Volume 15_Issue 7-8

VOLUME 15 ISSUE 7/8 JULY/AUGUST 2010

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Please see brief statement on adjacent page. ©2010 Abbott Medical Optics Inc. Abbott trademarks and products in-licensed by Abbott are shown in bold and italics. Accutane is a registered trademark of Hoffmann-LaRoche Inc. Cordarone is a registered trademark of Sanofi-Synthelabo, Inc. 2009.09.09-IL1311 Rev. B

ESCRS

EUROTIMES

july/august 2010 Volume 15 | Issue 7/8 This month...

Special Focus: Practice Development 4

Cover Story: Accreditation can be very beneficial for your practice

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Two ophthalmic surgeons reap the benefits of increased office space

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Practice Development Workshops at XXVIII ESCRS Congress previewed

20 Years of LASIK

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Pioneering discoveries helped pave the way for first LASIK procedure

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Proto-LASIK procedure was performed by Russian researchers

Cataract Update 12

Cataract surgery carries an elevated risk of retinal detachment

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Endophthalmitis prevention after cataract surgery

Cornea Update 14

Experimental gene therapy looks promising

Glaucoma Update 15

Studies prove effectiveness of laser treatment for glaucoma

Retina Update 19

Are topical therapies the future for AMD treatment?

Ocular Update

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24

Spanish research on treatment for limbal stem cell deficiency promising

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Updates from ARVO 2010

News 28

The Netherlands gives favourable reception to EUREQUO

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Clinical research symposia highlights for ESCRS congress

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EBOD examination a growing success

33

Exciting Young Ophthalmologists Programme planned for Paris

Features

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44 editorial staff

ESCRS

EUROTIMES

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

42 Out & About 43 Outlook on Industry 44 Industry News 45 EU Matters 45 Journal Watch 46 JCRS Highlights 47 Book Review 49 Bio-Ophthalmology 50 Eye On Travel 52 Calendar

With this month’s issue... WOC® 2010 SUPPLEMENT

Assistant Designer Janice Robb

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

Colour and Print Times Printers

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

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

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

Correction On page 13 of EuroTimes, June 2010, we featured an interview with Prof Theo Seiler on 20 Years of LASIK. Our CV stated that Prof Seiler is “professor and chairman of the Department of Ophthalmology at the University of Zurich in Switzerland”.

We have been asked to point out that while Prof Seiler is still a professor at the University of Zurich, the chair of the Ophthalmology Department in Zurich is Prof Klara Landau. It is the policy of EuroTimes to correct errors where they occur.

Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

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

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2009 and 31 December 2009 is 29,537.

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EUROTIMES

Editorial

ESCRS

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july/august

Medical Editors

Volume 15 | Issue 7/8

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

An open forum

Reporting innovative presentations and debates to our readers

by José Güell MD

International Editorial Board

E

uroTimes, the news magazine of the ESCRS, was founded in 1996 to bring timely clinical reports, technology updates and industry news to an audience now numbering over 29,000 ophthalmologists worldwide. The support of our industry advertisers makes this publication possible.

The clinical presentations and news items reported over the years are often based on small experimental studies and descriptions of new innovative techniques. Many of these innovations have become standard clinical practice; others are never heard of again.

The ESCRS co-publishes the Journal of Cataract and Refractive Surgery (JCRS) with the American Society of Cataract and Refractive Surgery. Publication in the journal is determined by peer review as is mandatory in all scientific journals. Its axiom is the publication of scientifically approved evidence in the pursuit of the advancement of cataract and refractive surgery.

EuroTimes is a tabloid publication and its content is not subject to peer review. The subject matter and opinions expressed in EuroTimes are neither approved or condoned by the ESCRS, its Board, its Publications Committee or its editors. The magazine is an open forum for communicating to our readers interesting and innovative presentations and debates.

Advertisements and supplements in the magazine are equally noncensored. They do not reflect the opinion, beliefs or endorsement of the editors or of the ESCRS. We trust our readers to be critical and discriminatory and form their own judgements about what they read and what they believe to be true.

I would like to take this opportunity to invite you, our readers, to send your comments, observations and criticisms to us. We would very much appreciate all your suggestions on how to make EuroTimes an even better magazine. Please contact us at eurotimes@escrs.org.

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA José Güell is president of ESCRS and a medical editor of EuroTimes

Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA

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paris 2010

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EURETINA Congress

XXVIII Congress of the ESCRS

www.euretina.org

www.escrs.org

2–5 September

4–8 September

Le Palais des Congrès

EUROTIMES | Volume 15 | Issue 7/8

Le Palais des Congrès

Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA

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contacts

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Cover Story

practice development

Tobias Neuhann – dr.neuhann@email.de Eckhard Weingäertner – Weingaertner@euroeyes.de Paul Rosen – phrosen@rocketmail.com

Is clinic certification worth it?

Documenting and monitoring quality improvement programmes can be costly, but the benefits are substantial

by Howard Larkin

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You learn everything about your clinic when installing a quality management system Tobias Neuhann MD

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I think there is a benefit to certification. It is quite a complex process, but it improves patient confidence as well as the efficiency of the clinic

Paul Rosen FRCS, FRCOphth

EUROTIMES | Volume 15 | Issue 7/8

I

n 1999, Tobias Neuhann MD invested more than €20,000 in the future of his Munich clinic. It wasn’t for anything as tangible as a new laser or diagnostic device, or construction or even marketing.

Instead, the money – along with a sizable chunk of his and his staff’s time – went to obtain ISO 9001 certification, making Augenklinik am Marienplatz the first private ophthalmic clinic in Bavaria to do so.

Developed by the International Organisation for Standardisation, a network of 162 national standards bodies headquartered in Geneva, Switzerland, ISO 9001 is a generic set of requirements for implementing a quality management system.

It requires, among other things, that an organisation: documents all of its business, production, and service processes; identifies customer needs that those processes should meet; monitors and measures process performance; and continually improves processes to serve customers better.

Certification requires inspection by an ISO-accredited external auditor to verify compliance with the standards, a process that must be repeated every two years.

The cost of implementing an ISO 9001 programme has come down considerably in recent years thanks to software and other do-it-yourself materials available through third-party vendors. Dr Neuhann suggests a programme might be implemented these days for as little as €2,000, not including staff time. Still, it includes no standards specific to healthcare, and the effort involved is significant. This prompts many to question whether it’s worth the cost for an ophthalmic clinic or hospital programme.

Specialised programmes, such as the LASIK-TÜV certification for laser refractive clinics available in Germany, and accreditation by global bodies such as the Joint Commission International, are also available. These programmes include detailed healthcare standards, but also require additional effort and expertise to achieve. Documenting and reworking clinic

and hospital processes to comply can take months of concerted effort.

But while the investment of financial and human resources is great, the rewards can be greater. Surgeons who have made the effort find it can reduce clinical errors, increase efficiency, and help attract qualityconscious patients. “I think there is a benefit to certification. It is quite a complex process, but it improves patient confidence as well as the efficiency of the clinic,” says Paul Rosen FRCS, FRCOphth, who chairs the ESCRS Practice Development Committee. He has not yet sought certification for his clinic outside standard government requirements, but is considering it.

In the future, certification or other proof of effective quality management may even be required as more national health plans and insurance companies move toward linking payment with outcomes and other measures of clinical quality and patient satisfaction, Dr Rosen suggests. “It’s difficult to tell, but I suspect they will.”

Effort pays off in quality and efficiency Even Dr Neuhann, who

is one of the most outspoken proponents of ophthalmic clinic certification, is uncertain if he has financially recovered his investment in quality management.

Nonetheless, he believes putting his clinic through the ISO 9001 certification process – and later the LASIK-TÜV certification process – has generated substantial benefits, including improved staff accountability and patient safety, which make the effort eminently worthwhile.

“Before when I saw that my knife was not so clean and I asked ‘why?’, normally the answer I got was ‘I don’t know; I just came from holiday.’ You never could find the responsible guy when things were not done right,” Dr Neuhann recalls. “Now I see everything – last week on Tuesday the process was done by this person and we saw this problem. We know what happened, so we can fix it.”

ISO standards require an organisation to compile a quality management handbook.

An internal quality manager is appointed to oversee the task, but producing the handbook involves every employee. Each employee must sit down and write out every step of every practice process that he or she is involved in – from answering phones to infection control and sterilisation procedures. These process descriptions are minutely detailed. For example, Dr Neuhann’s manual includes a script for what to tell patients when they are asked to place their chins on the autorefractor to get an accurate reading.

Such specificity compels practice managers and workers to think through every aspect of their jobs. “You learn everything about your clinic when installing a quality management system,” Dr Neuhann says. He estimates it took about four months of effort the first time around. Eckhard Weingäertner MD, who went through the process a few years later at his EuroEyes clinic in Stuttgart, estimates it took about 30 per cent of one staff member’s time for about two months to compile the initial quality management handbook.

Beyond clearly establishing what precisely is expected of each staff member, the exercise also proved very good for staff morale and building teamwork, Dr Neuhann says. “Everyone is involved, so it helps everyone know that what they do is valuable.” Detailed instructions for practice processes also help in training new employees, Dr Weingäertner adds. “They know exactly what they are supposed to do.”

ISO 9001 standards also call for keeping records of the execution of key processes and outcomes. While the processes and outcomes are not specified, they must be related to customer needs and satisfaction.

So steps like double-checking the power of an IOL before implanting it and outcomes such as how close post-op refraction came to the target would be considered relevant for purposes of meeting the standards,

though the clinic is under no obligation to adopt any specific standard.

Under ISO, an organisation is also required to maintain a quality improvement programme in which customer-focused process and outcome measures are used to identify opportunities for improving processes, and to measure the results of process changes. These principles originate in industrial quality management theory propounded by the likes of W Edwards Deming and Joseph Juran and are consistent with modern statistical quality improvement systems such as Lean and Six-Sigma.

The structured process improvement programme Dr Neuhann’s clinic adopted has helped strengthen patient identification and avoid performing procedures on the wrong patient or the wrong eye, he says. In the past, mistakes were made because staff would ask a patient about which eye was to be operated on – and sometimes, the patient got it wrong.

The clinic developed a more robust process that requires the head nurse and anaesthesia nurse to confirm the right or left eye in the chart.

Also, sometimes patients who are hard of hearing may respond when a similar name is called in the waiting room, Dr Neuhann notes. To avoid such mistakes, patients are given name tags at registration and nurses ask a patient’s first and last names before proceeding.

A better controlled process for handling and sterilising diamond knives also has paid off, Dr Neuhann adds. “If you aren’t nice to a diamond knife, it becomes blunt immediately and is very expensive to replace. I now have knives that last several months. The money I spent on process improvement is now coming back.”

Of course, any clinic could adopt a quality improvement programme, even one that fully meets ISO standards, without seeking external certification. However, Dr Neuhann believes there are several advantages to going through a third-party audit.

