ophthalmology and head of the Department of Ophthalmology, Medical University of Pécs, Hungary, and president of the Hungarian Society of Cataract and Refractive Surgeons (SHIOL).

LETTER TO THE EDITOR Dear editor, We read with surprise an article in EuroTimes entitled: Nurse-performed YAG laser capsulotomy etc…(Volume 14 Issue 11 November 2009, page 12). We think the idea of having nurses or other non-ophthalmologists and, even worse, non-MDs performing such a delicate procedure is not only utter nonsense, but also highly dangerous, not only for our patient but also for our profession, its status, and its place in the medical specialties. YAG laser is a procedure implying many potential risks: corneal damage, iris damage, damage to the implant, damage to the retina, etc. It demands from the practitioner not only a

perfect knowledge of the ocular anatomy and pathology, but also a special education in laser technology. (I remember a case of macular destruction by a defective YAG laser device.) And what happens in cases where there are complications? Who will be held responsible: the nurse, the supervising ophthalmologist (if there is one)? And why not let nurses perform other procedures with laser (iridotomy, trabeculoplasty, panphotocoagulation, PRK, etc.). Where will this stop? The paper says “benefits, but controversy”. We don’t see any benefit at all, except making ophthalmologic care “cheap”, in all possible meanings

of the word. Of course the politicians will love that. In addition, we do not see any ground for controversy: this is illegal practice of medicine and as such should be (and is) strictly outlawed and forbidden. Period. We are disappointed that EuroTimes offers space for such nonsense. EuroTimes should not take a neutral position on such a crucial subject, but an unequivocal stand in the defence of ophthalmologists and their profession. Dr René Trau MD, FEBO, Board Member and in the name of the BSCRS. 



Cataract Update 8 IOL subluxation after phacoemulsification is increasing 10 Preventing postoperative endophthalmitis


12 Refractive Lens

Refractive Lens 12 High degree of patient satisfaction with new-generation lenses 13 Restoring accommodation in the presbyopic eye may happen in near future


13 Refractive Lens

Refractive Laser 14 Advantages of using mechanical microkeratome include reduced price 15 Complications with femtosecond lasers are highlighted


18 Cornea

Cornea Update 18 New DALK procedure can reduce some complications More Contents 2




32 Features

> >

31 Features

34 Features





Published by The European Society of Cataract and Refractive Surgeons

Editorial Staff Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn

Glaucoma Update 19 The significance of blood pressure in development of glaucoma

Managing Editor Caroline Brick Production Editor Angela Sweetman Senior Designer Paddy Dunne

Retina Update

Assistant Designer Janice Robb Circulation Manager Angela Morrissey

20 Expert discusses the evolution of AMD

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

ESCRS News 21 Interest among surgeons increasing for EUREQUO 22 Looking ahead to the ESCRS and EURETINA meetings in September

Ocular Update

Contributors Devon Schuyler Eisele Nick Lane Stefanie Petrou-Binder Maryalicia Post Seamus Sweeney Gearóid Tuohy Colour and Print Times Printers

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ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100

23 EBOD exam 2010

Fax: 353 1 209 1112




26 Practice Development

6 Newsmaker Interview

28 Out & About

29 Industry News

30 Outlook on Industry

32 Journal Watch

31 In Your Good Books

33 JCRS Highlights

34 Eye on History

36 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.

As certified by ABC, the EuroTimes average net circulation for the 12 issues distributed between 01 January 2008 and 31 December 2008 is 28,144

35 EU Matters

With this issue... 4

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.

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Newsmaker Interview

ESCRS president José Güell will continue to build on the society’s educational initiatives José Güell

José Güell MD, PhD, assumes the role of president of the European Society of Cataract and Refractive Surgeons (ESCRS), after the active and successful term of Paul Rosen. Dr Güell is the director of Cornea and Refractive Surgery Unit, Institute of Ocular Microsurgery, Barcelona, Spain. He served as secretary of the ESCRS from 2004 to 2008, and is a member of the Editorial Board of the Journal of Cataract and Refractive Surgery, and co-editor of the Consultation Section. EuroTimes Editor Sean Henahan spoke with Dr Guell about his goals as incoming president. Q: What is your impression of the ESCRS today and what do you hope to accomplish during your presidency? A: In recent years the ESCRS has definitely become a primary source of education in Europe and even in other parts of the world in the fields of cataract and corneal refractive surgery. We have seen great success with our annual meetings, summer and winter, as well as in print and online. Our meetings offer excellent educational opportunities through our courses, symposia, lectures and related activities. Our web presence in particular has improved in recent years and is an incredible education tool. Members can access meeting information, read EuroTimes, and access incredible resources through ESCRS On Demand. EuroTimes provides a way to easily keep in touch with our membership, both in print and on the Internet. Without doubt my goal will be to continue this emphasis, which has shown great progress under Paul Rosen, Ioannis Pallikaris and my other predecessors. In the past 10 years the influence of the ESCRS has spread beyond Europe, and we are having a global influence. For example, we are attracting an increasing number of attendees from outside Europe. I think this is because we have been quite industry independent from the academic point of view. The academic level of our meetings is at the highest level in the areas of cataract and corneal refractive surgery. Another part of the story is that it may be more interesting for some people to come to some place like Paris than Dallas. Attendance has grown steadily over the past 15 years. Q: What initiatives are under way at the ESCRS? A: The organisation is exploring other ideas to expand our educational capabilities throughout Europe. For 6

example, we want to use our resources to show members where they can do short minifellowships, or for doctors, wherever they might be based, where to go to learn specific skills. We are also exploring new collaborations, such as our cooperation with ESASO, the School of Advanced Studies in Ophthalmology in Lugano, Switzerland. This will allow us ESCRS President José Güell at the opening ceremony of the 13th ESCRS Winter Meeting in Rome last year to offer longer training courses, something not possible with our summer and winter meetings. The European Registry of Quality Outcomes for Cataract and Refractive Surgery certification process that could be used (EUREQUO) also has fantastic potential throughout Europe. What we can do in this regard. EUREQUO is designed to is suggest guidelines, but the ESCRS facilitate the collection and analysis of cannot give titles, this can only be done cataract and refractive surgical outcomes through universities, which are vastly with the aim to develop evidencedifferent from one country to the next. based European quality guidelines. The Nonetheless, attendance and training at ESCRS is the lead partner along with our ESCRS events can help surgeons in the National Ophthalmology Societies many areas of their practice. across Europe, with funding assistance from the European Union. With active Q: How well is the ESCRS doing at reaching participation from doctors from around out to young ophthalmologists? Europe this will offer us a way to work together almost as if we were in the A: I think our young ophthalmologist same country. programme at the annual meeting is very good. We offer a full day of basic Q: One interesting debate going on now and advanced lectures. There is room is whether there should be a European for improvement; this is one of my qualification or certificate to perform LASIK goals. I would like to encourage the and other forms of refractive surgery. younger ophthalmologists to participate in the coordination and planning of this A: We have been working on this programme. idea for several years. Today, it is still

“I am personally very interested in seeing the ESCRS take a leadership role among ophthalmology societies to focus in one way or another on poverty in the world, using all of our resources”

impossible. There are major differences between the various national health systems throughout Europe. However, it is possible that we might be able to create some sort of certification for surgical residents. Beyond that it would be very difficult to create a

Q: How has the global economic crisis affected the ESCRS? A: The crisis has had many effects in many areas of practice. We’ve seen this in industry involvement and investment in our meetings. I think the crisis may make

Mini biography: Dr José L Güell was born on 1960. He is an associate professor of ophthalmology at the Autonoma University of Barcelona since 1991 and at Lugano University since 2009. He studied medicine and surgery at the Central University of Barcelona (1977-84). His Doctorate Degree about “LASIK, laser-assisted in situ Ketatomileusis” was presented “Cum Laude”. He performed his residency in Barcelona at the Autonoma University (1986-1989) at the Vall d’Hebró Unit. He did a clinical fellowship in Cornea and Refractive Surgery with Dr George Waring at Emory University, Atlanta (1989). He has been involved in refractive and corneal surgery since 1989 and in laser corneal surgery since 1993. LASIK and Iris Claw phakic IOLs have been his procedures of choice for the correction of myopia and astigmatism since October 1993, and Intracorneal Ring Segments, anterior and posterior lamellar corneal transplant surgery and ocular surface management including amniotic membrane and keratoprosthesis, his main activities since 1996. He was awarded the 2008 Rayner Medal at the annual meeting of the UKISCRS: United Kingdom and Ireland Society of Cataract and Refractive Surgeons and with the Senior Achievement Awards ISRS/AAO Presidential Awards, San Francisco 2009. it difficult for some doctors to attend our meetings, although attendance has not dropped off. It may be that our Practice Development programme can help our members to not only develop their practices, but to cope with the current economic problems. Q: What do you want to bring to the presidency on a personal level? A: I am personally very interested in seeing the ESCRS take a leadership role among ophthalmology societies to focus in one way or another on poverty in the world, using all of our resources. I am not just talking about groups doing cataract surgery in needy areas. I am talking about hunger and poverty. I’d like to look at ways to include lifespan in the developing world, so first we need to feed people so they can live long enough to get cataracts! I would like to work with the WHO and other groups, not just raising money, but raising awareness and sensibility of these issues. 

EyeWorld will be offering numerous opportunities to supplement your education while at the 2010 ASCRS Symposium and Congress using a variety of educational platforms—

mark your calendars now!

Save the Date! Expanded Program! EyeWorld Educational Activities to be held at World Cornea Congress VI and the ASCRS•ASOA Symposium & Congress

To register, please visit Please check often for updates.


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Cataract Update

Phacoemulsification may increase incidence of IOL subluxation Ulf Stenevi

Samuel Masket

Roibeard O’hEineachain in Barcelona

THE near universal adoption of


phacoemulsification for cataract procedures has resulted in an increased rate of IOL subluxation in Sweden, said Ulf Stenevi MD, Sahlgrenska University

Hospital, Mölndal, Sweden. “We are seeing an increase in the number of patients needing a second surgery. We hadn’t seen these before. We have a pretty good idea of which patients are at risk and the question we need to answer is: is phacoemulsification the better surgery for all eyes for all cataracts for all surgeons all the time?” said Dr Stenevi at a symposium on the management of subluxated IOLs at the XXVII Congress of the ESCRS. He noted that in the western region of Sweden, which has a population of 1.5 million, the number of patients requiring repositioning and suturing of their IOLs has increased over five-fold since the general adoption of phacoemulsification in Sweden around the year 2000. That is, while in the year 2000 IOL subluxations occurred in only 11 out of 57,000 patients with IOLs, there were 30 IOL subluxations among 92,000 patients in 2005. If the frequency of the complication had remained stable between those two time points there would have only been 18 subluxations in 2005, Dr Stenevi pointed out. Analysis of the patients’ records showed that the interval between surgery and the subluxations was generally around five years, strongly implicating the use of phacoemulsification as a contributing factor. Other surgical practices introduced around the same time include intraocular injection of antibiotics anaesthetics and steroids. The effect of such injections on the ciliary zonule remains unknown, Dr Stenevi said. Other risk factors identified included pseudoexfoliation or other concomitant eye disease, which was present in over half of patients with subluxated IOLs. In addition 35 per cent of patients had pre-existing glaucoma and 25 per cent had undergone previous surgery. Moreover, the patients had a high rate of complications during their surgery, including zonular dehiscence, capsular rupture and postoperative IOP

higher than 25.0 mmHg. Fortunately, the re-positioning and suturing procedures appear to have a good outcome in general with little effect on the cornea, visual acuity or IOP. The main complications have been recurrent haemorrhages and an occasional retinal detachment. Surgical options The main surgical options following IOL subluxation are either replacement or repositioning of the lens with either scleral or iris fixation. The best technique to use depends on the type of lens involved and the condition of the eye, said Samuel Masket MD the Jules Stein Eye Institute, UCLA Center for Health Sciences. Both iris and the scleral fixation have their respective advantages and disadvantages, Dr Masket said. Iris fixation avoids blind passage of needles through the vascularised ciliary body and obviates any need for conjunctival dissection. However, iris fixation is inappropriate in cases where trauma from surgery or other causes has destroyed iris tissue, and also in cases that have had total vitrectomies where such an approach may result in an unacceptable amount of irido-pseudophacodonesis “Scleral fixation is not dependent on adequate iris tissue and any IOL can be fixated to the sclera. It is a very physically stable form of fixation; it is also ideal for patients that have capsule tension rings and capsule tension segments. The negative is that we pass sharp needles through vascularised tissue in which the vessels are not visible,” Dr Masket noted. The most commonly employed scleral fixation technique initially was partial thickness scleral flap in which the sutures are tied to themselves under the flap. The full thickness lasso technique is the current standard approach for scleral fixation. A different, recently introduced technique is the reverse scleral pocket technique developed by Richard Hoffman MD. The surgery has the advantage of not requiring dissection of the conjunctiva, making it especially useful in patients who have had prior surgery for glaucoma or retinal indications. Another intriguing approach is the use of glue instead of sutures, as suggested by Amar Agarwal MD, Dr Masket continued. The technique involves externalising the haptic through the scleral flap and burying the haptic into a groove and then gluing the flap closed. However, no long-term data on that technique has been published yet, he added.