One is that it keeps the staff honest. “This kind of control I cannot do myself; it is an independent look at the clinic. I don’t have to say anything.”

A second advantage is credibility with patients. Dr Neuhann estimates that 20 per cent to 30 per cent of his patients are aware of the ISO and look for it as a confirmation of quality. The TÜV-SÜD and TÜV-NORD ISO certifications are especially well known, and are also sought by hospitals and clinics outside of Germany. These certifications are prominently featured as assurances of quality in advertisements for clinics involved in medical tourism. Certification may also be helpful in defending lawsuits because sticking to documented practice guidelines helps show that care was taken to reduce the chance of human error.

Perhaps most valuable is the peace of mind that comes from knowing the mistakes are being avoided, Dr Neuhann says. “It makes you sleep much better.”

These certifications also help satisfy insurance requirements for a quality improvement programme. Starting this year, German public insurers now require that a quality improvement programme be in place as a condition of payment, though Dr Neuhann says it will likely be a couple

of years before the requirement can be fully enforced. He estimates that about 80 per cent of eye clinics in Germany have a quality improvement programme in place and about 30 per cent are ISO certified.

Similar requirements are emerging in other European countries. From this year, the UK Care Quality Commission will require all public and private clinics to measure patient outcomes and have quality and safety assurance programmes in place to be registered. While the commission does not prescribe specific approaches to quality assurance or record keeping, it does consider an organisation’s adoption of recognised standards developed by medical specialty societies and other qualified experts, says Maureen Campbell, provider registration manager at the UK commission.

Accreditation or certification “is indicative to us that they are more likely to comply with regulations that we are likely to assess, but there is no list we follow,” she explains.

A more clinical approach As helpful as ISO 9001 can be for guiding an effective quality management programme, its lack of healthcare-specific requirements limits its utility in many clinic and hospital settings. Most countries maintain strict national accreditation standards for medical facilities. In the wake of outbreaks of mad cow disease, MRSA and other treatmentresistant organisms, many have adopted extremely strict infection control and hygiene requirements. Dr Neuhann credits the standards developed for Germany by the Robert Koch Institute for preventing outbreaks of toxic anterior segment syndrome in the country. On the other hand, he believes the initial requirement that all instruments be disposable, similar to current UK practice, was wasteful and unnecessarily strict. Along with the German ophthalmological society and refractive surgery commission, he campaigned for sterlisation standards that would allow diamond knives, a process that took two years.

Recognising a need to reassure patients of the safety of LASIK and other refractive surgeries, Dr Neuhann and colleagues, including Michael Knorz MD, PhD, also worked with TÜV-SÜD to develop LASIK-TÜV certification. To achieve this higher level of certification, laser clinics must be ISO certified and be listed by the refractive surgery commission. In addition, they must meet minimum volume requirements including more than 1,000 LASIK procedures in the preceding five years, provide proof of staff training and qualification, operate only within accepted refractive limits, maintain equipment to specified standards and keep complication rates below certain ranges.

“LASIK-TÜV certification prioritises the quality of the treatment and results. The certification is the result of combining the ISO 9001:2008 quality management system, an additional hygiene inspection and the specialist LASIK section,” says Michael Zimmer, who directs the programme.

However, because hygiene standards and other regulations vary so much from country to country, TÜV-SÜD does not offer the certification outside Germany, though it plans to develop an international version.

Don’t miss EUREQUO update, see page 28 EUROTIMES | Volume 15 | Issue 7/8

Dr Neuhann would like to see not only the LASIK standard internationalised, but also development of international certification standards for cataract surgery. “Cataract surgery is highly standardised and it is the same all over the world. It doesn’t make sense to have different standards in Belgium and France and Germany.” He notes that there are three or four different certification standards in Germany alone.

One major obstacle to standardising guidelines is European Union law, notes Carlo Ramponi MD, managing director of European operations for Joint Commission International, which accredits hospitals, including specialised eye hospitals, around the world. Most experience improvements in both clinical outcomes and customer service measures, such as waits for service in emergency rooms, after going through the comprehensive accreditation process, which can take from 12 to 40 months. Yet uniform requirements for healthcare are not allowed in the EU because they could have the effect of freezing standards in place in more developed countries, he notes.

“

Detailed instructions for practice processes also help in training new employees

Eckhard Weingäertner MD

However, Dr Ramponi believes that international standards are the future. Joint Commission International already accredits hospitals in 15 European countries and throughout the Middle East, Africa, Asia and South America. Many consider international accreditation as a key to their success in what has become a global healthcare services market. The clinical benefits could also be significant. “It would be great if hospitals in Singapore knew what was being done in Italy,” he says. “Better care and quality is a worldwide idea.”

ISO 9001 What it is:

Generic quality management system requirements developed by the International Organisation for Standardisation, a network of 162 national standards bodies headquartered in Geneva, Switzerland.

What it requires:

Establish a process-based quality management system; Document all practice processes in a quality manual; n Establish management structures to support quality improvement; n Establish quality goals related to customer/patient needs; n Plan and implement a quality improvement programme; n Track quality measures and adjust practice processes to improve quality; n Monitor and measure customer/patient satisfaction and other customer-focused outcomes; n Audit results regularly.

Organisations meeting all ISO 9001 requirements may be certified by undergoing an audit by an accredited ISO vendor to ensure compliance with all standards. Audits must be repeated every two years to maintain certification.

n n

Joint Commission International What it is:

International hospital accreditation and programme certification organisation that currently accredits healthcare organisations in 39 countries around the world.

What it requires: n

Adherence with detailed management structure, leadership and organisational standards designed to support quality patient care and continuous quality improvement; n Patient safety, including procedures to correctly identify patients and reduce medication and other care errors, and reduce infection risk; n Access to care, including registration, record keeping and follow-up requirements; n Patient family rights upheld; n Patient assessment standards, including requirements for staff seeing patients, conducting lab tests, etc; n Patient care, including procedures for emergency, end-of-life and other special circumstances; n Anaesthesia and medication administration requirements; n Quality improvement programmes in place throughout organisation; n Infection control and prevention; n Facility management and safety.

Accreditation is a rigorous process that typically takes a year or more for a hospital to prepare for. Hospitals must be re-accredited every three years.

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Editorial

july/august Volume 15 | Issue 7/8

More than standard!

Taking control of your practice

The Practice Development programme will give people an insight into the business of healthcare

by Paul Rosen

T

The OCULUS Keratograph 4 – a topographer that offers more than standard The Keratograph combines three instruments in one: keratometer, topographer and pupillometer. A keratoconus detection plus an automatic nomination for a contact lens are integrated.

The possibility to take fluo-pictures and –videos under slit lamp terms completes the package.

he principal focus of the ESCRS has been, and always will be, clinical education and research. However, there are other aspects to our professional lives which we ignore at our peril. Health services, whether privately or state funded, need a strong financial base to survive and provide all the support that our patients deserve. This is particularly relevant in a fast developing specialty such as ophthalmology, where technological advancement has been stunning, but which requires rapidly rising funding.

There is a limited financial resource, which has to be shared between areas such as defence, welfare, social care and others, as well as healthcare; money raised from taxation is not ever increasing and indeed in many countries is declining. Therefore, to advance and introduce new technologies, we have to maximise the efficiency of our practices, public or private, and work in a more a business-like way.

Often colleagues have told me: “I didn’t come into medicine to make money�. Such naivety will not survive the next decade. Without financial resources we can’t progress clinically or receive financial recompense including pensions.

The model for the delivery of healthcare appears to be changing rapidly away from the individual doctor treating their own patients, to corporatised healthcare provided by large organisations with profit the priority, using employed medical staff who may not be able to offer  the same commitment and responsibility as the independent surgeon treating their own specific patients. The latter will have built up a reputation which they will protect with high professional standards at all costs.

Clearly there are large clinics which provide excellent healthcare and often superb research programmes, but these are lead by unique clinicians who are also able businessmen and can achieve a balance between the two aims of excellence in healthcare and profit to support this in terms of investment.

As surgeons we will soon face a dilemma. We can take control of our destinies and run our practices as businesses in order to remain as truly independent practitioners. Our other option is to become employees in large organisations. Both models of healthcare are valid and legitimate, but we should make an active choice as to which way we wish to practice – and not complain after inaction.

The UK National Health Service is said to be moving towards a clinically-lead service, which if it lives up to its promises, should be a great leap forward. A recent article in the Harvard Business Review supports this philosophy (Lee, Harvard Business Review April 2010).

I believe business principles should be taught to medical students, to prepare them for the real world. Some of us have done MBAs and I would encourage anyone with the smallest of interest to look at this option. For the rest we have developed The Practice Development programme to give people an insight into the business of healthcare and to give them a chance to take control of their own destinies and  make a wider contribution to the organisations in which they work. I would encourage colleagues to take part in the ESCRS Practice Development Workshops which will take place during the ESCRS Congress in Paris in September and I would be delighted to hear your views on how we should develop these workshops in the future.

contact

Paul Rosen – phrosen@rocketmail.com

www.oculus.de Dr Paul Rosen is chairman of the ESCRS Practice Development Committee 'WTQVKOGU -GTCVQITCRJ /CTKGPMÂźHG EUROTIMES | Volume 15 | Issue 7/8

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Special Focus

practice development

Premium office design

Increasing your office space can create a more complementary setting for patients

First-class facilities for firstclass clients Sheraz Daya MD recently

by Sean Henahan in Budapest

EUROTIMES | Volume 15 | Issue 7/8

Courtesy of Erik Mertens MD

P

remium office design is an essential consideration in creating a premium practice. At a Practice Development Workshop held during the 14th ESCRS Winter Meeting, two leading ophthalmic surgeons described their experiences of moving into new clinic space when they outgrew their original facilities.

Erik Mertens MD had run out of space.

His successful practice in an Antwerp suburb was quickly growing beyond its 325 square metres of space.

“I needed a bigger space. All of the rooms were packed with equipment and our patient flow was starting to jam. We couldn’t get to our patients fast enough. Everyone was annoyed - staff, surgeons, and our patients,” Dr Mertens recalled.

By chance a building became available that offered 2500 square metres of space. But what would he do with all that room?

“It was a huge difference. When I bought the place I was originally going to use 600 square metres for my practice, and rent out the rest. I thought I could create a medical centre, maybe rent out to gynaecologists, orthopaedists and so on. But I realised I would not gain from having those specialists nearby, nor would they gain much from me.”

Instead, he created a medical centre catering to the same demographic he would be treating, the ageing, otherwise healthy baby-boomers. The Medipolis medical centre now includes his own ophthalmic surgery practice including an ambulatory surgery centre. However, it also includes cosmetic plastic surgeons, a hair replacement specialist, an anti-ageing specialist, dentists, a hearing aid shop, and an optical shop and also a pharmacy and beauty salon.

This creates a more complementary setting for everyone. Patients coming in for refractive surgery might also be candidates for cosmetic dentistry and vice versa. Patients also appreciate the ‘one-stop shopping’ where they can see the ophthalmologists and then pick up their prescription drops or their new glasses in the same building, he noted.

Establishing a new practice or expanding an existing practice requires a lot of planning and a little soul searching as well.

“There are a lot of things you need to think about. What do you need to do your job?

How many rooms? What kind of waiting area and so on. You also want to consider how to provide a premium service atmosphere.

Erik Mertens - e.mertens@medipolis.be Sheraz Daya - sdaya@centreforsight.com

technicians, two office managers and a general manager. All of these personnel not only smooth the workflow, Dr Mertens said, they allow him to do what he does best, practice medicine.

Erik Mertens expanded his ophthalmic practice which now includes a comfortable reception and waiting area

Courtesy of Sheraz Daya MD

8

Sheraz Daya recently expanded his practice into a purpose-built facility in West Sussex, offering patients a premium experience

I told my architect I didn’t want a clinic atmosphere, I wanted the patients to feel at home and at ease. We wanted them to feel that they were treated as people, not as numbers.”

The new ophthalmic centre, now complete, has a comfortable reception and waiting area filled with comfortable and stylish furniture.

Patients can have a cup of coffee and read a magazine, watch a DVD or go online either through the available WI-FI or by logging on to one of the flat screen Internet systems.

There are actually four waiting areas, so when one starts to get full, patients are guided to another area. Flat screens in each area also display services offered by the clinic.

“We give a lot of information to our patients. We have patient coordinators who explain the different surgical procedures.

We like to use the Eyemaginations computer programs as well.”

The ophthalmic practice now includes four receptionists, two patient coordinators,

expanded his practice into a purpose-built facility in a rural setting in West Sussex not far from London. This was a culmination of a voyage of self discovery, years of hard work, and a necessity, since his practice based at the National Health Service Hospital in East Grinstead was bursting at the seams.

“You want to think about what makes you tick when setting up practice. I had worked in one of the first laser centres in the UK. But I didn’t like what I was doing, didn’t like working for somebody else as a hired gun. I wanted to do something myself, so I set up my own centre.”

At first he mimicked the competition, trying to attract large numbers of patients in an effort to create a high-volume business.

Then he realised that he should capitalise on his own skills and abilities rather than trying to be like everyone else. Rather than compete for price shoppers, he decided to target patients who wanted premium service and had the means to pay for it.

He put his plan into action in 2001, and his business improved by 250 per cent in one year. He opened a bigger premises in 2003, and more recently opened the new hospital in the countryside.

“When we started planning our new facility the idea was to provide a first-class experience for all – staff and patients. Every detail mattered in terms of aesthetics and design and also in providing the right sort of experience going through the system, if patients are going to spend a lot of money on premium IOLs everything else has to be premium as well.

There can also be no compromise in terms of technology, he emphasised. This means using the best diagnostic and therapeutic technology available. For example, an IOLMaster is vital for optimum results with multifocal IOLs. Similarly, the femtosecond laser has become the new gold standard for laser vision correction.

“The premium experience starts at the initial phone contact, then continues with the first impression when they see the place, and continues through to a successful procedure and follow-up. The word of mouth is phenomenal for marketing your practice.

Vision correcting surgery is a life-changing experience and patients will spread the word.

But this won’t happen unless you provide a premium experience,” Dr Daya said.

Dr Daya’s Centre for Sight has locations in London as well as East Grinstead with a third unit due to open in neighbouring Surrey in August 2010.

9

Special Focus

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practice development

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Paris Workshops

ESCRS helps ophthalmologists learn about the business of ophthalmology

O

ne of the highlights of the XXVIII Congress of the ESCRS in Paris, France will be the Practice Development Workshops hosted by EuroTimes.

The purpose of the workshops is to help ophthalmologists in both private and public practice, to develop their business skills.

The programme for the workshops has been drawn up by the ESCRS Practice Development Committee chaired by Dr Paul Rosen, UK. The other members of the committee are Dr Oliver Findl, Austria, Dr Thomas Kohnen, Germany and Dr Jorge Alio, Spain. Â Business skills The workshops open on Friday September 3 with a special one-day masterclass delivered by Prof Keith Willey of London Business School, UK focusing on Business Skills for Ophthalmologists.

The workshop which runs from 9am to 5pm will lead participants through the key areas to be considered when committing to improve your practice. The session will blend lessons from growing businesses of all types based on research from London Business School together with the special considerations necessary in ophthalmology practice.

Participants will diagnose their own situation, learn from a case study based on the growth of a 30-surgeon practice and debate the issues.

The course fee for the session is ₏200 and only 50 places are available so early registration is advisable at www.escrs.org.  Marketing your practice The second day’s sessions will be held on Sunday, September 5 from 2pm to 4pm.

Among the guest speakers are communications consultant Kris Morrill of KAM Communications whose specialist topic is Changing the Paradigm for Marketing your Practice.

This workshop will focus on tools for evaluating your practice’s current marketing and then discuss strategies for improving the effectiveness of your marketing plans.

Special attention will be given to improving communication to patients. Â Telephone skills Rod Solar of LiveseySolar Practice Builders reveals the quantitative results of mystery

EUROTIMES | Volume 15 | Issue 7/8

calls conducted with over 30 private ophthalmology clinics across Europe.

His presentation reviews how prospective patients are greeted on the phone, what’s discussed, and differences between clinics when asking them to make appointments.

Finally, he’ll compare how clinics are performing against the best converting clinics in the industry and what clinics can do to improve their performance.  Business planning The third and final workshops session will be held on Monday 6 September from 2.30 to 4.30 pm.

Wilfrid Girard, founder and partner of medeuronet, located in Strasbourg, France will advise delegates on ‘How Business Planning Can Improve your Ophthalmological Practice’.

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Managing expectations Paul McGinn, barrister at law and editor of EuroTimes specialises in defending doctors and hospitals sued for malpractice. In his presentation “It’s all About Managing Expectations� he will discuss how ophthalmic surgeons can manage the expectations of their patients through the consent process. The take-home message is: a patient who understands the risks of eye surgery is more likely to accept a poor outcome.  Social media Oliver Findl, director of ophthalmology, Hanusch Hospital Vienna, Austria, and consultant ophthalmic surgeon at Moorfields Eye Hospital, London, UK, is also a member of the Practice Development Committee. In his workshop, Social Media –Why Ophthalmologists Should be Using the Internet, he will explain why ophthalmologists, young and old, should be using the Internet and social media including Facebook, YouTube and Twitter.  Contact us Workshops for Sunday and Monday are free of charge but are limited to 200 delegates. Delegates who plan to attend should book online in advance at www.escrs.org.

There will also be regular updates on the Practice Development Workshops on the EuroTimes website at www.eurotimes.org.

EuroTimes executive editor Colin Kerr can also be contacted for more information on the workshops at colin.kerr@escrs.org.

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10

Gholam Peyman – gpeyman1@yahoo.com

20 years of lasik

Ahead of his time on LASIK

In 1985 Gholam Peyman filed a patent on stromal ablation under a flap using an excimer laser, anticipating much of the procedure’s future development

by Howard Larkin in Chicago

Avoiding scars and pain Dr Peyman’s interest in laser refractive surgery dates back to 1977. Then a faculty member at the University of Illinois in Chicago, his investigations of the effects of lasers on eye tissues led him to experiment with CO2 lasers to modify corneal refraction in rabbits. The laser was applied to the cornea in different patterns, but all caused significant scarring. “My conclusions at that time were: 1) We have to wait for the development of an ablative laser and 2) We should not ablate the surface of the cornea but, instead, the ablation should take place under a flap in order to prevent scarring and other undesirable sequelae,” Dr Peyman says. He published the first paper on the topic in Ophthalmic Surgery in 1980.1 Dr Peyman’s interest was piqued again in 1982, when reading an article, in the journal Laser Focus from Bell Laboratories, describing the photo-ablative properties of the excimer laser on organic materials. “When I read about the excimer laser, I thought it would revolutionise corneal laser surgery. My mind was ready for it,” he recalls. The next year Stephen Trokel MD, PhD published his landmark study of excimer incisions on enucleated cow’s eyes, also conducted at Bell.

In 1985, Dr Trokel and his group published a paper that described using an excimer laser for radial keratectomy (RK) on an enucleated human eye. However, RK incisions failed to heal apparently due to removal of a thin layer of tissue between the sides of the cut, so most investigations shifted to surface ablation.

Dr Peyman took another route. “Because of my previous experience with the CO2 laser, I wanted to avoid surface ablation thereby preventing the potential corneal scarring Don’t miss Industry News, see page 44 EUROTIMES | Volume 15 | Issue 7/8

I have always been very aware of the potential limitations of my invention, and have devoted considerable time and effort over the years to find ways to ameliorate them Gholam A Peyman MD

and the pain associated with the removal of the corneal epithelium that exposes the nerves after surface ablation.

I applied for a patent in June 1985 describing the method of modifying corneal refractive errors using laser ablation under a corneal flap.” The filing anticipated several methods for directing a refractive laser, including “use of a variable diaphragm, a rotating orifice of variable size, and a scanning mirror which directs the laser beam towards the exposed internal stromal surface or the underside of the corneal flap.”

Dr Peyman tried to get an excimer laser for research from a firm in Finland, but the device was just too expensive.

However, he was able to evaluate the effects of various excimer lasers in conjunction with the Physics Department of the University of Helsinki (1985).

He had also purchased an infrared Erbium-Yag laser to evaluate stromal ablation under a hinged corneal flap2 in vivo in rabbit and primate eyes. He presented the research at the Association for Research in Vision and Ophthalmology in 1988, and published it in Ophthalmology in 1989. By this time he also had moved to Louisiana State University, where Marguerite McDonald MD and colleagues were developing PRK. However, as a retinal specialist, he was restricted and not involved in the project.

Surface ablation continued as the dominant procedure for some time, and Dr Peyman had little success getting manufacturers interested in laser ablation under a flap. In 1990, he sold the patent to Chiron. “They purchased it for a very little amount of money and that was the end of it,” Dr Peyman says. “However, I was happy that at least someone liked the concept and paid for my development costs.”

Mitigating LASIK side effects

Dr Peyman still conducts LASIK research, primarily to address some shortcomings. “I have always been very aware of the potential limitations of my invention, and have devoted considerable time and effort over the years to find ways to ameliorate them,” he says. Among these have been ablative and non-ablative inlays inserted under the corneal flap to allow a greater range of refractive correction (J Cataract Refract Surg. 2005)3, and the use of topical cyclosporine to enhance the recovery of corneal sensation after LASIK (.J Refract Surg. 2008 Apr;24(4):337-43)4.

Now as professor of basic medical sciences at the University of Arizona in Phoenix, Dr Peyman continues his research in other areas. He is currently developing a tonometer that can measure IOP and outflow through the eyelid for patients to use at home, and a pressure jet injector in which no needle enters the eye for non-invasive subconjunctival and intraocular injections. Why has he been involved in so many different projects? “I enjoy research,” he said.