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Cataract Update

Intracameral antibiotics reduce incidence of endophthalmitis Peter Barry

Steve Arshinoff

Dermot McGrath in Barcelona

THE use of intracameral cefuroxime not only reduces the incidence of postoperative endophthalmitis in cataract surgery but also seems to partially protect the visual outcome in affected patients, Peter Barry FRCS told delegates attending the XXVII Congress of the ESCRS. Presenting the microbiology results of the ESCRS study on the use of intracameral cefuroxime in the prevention of postoperative endophthalmitis, Dr Barry said that the data also showed that patients with streptococcal infections had strikingly worse visual outcomes and showed an earlier onset of disease than those with staphylococcal infections. “While there are limitations in terms of the statistical significance of the data, I would suggest that the take-home message is that intracameral cefuroxime reduced endophthalmitis by a rate of five over the control group, prevented blindness from endophthalmitis, and eliminated streptococcal endophthalmitis with its catastrophic sequelae in the 8,000 patients who received cefuroxime in the study,” he said. The landmark ESCRS study of 13,698 cataract surgery patients at 24 sites throughout Europe found that intracameral injection of 1.0mg of cefuroxime yielded an almost five-fold reduction in the rate of postoperative endophthalmitis compared with patient groups that did not receive the antibiotic. Dr Barry emphasised that the study design meant that the visual acuity data could not be subjected to rigorous statistical analysis. “In the study, the end point of the randomisation process was the occurrence of endophthalmitis. Once the diagnosis was made, the subsequent treatment was at the discretion of the treating surgeon so there was no standard treatment protocol. Therefore, the postoperative visual acuities were not measured on any particular time frame and because the treatments varied the statistical analysis is necessarily limited. However, the data is still worth looking at and reinforces the overall findings on the benefits of using intracameral cefuroxime as a prophylactic measure in cataract surgery,” he said. Of the 29 cases of endophthalmitis in the ESCRS study, 20 were proven and nine were unproven, said Dr Barry. “The definition of proven was that any suspect case had to have an anterior chamber and vitreous chamber tap and was considered proven endophthalmitis if there was either a positive Gram stain, a positive culture or polymerase chain reaction,” he said. Looking at the breakdown of the 20 proven cases of endophthalmitis, the responsible organisms were identified as 10

“The study demonstrates that intracameral cefuroxime, vancomycin and moxifloxacin were all individually significantly more effective at preventing postoperative endophthalmitis than no intracameral antibiotics, or antibiotics added to the infusion bottle” Steve Arshinoff MD, FRCSC staphylococcal infections in 11 patients, streptococcal infections in eight patients, and propionibacterium acnes in one patient. Dr Barry noted that although the postoperative visual acuities were not statistically tested, there was a striking difference in visual outcomes between cases of streptococcal and staphylococcal infections, with the outcomes being far worse in streptococcal cases. The final visual acuity range in staphylococcal infections was between 20/20 and 20/80, with no patient being legally blind, which was defined as 20/200 or worse. Three of those cases had received an intracameral cefuroxime injection. Conversely, the final visual acuity range in the eight streptococcal infections was between 20/20 and no light perception. Five of these patients were legally blind, all due to streptococci, and none of the five had received intracameral cefuroxime. All eight cases with streptococcal infection were in the groups that did not receive intracameral cefuroxime. Dr Barry added that comparison of the signs and symptoms in cases of proven and unproven postoperative endophthalmitis in the ESCRS study showed that swollen lids, pain, and opaque vitreous were statistically associated with the proven cases. Putting the results in context, he noted that to date intracameral cefuroxime remains the only prophylactic intervention proven to reduce rates of endophthalmitis after cataract surgery. “Although fourth-generation fluoroquinolones have been promoted as a potential substitute for intracameral cefuroxime, recent reports describing steadily increasing resistance of endophthalmitis isolates to fourth-generation fluoroquinolones ring a cautionary note,” he said. The positive impact of intracameral cefuroxime prophylaxis in cataract surgery was further highlighted by a separate retrospective study of over 26,000 surgeries carried out at the University Hospital Clinic of Lozano Blesa in Zaragoza, Spain. “We wanted to evaluate the incidence of endophthalmitis after cataract surgery and assess possible risk factors such as the type of anaesthesia, location of incision, use of intracameral cefuroxime, type of IOL, system

pathology, intraoperative complications and use of sutures,” said Zsuzsanna Valyi MD. Of 26,571 surgeries carried out from 1993 to 2008, the study found 93 eyes (0.35 per cent) with postoperative endophthalmitis, with a mean patient age of 74 years and a mean onset of the pathology of 12 days. Patients were treated with intravitreal antibiotics, vancomycin and ceftazidime in 69 cases and pars plana vitrectomy in 24 cases. The presenting visual acuity of the patients was less than 5/200 in 77 cases (83 per cent) and hypopion was present in 82 per cent of the cases. The microbiological samples were positive in 65 per cent of the cases, with staphylococcal infection responsible for 41 cases (67 per cent), staphylococcus aureus in 10 per cent, and streptococcus infection in eight cases (13 per cent). Researchers found that the type of anaesthesia, the location of the incision, the use of sutures, the type of IOLs and the existence of a systemic disease did not seem to be significant risk factors for developing endophthalmitis. However, there was a strong association between complications during surgery and the incidence of endophthalmitis, with posterior capsular rupture being the most common intraoperative complication reported. “After the introduction of intracameral cefuroxime into the surgical protocol there was only one case of postoperative endophthalmitis,” said Dr Valyi. “The final visual acuity was 20/40 in 47 per cent of patients and the worst outcomes were in the streptococcal affected patients. So we concluded that the introduction of intracameral cefuroxime led to a clear reduction in the incidence of endophthalmitis and also that the type of organism responsible has a direct bearing on the final visual acuity of the patients,” she said. While intracameral cefuroxime has proven its safety and efficacy in reducing the rates of endophthalmitis in cataract surgery, the ESCRS study has not demonstrated which is the most effective intracameral antibiotic. The fourth-generation drug moxifloxacin may represent an even more effective intracameral drug in preventing endophthalmitis, according to Steve Arshinoff MD, FRCSC. “My personal experience of over 3,000

cataract surgeries was included in the International Society of Bilateral Cataract Surgeons (iSBCS) Endophthalmitis Study, which to date includes over 91,000 eyes The study demonstrates that Intracameral cefuroxime, vancomycin and moxifloxacin were all individually significantly more effective at preventing postoperative endophthalmitis than no intracameral antibiotics, or antibiotics added to the infusion bottle. When iSBCS surgeons were subsequently asked to include their unilateral surgeries as well, a total of 74,450 eyes received intracameral antibiotics. The infection rate in the enlarged group with intracameral cefuroxime was 1/9,885, whereas it was zero of 25,025 eyes in the aggregated moxifloxacin and vancomycin groups, suggesting that intracameral moxifloxacin or vancomycin are probably more effective to reduce endophthalmitis than cefuroxime (p=0.06). In terms of pathogens covered, risk of allergy, mechanism of action and ease of preparation, moxifloxacin scores higher than any other intracameral drug currently available,” he said. Unlike time-dependent drugs such as cefazolin, vancomycin and cefuroxime, moxifloxacin is concentration-dependent and is more effective at killing bacteria in the eye when sufficient concentration levels are attained, despite residence times of only one to two hours at cidal levels (for any drug), said Dr Arshinoff. Another advantage of moxifloxacin is the fact that it is preservative-free and is well tolerated by the ocular tissues. “It has been shown to be gentle to endothelial cells and it has no detrimental effect on macular thickness as measured by OCT. In over 3,000 cases, I have not seen a single instance of postoperative fibrin formation or severe inflammation in the anterior chamber on the first postoperative day,” he said. Dr Arshinoff said the iSBCS is continuing to collect cases, and once the numbers are high enough to show definite significance of one drug over the others, the study will be published.

Don’t Miss Outlook on Industry Page 30

surgical outcomes

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EUREQUO European Registry of Quality Outcomes for Cataract & Refractive Surgery

What is EUREQUO?

by monitoring your results

Join the network

EUREQUO is a European Quality Registry for visual outcomes of cataract and refractive surgery

Quality registries create a sufficient basis for studying rare diseases, treatments and complications

The project aims to:


Improve treatment and standards of care for cataract and refractive surgery


Develop evidence-based guidelines for cataract and refractive surgery across Europe


Make significant impact on the exchange of best practice between practitioners in relation to patient safety

EUREQUO European Registry of Quality Outcomes for Cataract & Refractive Surgery

EUREQUO gives a unique opportunity to monitor and compare results

Collecting data will support you to make an audit report

The collection of your data will facilitate the analysis of surgical outcomes and the development of evidencebased European Quality Guidelines

The European Registry of Quality Outcomes in Cataract and Refractive Surgery Do not miss this opportunity to become part of the future. If auditing results and registering performance is not mandatory in your practice and your country it soon will be! Take this opportunity to learn how to prepare for it and come and see the benefits to be gained by you.

14th ESCRS Winter Meeting

This project, jointly funded by the European Union and the ESCRS aspires to register every cataract and refractive procedure performed in the 16 participating countries.

Free Paper Session: Refractive

EUREQUO aims to build up a network to facilitate the exchange of best practices, by making comprehensive data available for comparison of visual outcomes.

Corinthia Hotel, Budapest, Hungary Friday 12 February Time: 10.24 – 10.30 Venue: Room 2

M. Lundström SWEDEN Benchmarking and clinical improvement using EUREQUO output data

By demonstrating the results of your surgery you can market your business, win contracts and provide truly informed consent. From university departments to solo practitioners the benefits are there so come and see what is available to you!

Free Paper Session: Cataract 1

See for more information

Saturday 13 February

M. Lundström SWEDEN, L. Brocato IRELAND Time: 09.42 – 09.48 Venue: Grand Ballroom

Progress report from the EUREQUO project

Funded by

Refractive Lens

High rates of spectacle independence with newer accommodating IOLs Mayank Nanavaty

Sheraz Daya

Roibeard O’hEineachain in Barcelona




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Figure 1

“The data indicates the newer generation Crystalenses provide good distance, intermediate and near vision with a high degree of patient satisfaction” Mayank Nanavaty DO, MRCOphth, MRCSEd

The patients in the study had a mean age of 66 years, ranging from 56 to 88 years. Their mean spherical equivalent was -9.4 D. The indications for lens removal were either cataract or refractive lens exchange. All of the surgeries were performed by Sheraz Daya MD FRCS, Centre for Sight, East Grinstead, West Sussex, UK. Dr Daya removed the patients’ lenses through a 1.8mm clear corneal incision using a coaxial microincision cataract surgery technique with the Stellaris™ phacoemulsification system (Bausch & Lomb). He then implanted the Crystalens HD or Crystalens Five-O IOLs through an enlarged, 2.6mm incision. Dr Daya based the power of the lenses implanted on IOLMaster measurements of the axial length and keratometry, using the Holladay II formula. He adjusted the target refraction of the non-dominant eye for monovision with a spherical error of -0.25 D to -0.75 D. Approximately half of the non-dominant eyes had a target refraction of -0.5 D. Dr Nanavaty noted that there were no intraoperative or postoperative complications.

Good results for distance, intermediate and near vision At six months’ follow up, the mean monocular uncorrected distance vision was 20/27, and 78 per cent of patients achieved 20/30 or better, 88 per cent achieved 20/40 or better and around 38 per cent were 20/20 or better. In addition, uncorrected binocular distance vision was 20/40 in all eyes and 20/20 or better in 55 per cent of eyes (Figure 1). Mean postoperative manifest refraction at six months was -0.37 D. In addition, uncorrected monocular intermediate vision was 20/40 or better in 92 per cent of eyes, 20/25 or better in 69 per cent and 20/20 or better in 46 per cent. Binocularly, uncorrected intermediate VA was 20/40 or better in 98 per cent and 49 per cent had 20/20 or better binocularly (Figure 2). There was marked difference between monocular and binocular near vision results. Binocular uncorrected near vision was 20/40 or better in 95 per cent of patients and 20/20 or better in 49 per cent. However, monocular uncorrected near visual acuity was 20/40 or better in only 83 per cent and was 20/20 or better in only 15 per cent (Figure 3). Crystalens implantation also produced good results in a sub-group of five patients who had undergone prior corneal refractive surgery. The patients’ mean age

Figure 2

Courtesy of Mayank Nanavaty DO, MRCOphth, MRCSEd

THE newest version of the Crystalens® (Bausch & Lomb) can enable patients to achieve good near and intermediate vision through a combination of physiological accommodation, pseudo accommodation and monovision, said Mayank Nanavaty DO, MRCOphth, MRCSEd, Centre for Sight, East Grinstead UK. Since its introduction by Stuart Cummings MD a decade ago, the Crystalens has progressed from the original Crystalens AT-45 to the Crystalens 5-0 and the Crystalens HD, with features to improve its centration, optics and mechanical reliability, Dr Nanavaty told the XXVII Congress of the ESCRS. He noted that the haptics of the 5-0 and HD models of the accommodating lens have 30 per cent greater surface area of contact with the capsule’s perimeter, and a 90 per cent greater arc length. The newer models also have a 5.0mm optic, compared to the 4.5mm optic of the original AT-45 model. In addition, the optic of the newest lens, the Crystalens HD, also has a central 1.0mm zone with increased elevation of 3.0 microns to 5.0 microns to provide a pseudoaccommodative effect without reducing distance vision or contrast sensitivity, he said. In a single-surgeon chart-review study involving 139 eyes of 70 patients who underwent implantation with the Crystalens 5-0 or Crystalens HD IOL, 72 per cent reported total spectacle independence at a follow-up of six months with binocular uncorrected vision equivalent to that needed to read newsprint and drive, he said.

Figure 3

was 63 years (range 57-70). Their previous refractive procedures included LASIK in four cases, and radial keratotomy in one case, all carried out between the years 1989 and 2005. At one month’s follow-up the spherical equivalent had a mean value of -0.5 D and ranged from -1.25 D to 0.00 D. The postoperative cylinder had a mean value of -1.10 D, and ranged from -2.0 D to -0.50 D, and 60 per cent of eyes were within 0.25 D of target refractive outcome. In addition, uncorrected distance visual acuity 20/40 or better in all patients, and 60 per cent achieved 20/30 or better. Moreover, 80 per cent of patients achieved an uncorrected near visual acuity of J5 or better and 60 per cent were J3 or better. “The data indicates the newer generation Crystalenses provide good distance, intermediate and near vision with a high degree of patient satisfaction,” Dr Nanavaty concluded.