Courtesy of Gholam A Peyman MD

G

holam A Peyman MD is perhaps best known for his pioneering work in vitreo-retinal surgery, including intravitreal drug delivery, endoresection, development of the operating microscope with stereoscopic assistant head, the endolaser and the first 23-gauge vitrectomy system. While he limits his clinical practice to retinal diseases, he has developed techniques and instruments for treating a wide range of ophthalmic conditions, for which he has been granted 116 US patents. “I felt that I could contribute in management of the diseases affecting other parts of the eye” he says.

One such concept was modifying the curvature of the cornea for refractive purposes using an excimer laser to sculpt the corneal stroma or on the back surface of a corneal cap or flap – the procedure that would become known as LASIK. Dr Peyman first filed a patent on the concept in July 1985 (US patent 4,840,175) (see figure). After two revisions of the application, the patent was finally granted in June 1989, about six months before Ioannis Pallikaris MD, PhD performed the first LASIK procedure on a human eye.

“

First page of Dr Peyman’s patent for LASIK

1- Peyman GA, Larson B, Raichand M, Andrews AH. Modification of rabbit corneal curvature with the use of carbon dioxide laser burns. Ophthalmic Surg. 1980 May;11(5):325-9.

2- Peyman GA, Badaro RM, Khoobehi B. Corneal ablation in rabbits using an infrared (2.9-micron) Erbium;YAG laser.

Ophthalmology. 1989 Aug;96(8):1160-70.

3- Peyman GA, Beyer CF, Bezerra Y, Vincent JM, Arosemena A, Friedlander MH, Hoffmann L, Kangeler J, Roussau D. Intracorneal inlay Photoablative inlay laser-assisted in situ keratophakia ( PAI-LASIK) in the rabbit model. J Cataract Refract Surg. 2005 Feb;31(2):389-97.

4- Peyman GA, Sanders DR, Batlle JF, Féliz R, Cabrera G. Cyclosporine 0,05% ophthalmic preparation to aid recovery from loss of corneal sensitivity after LASIK . J Refract Surg. 2008 Apr;24(4):337-43.

11

20 years of lasik

Russia and LASIK

Siberian researchers deserve credit for early proto-LASIK procedure, says excimer laser pioneer

by Roibeard O’hEineachain in Dublin

A

mong the many different strands of research that together contributed to the creation of the LASIK procedure as we know it today is the little-known work of a Russian team of ophthalmologists who were the first to perform an excimer laser ablation on the stroma beneath a corneal flap.

At a meeting held at the Columbia University in New York in September 1990 by the Edward S Harkness Eye Institute and the Columbia University College of physicians and Surgeons, two Russian ophthalmologists Alexander M Razhev MD and VP Chebotaev MD, from the Novosibirsk Institute in Siberia, reported their two-year follow-up after performing laser ablation beneath a hand-cut reflected corneal flap using a home-made excimer laser, Stephen Trokel MD, Columbia University, told EuroTimes in an interview.

“Jose Barraquer really deserves credit for the idea of corneal reshaping using industrial technology and many of the keratomileusis surgeons jumped on the idea of using the excimer laser instead of a cryolathe. However, the Russians were the first to cut a flap and operate on the stromal bed, and should be recognised,” Dr Trokel said.

In their report, the Russian researchers first described their histological findings with two excimer lasers, one, an ArF laser with a 193 nm wavelength, and the other, a KrCl laser with a 223 nm wavelength. They then described their clinical results for performing PRK procedures in eyes with high myopia, which ranged from 14.0 D to 22.0 D. They noted that although the surface treatment substantially reduced the patients’ myopia, it also resulted in visually significant haze and up to 5 D of astigmatism. Concerned about the possible role of the destruction of Bowman’s membrane in these complications, the Russian team modified their technique for the treatment of four subsequent patients with myopia ranging from -15.0 D to -16 D. Using a 5.0mm trephine, they cut 100 microns into the central cornea and then performed lamellar keratectomy with a knife and folded the resulting flap away from the stroma. They then applied the laser ablation with a rotating mask technique. Following the ablation, they used a biologic adhesive to fix the flap back in place upon the stroma and provided patients with contact lenses.

The patients’ initial postoperative refraction EUROTIMES | Volume 15 | Issue 7/8

ranged from -1.0 D to -3.0 D and uncorrected visual acuity was 20/60 or better in all eyes.

At two years’ follow-up, the patients had 1-2 D of regression, minimal astigmatism, and no visually significant haze. The researchers concluded that the low haze and astigmatism was due to the preservation of Bowman’s membrane.

“They were right about the haze but the evidence of most research does not support a role for the flap in preventing astigmatism.

Still, they were more right than wrong in their approach,” Dr Trokel said.

The Russian team also performed the same “proto-LASIK procedure” in five hyperopes, whose preoperative refraction ranged from +15.0 D to +19.0 D. In these patients they applied the laser energy to the central 1.0mm to 1.5mm of the cornea. As in the myopes they observed a dramatic improvement in refraction, to +2.0 D to +4.0 D. Dr Trokel noted that many were considering re-shaping the cornea from within. “As soon as commercial instruments were being developed there was discussion about a Barraquer style keratomileusis, a stromal bed keratomileusis and surface PRK. The latter was tried initially because it was easier and didn’t require a microkeratome, which would have added a whole new layer of risk. Nonetheless, the international cadre of keratomileusis surgeons were talking flap from the onset, Hugo Nano in Buenos Aires, Burrato in Milan and others,” he said.

Dr Trokel said that LASIK would not have been developed without the work of Jose Barraquer MD in Colombia. Not only did he invent the microkeratome, but he also set in motion the quest to discover the ideal tool for reshaping the cornea. The LASIK procedure, as first demonstrated by Ioannis Pallikaris MD, was the culmination of this research, he said. “It was Barraquer who really pointed out that the tools the surgeons were using were not up to the task of refractive surgery.

He sought out the most precise tool available to him and used a jeweller’s lathe. I found a better tool in the form of the excimer laser.

However, Pallikaris really deserves credit for assembling the LASIK operation in its final form, the guarded microkeratome, the hinged flap and the bed ablation. And people keep making it better,” he added.

contact Stephen Trokel MD - trokel@columbia.edu DG LQMHFWRU DOO PP[ PP (1* Y MPR (XURWLPHV LQGG

Update

cataract

Cataract surgery increases retinal detachment risk

Those at highest risk are young patients, males, myopes, and those who have no PVD

by Roibeard O’hEineachain in Budapest

E

ven with the use of the most modern and careful phacoemulsification techniques in otherwise healthy patients, cataract surgery carries an elevated risk of retinal detachment, said Horst Helbig MD, University Hospital, Regensburg, Germany, at the 14th ESCRS Winter Meeting.

Cataract surgery changes the physiology of the eye, Dr Helbig said. The smaller size and more forward position of the IOL, compared to the cataractous lens it replaces, causes a reduction in the volume of the lens and an increase in the volume of vitreous cavity.

Moreover, the removal of the crystalline lens and the anterior capsule results in an alteration in the diffusion barriers between the vitreous and anterior chamber, and that in turn will lead to accelerated vitreous liquefaction, he pointed out.

“This is the clue to understanding the pathophysiology of pseudophakic retinal detachment. What we see is a change in the concentration of hyaluronic acid in the vitreous. It is much lower in aphakic eyes than in phakic eyes and it is lower after intracapsular cataract surgery than after extracapsular surgery. After cataract surgery the biochemical composition of the vitreous changes and we have posterior vitreous detachment [PVD] as a result,” Dr Helbig added.

Direct evidence of an association between cataract surgery and PVD comes from a recently published study from New Zealand. The study showed that among 149 patients aged 50 to 60 years who underwent unilateral cataract surgery, the incidence of PVD after five years was 51 per cent in the

treated eyes, compared to only 21 per cent in their unoperated fellow eyes (Hilford et al, Eye 2009; 23:1388-1392).

Epidemiological studies provide evidence of an association between cataract surgery and retinal detachment. The Blue Mountain Eye Study (Panchapakesan et al, Br J Ophthalmol. 2003; 87(2): 168–172) and the Beaver Dam eye study (Klein et al, Ophthalmology 1997; 104 :573) show that altogether around six per cent of the population have IOLs. However, statistics from Sweden Germany and Spain are consistent in showing that about one-third of patients with retinal detachment are pseudophakic.

Modern phaco provides limited protection Dr Helbig noted that

cataract surgery has changed considerably since the time of those population studies.

Nonetheless, more recent evidence shows that a risk of retinal detachments persists even with more modern phacoemulsification techniques.

For example, in a Danish study which involved over 6,000 consecutive eyes which had undergone phacoemulsification during the years 1996–1998, the eight-year cumulative incidence of retinal detachment was nearly nine times higher than the incidence in the general population during the same period (Boberg-Ans et al, Acta Ophthalmol Scand 2006; 84 (5): 613-618).

The relative risk was highest in the first years after surgery and tended to flatten out by 10 years, Dr Helbig noted.

Another finding of the study was that the risk of retinal detachment surgery decreased

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as the age at surgery increased. Therefore, patients aged 59 years or younger at the time of surgery had a 10-fold higher likelihood of having a retinal detachment following cataract surgery, but those aged 70-79 years at the time of surgery had only a 2.6-fold higher likelihood for the complication and those 80 years or older had no increased risk. The study also showed pseudophakic men had a 2.5-fold increased risk for the complication compared to women.

The reduced risk among older patients probably derives from the fact that they will more likely have undergone an idiopathic PVD, Dr Helbig said. The detached vitreous, though displaced after cataract surgery by the partial evacuation of the capsule, imposes little if any tractional forces on the retina as it moves forward. On the other hand, even the apparent occurrence of a posterior detachment is not always enough to completely eliminate the risk of the complication.

“Usually we consider a posterior vitreous detachment to have taken place if the posterior pole is detached, but we’ve known patients who had an acute posterior vitreous detachment years ago and they still get a retinal detachment after cataract surgery,” Dr Helbig cautioned.

Additional risk factors One still debated question in ophthalmology is whether and to what degree cataract surgery amplifies the already elevated risk of retinal detachment among myopes. The published literature provides considerable evidence of myopia’s role in the complication, dating back to a study published in the 1950s (Bohringer et al. Ophthalmologica 1956; 131: 331–334). That study showed that by their seventh decade of life, patients had a 2.4 per cent risk of retinal detachment if they had -5.0 D to -9.0 D of myopia, compared to only a 0.56 per cent risk if they had -1.0 D or less of myopia.

In a more recent study involving more than 2000 patients with axial length greater than 27mm, researchers found using Kaplan-Meier-analysis that after 10 years about five per cent of eyes developed retinal detachment. Given that most cataract patients undergo surgery in both eyes, the

“

Based on this evidence I am convinced that cataract surgery significantly increases the risk for retinal detachment Horst Helbig MD

data indicated that there was a 10 per cent risk of the detachment for each patient (Neuhann et al, JCRS 2008; 34:1644-1657).