Gary Finnegan in Leeds

A DEEPER appreciation of the age-related changes in accommodative anatomy is the key to turning back time on presbyopia, according to Adrian Glasser PhD, University of Houston. Lens stiffness increases with age while the ciliary muscle can still function, even in patients who have lost accommodation capacity, he said, adding that this has been poorly understood in the past. Dr Glasser, who delivered the Pearce Medal lecture at the UKISCRS annual meeting in Leeds, said efforts to surgically restore accommodation in presbyopes have too often fallen short. He said the use of subjective measurements of accommodation had given the false impression that scleral expansion bands and some types of IOL can reverse presbyopia, but objective assessment revealed their effectiveness to be marginal. However, despite being frustrated by progress to date, Dr Glasser said he was optimistic that some of the innovative solutions currently in the pipeline could potentially solve the long-standing problems. “Although I believe that accommodation restoration concepts have thus far been disappointing, there are many different approaches being investigated, including some very interesting accommodative IOL ideas that are coming down the pipeline, and I believe that these may hold some tremendous hope for the future,” he said. Dr Glasser said there is a growing interest in the possibility that surgeons may soon be able to restore accommodation in the presbyopic eye. “This effort is not aimed at simply alleviating the symptoms of presbyopia but actually restoring dynamic accommodation to the eye,” he said. Dr Glasser stressed that the anatomical changes associated with presbyopia begin early in life but only become problematic in middle age. “The progression of presbyopia actually starts when we are young and ultimately culminates in a complete loss of accommodative ability. So the loss of accommodation is probably just a timepoint in a continuum of age-related changes that are occurring in the human lens,” he said. Dr Glasser described how his team measured the flexibility of lenses in young and old cadaveric eyes by using a mechanical stretching device. He showed that younger human lenses are capable of producing between 12 D and 16 D of accommodative change but that applying the same amount of mechanical strain to 60-year-old and older lenses fails to produce any change. “This is an indication that by 60 years of age the human lens has completely

Refractive Lens

Adrian Glasser

lost its ability to undergo accommodative changes,” he said. Dr Glasser cited studies by Heys et al, 2004 which show a massive increase in lens stiffness is the basis of presbyopia, with experimental data showing a four-fold increase in the mechanical stiffness in human lenses after 50 years of age. “What’s interesting is that this Optics of accommodation. The diagrams show the light rays from the object and how the light Dr Glasser’s co-author, Dr Dorothy Win-Hall, demonstrates the subjective progressive converges towards the retina to form an in-focus or an out-of-focus image. The images to the right measurement of accommodation as a near chart is moved slowly towards increase depict the shape of the lens in the eye either in the unaccommodated state (upper two) or in the the eyes until the near target can no longer be maintained in clear focus. in stiffness accommodated state (lower red image) The distance between the eyes and the near chart is then used to represent the subjectively measured accommodative amplitude. The subjective test continues overestimates the objectively measured accommodative amplitude beyond 50 years of age, said this is proven to be less reliable than objective techniques when measuring the age at objective measurements such as the Grandaccommodation. which accommodation is completely lost. Seiko autorefractor. There are also several types of A 19-year-old human lens has a stiffness “The Grand-Seiko gives an objective accommodative intraocular lenses currently measure of about 60 Pascals which is measurement of the true accommodative in development. These include single optic relatively uniform across the cortex and optical change that occurs in the eye. If lenses that can undergo a forward shift nucleus, whereas by 64 years of age you we compare the objectively measured to produce an accommodative refractive see a profound increase in stiffness ranging accommodative response with the change in the eye. from 5,000Pa up to about 20,000Pa in the subjective technique, we see that the “Certainly moving an optic forward in nucleus,” he said. subjective technique overestimates the the eye will produce an accommodative Dr Glasser said the age-related decline in optical change in the eye by about as much response. However, this is a relatively lens flexibility means that if accommodation as 2 D to 3 D.” inefficient process. A 1.0mm forward is to be restored to the eye, it is essential The disparity between subjective and movement would be required to produce that the ciliary muscle should still function. objective measurements has given a about 1 D of accommodation,” Dr Glasser Dr Glasser cited studies by Strenk, et al skewed picture of how effective some said. 1999 which used high resolution magnetic new techniques can be in restoring Other devices use a dual optic lens resonance imaging to show that in younger accommodation, according to Dr Glasser. system that produces an accommodative people, lens thickness increases during an He described a 50-year-old patient who had refractive response when the optics move effort to accommodate but by 60 years undergone scleral expansion band surgery apart. In this case, about 0.5mm increased of age, when people make an effort to and 19 months after the operation, had separation between these optics can accommodate, there is no change. Similarly, poor distance-corrected near visual acuities. produce about 3 D. This, according to Dr lens diameter decreases in young subjects Of greater significance was that subjective Glasser, is a somewhat more promising during accommodation but by 60, there is measurements suggested the patient might system. no change to lens diameter with an effort to have had good accommodation. He also highlighted other techniques that accommodate. “However, when we did objective involve refilling the capsule with a polymer “One can also measure the distance measures of accommodation, we found that or creating accommodative lenses that truly across the eye to the ciliary processes – the the stimulus response functions for both undergo a change in optical power by virtue ciliary ring diameter. But in all individuals, eyes were essentially flat. The individual had of an increase in surface curvature. These the ciliary body moves when they make an no objectively measurable accommodation,” lenses are more efficient and could produce effort to accommodate, even though the Dr Glasser said. up to 7 D of accommodation, he said. lens thickness and diameter do not change,” His group subsequently tested several To date, the best-known single products Dr Glasser said. scleral expansion band patients and and techniques “have not been very compared them with presbyopic control encouraging”, said Dr Glasser, but he said Objective measurement subjects. Dr Glasser concluded that there were several other designs currently of accommodation scleral expansion band surgery does not at the early stages of clinical trials and these Measuring accommodation in the clinical restore accommodation to the presbyopic promised better outcomes in the future. setting is commonly done using the eye and urged colleagues to employ subjective push-up test, but Dr Glasser 13

Courtesy of Adrian Glasser PhD

Improved understanding of accommodative anatomy offers hope for presbyopes

Refractive Laser

Mechanical microkeratome delivers predictable flaps and smooth stromal beds Osama Ibrahim

Dermot McGrath in Manama

USING a mechanical microkeratome offers surgeons a safe and efficient means of flap


creation in LASIK procedures and produces residual stromal beds of excellent smoothness and quality, according to Osama Ibrahim MD. “The One Use-Plus SBK (Moria SA) is

simple, easy to use, safe and effective. The flaps created by this microkeratome are predictable and consistent in terms of thickness, shape and size and produce high-quality stromal beds,” he told delegates attending the 10th Middle East and African Council of Ophthalmology Congress in Manama, Bahrain. Dr Ibrahim, professor of ophthalmology at Alexandria University, Egypt, said that the flaps created by the One Use-Plus are around 100-micron thickness on average and do not weaken the biomechanical properties of the cornea. “This microkeratome results in preservation of the larger corneal nerves. There is also less incidence of postoperative dry eye, reduced loss of corneal sensitivity, greater flap thickness predictability, faster visual recovery and fewer complications,” he said. Other advantages of thin-flap LASIK include better quality of vision as a result of fewer flapinduced higher order aberrations, better contrast sensitivity, less glare and haloes, and a thicker stromal bed, said Dr Ibrahim. “This means we can widen the indications somewhat to treat more patients with thinner corneas and higher levels of myopia. It is also easier to perform enhancements if required for these patients,” he added. Dr Ibrahim told EuroTimes that his preferred safety margin is to leave 280 µm of unablated stroma after laser treatment. “In order to achieve this, we measure thickness before and after the One Use-Plus flap and make sure the remaining stroma is at least 280 µm plus the estimated laser ablation depth. We have no cut-off point in terms of visual acuity – we only promise bestspectacle corrected visual acuity, even if it is not 20/20,” he said. This type of thin-flap treatment is particularly suitable for a patient with a visual acuity between -6 D to -8 D and a pachymetry of 480µm to 520µm who may be unsuitable for treatment with other microkeratomes, said Dr Ibrahim. Describing the properties of the microkeratome, Dr Ibrahim explained that the One UsePlus SBK is a fully automated microkeratome with two independent motors, one for blade oscillation at 15,000 rpm and one for blade advancement with

a faster or slower forward speed. The heads and plastic rings are single patient-use, reducing sterilisation requirements and routine wear and tear. Dr Ibrahim’s study included 151 eyes of 83 patients: 19 eyes of 11 patients were treated with the single-use plastic suction rings and the rest with the metal reusable ring. In all cases, the nomograms provided by the manufacturer were used to determine the correct ring size and stop setting according to the corneal curvature and type of ring. A new microkeratome head was used for each eye. The central corneal thickness was measured immediately before and after the microkeratome pass using an ultrasound pachymeter, and the central flap thickness was calculated using the subtractive method. After flap creation, the hinge width and flap diameters were measured. Subjective assessments of the quality of the flap bed and edge were made and the rate of intraoperative and postoperative complications were reported. Biomechanical properties with the ORA device (Reitcher, USA) were also measured at one month postoperatively in 50 eyes to assess the biomechanical response of the cornea. With reusable rings, the average flap thickness was between 73 and 135 µm, with a standard deviation between 8 and 14 µm. The flap diameters with reusable rings were at least 0.5mm larger than with the single-use plastic rings. The flap thickness overall averaged 108 µm (±11µm, ranging from 77 to 123 µm). The changes in biomechanical properties were minimal, with a difference of -18.65 per cent in corneal hysteresis readings after one month. In all cases, there was notable smoothness of the stromal beds and the flaps were of a good quality. There were no complications: no buttonholes, no defective flaps, no uncompleted flaps, no abrasions, no cases of diffuse lamellar keratitis and no infection. While Dr Ibrahim also uses both IntraLase and Visumax femtosecond laser technology for flap creation, he believes that it is important to be able to offer his patients a safe and effective alternative to the femtosecond device. “We usually start by offering femto-LASIK as state-of-the-art technology to our patients. However, if pricing is an issue – which happens in many cases – we assure the patients that we can have almost the same accuracy and predictability by using the One Use-Plus microkeratome and then let them make their choice.” Dr Ibrahim added that the cost of femtosecond LASIK in the Middle East region is almost double the price of standard LASIK, which is a strong factor in favour of the mechanical microkeratome. In order to properly assess the relative merits of both technologies, Dr Ibrahim said that he is conducting a study comparing the Visumax laser with the One Use-Plus SBK.

Gary Finnegan in Leeds

THE benefits of femtosecond lasers are well documented, but the euphoria may have led surgeons to overlook the complications that come with this groundbreaking technology, warns Wayne Crewe-Brown MD. Speaking at the refractive session of the United Kingdom and Ireland Society of Cataract and Refractive Surgeons (UKISCRS) Annual Meeting, Dr Crewe-Brown, of Kent in the UK, believes potential downsides arising from suction breaks and gas bubbles in the anterior chamber should be highlighted, particularly given the growing number of new femtosecond lasers coming to the market. “Femtosecond flaps are a relatively new innovation in refractive surgery and, like all innovations, one tends to be blinded by the advantages of the technology and forget about the fact that any surgical procedure must have complications,” he said.

“In some corneas, starting the pattern near the limbus can allow gas to collect circumferentially in the perilimbal area, reducing OBL” The precision and improved outcomes offered by blade-free flaps have proven to be a major boost to LASIK over the past decade, with patients benefiting from a reduction in human error and mechanical breakdown. Dr Crewe-Brown disputes none of this, but he notes that the intraoperative and postoperative complications must be acknowledged if risks are to be reduced. He presented a list of intraoperative events that can arise during femtosecond surgery, including opaque bubble layer (OBL), vertical gas breakthrough, horizontal gas breakthrough, thin flaps, decentred flaps and suction breaks. “OBL is essentially a collection of gas bubbles in the intralamellar spaces above and below the resection plane. They can hinder laser tracking systems, and can also obstruct or distort ultrasound measurements taken during intraoperative pachymetry,” Dr CreweBrown said. OBLs can be divided into two major categories. Early OBLs, otherwise known as ‘hard OBLs’, develop early and spread ahead of the raster pattern. Late OBLs appear as opaque patches in areas the raster pattern has already passed through. “This can interfere with the effectiveness of additional laser pulses and make flap lifting more difficult. The most important thing is that it can impede some excimer laser tracking

systems. It’s very important to recognise this and delay treatment for those patients until the OBL is absorbed spontaneously, something which usually happens within an hour or so,” according to Dr Crewe-Brown. He suggested a number of ways to avoid OBL, including making adjustments to the pocket depth, pocket width and pocket line, and changing the hinge angle to help optimise gas evacuations. Some surgeons have also found that lighter applanation reduces OBL and others have found that the problem can be minimised by modifying the raster energy and line separation. “In some corneas, starting the pattern near the limbus can allow gas to collect circumferentially in the perilimbal area, reducing OBL,” Dr Crewe-Brown added. Another potential complication with femtosecond flaps is vertical gas breakthrough (VGB). This can occur when the laser is programmed too thin – generally 100µm or less – and can also happen when there is a focal break or scar in the Bowman’s Layer. Thin flaps, which have similar causes and effects to VGB, can often lead to difficulty in lifting and this in turn can result in tearing. Dr Crewe-Brown recommends using the Eisner bubble pachymetry technique prior to lifting in order to verify a safe flap thickness. A somewhat less pressing issue is horizontal gas breakthrough (HGB) which can occur if the pocket is overly efficient and the gas is vented in quick bursts. “It’s not usually a serious problem but it can lead to irregular patterns on the stromal bed. Good docking techniques and appropriate raster and pocket settings decrease the likelihood of HGB occurring,” he said. According to Dr Crewe-Brown, surgeons can limit the risk of suction breaks – another complication associated with femtosecond lasers – by assuring “proper centration and suction” before docking. “Eliminate all X and Y movements of the gantry as soon as the cone is docked and avoid major hand movements when holding the Suction Ring Assembly. Continually monitor the applanated area after the Z down is completed and reassure the patient while the laser is firing to keep them calm and relaxed,” he told the Leeds meeting. Perhaps the worst intraoperative event that can occur with femtosecond flaps occurs when gas bubbles diffuse into the anterior chamber. “While this is by no means a complication, the bubbles can disrupt an excimer laser’s tracking system. It’s an absolute curse because they take a long time to absorb, sometimes several hours,” he said. Problems arising from decentred flaps can be avoided by pre-screening for patients with larger shifts in their angle kappa. Dr Crewe-Brown recommends marking the visual axis as a target for the suction ring and advised colleagues not to accept a loss in flap

Refractive Laser

Femtosecond laser complications are being overlooked amid enthusiasm for new technology diameter greater than half a millimetre. provides greater flap stability, and the new Postoperative events can also arise generation of IntraLase technology – which following femtosecond laser surgery, will become available more widely in the although most such complications are rare. future – has an inverted bevel-in side cut Inflammation or diffuse lamellar keratitis architecture that contributes even more (DLK) is characterised by the appearance stability,” he said. of a non-infectious inflammatory reaction in the interface, one to five days after LASIK. However, the occurrence of DLK has been dramatically reduced since the advent of very low energy femtosecond lasers. Other uncommon phenomena that can appear between the second and sixth postoperative Using this marker the surgeon week are impresses three dot-shaped photophobia landmarks at the 3, 6, & 9 and transient o'clock positions. The tips of marking light sensitivity pattern the prongs are flattened to syndrome prevent damage to the epithelium even if the patient (TLSS). Patients inadvertently moves. with TLSS present with K3-7908 Alignment Marker moderate to extreme light sensitivity, a good UCVA, and no slit To correctly position the lamp findings. gauge, the surgeon simply However, aligns the notches on they usually the inside edge of this respond well instrument with the dots to low-dose produced by the Henderson steroids despite Alignment Marker. photophobia K3-7904 Degree Gauge being a source of great frustration for patients. Finally, Dr Crewe-Brown Once the gauge is oriented, said that while the surgeon simply aligns the it is thought marks of this instrument with that the flap the desired degree lines on biomechanics the gauge. This produces two of femtosecond thin lines along the axis of lasers reduces astigmatism which can be the incidence used to correctly align the of striae and toric IOL. epithelial K3-7912 Toric IOL Marker ingrowth thanks to the circular Instruments designed by Bonnie Henderson, MD of Boston, Massachusetts “manhole cover-shape” of the flap, these 4 Stewart Court, Denville, NJ 07834 • USA problems could ☎ 973-989-1600 • still occur on occasion. “The bevelled edge angle

Henderson Instruments for toric IOLs

Mark the patient

Orient the gauge to the marks

Mark the axis of astigmatism


Cornea Update

New DALK technique is delivering promising early results Jorg Krumeich

Dermot McGrath in Barcelona

Courtesy of Hamed M Anwar MD, FRCS

A NEW technique which uses physiological saline solution instead of air to bare Descemet’s membrane in deep anterior lamellar keratoplasty (DALK) procedures shows promising early results, according to Jorg Krumeich MD. “Deep anterior lamellar keratoplasty is the most difficult operation of the anterior segment. An estimated 12 per cent to 30 per cent of these procedures result in perforations when air is used. Physically air is not the optimal means of separating tissue because of its distribution and the fact that it is difficult to control the amount of air needed for the big bubble,” he said. By contrast, Dr Krumeich, in private outpatient clinic in Bochum, Germany, said that using saline solution in what he calls the “water pillow technique” makes for a less invasive procedure, easier tissue separation and ultimately greater control of the surgery. Describing the approach in more detail, Dr Krumeich said that there are several distinct steps in the procedure. Using the values taken from Orbscan readings, Dr Krumeich performs an initial trephination of 8.0mm down to 90 per cent of the thinnest corneal value. The next step is the creation of a second entrance point inside the primary trephination, which allows for a clearly defined extension of the parenchymal blowup. The anterior stroma is then removed down to the base of the primary trephination. Once the water pillow has been formed, air is introduced into the anterior chamber via a paracentesis, allowing the folds in Descemet’s layer to become visible.

Figure 1: A - Cross section of keratoconic cornea with hydrops scarring; B - appearance after performing a near-Descemet dissection, (note the residual scarring in the underlying layer of stroma); C - appearance after placing the donor cornea over the recipient stromal bed

“The visualisation of these folds is an important guide for the surgeon and they usually become apparent once air is introduced into the chamber,” said Dr Krumeich. The water pillow is then enlarged and deepened by pushing saline through the remnant stroma before being incised with a special DALK cannula. Double-running antitorque sutures were used for fixation of the graft. The most frequently encountered complication of DALK is perforation of Descemet’s membrane, and the water-pillow technique allows surgeons to significantly reduce the risk of this particular complication, emphasised Dr Krumeich. “I think this procedure helps to avoid many of the perforations we are The latest ophthalmology news used to encountering in and views online from EuroTimes DALK procedures. We have experienced just four perforations out of Visit to read 87 cases performed thus the latest issue and access our far with equivalent visual complete range of online services outcomes comparable to those achieved with the conventional Big Bubble technique,” he said. ESCRS




DALK for posthydrops scarring DALK can be successfully employed in combination with a planned near Descemet’s dissection (PNDD) for patients with posthydrops corneal scarring,

Figure 2: Postoperative appearance at 12 months. Inset shows an underlying hole in Descemet’s membrane

according to Hamed M Anwar MD, FRCS, Magrabi Eye Hospital, Jeddah, Saudi Arabia. “Our clinical experience has shown that DALK-PNDD can be performed safely, reliably and reproducibly for post-hydrops scarring. There is no risk of endothelial rejection, as with penetrating keratoplasty (PKP) procedures, and another advantage is that we don’t need to be as stringent as usual about the quality of the donor materials,” he said. Dr Anwar said that the procedure is a reasonable alternative to PKP in selected patients at a higher risk of undergoing endothelial rejection, but that there is some trade-off involved in the final outcome. “The disadvantages of this approach act are that it has a slow learning curve, it is time consuming and the visual acuity is not as good as PKP due to the formation of a stromal optical interface,” he said. Dr Anwar explained that corneal hydrops is a possible complication of advanced keratoconus, a disease which is on the increase in the Middle East region. A fissure or split within Descemet’s membrane allows aqueous influx into the stroma and the cornea may become acutely swollen and opaque. “Over the passage of time, opacification and oedema of the corneal stroma decreases with a resulting full thickness scarring causing corneal flattening. This may or may not improve the vision of a patient with glasses or with rigid contact lenses,” said Dr Anwar. In those cases where the patient’s vision has not improved, management has traditionally been to perform a PKP, Dr Anwar said. “This has several advantages. There is no stromal interface and better vision but it carries a bigger risk of endothelial rejection

and the necessity for long-term steroid use.” Dr Anwar’s retrospective, noncomparative case series included 22 eyes of patients with corneal scarring secondary to corneal hydrops. Describing the surgical technique, Dr Anwar said that first a 300-micron superficial trephination is performed after which air is injected into the corneal stroma to make the superficial cornea opaque. This is followed by a superficial keratectomy performed centripetally, with the surgeon dissecting towards the centre. “We then fashion some small stromal pockets with a super blade and then we hydrate the cornea with BSS and inject air to aerate the stroma. A deep cut down to a pre-Descemet’s membrane level is then performed with a super blade and a lamellar dissection is extended in a ring-like fashion circumferentially using a pair of corneal scissors and a blunt corneal dissector. The central area of the cornea is then gently dissected with a Beaver blade and the central scar is then carefully sliced through. Descemet’s membrane is removed from the donor and the donor is then sutured into place,” he said. The mean spherical equivalent after 12 months’ follow-up was -3.25 D and the mean refractive cylinder was -3.42 D. Best spectacle-corrected visual acuity was 20/40 or better in 12 eyes (71 per cent) with a 77.2 per cent follow-up rate. Complications included six central microperforations, which were remedied by air tamponade. There were no cases of double anterior chamber formation and no conversions to PKP were necessary, he concluded.

By Howard Larkin in Boston

found it unclear whether the level of blood pressure is a risk factor for development or progression of open-angle glaucoma LOW ocular perfusion pressure, defined as in an individual patient. For example, the blood pressure minus intraocular pressure, is Blue Mountain Eye Study reported in 2004 associated with increased risk of open-angle showed a positive correlation between glaucoma, according to statements released blood pressure and open-angle glaucoma, this year by an international consensus panel. but the Barbados Eye Study reported However, its impact on individual patients in 2002 did not, Dr Araie pointed out. is uncertain, though some clues exist as to However, other evidence suggests that which patients might be more vulnerable lower blood pressure may be a risk factor to blood pressure-related glaucoma risk, for patients with abnormal blood flow said Makoto Araie MD, PhD, professor and autoregulation, he said. chairman of ophthalmology, University of The consensus panel did conclude that Tokyo Graduate School of Medicine, Japan, low ocular perfusion pressure is a risk and co-leader of the Global Glaucoma factor for primary open-angle glaucoma. Network blood flow consensus panel. Evidence supporting this statement includes Speaking at the World Glaucoma population-based studies in the US, West Congress, Dr Araie also reported that Indies and Italy involving a wide range of while drugs, both systemic and eye drops, racial and ethnic groups showing the risk have been shown to affect ocular blood of open-angle glaucoma is three to six flow, the impact of drug-induced blood times higher in subjects with low perfusion flow changes on glaucoma progression pressure. Nine-year results from the has not been adequately studied and Barbados Eye Study found a risk ratio of remains unclear. Convened last May in Ft nearly 3.0 for mean perfusion pressure Lauderdale, Florida, US, the blood flow below 40 mmHg, Dr Araie noted. consensus panel consisted of more than 100 The panel also found that ocular blood glaucoma experts from all over the world. flow parameters as measured by various It considered the evidence of the role of methods are also likely to be impaired in impaired ocular blood flow in glaucoma; open-angle glaucoma, particularly normal disease mechanisms leading to impaired tension glaucoma. Studies show lower ocular blood flow; the impact of drugs blood flow velocity and higher resistance and other modifiable factors; and the indexes in both the ophthalmic artery and relationship between glaucoma and the central retinal artery in POAG and NTG systemic vascular diseases. patients compared with normal controls. Reduction of ocular blood flow with age The role of blood pressure has been shown by various methods, which Population-based studies across different may partially explain increased glaucoma ethnic groups have consistently found a incidence with age. Optic nerve head blood positive correlation between systemic blood flow may also show nocturnal dipping in pressure and intraocular pressure, the normal-tension glaucoma patients, Dr • AP crystalens 250x90 4/03/09 Page 1 consensus panel concluded. But the panel 9:18 Araie added.

Vascular dysregulation as a risk factor The panel also determined that systemic vascular dysregulation may contribute to the pathogenesis of glaucoma, more likely in people with lower intraocular pressure. It is thought that vascular dysregulation may result in defective autoregulation of ocular blood flow and instable blood supplies to tissues associated with glaucoma, Dr Araie said. One mechanism that has been implicated is endothelial dysfunction associated with endothelin-1 and NO system abnormalities. One study showed blood flow in the forearm increased less in response to blocking endothelin in patients with normal-tension glaucoma than subjects without, suggesting that the abnormal systemic blood flow response may be related to reduced ocular perfusion. Normal-tension glaucoma patients also show lower flow-mediated vasodilation in response to NO produced by endothelial cells, also suggesting ocular blood flow restrictions may be related to systemic vascular regulation problems. Systemic factors also possibly related to unstable ocular blood flow include nocturnal blood pressure overdipping, sleep apnoea and migraine. Suspicious and glaucomatous disc changes have been shown to occur at a higher rate in patients with sleep apnoea than in normal controls. Other, less certain, systemic indicators of increased glaucoma risk may include the presence of atrial fibrillation, atherosclerosis, haemorheologic abnormalities or unusual ocular perfusion pressure changes related to body position, Dr Araie said. Certain drugs, even when formulated as eye drops, may have an impact on ocular blood flow and its regulation, the panel found. Studies in monkeys have shown that even low concentrations of topically instilled drugs can penetrate at pharmacologically active levels to

Glaucoma Update

Consensus panel examines clinical relevance of ocular blood flow in glaucoma

the ipsilateral retrobulbar space where they can affect vessels nourishing the ocular nerve head and choroid. Dr Araie noted that more than 400 journal articles have been published on the effects of various topical drugs on ocular blood flow as measured by various methods. Despite this, the impact of eye droprelated changes in ocular blood flow on the development and progression of glaucoma remain unknown. This may be because the effects of topical drugs, if any may be small; the studies of these drugs are relatively small-sized, and they focus on short-term effects. However, there is some evidence that carbonic anhydrase inhibitors may increase ocular blood flow and improve blood flow regulation beyond what would be expected from their intraocular pressure-reducing properties alone, he added. A variety of systemic drugs also have been shown to affect ocular blood flow, the panel found. These include CAIs, Ca2+ antagonists, ACE inhibitors, angiotensin receptor inhibitors, and phosphordiesterase-5 inhibitors, Dr Araie reported. But the impact of these agents is also unknown, as no large, randomised controlled studies have been conducted to determine the effects of ocular blood flow regulation on glaucoma development or progression. The panel also found the evidence linking systemic diseases, including diabetes and cardiovascular diseases, is inconclusive. Documents from the Global Consensus Meeting on Ocular Blood Flow and Glaucoma will be available on the WGA’s website and published as a hardcover book by Kugler Publications (Amsterdam, the Netherlands).

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Retina Update

AMD – a disease of the ageing RPE Arthur H Neufeld

Gearoid Tuohy PhD in Vienna

THE next challenge in age-related macular degeneration (AMD) research is to synthesise the vast body of pre-clinical and clinical research knowledge to improve and extend our understanding of the disease. Three main areas providing future therapeutic opportunities include genetics, drug delivery and a deeper understanding of the molecular and cellular biology underlying the pathophysiology of AMD. At this year’s Winter EURETINA Conference, Prof Arthur H Neufeld, of Northwestern University School of Medicine, Chicago addressed the third topic – understanding the molecular and cellular biology of AMD – and reported to attendees on the evolving picture of how AMD might occur. In considering the disease of AMD Prof Neufeld admitted that one question that had always bothered him is, “how can an individual be born with a genetic mutation for which the phenotype doesn’t show up for 60, 70 or 80 years?” For most of our evolutionary history, AMD was never a problem and, according to Prof Neufeld, it is increasingly evident that growing old is at the core of the matter. In Prof Neufeld’s own words the answer to his rhetorical question is remarkably simple – “being old is different than being young”. To convince the conference of this relatively simple thesis, Prof Neufeld presented data to show that three key events related to ageing are likely to affect the normal physiology of the retinal pigment epithelium (RPE). These changes included age-related damage to the mitochondria, age-related iron overload and an age-related increase in excretory activity. A review of some of the basic physiology of the retina shows that the RPE cells are phagocytic, “every morning they take a bite out of a photoreceptor cell, put it into a phagosome and digest the material which is then released from the cell and washed away by the blood vessels,” explained Prof Neufeld. The question that had exercised Prof Neufeld and his research group, directed by Dr Ai Ling Wang, for a number of years was, “what age-related changes in the RPE would make this process of normal physiology susceptible to AMD?” According to Prof Neufeld a broad range of experiments on mitochondrial DNA damage, iron overload and excretory activity now show that such events may be sufficient to create the substrate for AMD pathology. Mitochondrial damage Measurements of mitochondrial DNA (mtDNA) damage over the life span of an 20

animal show that such damage accumulates over time. Analysis of the eyes in an old mouse versus a young animal show that the drusen contains increased levels of markers for mtDNA damage. This new finding suggests that the increase in mtDNA damage adds additional work to an ageing retina and, when combined with other factors, a tipping point will be reached in older animals whereby the “system” begins to stutter. The iron factor One of these “other factors” is an agerelated iron overload in which the RPE of older animals becomes loaded up with iron that eventually creates functional consequences. Phagocytosis experiments performed by Prof Neufeld’s group in tissue culture experiments show cells loaded with iron have a markedly reduced level of phagocytosis. In iron-treated cells, iron overload decreases one of the key players in the phagosome – a protein known as FAK (focal adhesion kinase). Extending the findings to animals shows that older animals have less FAK and, less phosphorylated FAK. Consequently, given that FAK phosphorylation is required for internalisation of the phagosome, phagocytosis now runs into a serious problem in older animals. Release of waste products Knowing that the RPE cells, with time, accumulate high levels of “junk”, Prof Neufeld turned his attention to understanding how the cells get rid of such waste materials from the cell. It is well established that phagosomes come into the cell, lysosomes empty into the phagosome and form an endosome and the exosomes contained in the endosomes are released and washed away by the blood circulation. In fact you can find exosomes in abundance in the blood, urine and other waste materials of the body. They are ubiquitous tiny vesicles released from every cell, including RPE cells. The exosomes are involved in the release of intracellular proteins into extracellular space and these released intracellular proteins are also found in drusen, representing a significant link. Prof Neufeld and his research team looked at markers for this exosome activity, including CD63, LAMP2 and CD81. In tissue culture systems when the mtDNA of ARPE19 is damaged together with feeding them outer segments, large increases in several of the exosome markers have been observed. In essence, when the cells are under stress, exosome activity is increased. In vivo in humans with AMD and in older animals, the drusen is loaded with exosome markers and the exosome markers appear to be

clinging to Bruch’s membrane. Guilt by association was the minimum suspicion. It soon came as no surprise that looking at the proteomics of drusen and comparing the results with what is excreted by exosomes, there appeared to be an almost fingerprint match. In other words, exosomes may be a major source of the proteins found in drusen. When considered together it can be seen that there is a lot going on in the RPE cells: there is increased demand for phagocytosis of damaged mtDNA, there is impairment in the phagosome biology itself due to iron overload and there is increased excretory activity. In short, RPE cells in the ageing retina represent extremely busy places. Such an abundance of activity in old cells would obviously increase the stress to the point where such cells might seek help by calling in the cavalry and it is exactly such calls that were detected by the research group when they examined chemokine signalling.