“The steep increase appears to level after 10 years. That makes sense if you consider the slow effect of the changed barrier and the increased fluid currents that wash out the vitreous and change the composition of the vitreous and cause a posterior vitreous. This is a mechanism that takes time. So really it’s not over when the phaco probe is out, it’s not over for at least 10 years,” Dr Helbig added.

A recent study from Taiwan in nearly 10,000 eyes (Shen et al, AJO, 2010, 149, 113-119) confirms the late increased rate of retinal detachment after cataract surgery describing an alarming 20 per cent rate of retinal detachments in young myopics 10 years after cataract surgery.

One way improved cataract surgery techniques could, in theory, reduce the incidence of retinal detachments after cataract surgery is by reducing intraoperative complications. A British case-control study indicated that capsular tears increase the risk of retinal detachment by 20-fold and zonular dehiscence increases the risk for the complication by 12-fold (Tuft et al, Ophthalmology 2006; 113 (4): 650-656).

“Based on this evidence I am convinced that cataract surgery significantly increases the risk for retinal detachment. The risk persists for at least 10 years and the most probable mechanism is that it induces vitreous liquefaction and posterior vitreous detachment. Those at highest risk are young patients, males, myopes, and those who have no posterior vitreous detachment,” Dr Helbig concluded.

Update

Cataract

Preventing endophthalmitis

ESCRS Endophthalmitis Study chairman responds to study’s critics

by Roibeard O’hEineachain in Budapest

Answering the critics Critics of intracameral cefuroxime as an endophthalmitis prophylaxis will sometimes

point out that cefuroxime is a very old antibiotic that is not effective against such pathogens as MRSA, enterococcus such as S Faecalis and Pseudomonas, Dr Barry noted. They may argue furthermore that it is not commercially available in a liquid preparation suitable for intracameral injection, and it therefore could, through the use of “Kitchen Pharmacy” increase the incidence of TASS, he said.

Dr Barry said that his response to such arguments is that cefuroxime works. Its efficacy is proven, not only in the 8,000 patients in the ESCRS study who received it but also in 425,000 patients in Sweden, where its use has been routine for some years now.

Moreover, as regards difficulties arising from having to prepare the antibiotic in the operating room, Dr Barry noted that there was only minimal incidence of TASS in the 8,000 procedures using the intracameral antibiotic in the ESCRS Endophthalmitis Study.

Some have expressed concern about anaphylactic reactions to cefuroxime in patients who are allergic to penicillin, Dr Barry said. However, cefuroxime does not have a close enough affinity to penicillin to cause allergic reactions in patients with penicillin allergy, he noted. Therefore, although it is unsafe to use some of the other cephalosporins in patients allergic to penicillin, cefuroxime itself does not appear to pose much of a risk, he said.

“I would argue that cephalosporins can be prescribed to people who are allergic to penicillin so long as you are using cefuroxime it is the molecular structure of the side-chain of the individual cephalosporin that runs the risk,” Dr Barry added.

There has been one reported case of anaphylaxis with intracameral cefuroxime (Villada et al, JCRS 2005; 31:620-621).

Fortunately the patient quickly recovered, following the prompt administration of steroids antihistamines and ephedrine.

Dr Barry pointed out that even with this one reported case, the incidence of the complication must be considerably lower than the incidence of endophthalmitis

Don’t miss Eye on Travel, see page 50 EUROTIMES | Volume 15 | Issue 7/8

among patients who do not receive intracameral antibiotics.

“I believe if you are going to withhold cefuroxime because of your anxiety of a vague history of a penicillin allergy you must remember that the Swedish rate of endophthalmitis among patients who do not receive cefuroxime is seven times higher than among those who do,” he said.

Another criticism of the ESCRS Endophthalmitis Study has been that the rate of the complication among patients not receiving the intracameral antibiotic was “extraordinarily high” (Editorial, Ophthalmology 2007; 114:831-20) at 0.35 per cent. However, in Sweden – a country that has in many ways pioneered quality control in cataract surgery – the rate of endophthalmitis is almost exactly the same among patients not receiving the antibiotic as it was in the Endophthalmitis Study.

Regarding the alternatives to intracameral cefuroxime, topical fourthgeneration fluoroquinolones has many proponents but the evidence supporting its use is quite small compared to that for cefuroxime.

Another alternative is intracameral moxifloxacin; however there is emerging resistance to the agent and its safe dose is not known. It is also not effective against MRSA. Moreover moxifloxacin has entered the food chain through its use in chicken farms in the US, which will probably render it useless as a prophylaxis against infection in the years to come.

“If we are accused of kitchen pharmacy using cefuroxime and making it up ourselves, then I would suggest that taking a dropped bottle of commercially available moxifloxacin is worse. It can really only be called toilet pharmacy,” he added.

Dr Barry concluded his presentation with an appeal to industry for a single unit dose of FDA-approved cefuroxime for individual use in cataract surgery.

“

The ESCRS Endophthalmitis Study is a gold standard study with Class 1 data which unequivocally demonstrated that intracameral cefuroxime is effective in preventing postoperative endophthalmitis after cataract surgery Peter Barry FRCS

EUROTIMES

ESCRS

I

ntracameral cefuroxime still remains the prophylaxis of choice for the prevention of endophthalmitis after cataract surgery, since unlike some suggested alternatives, its use is supported by robust data, said Peter Barry FRCS, St Vincent’s University Hospital and Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

“The ESCRS Endophthalmitis Study is a gold standard study with Class 1 data which unequivocally demonstrated that intracameral cefuroxime is effective in preventing postoperative endophthalmitis after cataract surgery,” Dr Barry, chairman of the ESCRS Endophthalmitis Study Group, told attendees at the 14th ESCRS Winter Meeting.

Reviewing the findings of the ESCRS Endophthalmitis Study, Dr Barry noted that, among 1600 cataract patients in the randomised control trial, intracameral cefuroxime at the end of surgery reduced presumed and proven endophthalmitis five-fold, from 0.35 per cent to 0.05 per cent. In addition it eliminated streptococcal endophthalmitis, eliminated blindness from endophthalmitis and induced minimal toxic anterior segment syndrome (TASS), he said.

Dr Barry noted that, overall, there were 11 staphylococcal infections, eight in the control groups and in the intracameral cefuroxime groups. The patients’ final visual acuity ranged from 20/20 to 20/80 and no cases were legally blind, defined as visual acuity of 20/200 or less, he said.

By comparison, among eight cases of streptococcal infection, all in the control group, final visual acuity ranged from 20/20 to no light perception and five eyes were legally blind, he pointed out.

“I would suggest that the cefuroxime not only reduces your endophthalmitis risk by a factor of five but seems to exert a particular degree of protection against the organism we fear most, the streptococcus,” he added.

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13

14

Update

23 INTERNATIONAL CONGRESS OF GERMAN OPHTHALMIC SURGEONS rd

cornea

October 21st – 24th, 2010 Congress Center Hamburg

Cornea gene therapy

Experimental applications are promising

www.doc2010.de VIDEO LIVE SURGERY OCTOBER 21ST AND 22ND, 2010

by Howard Larkin in Boston

*DEADL

INE

MAIN TOPICS

June 15 th , 2010

(Simultaneous translation English - German)

° Honorary Lectures ° Cataract surgery ° DOC – ISRS / AAO Symposium ° Glaucoma surgery ° Vitreoretinal surgery ° Corneal surgery ° Orbita, lacrimal and lid surgery ° Forum Eye surgery in the developing countries FREE PAPER SESSION* SCIENTIFIC POSTERS/ePOSTERS* SURGICAL FILMS*

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23rd International Congress of German Ophthalmic Surgeons, Congress Center Hamburg, October 21st - 24th, 2010

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EUROTIMES | Volume 15 | Issue 7/8

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T

he cornea presents unique opportunities and challenges for gene therapy with potential applications ranging from treating dystrophies to reducing haze after surface ablation, reported Mark Rosenblatt MD, PhD at the Sixth World Cornea Congress.

Experimental applications are promising, but further investigation of the molecular mechanisms of corneal disease and development of improved animal models are necessary to move forward, said Dr Rosenblatt, Weill Cornell Medical College, New York.

“You can add a gene to express more of a protein. Theoretically you can excise a bad gene and replace it with a new one. A more recent technique is to use small inhibitory RNAs to create functional knock-outs. We don’t remove the gene but use special genetic elements to turn off the expression of the defective gene. I think this is going to be very important to treat many of the dystrophies in the cornea,” he said.

Genes can be inserted through viral or non-viral vectors. Retroviral, lentiviral and adeno-associated virus vectors insert their DNA into the target cell DNA, and are expressed over the long term. Adenovirals are more transient, as are non-viral vectors, such as liposomes and naked DNA. Non-viral vectors tend to be less efficient in transferring genetic material, though transfer rates are improving.

As far back as 1990, gene therapy was used in treating severe combined immunodeficiency (SCID) with apparent success, Dr Rosenblatt said. But gene therapy did not enter routine clinical use because there also have been serious failures. These include an 18-year-old patient dying in 1999 likely due to a high dose of adenoviral vectors to which he was susceptible. Also, in the early 2000s some of the patients treated for SCID early on developed lymphoma, he noted.

Still, gene therapy has many potential applications and the eye is an attractive location. For one, the eye is very accessible and is a separate compartment, making it possible to test gene therapy in minute quantities that reduce the risk of systemic reactions.

Applications for retinal disease are more advanced. A gene therapy for Leber congenital amaurosis is in human trials with early success in restoring vision. It was

developed in a canine model with the dog Lancelot literally becoming the poster animal for gene therapy research, Dr Rosenblatt said. Unfortunately, no similar models are available for corneal disease. “Having this large animal model available is one reason why retinal gene therapy has progressed quicker than corneal gene therapy.”

Nonetheless, many corneal gene therapy approaches are possible or in development.

Dystrophies are good candidates. But specific gene therapies have not yet been developed despite the discovery that one gene is responsible for many corneal dystrophies.

“We don’t even know the cell types involved and we have a poor biochemical understanding of what causes the dystrophy.

Is it a gene deficiency? Likely not; it is probably dominant negative, meaning abnormal protein is interacting with normal protein that then leads to the phenotype.

It has been very difficult to develop animal models for these dystrophies.”

Also, the genes responsible for some common conditions, such as Fuchs’ and keratoconus, have not yet been discovered.

Stable viral vectors would be best for treating dystrophies because these are lifelong conditions, Dr Rosenblatt added.

Another potential target for corneal gene therapy is graft rejection, which is a significant problem following penetrating keratoplasty. However, there are multiple immune pathways to rejection and multiple triggers for rejection, including neovascularisation and infections.

“The approach needs to be to the critical pathway to immune modulation, but really what is the master regulator; probably there is no single one for each patient.”

An approach might involve identifying and prioritising pathways and targeting them with long-acting vectors. The therapy could be applied ex vivo using donor transplant tissue or in vivo using injections.