“If you don’t have the correct CFH (complement factor H [allele]), if you don’t have the correct complement system, if you cannot control the activity of these cells, you will go on to develop AMD – everything before that is normal” CCL2 (chemokine [C-C motif] ligand 2) is a chemokine that recruits leukocytes to a “stressed” tissue and it appears to be up-regulated in older animals. Microarray analysis identified several other pathways that are up-regulated in the RPE cells, including complement cascades. This cry for help from the RPE is answered by leukocytes, which begin to invade the RPE in an effort to assist clearing up the growing accumulation of cellular debris. Microarray studies looking at young versus old animals have shown an increase in the activity of genes associated with the complement pathway in the old animals. Immuno-histological examination of the tissue of younger animals shows that complement is laid down in a thin line along Bruch’s membrane however, in the older animals the pattern is discontinuous and clumpy; ageing appears to associate “with a rearrangement of how complement is being laid down on Bruch’s membrane,” according to Prof Neufeld.

As mice don’t have a macula or drusen, interpretation can be difficult. However, despite the absence of a macula and human drusen in the mouse model, Prof Neufeld argues that there is “mouse drusen” and that their research has shown abundant proteins to be associated with such deposited material. All of these events lead to an increase in inflammatory and immunological activity and, according to Prof Neufeld, this is likely to be a consequence of normal age-related changes in the RPE. Pulling all these various strands of evidence together paints a credible explanation of what is occurring behind the scenes. In the young animals, explained Prof Neufeld, the lysosomes empty into the phagosome to produce an endosome and the material is released by the exosomes, which is delivered to the blood to be washed away and excreted. However, in the older animal things are very different: phagocytosis is slowed down, iron has affected the internalisation of the phagosome, mitochondria are being damaged, all of which results in a lot of accumulating junk to be cleared. Although the volume is processed through the “system” some of it literally “sticks” and what sticks grows into drusen. At that point inflammation becomes important, leukocytes invade the RPE and the seeds of AMD are sewn. “If you don’t have the correct CFH (complement factor H [allele]), if you don’t have the correct complement system, if you cannot control the activity of these cells, you will go on to develop AMD – everything before that is normal,”explained Prof Neufeld. “It is normal to have the chemokines call for help, it is normal for the leukocytes to invade the retina; however, it is the lack of the control of the otherwise normal ageing activity that makes the difference in AMD pathology.” Prof Neufeld’s hypothesis to explain the events that lead to AMD are that “the ageing RPE/choroid provides the substrate for the development of the disease; normal ageing of the RPE/choroid results in increased immunological/ inflammatory activity and AMD is caused by a loss of control of the immunological/ inflammatory pathways during the normal ageing process.” If such a picture turns out to be validated among other research groups, then significant advances may be expected to meet the challenge of obtaining a more detailed understanding of the molecular and cellular biology of AMD in the years ahead.

EUREQUO on target for 2010 Two free papers detailing the progress of the EUREQUO project will be presented at the 14th ESCRS Winter Meeting in Budapest

Mats Lundström

EUREQUO, which is co-funded by the European Union and the ESCRS, aims to make a significant impact on the exchange of best practice between practitioners in relation to patient safety in this field and national ophthalmology societies of the participating countries will have an active role in the implementation of the project at national level.

The free paper details how a National Registry is being set up in each participating country. The data collection involves individual practitioners, small- and medium-sized clinics, large faros_250x140_EuroT_e 2.10.2009 hospitals and universities

The first free paper, from Mats Lundström MD and EUREQUO Project Manager Lucia Brocato will give delegates a progress report on the project which aims to improve treatment and standards of care for cataract and refractive surgery and to develop evidence-based guidelines for cataract and refractive surgeries across Europe. The free paper details how a National Registry is being set up in each participating country. The data collection involves individual practitioners, small- and medium-sized clinics, large hospitals and universities. Once the data is recorded, it will be processed and disseminated in the EUREQUO database. Data collection will be via Internet (forms or transfer of data from existing electronic systems). Data collected will be analysed by the EUREQUO Steering Committee and ESCRS Board. The free paper shows that the project is in a pilot and evaluation phase. Data has been entered from pilot countries and from legacy systems (ECOS, RSOIS, and Dutch and Swedish registries). The number of 14:49 Uhr Seite 1 and sites is increasing. participating surgeons

The roll out of the system to all participating countries will occur during 2010. “The EUREQUO project is proceeding according to the plan,” the authors conclude. “The system is ready to use for benchmarking and clinical improvement work and will soon be able to suggest evidence-based guidelines.” Benchmarking and clinical improvement In the second free paper, Dr Lundström has evaluated Benchmarking and clinical improvement using EUREQUO output data. The purpose of this free paper is to show how outcomes data from the EUREQUO system can be used for benchmarking and clinical improvement work “The EUREQUO database contains data from many centres in Europe and also data from large national databases,” said Dr Lundström in his free paper. “The database has a report function and gives output data both for the surgeon, the country and the whole database. A large number of selections can be made including time period, demographic data, surgical method and



EUREQUO European Registry of Quality Outcomes for Cataract & Refractive Surgery

co-morbidity. The output data is displayed as frequency tables or graphs,” he said. For cataract outcomes final visual acuity, biometry prediction error and surgical complications are important quality indicators that the system delivers for comparison and benchmarking purpose. For refractive surgery outcomes a set of standard graphs will be delivered showing the requesting surgeon’s results. Examples with realistic data from the system will be shown. “The output of data from the EUREQUO system is suitable for comparison, benchmarking and audit purposes,” Dr Lundström concludes.

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Paris 2010

Jose Guell

ESCRS/EURETINA meeting in Paris will encourage closer links between surgeons

Bill Aylward

For the first time, the ESCRS Congress will partner the 10th European Society of Retina Specialists (EURETINA) Congress which will also take place at Le Palais des Congres from Thursday 2 to Sunday 5 September, immediately preceding the XXVIII ESCRS Congress. Both meetings will run concurrently on Saturday 4 and Sunday 5 September. Each Society will retain their distinct branding and scientific programmes. There will be two ESCRS/EURETINA symposia on Saturday 4 September and Sunday 5 September on the topics of Endophthalmitis and Myopia in Cataract Patients. The expected attendance of close to 8,000 cataract, refractive, cornea and retina surgeons will have access to one Industry Exhibition which will open on Friday 3 September and close on Tuesday 7 September. Delegates from the ESCRS and EURETINA Congresses will have access to the same exhibition. For many years there has been close collaboration between ESCRS and EURETINA and the presidents of the

two societies said the partnering of these meetings will encourage further links between cataract and retina surgeons. “The ESCRS is delighted to link its XXVIII Congress with the 10th EURETINA Congress,” said Dr Jose Guell, president of ESCRS. “We believe that the meeting in Paris will be a very important meeting for both societies with an excellent scientific programme and exhibition. “The ESCRS is breaking new ground by holding its 14th Winter Meeting in Budapest, Hungary, the first time we will hold our Winter Meeting in Eastern Europe. The ESCRS/EURETINA meeting in Paris in September is another historic initiative for the ESCRS and will play an important role in shaping our plans for the future.” The president of EURETINA Dr Bill Aylward said that the EURETINA meeting has gone from strength to strength in recent years and the holding of the 10th EURETINA Congress in Paris marked another significant landmark in the society’s development.

“As retina specialists, it is important that we share our knowledge and expertise with colleagues in other specialties and I am delighted that for the first time we will have the opportunity to hold an ESCRS/ EURETINA meeting under the one roof,” said Dr Aylward. “The expertise and infrastructure made available to EURETINA through the ESCRS office in Dublin has allowed EURETINA to become a much stronger and more influential society,” he said.


14th ESCRS Winter Meeting

For information on the XXVIII ESCRS Congress visit For information on the 10th EURETINA Congress visit

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In association with the Hungarian Society of Cataract and Refractive Surgeons (SHIOL)


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THE Executive Board Members of the European Board of Ophthalmology (EBO) are already looking towards spring in Paris where the 2010 EBO Diploma examination (EBOD) will take place. This annual exam is scheduled for Friday May 7 and Saturday May 8, 2010, immediately prior to the French SFO Congress. The 2009 EBOD examination proved to be the most successful to date. With a total number of 308 candidates from 25 European countries and 168 examiners from 27 countries, this saw approximately a 10 per cent increase from 2008, a trend expected to continue for the EBO. Preparations have been in full swing since the completion of the 2009 exam and several new features of the EBOD examination format need to be emphasised. For one, the 2010 examination will see the introduction of negative marking. EBO has in past years invested a lot of time and effort in the careful validation and professional analysis of all questions and answers included in each exam. The analysis as performed by EBOD assessment officer, Danny Mathysen MSc from Antwerp University Department, will be published on the EBO website. It has confirmed that the introduction of negative marking will increase the discrimination power of the examination to better distinguish between good candidates and those who were benefiting from wild guessing. This decision has been well researched and discussed in depth by the EBO Executive Board prior to its implementation. While EBO does not intend to reduce the pass rate by this new feature, it hopes that it will offer a fairer scoring system. Every year EBO receives several enquiries regarding the eligibility terms and conditions of who can sit the annual exam. At present, regulations state the following: Anyone who is a certified specialist in ophthalmology in a country of the European Union or Norway, Switzerland, Croatia and Turkey, is eligible to sit the EBOD examination, on condition that the candidate’s eligibility is authorised by the relevant EBO national delegate from the country of the applicant’s training. Certified specialists who succeed in the EBOD exam will be immediately awarded the diploma certificate, granting them the title of Fellow of the European Board of Ophthalmology (FEBO). It is also possible to sit the examination during the last year of residency or, in the UK, after four years of residency training, or after additional training in the countries listed above in the case that the title of specialist was obtained in other countries, and upon approval of the candidate’s head of department and an EBO national delegate of their country of additional

training. In such cases a temporary certificate will be awarded to those who successfully passed the EBOD exam. Once these candidates go on to achieve specialist certification in their country of representation as listed above, they will then receive their FEBO Diploma from their country’s EBO national delegate and are then also entitled to use the FEBO title. And how is the examination organised? As is explained in detail on the EBO website ( (http://www. the examination consists of 52 multiple choice questions (MCQs), which cover any basic science, medical or surgical topic relevant to the practice of ophthalmology. The languages available for this written MCQ exam are English, French and German and each candidate must select one preference at the point of application. This written examination will take place from 09.00 - 11.30 on Friday May 7, 2010. Each candidate must then sit four separate viva-voce (oral) exams of 15 minutes each. These will be conducted the same day in the afternoon by four panels of two examiners, one of whom will be international and one national to the candidate. The reason for this being that, while the languages catered for in the viva-voce exam are English, French and German, whenever possible at least one examiner in each pair will be selected to speak and understand the candidate’s native tongue in case of difficulty. Topics of the viva-voce are divided as follows: A) Optics, Refraction, Strabismus and Neuro-ophthalmology; B) Cornea, External Diseases, Orbit and Ocular Adnexa; C) Glaucoma, Cataract and Refractive Surgery; and D) Posterior Segment, Ocular Inflammation and Uveitis. So in total each candidate will be questioned by eight experts for 60 minutes, during which he/she will be expected to answer an average of 20-25 questions. In each panel emphasis will be placed on the following: Recognition by the candidate in presented material of abnormalities and diseases that affect the eye, ocular adnexae and the visual pathways. Diagnosis: The ability of the candidate to synthesise clinical, laboratory and histopathological data in order to arrive at a correct diagnosis and differential diagnosis. Treatment: Candidates will be expected to provide a reasonable and appropriate plan for medical and surgical management of patients with the conditions depicted or described. A score of up to 10 will be given to candidates, while the pass rate is six. Each pair of examiners will allocate one score for the examination topic concerned and oral examination will in total bring

Ocular Update

European Board of Ophthalmology prepares for the next diploma examination in Paris

60 per cent of the final mark with 40 by many of the EU countries, in which the per cent being the result of the written attending EBO candidates still need to, examination. in addition, pass the full local exam as a All marks are processed electronically separate and mandatory task. and calculated using professional EBO hopes that in showing the programmes and tools. The results are professionalism and benefit of the then discussed by the panel of executives harmonisation of training, the EBOD and experts before the final ranking is examination will become a widely published the day after the examination, accepted benchmark test of knowledge revealing the new set of EBO certified in all countries of Europe. It should specialists. In recent years the pass rate be emphasised that in so doing, no has been between 85-90 per cent and sovereignty is lost on the part of the negative marking should not, by itself, national professors. The important issue reduce this figure. is that the option is available to those Recommended literature consists residents who wish to try and pass the mainly of Kanski and AAO BSCS books, EBOD examination, without giving the with the aid of atlases such as Spalton and feeling that they are ultimately repeating some other European volumes listed on the whole local examination. However, as the website. the EBOD examination does not test fully The award ceremony that follows the for practical skills and professionalism and, day after the exam is a memorable event, as it does not oversee all the rotations where professionally crafted diplomas are being executed, local control is still awarded to the successful candidates in required. How this is implemented remains the presence of examiners that comprise to be decided by the national bodies. of many illustrious names in ophthalmology from a range of European countries. For further information on the EBOD The EBOD examination in most examination please go to easyPhaco_sw_95x140_EuroTimes 5.10.2009 10:43 Uhr Seite 1 countries of the European Union is ( voluntary and does not, by itself, deliver the right to practise in the EU. However, in some ® countries like Switzerland, Fluidics on… France, The Turn up vacuum (600 mm Hg/50ml for Netherlands, peristaltic, 500 mmHg or more for venturi), Belgium, and let the elaborate fluidics concept of Slovenia the Oertli system work for you! and Austria Even though it sounds implausible – Oertli the EBOD easyPhaco® Technology brings to you examination • unprecedented chamber stability has now either • perfect emulsification replaced or • efficient fragment aspiration been accepted And all of this without the undesired side as an alternative effects hitherto caused by high vacuum. to their own National New and faster: Oertli easyPhaco® – the Specialist technology which makes fluidics to your best friend Examination. An increasing number of European countries are New and better: The Oertli easyTip® 2.2 mm Intelligent needle design and drastically improjoining from ved fluidics properties – Oertli easyPhaco® year to year in Technology brings visible and perceptible recognising the advantages. EBOD exam as at least part of OS3 their national examination. However, EBOD has not yet been acknowledged