Laser refractive surgery is another potential target. Despite submicron precision of excimer lasers, refractive surgical outcomes are not entirely predictable, and surface ablation can lead to corneal haze, Dr Rosenblatt said. One goal would be to make keratocytes more quiescent and reduce haze formation.

contact Mark Rosenblatt – mar2058@med.cornell.edu

15

Update

Glaucoma

Patients are individuals – the solution is unique: AT LISA® multifocal IOLs

Laser trabeculoplasty

SLT as primary glaucoma therapy

by Howard Larkin in Boston

E

ffective and repeatable, selective laser trabeculoplasty is gaining ground as a primary therapy for mild to moderate primary open-angle glaucoma (POAG), Garry P Condon MD, Drexel University College of Medicine, Pittsburgh, Pennsylvania, US, told a Glaucoma Day symposium at the ASCRS annual meeting.

The road to clinical acceptance for laser treatment of glaucoma has been long. As far back as 1995, the Glaucoma Laser Trial demonstrated the efficacy of lasers in treating glaucoma. The study group reported that argon laser trabeculoplasty (ALT) was as effective as medical treatment for lowering intraocular pressure in patients with POAG. Nonetheless, ALT never caught on as a firstline treatment, Dr Condon noted.

“Why didn’t we use it? ALT produced visible thermal issue damage to the trabecular meshwork and complications including pain, peripheral anterior synechiae and inflammation. Also, retreatment results were poor, leading to a reputation for ALT as a ‘one-shot deal’,” he commented.

With the introduction of the Q-switched Nd:YAG laser by Mark Latina MD in 1997, many of the problems of ALT were addressed, opening the way for greater use of lasers early in glaucoma treatment. Known as selective laser trabeculoplasty (SLT) because it affects only melanin-pigmented cells in the trabecular meshwork, this new technology lowered IOP as much as ALT with 6,000 times less energy and without thermal tissue damage. Pain and complications are reduced.

Subsequent studies with three-yearsplus follow-up have shown that SLT is as long-lasting and effective as ALT as an adjunctive therapy, Dr Condon said. The US FDA approved SLT in 2001. More recently, titanium-sapphire lasers in conjunction with the Gold Shunt (Solx) have shown promise in early tests. But the growing body of evidence supporting the efficacy, safety and repeatability of SLT makes it a leading glaucoma option.

In the early 2000s, this success prompted Shlomo Melamed MD of Israel to consider SLT as a primary therapy. In 2003 he reported a 90 per cent response rate with an average of 5.0 mmHg and 30 per cent IOP reduction in 45 eyes treated with SLT followed for one year. Similarly, studies comparing SLT with medical therapies, mostly prostaglandins, in EUROTIMES | Volume 15 | Issue 7/8

the US and Canada, have shown comparable response rates over follow-up periods of eight to 12 months, Dr Condon said.

While the repeatability of SLT has been controversial, Dr Condon pointed to a 2009 study in the Journal of Glaucoma by Bryan Wong and colleagues. It found that while secondary SLT treatments that were delivered one to three months after an initially successful 360 degree treatment did not reduce IOP as much as the initial therapy, treatments repeated after six and 12 months were just as effective as initial therapy, typically reducing IOP by 5.0 to 6.0 mmHg. Dr Condon believes theory supports repeatability. With a pulse time of about three nanoseconds, SLT heats melanin-containing cells without disturbing surrounding tissue.

This is thought to initiate a chemically mediated response prompting macrophages to clean up the affected cells, increasing the porosity of the trabecular meshwork in the process. ALT might also stimulate the same response, but because it permanently damages the tissue left behind there may be less reserve for future treatment, and mechanical factors could reduce retreatment efficacy, he added.

Still, SLT is not for everyone. Sensible patient selection criteria would include patients in need of a reasonable IOP, ie, mid-teens to mid-20s, with mild to moderate disc or visual field damage. Patients in a crisis, with advanced disease and high IOP, or who are not controlled with three-plus medications are poor candidates, he noted.

For eligible patients, Dr Condon likes to start SLT early, usually with a 180 degrees or 360 degrees treatment to start.

He also offers SLT as a second-line therapy for patients who are not controlled with a prostaglandin, or when he suspects noncompliance with medication is an issue.

Generally, he sees an IOP drop of 4-8 mmHg or more in 70 per cent of patients, with those with the highest initial IOP seeing the greatest drop and those on multiple medications the least. IOP spikes are most common among patients with pigmentary glaucoma. Final effects are generally observed six to eight weeks after treatment.

This combination of effectiveness, reduced side effects and retreatment potential make SLT an attractive laser option, Dr Condon concluded.

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Garry Condon - garrycondon@gmail.com AT_LISA_eurotimes_120x300_100622.indd 1

22.06.2010 15:04:20

paris 2010 10TH EURETINA Congress

MAIN SESSIONS MAIN SESSION 1: Research I: Retinal Imaging Chairperson: E. Stefansson Thursday 2 September 10.00 – 11.30 ~ MAIN SESSION 2: Research II: Stem cells / Gene therapy / Prosthesis Chairperson: D. Wong Thursday 2 September 11.30 – 13.00 ~ MAIN SESSION 3: Imaging to Monitor Progression Chairperson: J. Cunha-Vaz Thursday 2 September 14.00 – 16.00 ~ MAIN SESSION 4: Vitreoretinal Surgery Chairperson: B. Aylward Friday 3 September 08.00 – 10.00 ~ MAIN SESSION 5: Vascular Diseases and Diabetic Retinopathy Chairperson: F. Bandello Friday 3 September 14.00 – 16.00 ~ MAIN SESSION 6: Intraocular Inflammation - Uveitis Chairpersons: P. Lehoang, C. Pavesio, JJ. De Laey Friday 3 September 16.00 – 18.00 ~ MAIN SESSION 7: Innovation in Vitreoretinal Surgery Chairperson: A. Gaudric Saturday 4 September 08.00 – 10.00 ~ MAIN SESSION 8: Anterior/Posterior Segment Surgery Chairperson: G. Richard Saturday 4 September 11.00 – 13.00 ~ MAIN SESSION 9: Intraocular Tumours: New Perspectives Chairperson: E. Midena Saturday 4 September 14.00 – 16.00 ~ MAIN SESSION 10: AMD: Imaging Metrics Chairperson: F. Holz Saturday 4 September 16.00 – 18.00 ~ MAIN SESSION 11: AMD: Inflammation or Ischemia?

Chairpersons: E. Stefansson & G. Soubrane Sunday 5 September 08.00 – 10.00 ~ MAIN SESSION 12: AMD: Metabolic or Degenerative?

Chairpersons: G. Soubrane & E. Stefansson Sunday 5 September 11.00 – 13.00 ~ MAIN SESSION 13: German Retinal Society Chairperson: H. Heimann Sunday 5 September 10.30 – 12.30

paris 2010

2–5 September Le Palais des Congrès

www.euretina.org

THURSDAY 2 SEPTEMBER Bordeaux

Havane

351

353

Wetlab

08.00 09.00 FREE PAPERS

10.00 11.00

MAIN SESSION 1

12.00 13.00

MAIN SESSION 2

FREE PAPERS

RETINAL DETACHMENT COURSE UVEITIS COURSE

14.00 15.00

MAIN SESSION 3

SURGICAL SKILLS COURSE

EUROLAM

16.00 17.00

OPENING CEREMONY WELCOME RECEPTION

18.00 19.00 20.00

FRIDAY 3 SEPTEMBER 08.00 09.00

Main Hall Ternes

MAIN SESSION 4:

Bordeaux

COURSE 1: Macular Dyst.

Havane

351

353

Wetlab

251

FREE PAPERS

COURSE 2

COURSE 3

COURSE 4

COURSE 6

FRENCH/ISRAELI SYMPOSIUM

10.00 PFIZER SATELLITE SYMPOSIUM

11.00 12.00 13.00

KREISSIG LECTURE

MAIN SESSION 5

FRENCH/BRITISH SYMPOSIUM

20.00

SURGICAL SKILLS COURSE

BAUSCH+LOMB SATELLITE SYMPOSIUM

COURSE 7

COURSE 8

COURSE 9

COFFEE BREAK MAIN SESSION 6

COURSE 10

18.00 19.00

COURSE 5

NOVARTIS SATELLITE SYMPOSIUM

16.00 17.00

FREE PAPERS

AMSTERDAM RETINA DEBATE

14.00 15.00

COFFEE BREAK

ALCON SATELLITE SYMPOSIUM

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COURSE 11

COURSE 12

EVI.CT.SE

2–5 September

INSTRUCTIONAL COURSES

Le Palais des Congrès

EURETINA LECTURE

THE 2010 KREISSIG AWARD

Thursday 2 September 16.20 – 16.35

Friday 3 September 11.00 – 12.00

Retinovascular disorders of childhood

Immunology in Uveal Melanoma: Friend or Foe?

Tony Moore

Martine Jager

UK

The Netherlands

Bordeaux

351

353

251

Grand Amphitheatre

07.00 08.00 09.00

COURSE 13

FREE PAPERS

COURSE 14

COURSE 15

10.00 11.00 12.00

THEA SATELLITE SYMPOSIUM

COFFEE BREAK

MAIN SESSION 8

FAN CLUB

13.00 ALLERGAN SATELLITE SYMPOSIUM

14.00 15.00

MAIN SESSION 9

16.00

FREE PAPERS

COFFEE BREAK

COURSE 16

FREE PAPERS

COURSE 17

DORC SATELLITE SYMPOSIUM

COURSE 18

COURSE 19

COURSE 20

JOINT SYMPOSIUM ESCRS Myopia

COFFEE BREAK

17.00

MAIN SESSION 10

18.00

ARVO SYMPOSIUM

FREE PAPERS

COURSE 21

Screening for Diabetic Retinopathy Organiser: C. Egan UK

4.

ESASO EURETINA: New & Future diagnostic tools for retinal diseases

Organiser: G. Guarnaccia Italy & B. Corcóstegui Spain

6.

What, When and How: Surgical Discussions Organiser: C. Mateo Spain

7.

Electrophysiology Organiser: G. Holder UK

8.

Simple Approach to PVR Management Organiser: B. Corcóstegui Spain

9

Advanced OCT Organiser: A. Polito Italy

10.

Screening and Management of ROP Organiser: A. Kychenthal Chile & G. Caputo France

11.

How to read Autofluorescence Images Organiser: F. Holz Germany

12.

Vitrectomy in Diabetes Organiser: A. Laidlaw UK

13.

ARMD Organiser: G. Soubrane FRANCE

New Strategies in Trauma Organiser: C. Forlini Italy

16. Managing Complications in Vitrectomy Surgery

Organiser: P. Sullivan UK 17. Current Management in Uveal

Melanoma 2010

Organiser: D. Pelayes Argentina

SUNDAY 5 SEPTEMBER Bordeaux

Havane

351

353

MAIN SESSION 11

FREE PAPERS

COURSE 23

COURSE 24

Grand Amphitheatre

08.00

10.00 COFFEE BREAK

11.00

13.00

2.