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Practice Development

Improving the performance of a practice website will help ophthalmologists to capture new patients


ith two-thirds or more of potential refractive surgery patients looking for information online, an effective practice website is a must for capturing new patients, according to David W Evans PhD, president of Ceatus Media Group LLC, San Diego, US. At the XXVII Congress of the ESCRS in Barcelona, he offered tips for improving website performance. Visually appealing with a strong marketing message Patients look for websites for information, but they stay on sites that are appealing, Dr Evans notes. He recommends developing a central message for your site – and the rest of your marketing efforts – that is concrete and positive, and emphasises the advantages patients will gain from your services. Website graphics should support that message. “What you are really selling with refractive surgery is freedom from glasses, a new lifestyle. You can do sports, and scuba dive without contacts.” Examples of effective messages he gives include: “A New Life – Freedom from Glasses,” and “Our Commitment: Your Sight for Life.” While you will want to include information about your training and experience to perform such surgery, making the doctor the central message is usually not the best strategy, Dr Evans says. Easy to navigate Patients need to be able to find information on procedures, your practice and you. Your home page should include easy-to-find links to all content arranged by category. Each page should have navigation links to the home page and other site content. Informational Patients want detailed information on procedures, technology, your background, and how other patients you have treated have fared. Dr Evans says research shows that 44 per cent of patients look for patient testimonials and experience, so include this content if it is allowed in your country. If you are worried about your home page getting too busy, Dr Evans recommends looking at news sites for comparisons. “See if your page is less busy or more busy than the BBC home page. That is a good gauge. People expect a lot of information, but you have to set it up, so it can be easily found.” 26

Improve website performance: effective marketing message and prominent contact information

Easy to contact you Your email and phone number should be highly visible on every page of the website. Otherwise, why bother? Prominent call to action Your site should give a reason to contact you now. Messages like “Complimentary LASIK Consultation”, can motivate potential patients to call or email. “You want to show immediately how the patient can benefit from contacting you,” Dr Evans says. But it’s critical to be ready. Staff members who answer phones and email must know how to communicate with patients and bring them in for consultations. Search engine-friendly Making your site search engine-friendly will help put it on the main road of the information super highway. The two main ways to do it is through payper-click advertising and search engine optimisation. Both rely on search terms users enter when using Google or other search engines. Pay-per-click advertising appears alongside organic search engine results when specific search terms, such as “LASIK” or “laser eye surgery” are used. Each time someone clicks through to your website, you pay the search engine firm a fee. With Google, you can cap the amount you pay each day, week or month, so you don’t break your budget. You can also limit your exposure geographically, so your ad only comes up

when someone searches for your term in your area. Pay-per-click is easy to use and easy to budget, but it does not create a lasting web presence – as soon as you stop paying, your ad stops appearing. Also, only about one in seven users will click on an ad. Fraud can be a problem. Competitors have been known to click through these ads repeatedly to use up your advertising budget, Dr Evans notes. Search engine optimisation also relies on search terms. Search engines regularly crawl through content on the web, and categorise and rank it. When a search term such as “laser eye surgery” is entered, pages with relevant content are displayed in rank order from highest to lowest. Google and others jealously guard the complex algorithms they use to rank sites, and are constantly revising them to defeat those who try to game them. But in general, sites are ranked by the number of times specific search terms are used in page names, page subheads, and content. Their rankings also depend upon how many internal and external links exist to a specific search term. To optimise your site, Dr Evans recommends doing a little research to find out what terms are most commonly used in your area to find the service you want to promote – it may be “laser eye surgery”, or “LASIK,” but this varies by market. Note that large organisations, including trade groups, government agencies and even Wikipedia, put a lot of resources into having their sites appear

by Howard Larkin

when you search on generic terms. So it’s also important to optimise your site for more specific terms, such as your location, practice name and personal name. This will help ensure that your site comes up when someone looks for “London” and “LASIK,” and most certainly when they search for practice or your name. Dr Evans recommends choosing a page on your site to optimise for your most important search term. For example, you may want your home page to come up on a search for any combination of “laser eye surgery, LASIK, London, Fleet Street Eye Surgery, Mr Edward Jones.” All of these terms should be used in the name of the home page. They should also appear in headlines and text on the page. Inside your site, these terms should be linked to the home page where they appear in text. Links from external websites to your home page are even more valuable in moving your website up the search engine ranks. You get more credit for links from sites with similar content, and from sites that search engines rank highly, such as university websites. Links from websites with high PR (page rank) and business directories also help, and are relatively easy to place. Also, frequently adding content and links tends to improve your rank. While optimising and maintaining web content can be time consuming and expensive, it has staying power and credibility you don’t get with ads. “Whether you like it or not, people ascribe a lot of credibility to Google rankings,” Dr Evans says. Moving to the top can help bring in patients and revenue. Surgeon directories can also be a useful way to boost your online visibility, because the best directories rank for the top search terms that your own website would have difficulty ranking for. Further, consumer studies show that patients are twice as likely to convert to a consultation if they see your practice in multiple places on the Internet. So, if they find your website online and then find your practice information again in a surgeon directory, that can help in the conversion process. When evaluating directories to list your practice, you should make sure of a few characteristics; the site ranks highly for important search terms, the site has very good content that lends credibility to your practice, the site allows you to place detailed information about your practice on the directory and the directory provides a link to your website.

World Ophthalmology Congress® 2010 ICC, Berlin, Germany XXXII International Congress of Ophthalmology 108th DOG Congress 5 - 9 June 2010 AAD Congress 2010 3 - 6 June 2010

WOC® 2010

International Council of Ophthalmology (ICO) (Sponsor) German Society of Ophthalmology (DOG) (Host) German Academy of Ophthalmology (AAD) (Co-Host)

See you

WOC® 2010 Executive Committee: President Professor Gerhard K. Lang Secretary General Professor Anselm Kampik Treasurer Professor Jochen Kammann Program Director Professor Gabriele E. Lang DOG Managing Director Dr. Philip Gass

WOC® 2010 Honorary President Professor Dr. Bruce E. Spivey, ICO President WOC® 2010 Scientific Program Committee Chair: Professor Stephen J. Ryan Co-Chairs: Professor Bernd Bertram Professor Gabriele E. Lang Professional Congress Organizer Monika Porstmann Porstmann Kongresse GmbH Venue ICC Berlin

design alliance Büro Roman Lorenz München June 2009


Out & About

Delegates attending WOC 2010 should take a walk through the Enlightenment in Berlin

By Renata Rubnikowicz


great city’s history is displayed in its great monuments and rich museums, and Berlin certainly has no shortage of fine art. But just as the two bears on Berlin’s coat of arms signify its joining together with Cölln on the other side of the river Spree in 1307, so science has marched with arts down the centuries – most notably as the town developed as a centre of the Enlightenment under Friedrich the Great in the 18th century. For delegates attending the The World Ophthalmology Congress 2010 (WOC® 2010) in Berlin, a major attraction will be the annual “Long Night of the Sciences”. On the evening of Saturday 5 June, from 5pm to 1am, dozens of learned institutions will open their doors to celebrate the city’s tenth such festival. Hundreds of events, including lectures, guided tours, experiments, readings, interactive demonstrations, workshops, performances, concerts and even cookery demonstrations will make science come alive for all ages and interests. The programme will be posted on www. (http://www. from 10 May. Tickets and printed listings will be available from 20 May. One of the educational establishments taking part is the Humboldt University, now based at the Adlershof campus in the south-east of the city. (Will there be cats in boxes at its Erwin Schrödinger Centre that night? No one knows.) The university’s first home when it was founded in 1810 was the former Palace of Prince Heinrich of Prussia on Unter den Linden, a 1.5km-long boulevard that was already the backbone of Enlightenment Berlin. Stroll down this route, originally a ride down to the hunting grounds of Tiergarten, and you have an instant introduction to Berlin’s historic past as a centre of learning. Begin at the magnificent Brandenburg Gate, opened in 1791, and so a relative latecomer to the area. Its crowning glory, the Quadriga statue showing Victory in her chariot, was taken by Napoleon in 1806 and held by him for eight years before she was reclaimed to reign again over Pariser Platz. Once a symbol of the division of the city after World War II, the gate has become a symbol of its reunification two decades ago. This is where US President Ronald Regan said, “Mr Gorbachev, tear down this wall.” JFK spoke here too, and nearby you’ll find a photographic archive chronicling the Kennedy family. Now rebuilt like so much of the well restored centre of Berlin, the Hotel Adlon opposite claimed the Emperor Wilhelm II as its first guest when it first opened a century ago. Comparing its marble with that in his palace, he apparently said, “mine is not as shiny and nicely polished.” With certain 28

Brandenburg Gate

unavoidable interruptions, the hotel has been welcoming royalty and celebrities, including Garbo, Chaplin and Einstein, ever since. If you don’t want to try one of its three Michelinstarred restaurants, you can still experience the glamour with afternoon tea or a glass of champagne in the Lobby Bar. Passing the British and Russian embassies, and the Deutsche Guggenheim Museum (which has an exhibition of the work of Kenyan-born artist Wangechi Mutu until 13 June) you come to the Berlin State Library (Staatsbibliothek) which can claim a lineage stretching back three and a half centuries and whose expanding collections are now housed in various different buildings around the city. A new reading room is being constructed in the current, century-old building on Unter den Linden to replace the central domed reading room which was damaged during the second world war. As well as being Germany’s largest research library – with more than 10 million books – the institution is also the guardian of treasures such as a Gutenberg Bible and original scores by Bach, Beethoven and Mozart. Crossing the boulevard near a statue of Frederick the Great on his horse, you find the curving Baroque frontage of the Alte Bibliothek or Old Library, which the Staatsbibliothek replaced when it became too small. Nicknamed “Kommode,” or “chest of drawers” by Berliners, it had its origins as a royal library. Now it is one of

the many buildings that make up Humboldt University and forms one side of Bebelplatz, once Kaiser Franz Joseph Platz and centrepiece of the Prussian Enlightenment. Planned in 1740, this square was inspired by the Forum of ancient Rome. Yet here is one of the jarring notes in the otherwise elegant Enlightenment symphony of the area. This is the place where, on 10 May 1933, Nazis burned books on Hitler’s blacklist. A square of glass set in the ground showing a sunken library lined with empty bookshelves with a line from Heinrich Heine – “Where they burn books they end by burning people” – is a reminder of the shocking event. More harmoniously, Bebelplatz is also home to the celebrated Staatsoper. The original building on this site was the first in Frederick II’s “Forum Fredericianum” and gave the square its prewar name. Destroyed by fire in 1843, it was soon rebuilt and remains one of the world’s most beautiful music spaces. On the nights of 5 and 6 June, the state opera house proclaims “Opera for Everybody” (, with a live broadcast of Eugene Onegin on 5 June, and a live concert by the State Orchestra conducted by Daniel Barenboim on Bebelplatz the following night, 6 June. Next to the opera house look up to see the copper dome of St Hedwig’s Cathedral, Berlin’s only Catholic place of worship until 1854, and like so much of central Berlin, reconstructed after the second world war

along the lines of the 18th-century original, which itself was closely modelled on the Pantheon in Rome. Further along Unter den Linden is the Neue Wache, once a royal guardhouse and now an antiwar memorial with a sculpture by Käthe Kollwitz of a mother holding her dead soldier son, and, finally, the Zeughaus or Arsenal. The oldest building on Unter den Linden, its first stone was laid in 1695. By the 18th century it had become Prussia’s greatest weapons’ hoard, and home to the first Royal Weapons and Model Collection, which was opened to the public in 1831. At the end of the 19th century it was reconstructed as a pantheon of Prussian military history, eventually becoming, in the days of the German Democratic Republic, a museum of German history with a Marxist-Leninst bent. Now it offers a permanent exhibition – with a walk through 2,000 years of German history – and temporary exhibitions (in June there will be a display of 20th-century photography) in an annex built by the celebrated modern architect IM Pei. Ahead lies the Schlossbrüke, the bridge that leads over the western channel of the river Spree to Mueuminsel, or Museum Island, but such are its many riches that it would be better to save them for another day. * For further information on WOC 2010, which takes place from June 5 to June 9, 2010, visit

Industry News

Industry News

Recent developments in the vision care industry Next big thing? Well-known US eye surgeon Brian BoxerWachler MD, Los Angeles, California, celebrated his birthday recently with the official launch of LASIK Idol, an original song and video competition that will give one lucky contestant the chance to perform their way to perfect vision. Contestants may enter by submitting an original musical performance explaining why they deserve to win a free LASIK procedure valued at $6,700. To show his enthusiasm and demonstrate that just about anyone can enter the contest, Dr Boxer-Wachler and the ‘posse’ of Boxer Wachler Vision Institute have created their own hip-hop debut, featured on the LASIK Idol website. Dr Boxer-Wachler commented, “I wanted to do something fun and different to give people the chance to receive a free LASIK procedure. This procedure can change your life as it has changed my life, and everyone deserves a shot at perfect vision. With a bit of creativity and fun, anyone can make a convincing video, and I can’t wait to see what people come up with!” Alcon expands portfolio to include glaucoma Alcon has announced that it has entered into a definitive agreement to acquire Optonol Ltd., a medical device company that develops, manufactures and markets novel miniature surgical implants used to lower intraocular pressure (IOP) in patients with glaucoma. With this acquisition, Alcon will acquire Optonol’s Ex-PRESS™ Mini Glaucoma Shunt. This agreement

Regulatory News

will complement Alcon’s pharmaceutical products that lower IOP in patients with glaucoma and ocular hypertension, the company says. “This transaction demonstrates Alcon’s strong commitment to providing physicians with comprehensive treatment options for patients with glaucoma, the world’s second leading cause of blindness. This surgical procedure provides incremental surgeon and patient benefits over trabeculectomy, which is currently considered the standard of care in glaucoma surgical therapy,” said Robert Warner, Alcon’s vice-president of US pharmaceutical products. The Ex-PRESS™ device reduces IOP by diverting the aqueous humour from the anterior chamber into the subconjunctival space of the eye. The procedure has comparable IOP lowering effectiveness to a trabeculectomy, but it is more predictable, more efficient and associated with less postoperative complications. The Ex-PRESS™ Mini Glaucoma Shunt is approved for use in the US, Europe, Canada, Australia and several other countries. “The acquisition of Optonol is part of our strategy to bolster organic growth with targeted investments in key therapeutic areas that have the potential to contribute in both the near and long term. Because the product is already approved in the US and other major markets it will begin contributing commercially in 2010,” said Kevin Buehler, Alcon’s president and chief executive officer.

CE Mark for Presbia Presbia announced its Flexivue™ micro-lens received CE certification for its products sold within the European Economic Area ( European_Economic_Area). Specifically, the CE mark certifies that Flexivue has met European Union consumer safety, health and environmental requirements. The Flexivue is a three-millimetre-diameter optical lens that is implanted in the cornea, by the creation of a pocket using the same kind of femtosecond laser routinely used for LASIK surgery. The procedure typically takes less than 10 minutes, is performed on the non-dominant eye, and does not require general anaesthesia. The developers believe the product will provide a safe, effective, permanent yet reversible correction of presbyopia. The company has established a Medical Advisory Board headed by Prof Ioannis Pallikaris of the Institute of Vision and Optics of the University of Crete. Two other well-known eye surgeons, Michael Gordon and Robert Maloney also joined the board recently. The company Presbia is now conducting postmarket surveillance of the Flexivue lens at the Institute of Vision and Optics of the University of Crete under the supervision of Prof Pallikaris.

Company News

Carl Zeiss Launches Online OCT Resource If you use OCT in your practice, Carl Zeiss Meditec has a relevant resource. The company recently launched a new online resource for the eye surgeons: ‘Eye on OCT’. The company says the new site is the most extensive resource for news and education about OCT technology and clinical application for ophthalmologists, optometrists and other eye care professionals. It contains a broad compendium of resources including Physician Spotlight (physician demonstrations, interviews and commentary about current OCT applications in ophthalmology), links to original sources for the latest peer-reviewed journal articles related to ophthalmic OCT, links to breaking news articles, case reports and educational presentations, and high-definition images illustrating a broad range of eye diseases. Alcon Independent Director Committee reviewing Novartis’ merger proposal Alcon has announced that Novartis has exercised its option to purchase the remaining shares in Alcon owned by Nestle at a weighted average price of US$180 per share in cash.  Upon completion of the purchase, Novartis will own an approximate 77 per cent interest in Alcon.  Alcon also announced that Novartis has submitted a proposal to the Alcon Board of Directors relating to the remaining approximate 23 per cent publicly-held minority interest. For more information see

New products New tools for retinal surgeons Bausch & Lomb Storz Ophthalmic Instruments announced the release of a new singleuse end-gripping forceps for vitreoretinal surgery. The forceps, available in 12- and 25-gauge options, are designed for safety, consistency and convenience and features an ultra-thin end-gripping tip for enhanced visibility and grasp with an ergonomic handle consistent with the popular Storz Ophthalmics reusable design. According to Bausch & Lomb, both the 23- and 25-gauge versions are available in boxes of two and six for facility convenience. The company has also announced the release of the E2013TMICS Capsulorhexis Forceps with Seibel Ruler. This instrument is designed for creating the capsulorhexis during microincision cataract surgery and its tips are serrated to provide excellent grasp of the capsule. New diamond knives for micro-incision cataract surgery  Katena has introduced two new diamond knives for micro-incision cataract surgery (MICS). The MICS Trapezoidal Diamond Knife is designed for surgeons who prefer to perform phaco through a 2.1mm incision and then widen the incision to 2.4mm for insertion of the IOL. The knife features a gem quality, trapezoidal-shaped diamond blade with four cutting edges, measuring 2.1mm at the shoulder and 2.4mm at the base. Also available is the MICS Diamond Knife which features a 2.2mm wide, keratome-shaped blade with four cutting edges for creating a precise incision through which a surgeon can perform all aspects of MICS. ( 29


Outlook on Industry


Benz is striving for better IOL materials with a major focus on research and development

our years ago, Patrick H Benz PhD got so frustrated looking for a way to add blue filtering to IOLs without reducing contrast sensitivity that he spent his Christmas holiday scouring the scientific literature. What he found was that a single natural chromophore in the crystalline lens with a unique radiation absorption profile is largely responsible for protecting the retina of young adult humans and many animals. Derived from tryptophan, it blocks virtually all light wavelengths below 400 nm and almost none above 440 nm, creating a moderate violet filter, no blue filtering, and nearly complete UV protection for the retina. “I was amazed to find that no one was using it in IOLs,” says Dr Benz, founder and president of Benz Research & Development, a major supplier of IOL and contact lens materials. So he set out to do just that. The challenge was to convert the natural chromophore, known chemically as 3-Hydroxykynurenine glucoside, into one that can be incorporated into the polymer matrix of acrylic IOL materials, Dr Benz explains. The transformation wasn’t too difficult. “There is a sugar on one end, an amino acid on the other, and the chromophore in the middle. So I took the sugar off and added a monomer in its place and patented it.” The result is Benz Natural Yellow™ – and it works every bit as well as Dr Benz hoped. Not only can it be easily polymerised into existing approved IOL materials, it yields an acrylic lens with

a spectral absorption profile nearly identical with that of a young adult human crystalline lens. Unlike some other blue filtering IOL materials, Natural Yellow™ does not block so much blue light, therefore it does not impair scotopic vision, Dr Benz points out. He believes that the loss of any additional retinal protection theoretically gained by blocking blue rays longer than 440 nm is more than offset by the proven functional loss. “Why would humans evolve a blocker that reduces night vision? This is the filter selected by millions of years of evolution for healthy retinal function. It is very intellectually satisfying to put it back into replacement lenses.” Natural Yellow™ is now available to IOL manufacturers in hydrophobic and hydrophilic bulk acrylic materials and machine-ready blanks. Purity can prevent calcium opacification Hydrophilic lens materials offer many potential advantages – flexibility for easy insertion through small incisions and inherent biocompatibility in the aqueous environment to name two. But they also suffer from some shortcomings. The possibility to opacify due to calcium deposits in some patients is one. Purity of lens materials is a key to preventing calcium deposits, Dr Benz says. Calcium deposits can occur when negatively charged carboxylate ions of any methacrylic acid in the polymer pull positively charged calcium ions out of solution as aqueous diffuses through

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the acrylic matrix. Once calcium binds to a methacrylic acid molecule, calcium phosphate molecules accumulate, leading to opacities. This takes time, most probably because the concentrations of both calcium ions and methacrylic acid are low, Dr Benz notes. But it is inevitable when sufficient acid is present in the matrix, he adds.

Unlike some other blue filtering IOL materials, Natural Yellow™ does not block so much blue light, therefore it does not impair scotopic vision, Dr Benz points out The best way to prevent this type of calcium deposit is to have the lowest possible methacrylic acid level in the polymer. Benz does it with a new manufacturing process that starts with 99.9 per cent pure monomer which is put through a series of formulation and polymerization processes to produce a polymer with near zero acid, Dr Benz says. “By providing ultrapure, zero acid polymer, we can eliminate any possibility of calcification of hydrophilic IOLs as a complication of IOL implant surgery due to the IOL material.” Quality control reduces glistening Glistenings are an inherent problem with hydrophobic acrylic IOLs, Dr Benz notes. They occur because water naturally infiltrates the polymer. “Water is one of the smallest molecules, even smaller than oxygen and nitrogen. It is impossible to keep it out.” Typically, a hydrophobic lens saturates at between zero per cent and 3.0 per cent water, Dr Benz says. But the water does not become part of the polymer matrix as it does in hydrophilic materials. Instead, the water is repelled by the hydrophobic lens material, causing it to aggregate into droplets in any gaps in the matrix. Because these droplets have a lower refractive index than the surrounding acrylic material, they distort light passing through, or glisten. Whether glistenings are a problem depends on how many there are and how big they are. IOLs with high levels of glistenings have been shown to reduce contrast sensitivity and increase glare sensitivity at clinically significant levels, Dr Benz says.

by Howard Larkin

Chemistry has a cure for this problem as well. “In a hydrophobic lens material you want a relatively small and constant polymer matrix. That way when glistenings do form they are small,” Dr Benz says. By carefully choosing the polymer components and controlling the polymerization processes, he has been able to keep glistening at a very low and consistent level in the Benz HF-1 hydrophobic acrylic material. Glistenings are checked in each batch of material. On average, this material measures 718 +/-142 on the glistening severity index developed by William Trattler MD. By contrast, some hydrophobic acrylic lenses on the market average 8,589 on the same scale, ranging from 327 to 46,361. “I try to make high-performance materials that are very consistent in large batches,” Dr Benz says. In addition to bulk acrylic materials, he provides blanks that manufacturers can mill into IOLs. These blanks come in batches as large as 45,000 pieces, helping ensure consistency of the lenses produced and minimising down time for testing and adjusting tooling for new batches. Such meticulous quality control also contributes to the consistency of expansion of hydrophilic acrylic materials. This is essential to achieving high-quality optics because the lenses are machined in a dehydrated state, and then expand when hydrated. The expansion must be precisely predictable to hit the desired lens power.

“I try to make highperformance materials that are very consistent in large batches,” Dr Benz says. In addition to bulk acrylic materials, he provides blanks that manufacturers can mill into IOLs Dr Benz sees this devotion to materials as a strong point for his firm. “Benz is a materials and function-driven business. I know my materials right down to the monomer. I know exactly how pure they are. And when you are implanting something forever, you need it to be as pure as it can be.”

by Seamus Sweeney

Surgical Techniques in Ophthalmology – Cataract Surgery Series Editors In Chief: Ashok Garg and Jorge L Alio Publisher: Jaypee Brothers, New Delhi, 2010


he volume now under consideration is that devoted to cataract surgery. Like other areas of ophthalmic surgery, this area has undergone dramatic changes in technique, equipment used, and general approach over the last two decades. The need for such a book is evident. The World Health Organization estimates that nearly half of world blindness is caused by age-related cataract, and with the relative decline of infective causes and an ageing population globally, this is set to increase. While cataracts may be associated with ageing, interventions exist, and in the developed world have reached the point where practitioners are increasingly concerned about minimising complications and achieving optimal outcomes, as much as just “doing the surgery.” This book is published in India, and the editors are to be commended on the wide range of nations represented among the contributors. There are particularly many from India, as well as representative contributors from Japan, the US, Russia, Spain, Italy, Belgium, and Mexico. An awareness of how local conditions determine treatment is important if solutions to the cataract problem are to spread around the world.

Cataract surgery techniques come in a handy package of knowledge Furthermore, the torrent of information in all areas of the biomedical science is a problem for clinicians trying to make sense of so many new and radical developments and apply them to their own practice. This series from Jaypee Brothers is intended to bring this flow of information into a handy package of knowledge, which clinicians will hopefully apply with wisdom and skill. In this age of ubiquitous information, it is sometimes argued that the editorial function – whether in newspapers or scientific journals – is obsolete. Books such as this are evidence that the need for judicious editorial presentation of the information available is still as important as ever. The book is divided into three sections. The first is titled, “Evolution of Various Cataract Surgery Techniques and Technology.” This would imply a primarily historical approach, focusing on the development of the techniques we now use. However, the section focuses more on surveying the range of current techniques used and the clinical application. The section is heavily illustrated with full colour photos and plentiful tables. The section is also the longest in the book and seems to me more a section of detailed reviews of current practice than a discussion of how techniques and technology evolved. Ironically in the text, authors use the term “pearls,” as in “surgical pearls.” Of course, this use of the term refers to gems of wisdom, usually of a technical or diagnostic nature. However the word



“pearl” is sometimes applied to cataract in colloquial English, with terms such as “pearl-eyed” being used. The second section, titled “Management of Complicated Cataracts and Cataract Surgery Complications,” addresses such difficult situations as a glued IOL, traumatic cataracts, and the use of phaco emulsification in complicated cases. The third section looks into the future and reviews advances in cataract surgery techniques and technology. As always, this section contains some of the most interesting and compelling chapters. We read of a new era of wavefront-guided cataract surgery, phaco without ultrasound, the use of lasers in cataract surgery, and many other cuttingedge topics. The book is generally clearly laid out and very richly illustrated. It is quite a substantial book, of the dimensions of a sheet of A4 paper but obviously much thicker. It is more a reference text than a portable, rapid-consultation book. I felt that the typeface of the text was rather


In Your Good Books

small and some of the pages were textheavy. I also felt that the book could have been more userfriendly if the text was laid out with a single column per page, rather than two columns, as this increased the “busyness” of each page. This text is clearly aimed at practitioners, and could be described as a heavy-duty text suitable for practitioners a little more than trainees. The chapters are copiously footnoted and clearly the editors have encouraged a grounding in evidence-based medicine. Generally the style is clear, although obviously prior knowledge of a high degree is assumed. This is not a text for medical students – unless they are at an extreme of diligence and obsessional attention to detail, and one would prefer they were gaining some clinical experience rather than immersing themselves in books of this complexity. Rather this is a book for cataract surgeons and trainees who want a synthesis of international current thinking on the topic.

российский выпуск RUSSIAN language edition ONLINE Visit: 31

Journal Watch

Journal Watch

by Sean Henahan

Vision science highlights from the world’s leading journals of medicine and science

Laser surgery does not appear to have long-term effects on corneal cells Neither LASIK nor PRK appear to be associated with lasting changes to cells lining the inside of the cornea at nine years after the procedure, a new study concludes. Researchers at the Mayo Clinic studied 29 eyes of 16 patients who had undergone LASIK or PRK. Photographs of the cells lining the cornea (endothelial cells) were taken and analysed before and nine years after surgery. Nine years after surgery, the density of cells lining the cornea had decreased by 5.3 per cent from their preoperative state. However, the annual rate of corneal endothelial cell loss in the eyes of patients who had had surgery was not significantly different from that of 42 eyes that had not undergone either procedure. The finding suggests that corneas after keratorefractive surgery should be suitable for posterior lamellar keratoplasty, the researchers note.

Excimer Laser Keratorefractive Surgery”, Nov 2009; 127: 1423 - 1427.

SV Patel et al., Archives of Ophthalmology, “Corneal Endothelial Cell Loss 9 Years After

Y Shen et al., Anesthesia & Analgesia, “The Prevalence of Perioperative Visual

Waking up blind Postoperative visual loss is a feared complication of anaesthesia and surgery. A new study reports that it is more common after certain types of procedures, notably cardiac surgery and spinal fusion procedures. US researchers looked at a large nationwide database of more than 5.6 million patients undergoing common surgical procedures between 1996 and 2005. They report that the overall rate of postoperative visual loss is low and has decreased significantly, and now occurs in two cases per 10,000 surgeries. In addition to cardiac and spinal surgery, patients undergoing hip replacement, knee replacement, or colorectal surgery were also at increased risk. One surprising finding was that patients under 18 years old were one of the highest-risk groups.

Loss in the United States: A 10-Year Study from 1996 to 2005 of Spinal, Orthopedic, Cardiac, and General Surgery”, November 2009, Volume 109, Issue 5 1534-1545. Low-dose aspirin and AMD Low dose aspirin is often prescribed for its cardiovascular protective effects in at-risk patients. A new study suggests that this benefit does not extend to AMD. Some 39,867 healthy female health professionals aged 45 years or older were assigned randomly to receive either 100mg aspirin on alternate days or placebo and were followed up for the presence of AMD for an average of 10 years. After 10 years of treatment and follow up, there were 111 cases of AMD in the aspirin group and 134 cases in the placebo group, not considered a statistically significant difference. WG Christen et al., Ophthalmology, “Low-dose aspirin and medical recordconfirmed age-related macular degeneration in a randomized trial of women”, 2009;116(12):2386–2392.

1 EuCornea Congress June 17-19 32



European Society of Cornea and Ocular Surface Disease Specialists


Local Organiser: Giancarlo Caprioglio ITALY Scientific Co-ordinator: Paolo Vinciguerra ITALY



C o r n


In conjunction with Società Italiana Cellulle Staminali e Superficie Oculare (S.I.C.S.S.O.), Refr@ctive.on-line and Societa’ Oftalmologica Universitaria (S.O.U.)