The Characteristics and Interpretation of SD-OCT

Organiser: C. Delaey Belgium

15.

20.00

12.00

REGULAR INSTRUCTIONAL COURSES: 1.

Macular Dystrophies

Organiser: E. Souied France

14. Guidance in intravitreal therapy

Organiser: U. Schmidt-Erfurth Austria

COURSE 22

19.00

09.00

Retinal Detachment Organiser: I. Kreissig Germany

5.

Management of proliferative diabetic retinopathy

Organiser: A. Laidlaw UK

GENERAL ASSEMBLY

MAIN SESSION 7

2.

3.

SATURDAY 4 SEPTEMBER Main Hall Ternes

FULL DAY COURSES: 1.

Uveitis

Organiser: C. Pavesio UK

MAIN SESSION 13 MAIN SESSION 12

FREE PAPERS

14.00 * Please note that this is a preliminary programme and the content may be subject to change

Available at www.euretina.org: • Congress Registration • Courses and Wetlabs • Full Programme Info • Hotel Bookings • Membership Application

JOINT SYMPOSIUM ESCRS Endophthalmitis

18.

2010: The up-to-date Vitrectomy Techniques using only 25G and 25 Plus+ Organiser: T. Nikolakopoulos Greece

19.

Surgical Approach to the Vitreoretinal Interface Organiser: P. Brazitikos Greece

20.

Small Incision Vitrectomy Organiser: C.Pruente Switzerland

21. Managing diabetic macular oedema: pearls and pitfalls

Organiser: E. Midena Italy 22. Fluorescein and ICG-angiography – interpretation and diagnosis of macular diseases

Organiser: D. Pauleikhoff Germany 23. Modern OCT imaging: Clinical value and scientific perspectives

Organiser: U. Schmidt-Erfurth Austria 24. Vitreoretinal Complications of Cataract Surgery

Organiser: B. Little UK *Instructional courses available on ticket only basis

paris 2010

EUROTIMES

Saturday 4 September

Satellite Education Programme

Morning Symposia

™

SATELLITE EDUCATION PROGRAMME

10TH EURETINA Congress 2-5 September 2010

10:00 – 11:00

Nutrition and AMD. Evidence Based Medecine. From AREDS to ALIENOR and PIMAVOSA studies Room: 351 Moderator: J. F. Korobelnik FRANCE Speakers:

Friday 3 September

Sponsored by

Morning Symposia

Evening Symposia

10:00 – 11:00

Treatment Paradigms in Surgical and Medical Retina

Pfizer Satellite Symposium Room: Amphitheatre Bordeaux Sponsored by

Lunchtime Symposia (lunchbox included) 13:00 – 14:00

Novartis Satellite Symposium Room: Amphitheatre Bordeaux Sponsored by

13:00 – 14:00

Empower Your Future with Sutureless Vitrecomy The Stellaris PC Launch Symposium Room: 351

Lunchtime Symposia (lunchbox included) 13:00 – 14:00

Inflammation and Retinal Disease

18:00 – 18.15 Registration 18:15 – 20.00 Symposium (Reception to follow)

Room: Amphitheatre Bordeaux

Room: Amphitheatre Bordeaux

Moderators:

Moderator: A. Augustin Germany

Introduction and Welcome

Opening Remarks

A. Loewenstein ISRAEL Exudative AMD Subtypes: RPE-Detachments, RAP, and Polypoidal Choroidal Vasculopathy”

J. Ambati USA Inflammation and Retinal disease, is it more to it than VEGF?

A. Augustin GERMANY Medical and Surgical Approaches to Diabetic Macular Edema

C. Claes BELGIUM Diabetic Retinopathy: New Trends and Techniques S. Rizzo ITALY Conventional retinal Detachment Surgery Versus Primary Vitrectomy: Techniques, Complications and Results A. Augustin GERMANY Closing Comments

Moderator: Y. Le Mer France

G. Coscas France, F. Bandello Italy

A. Kampik Germany Steroids in Management of Macular Edema – A relevant option to anti-VEGF therapy S. Lightman UK Steroids in Management of Uveitis F. Bandello Italy Combination therapy, the future for Macular Disease Management?

A. Loewenstein Israel Patient cases - Panel debate Sponsored by

Sponsored by

J. Nadal SPAIN The Benefits of TSV for your Patient

13:00 – 14:00

New D.O.R.C Vitreoretinal Developments

C. Awh USA Light Matters

Room: 351

P. Stodulka CZECH REPUBLIC Field Experience with the Stellaris PC

Sponsored by Sponsored by

Please note that this is a preliminary programme and is subject to change

Register online EUROTIMES www.euretina.org/satellites ™

SATELLITE EDUCATION PROGRAMME

M. N. Delyfer FRANCE M. B. Rougier FRANCE

Update

retina

Treating AMD

Topical therapies to open new front in war against AMD

by Dermot McGrath in Paris

A

new generation of highly potent topical therapies could open up potentially exciting avenues for the future treatment of choroidal neovascularisation (CNV) and age-related macular degeneration (AMD), according to Baruch D Kuppermann MD, PhD. “In terms of topical therapy for CNV and AMD, poor ocular penetration has historically limited the use of such therapies for posterior segment diseases. However, we are now seeing small-molecule drugs with high potency being developed to meet this challenge,” he said.

Addressing the Macula 2010 meeting, Dr Kuppermann, professor of ophthalmology and biomedical engineering at the University of California Irvine, said that significant progress has been made in overcoming the limitations of previous attempts to develop topical therapies for CNV/AMD. “Pre-clinical studies show many of these agents to have good posterior segment penetration, as well as high safety and efficacy in animal models of CNV and vascular leakage that served as benchmarks for the development of drugs such as Lucentis and Macugen. Clinical studies are under way which should tell us a lot more about the potential of these drugs to

obtain therapeutic drug concentrations in the posterior segment of the eye after topical drug administration,” he said.

Discussing the ocular transport scheme for topical drugs, Dr Kuppermann noted that there are a variety of possible routes for therapeutic agents to reach the target area.

“Topical agents can diffuse across the cornea into the aqueous humour and then to the posterior tissues. Drugs can enter directly through the pars plana without encountering the blood-retinal barrier by diffusing across the conjunctiva, sclera, and choroid, followed by penetration of Bruch’s membrane and the retinal pigment epithelium,” he said.

The transcorneal route has many features which limit drug penetrance to the posterior segment. Because the cornea is a unique tissue that has an aqueous phase (stroma) sandwiched between two lipid layers (epithelium and endothelium), a drug that is both hydrophobic and hydrophilic can penetrate corneal tissue more freely, said Dr Kuppermann. Conversely if a drug is a pure polar or a pure non-polar compound, it does not penetrate the cornea so effectively.

The trans-conjunctival-scleral route to the posterior segment makes sense for a number of reasons, said Dr Kuppermann.

Firstly, mechanically blocking off the corneal surface has little effect on drug penetration into the posterior tissues, suggesting that the conjunctival route is the more important for posterior segment drug delivery. Also, the sclera has a large and accessible surface area and a high degree of hydration that renders it conducive to water-soluble substances. It is relatively devoid of cells, has few proteolytic enzymes or protein-binding sites that can degrade or sequester drugs and scleral permeability does not appreciably decline with age, he said.

Dr Kuppermann identified five drugs that are to the forefront of the race to develop topical therapies for posterior segment diseases: ATG3 (CoMentis), OT-551 (Othera Pharmaceuticals Inc.), TG100801 (TargeGen), Pazopanib (GlaxoSmithKline), and OC-10X (OcuCure).

contact

Baruch D Kuppermann MD, PhD -bdkupper@uci.edu

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19

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Friday, 3 September Treatment Paradigms in Surgical and Medical Retina

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Moderator and Speaker: Prof. Albert J. Augustin (Germany)

18:00 – 18:15 Registration 18:15 – 20:00 Symposium (reception to follow)

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Le Palais des Congrès de Paris, Bordeaux Room, 3rd Level

18:15 – 18:45 Registration and Light Refreshments 18:45 – 19:45 Symposium 19:45 – 20:45 Reception

Sunday, 5 September Maximizing Surgical Outcomes: Therapeutic Considerations and Clinical Experiences Le Palais des Congrès de Paris, Room 252 A/B, 2nd Level 12:30 – 13:00 Registration 13:00 – 14:00 Symposium (lunch boxes provided) Moderator: Dr. James P. McCulley (US) Faculty: Prof. Dr. José Manuel Benítez del Castillo (Spain) Prof. Uwe Pleyer (Germany) Prof. Maurizio Rolando (Italy)

Register for all of the events online:

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12:30 – 13:00 Registration 13:00 – 14:00 Symposium (lunch boxes provided) Moderator and Speaker: Dr. Khiun Tjia (Netherlands) Faculty: Dr. Robert H. Osher (US) Dr. Abhay R. Vasavada (India)

Moderator: Dr. Francesco Carones (Italy) Faculty: Dr. Arthur Cummings (Ireland) Dr. John Kanellopoulos (Greece) Prof. Thomas Kohnen (Germany) Prof. Theo Seiler (Switzerland)

Monday, 6 September Surgical Techniques: Injecting the Latest Technologies Le Palais des Congrès de Paris, Bordeaux Room, 3rd Level

Moderator: Dr. Donald N. Serafano (US) Faculty: Dr. Marino Descepola (Canada) Dr. Rudi Nujits (Netherlands) Mr. Richard Packard (UK)

12:30 – 13:00 Registration 13:00 – 14:00 Symposium (lunch boxes provided)

Alcon in Paris EURETINA/ESCRS Congresses 3-6 September 2010

SURGICAL FACULTY Dr. Lucio Buratto

PANEL FACULTY Dr. Donald N. Serafano

Host Surgeon Medical Director Center Ambrosiano de Microchirurgia Oculare (C.A.M.O.) Milan, Italy

Moderator Complete Eye Care Associates Clinical Associate Professor University of Southern California Los Alamitos, California

Dr. Takayuki Akahoshi

Prof. Beatrice Cochener

Director of Ophthalmology Mitsui Memorial Hospital Tokyo, Japan

Dr. Luis Cadarso

Head of Ophthalmology Hospital Meixoeiro Medical Director Clinica Cadarso Vigo, Spain

Dr. Philippe Crozafon

Professor of Ophthalmology University of Brest Brest, France

Dr. Ozana Moraru

Medical Director Oculus Eye Clinic Bucharest, Romania

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ESCRS

EUROTIMES

™

3–6 September 2010 During the XXVIII Congress of the ESCRS Le Palais des Congrès, Paris, France

Day 1: Friday 3 September 09.00 – 17.00

Transforming your Ophthalmological Practice Business Skills for Ophthalmologists Keith Willey, associate professor, London Business School This one-day masterclass will lead participants through the key areas to be considered when committing to improve your private practice – making it more successful and profitable in attracting patients and colleagues.