Journal of Cataract and Refractive Surgery jointly published by the ESCRS and ASCRS

Clear lens extraction in pathological conditions Extraction of a clear lens is an effective treatment option in some cases where a pathologic condition exists. For example, in the event of primary angle-closure or primary angle-closure glaucoma, extraction of a pathologically large lens can prevent acute pupillary block and lower intraocular pressure. Other examples include during vitrectomy, where extraction of a clear lens facilitates thorough removal of the peripheral vitreous. In some cases of eyes scheduled for penetrating keratoplasty, an early-stage cataract should be removed simultaneously if it is anticipated that later cataract surgery will be difficult. However, because visual function with a young crystalline lens is better than with an IOL, surgeons hesitate to perform extraction of a clear lens in younger patients. Japanese researchers conducted a study in four age groups (40s, 50s, 60s, 70s) comparing all-distance visual acuity and contrast visual acuity with and without glare (glare visual acuity) between phakic eyes with a clear lens and pseudophakic eyes with a monofocal intraocular lens. They found that the region of ocular accommodation in phakic eyes, even with an almost clear lens, was similar to the region of apparent accommodation in pseudophakic eyes at 60 years of age and older. Because contrast sensitivity with and without glare was equivalent at 40 years of age and older, they observe that visual function in phakic eyes 60 years of age and older was virtually the same as in pseudophakic eyes 60 years of age and older. Accordingly, they conclude that removal of a clear lens is justified at 60 years of age and older, at least in eyes with certain pathologic conditions, such as primary angle-closure glaucoma, and in eyes that are to have vitrectomy for severe vitreoretinal disease. K Hayashi et al., JCRS, “Comparison of visual function between phakic eyes and

pseudophakic eyes with a monofocal intraocular lens”, Volume 36, Issue 1, Pages 20-27.

J Alio et al., JCRS, “Microincision cataract surgery with toric intraocular lens implantation

by Thomas Kohnen

JCRS Highlights

JCRS Highlights

for correcting moderate and high astigmatism: Pilot study”, Volume 36, Issue 1, Pages 44-52.

MICS toric IOL At least 15 per cent to 20 per cent of cataract patients have 1.5 dioptres or more of corneal or refractive astigmatism. With increased patient expectations, the trend is not only to remove the cataract but also to address the problem of preexisting astigmatism at the time of surgery. J Alio and colleagues report encouraging results with a new MICS toric IOL in the treatment of moderate to high astigmatism in patients with cataract. In a prospective nonrandomised study, 12 cataract patients with at least 2.00 dioptres of astigmatism underwent MICS followed by implantation of an Acri.Comfort 646 TLC toric IOL in the capsular bag through a 1.8mm incision. The mean refractive cylinder decreased significantly after surgery, from −4.46 D ± 2.23 (SD) to −0.45 ± 0.63 D (P<.05). Astigmatism analysis by vectors showed a mean surgically induced astigmatism vector of 0.99 × 1 degrees and a mean difference vector of 0.23 × 8 degrees. The mean index of success was 0.11 ± 0.15. Ninety-one per cent of astigmatism was corrected. The mean IOL axis rotation was −1.75 ± 2.93 degrees; the rotation was 10 degrees or less in all eyes. No complications occurred. Larger studies are recommended.



Eye on History


Cross-Atlantic cooperation impels progress and discoveries in ophthalmology

ust as explorers and inventors from Europe and North America joined forces to unlock nature’s secrets hundreds of years ago, so too do ophthalmologists from both continents now join forces to discover elusive facts about the human eye. That sentiment of cooperation and discovery resonated throughout the 17th Congress of the European Society of Ophthalmology (SOE), which took place last year in mid-June in Amsterdam, The Netherlands. In his keynote presidential address to the congress, Dutch professor Gabriel van Rij stressed the importance of stimulating worldwide cooperation between ophthalmologists. Ophthalmology knows no boundaries, and meetings like the SOE congress allow doctors from all over the world discuss the latest developments in their fields of expertise and share a common culture and heritage, he told his audience. Extending his hand from across the Atlantic, the president of the American Academy of Ophthalmology (AAO), Dr Michael Brennan, acknowledged the debt that modern ophthalmology owes to Europe. In so doing, he recalled the historic links between North America and Europe since the time that the Dutch East India Company sent a British captain, Henry Hudson, upriver from the then-Dutch colony of New Amsterdam in search of the elusive Northwest passageway to Asia. “Some years later,” said Dr Brennan, “that same river, the Hudson River, fortified at West Point by French and Polish military engineers, assured the independence of our colonists.” Like those early explorers, the ophthalmologists of today are committed to exploring new passageways in science and technology for the betterment of their patients. The links between American and European ophthalmology surfaced again at the congress thanks to a poster presentation from Sibylle Scholtz PhD and Gerd U Auffarth MD, International 34

Vision Correction Research Centre (IVCRC), Department of Ophthalmology, University of Heidelberg, Germany. The poster was the most viewed e-poster among delegates attending the 17th Congress and also winner of the best e-poster prize. In their poster, Dr Scholtz and Dr Auffarth outlined how the first efficient bifocal glasses for presbyopes were invented by the great 18th century American statesman, Benjamin Franklin. Franklin was a leading scientist, politician, publicist and diplomat who, as one of the Founding Fathers of the United States, signed the Declaration of Independence in 1776. Franklin also founded the first public lending library in America, organised the first volunteer fire brigade in Pennsylvania and printed a new currency for the state of New Jersey based on innovative anti-counterfeiting techniques. But for ophthalmologists, it is Franklin’s contribution to science and medicine which marks him out as a true innovator. His theories about electricity led to the Sibylle Scholtz invention of the first lightning rod. He also invented the glass harmonica, the “Franklin stove”, binoculars and a urinary catheter. That body of work would have been an impressive legacy in itself, but for ophthalmology, Franklin’s lasting legacy is his contribution to the treatment of presbyopia. Julius Hirschberg, in Volume 3 of his landmark series, The History of Ophthalmology, refers to a letter by Franklin to his friend and early economist, George Whatley. In his letter to Whatley, Franklin wrote: “I previously had two kinds of spectacles. When I travelled, I sometimes wanted to read and sometime wanted to look at a distance. I did not find it convenient to change my glasses all the time and so I had a pair of each cut in half and then fused them in one frame. I now can wear my spectacles all the time and I only have to move my eyes up to see at distance or down to read; the appropriate lenses are always there.”

by Colin Kerr

Signing of Declaration of Independence

As with so many inventions, the actual inventor is disputed. Some historians argue that two contemporaries of Franklin – the America-born portrait artist Benjamin West (1738-1820) or the British portrait artist Joshua Reynolds (1723-1792) – invented bifocals. Historians also point out that as early as the 1600s, scientists had fused split lenses of different convexities. Whether it was Franklin, West, Reynolds or some other inventor who actually produced the first bifocals, it is undoubtedly true that bifocals were the inspired product of the great ideas and emerging technology that marked the Age of Enlightenment in the late 1700s in Europe and America. The inspiration that Franklin personified in the 18th century continues to be carried by a new generation of doctors. And, in the same manner as Franklin exhorted his contemporaries, so too will today’s ophthalmologists join in: “Let the experiment be made.”

Benjamin Franklin

by Paul McGinn


n a major legal victory for ophthalmic device manufacturers, the European Court of Justice has upheld the European Union’s 10-year limitation period on lawsuits for defective products. The decision, handed down at the end of 2009, removes a major legal headache for manufacturers and suppliers of ophthalmic and other medical devices. Until the ruling, manufacturers faced some uncertainty about whether they could be liable for a defective product for more than 10 years under the EU’s special no-fault law on defective products. The law, known as the Directive on Liability for Defective Products and introduced to the EU in 1985, provides for a two-fold time-limit on a producer’s liability for a defective product. Article 10 of the directive provides that a consumer has three years to sue the manufacturer from the time at which he or she became aware, or must have become aware of: the damage from the product, the defect in the product, and the identity of the producer of the product. In addition to the three-year limitation period based on the specific case, Article 11 of the directive also provides for an absolute 10-year limitation period on lawsuits based on the directive’s no-fault provisions. The 10-year limitation period starts to run from the day on which the product was placed into circulation. In this particular case, the European Court was asked whether a national court could extend the absolute 10-year time period limitation in certain situations. This case began in the UK, where the mother of Declan O’Byrne blamed his brain damage on the HiB vaccine that he received at the age of two years. The manufacturer of the vaccine was the French company Pasteur Mérieux Sérums et Vaccins SA, which later changed its name to Aventis Pasteur SA (‘APSA’). The vaccine was distributed in the UK by the English company Mérieux UK Limited, a wholly-owned subsidiary of APSA. APSA set up a joint venture with Merck Inc. in 1994. Later, Mérieux UK Limited was converted into a subsidiary of the joint venture, and subsequently changed its name to Aventis Pasteur MSD (‘APMSD’). The vaccine administered to the boy was part of a consignment of a number of units of HiB vaccine sent by the French manufacturer to the UK distributor on 18 September 1992. In late September or early October 1992, part of the consignment, including the vaccine administered to the boy, was sold by APMSD to the UK Department of Health and delivered to a hospital designated by the department, which in

EU court ruling provides legal certainty for ophthalmic device manufacturers when sued by patients for defects

turn supplied the vaccine to the general practitioner who vaccinated the boy on 3 November 1992. On 2 November 2000 the boy, suing through his mother, commenced proceedings against APMSD. In particular, the boy’s lawyers alleged that the HiB vaccine was defective and that it had been produced by APMSD. APMSD defended itself by arguing that it was merely the distributor of the vaccine administered to the respondent. On 17 April 2002, in reply to a request to that defence, APMSD identified Pasteur Mérieux Sérums et Vaccins SA as the manufacturer. On 16 October 2002, the boy’s lawyers commenced a separate lawsuit against APSA, seeking damages on the basis that APSA was the producer of the vaccine. In this second lawsuit, APSA admitted that it was the producer of the vaccine but submitted that the action against it was barred under the 10-year limitation period of the Directive on Liability for Defective Products. The company argued that the latest that the vaccine had been put into circulation was when it was received by APMSD on 22 September 1992. On that basis, the company argued that the limitation period of 10 years provided in the directive expired on 22 September 2002, three weeks before the commencement of the second lawsuit. In addition to the second lawsuit against APSA, the boy’s lawyers applied on 10 March 2003 in the first lawsuit against APMSD for APMSD to be substituted as defendant by APSA. In support of that application, the boy’s lawyers argued that when bringing the first action in November of 2000 they mistakenly believed that APMSD was the producer of the vaccine. In opposition to the application, APSA contended that, in so far as national law permitted such a substitution of parties after the expiry of the 10-year limitation period, it was incompatible with the directive. Ultimately, the cases reached the House of Lords, the highest court in the UK. When that court heard the cases, they asked the European Court of Justice to rule on whether the national law that allowed the substitution of the names of the parties after the expiration of the 10-year limitation period was compatible with the absolute 10-year limit imposed by the directive on liability for defective products. Last December, the European Court ruled that the directive did not provide for procedural mechanisms to deal with the situation – as in the O’Byrne case – where an injured person brings an action for liability for a defective product and makes an error as to the identity of the producer. Thus, it is, as a rule, for national law to determine the conditions in accordance

with which one party may be substituted for another in the context of such an action. That having been said, the European Court ruled that national courts cannot apply their own laws in a way that permit a lawsuit based on the directive to be brought against the producer, after the expiry of the 10-year period. To do so would undermine the principle of legal certainty. The principle of legal certainly is a central part of the directive, according to the European court. That principle arises as a counter-balance of rights within the directive, which is based on the principle of no-fault liability. In the directive, any consumer who claims injury because of a defect in a product can win his lawsuit against the manufacturer by simply establishing that the product was defective. Under the directive, the consumer does not have to also establish that the manufacturer was negligent in making and placing the product on the market. This was a major change from the law that preceded the introduction of the directive.  To counter-balance the rights of the consumer under the directive, the directive also introduced the 10-year limitation period as a safeguard for manufacturers, the court ruled. “The harmonisation of the rules on limitation pursued by that directive was intended by the Community legislature in the interests both of the injured person and of the producer,” the court wrote. The court noted that the 10-tear time limit is “a reasonable length of time, having regard to the gradual ageing of products,


EU Matters

the increasing strictness of safety standards and the constant progressions in the state of science and technology.” The court added that the 10-year time limit “is also intended to take account of the fact that that liability represents, for the producer, a greater burden than under a traditional system of liability, so as not to restrict technical progress and to maintain the possibility of insuring against risks connected with that specific liability.” Against that background, the court ruled that a national court cannot extend the 10-year limit. “An outcome to the contrary would amount, first, to accepting that the 10-year limitation period set out in Article 11 of Directive 85/374 can be interrupted with regard to a producer for a reason other than that proceedings have been instituted against him, which would be inconsistent with the complete harmonisation pursued by that directive on that issue,” the court held. In coming to that finding, the court also ruled that where a person injured by an allegedly defective product was not reasonably able to identify the producer of the product, the injured person could sue the supplier under the directive, and the supplier would be held legally liable for the defect if it failed to inform the injured person promptly of the identity of the manufacturer or its own supplier. For more details about the case, titled Aventis Pasteur SA v OB, please visit the website of the European Court of Justice at (

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Calendar February

February 2010 4-7 Athens, Greece 24th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery



Budapest, Hungary 14th ESCRS Winter Meeting Web:


Frankfurt, germany Frankfurt Retina Meeting 2010 Web:

March 2010 4-7

Prague, Czech republic 1st World Congress on Controversies in Ophthalmology (COPHy)



Ljubliana, Slovenia 4th Ljubliana Refractive Surgery Meeting

June 2010



VENICE, ITALY 17-19 1st EuCornea Congress

COMO, ITALY International Congress on Imaging and New Treatments in Retinal Diseases



COLORADO, USA Snowmass Glaucoma Conference

July 2010




Boston, ma, USA World Cornea Congress VI



Boston, ma, USA ASCRS/ASOA Symposium and Congress


NATAL, BRAZIL XI International Congress of Cataract and Refractive Surgery


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MONTREAL, CANADA ISER 2010 XIX Biennial Meeting of the International Society for Eye Research





Vilnius, Lithuania XIII Baltic Ophthalmologicum Balticum Web:

September 2010 2-5

VENICE, ITALY 1st EuCornea Congress Web:


Paris, France 10th EURETINA Congress


XXVIII Congress of the ESCRS

Beijing, China 25th Congress of the Asia-Pacific Academy of Ophthalmology (APAO) in combination with the 15th National Congress of the Chinese Ophthalmological Society (COS) Website:

October 2010 6-9

crete, greece European Assocation for Vision and Eye Research 2010



chicago, IL, usa American Academy of Ophthalmology



Hamburg, germany 23rd International Congress of German Ophthalmic Surgeons


April 2011 26-30

San Diego, CA, USA ASCRS/ASOA Symposium and Congress



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BERLIN, GERMANY World Ophthalmology Congress


June 2010 5-9

August 2010

May 2010 19-22


CRETE, GREECE Aegean Cornea X

April 2010


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Volume 15_Issue 2  

ESCRS convenes 14th ESCRS Winter Meeting in Budapest VOLUME 15 ISSUE 2 FEBRUARY 2010

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