The session will blend lessons from growing businesses of all types based on research from London Business School together with the special considerations necessary in ophthalmology practice.

Participants will diagnose their own situation, learn from a case study based on the growth of a 30-surgeon practice and debate the issues.

The key take-away message from this session will be a comprehensive understanding of the steps necessary to grow your practice and an appreciation of how to reconcile your personal appetite for the risks, efforts and rewards involved.

Course fee €200. Only 50 places available.

Day 2: Sunday 5 September 14.00 – 14.15

14.45 – 15.00

Introduction and Welcome

Q&A

Paul McGinn, barrister at law and editor of EuroTimes

14.15 – 14.45 Building a Practice Website David W Evans, PhD, MBA, president, Ceatus Media Group LLC This presentation will provide a step–by–step account of how to develop a practice website. It will also offer practical advice to ophthalmologists on how to reduce maintenance and development costs to a minimum and how to ensure that your website is easy to access and to navigate for your existing patients and potential patients.

15.00 – 15.20 Changing the Paradigm for Marketing your Practice Kris Morrill, KAM Communications This workshop will focus first on tools for evaluating your practice’s current marketing and then discuss strategies for improving the effectiveness of your marketing plans. Special attention will be given to improving communication to patients, including examples of what works and does not work when talking to patients.

Day 2: Sunday 5 September (continued) 15.20 – 15.30

15.50 – 16.00

Q&A

Q&A and close

15.30 – 15.50 Differences in Telephone Practices amongst European Ophthalmology Clinics Rod Solar, LiveseySolar Practice Builders Rod Solar reveals quantitative results of mystery calls conducted with over 30 private ophthalmology clinics across Europe. His presentation reviews how prospective patients are greeted on the phone and differences between clinics when asking them to make appointments. Finally, he’ll compare how clinics are performing against the best converting clinics in the industry and what clinics can do to improve their performance.

Day 3: Monday 6 September 14.30 – 14.35

15.50 – 16.00

Introduction and Welcome

Q&A

Paul McGinn, barrister at law and editor of EuroTimes

14.35 – 15.15 How can Business Planning Improve your Ophthalmological Practice?

Wilfrid Girard, medeuronet, Strasbourg, France.

This workshop, using a case study, will explain why a thorough business plan is an important component of growing an ophthalmology practice, ensuring continued success, as well as helping to protect it from economic downturns.

15.15 – 15.30 Q&A

15.30 – 15.50

16.00 – 16.20 Social Media – Why Ophthalmologists Should be Using the Internet, Including Facebook and Twitter Oliver Findl, director of ophthalmology, Hanusch Hospital Vienna, Austria and consultant ophthalmic surgeon at Moorfields Eye Hospital, London, UK In this workshop, Oliver Findl will explain why ophthalmologists, young and old, should be using the Internet and social media including Facebook, YouTube and Twitter

16.20 – 16.30 Q&A and close

“It’s all About Managing Expectations” Paul McGinn, barrister at law and editor of EuroTimes Paul McGinn, who specialises in defending doctors and hospitals sued for malpractice, will discuss how ophthalmic surgeons can manage the expectations of their patients through the consent process. The take-home message is: a patient who understands the risks of eye surgery is more likely to accept a poor outcome.

Workshops are free of charge but are limited to 200 delegates. The fee for the one day masterclass is €200.

Please book in advance online at www.escrs.org

24

Update

Ocular

ocular surface reconstruction Clinical use of in vitro expanded stem cells has to comply with EU directives on tissue and cell culture as well as Spanish health regulations

by Dermot McGrath in Paris

I

nitial results indicate that ex-vivo expanded limbal stem cell transplantation is a promising technique to safely and effectively treat patients with limbal stem cell deficiency, according to a Spanish research team.

“It is still very early days and obviously we need more studies and longer follow-up to confirm these results, but we have clearly demonstrated that it is possible to culture and expand limbal stem cells in compliance with the latest good manufacturing practice (GMP) as well as stringent European Union and Spanish regulations,” said Margarita Calonge MD, PhD, professor of ophthalmology at the University Institute of Applied Ophthalmobiology (IOBA), University of Valladolid, Spain.

The IOBA/IBGM (University of Valladolid) is one of the first centres that meets all standards imposed by both the European Community and by the Spanish Medicines Agency to perform such transplants in accredited mobile production facilities.

Dr Calonge noted that limbal stem cell deficiency (LSCD) syndrome is defined as a failure of corneal epithelial stem cells due to destruction or dysfunction. Ocular conditions with abnormalities of ocular surface repair include congenital diseases such as aniridia, systemic conditions such as Stevens-Johnson syndrome or more commonly due to infection or trauma.

Conjunctivalisation, stromal scarring, vascularisation, ulceration and chronic inflammation associated with severe LSCD can result in vision loss and chronic pain. Restoring ocular health in these eyes has traditionally been frustrating, noted Dr Calonge, since autologous non-expanded limbal grafts risk damage to the healthy eye and allogeneic grafts are susceptible to immunological rejection.

“Traditional allograft limbal transplantation usually fails in the long term due to immune rejection and the risk of stem cell failure in live donors,” said Dr Calonge. She cited a multicentre retrospective case series analysis of limbal transplantation by Torres et al (Arch Soc Esp Oftalmol 2008, 83: 417-422) which showed a high failure of allografts for such patients after almost 20 months’ follow-up.

An alternative method using either allogeneic or autologous limbal epithelial stem cells cultured on human amniotic membrane has been proposed as a safe and effective method of reconstructing the corneal surface and restoring useful vision in patients with LSCD.

Dr Calonge noted that the clinical use of in vitro expanded stem cells has to comply with EU directives on tissue and cell culture as well as Spanish health regulations.

“Stem-cell therapy studies in humans are deemed as clinical trials and must be conducted in compliance with good clinical practice (GCP). Stem cells, like drugs, are to be manipulated only under strict good manufacturing practice procedures in accredited clean-room environments,” she said.

Straightforward technique Once the cells have been cultured in the lab, the technique for transplanting them to the required area is relatively straightforward, said Dr Calonge. (Surgeon is Dr Herreras.)

“It is quite simple, as the amniotic membrane sheet covered with limbal stem cells is placed cells-down on top of the ocular surface, covering the entire cornea, limbal area and adjacent conjunctiva. It is then sutured to the conjunctiva. The most difficult part is actually to prepare the bed, which in some cases depending on the causative pathology leading to limbal stem cell deficiency, means that it is essential to leave a bare sclera and to remove all conjunctival-like and fibrous tissue that has encroached upon the cornea,” she said.

Eleven out of the 12 patients at IOBA have been successfully treated so far using this method. Dr Calonge said that success in these cases was defined as an improvement in the defined clinical parameters of LSCD including an improvement in symptoms/visual acuity, restoration of a more normal corneal phenotype on impression cytology, and appearance of a regular hexagonal basal layer of cells on corneal confocal microscopy (HRTIII-cornea module).

The one failure thus far, a patient with chemical injury, failed because of a secondary infectious conjunctivitis.

“This young patient works in a dirty environment.

We believe the reason was not a primary failure of the transplanted cells, but a secondary one,” she said.

The case for cultured cells While some specialists have argued that it is better and more economic to perform auto-limbal transplantation rather than implanting autologous cultured cells for patients with a sufficiently large portion of healthy limbus in the

n n n n n n

EUROTIMES | Volume 15 | Issue 7/8

Symposia Free Papers Other Key Sessions Video Competition Winners ePosters Medal Lectures

contralateral eye, Dr Calonge believes that the future lies in cultured cell transplantation.

“This was precisely the technique done until a few years ago and is still performed in some places. To deal with a 360-degree limbal deficiency, which is usually the case, one needs 180-degrees of donor tissue, in other words two pieces of 90-degrees each. This is a lot of tissue, putting the donor eye at risk. Patients are also very reluctant to have their ‘good eye’ subjected to any surgical procedure.

Additionally, the surgical technique to properly remove that much limbal tissue is complex and is very time consuming,” she said.

The outcomes with donor tissue from cadaver eyes are also problematic, points out Dr Calonge. “Again, it is a lot of donor tissue and with the same complexity for tissue extraction but with an elevated risk of graft rejection. Also these patients need immunosuppression with more than one drug for three years or perhaps even for the rest of their life. Most cases treated with this approach have failed long term, the majority of them during the first year,” she said.

In contrast, the in vitro expansion allows for just one square millimetre to expand in culture, said Dr Calonge. “We know that cultured cells tend to lose their immunogenic potential. We only use one drug, for one year and it is likely that this protocol can be shortened in the future,” she said.

Discussing the key factors that favour a successful limbal cell transplant, Dr Calonge said that the cause of limbal insufficiency is perhaps most influential. “Bilateral cases of immune-based cicatrizing conjunctivitis, for example Stevens-Johnson syndrome, Lyells syndrome, mucous membrane pemphigoid or some severe chemical burns are more difficult cases to deal with,” she said.

Future perspectives Looking to the future, Dr Calonge said that improvements to the current technique could include experimental approaches to using extraocular stem cells obtained with minimal disturbance to the patient, as well as autologous cells or allogenic cells with little or no capacity to elicit an immune response. Another bonus would be to reduce the costs of cell culture expansion.

“Everything has become very complicated since the EU decided to give cultivated cells the status of a medical drug. Although it has been a positive move to regulate this activity the current legislation is too strict while still allowing some clinics to offer stem cell treatments with zero scientific support behind them,” she said.

Dr Calonge added that IOBA is planning to forge closer links and collaborate actively with the research team of Dr Julie Daniels at the University College of London, one of the pioneers of in vitro expansion of limbal cells under GMP conditions.

contact

Margarita Calonge - calonge@ioba.med.uva.es

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26

Update

Setting the standard.

Ocular

News from ARVO 2010

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Artificial retina Artificial retina implantable systems are making their way from the lab into the clinic. German researchers reported promising results in an initial clinical study of one such implant. Eleven patients have received the ‘Retina Implant’ since 2005. The researchers reported that blind patients were able to view and focus on objects as their eye and head naturally moved. The experimental device includes a 1500 pixel “camera chip” implanted under the retina. The implant works without assistance from external devices.

“Our first clinical trial provided encouraging information about the safety, visual results and placement of our microchip. The results presented today are encouraging news in the fight to restore vision to patients suffering from retinitis pigmentosa,” said Prof Eberhart Zrenner MD, director and chairman of the Institute for Ophthalmic Research at the Centre for Ophthalmology of the University of Tübingen, Germany.

A new clinical trial is scheduled to begin shortly. More information is available at: www.retina-implant.de.

Couch bad for eyes The couch potato lifestyle, already a well-known risk factor for cardiovascular disease, also appears to affect the retina. Researchers examined the association of physical activity and television viewing time with retinal vascular calibre and explored the differences in white, black, Hispanic and Chinese racial/ethnic groups.

They evaluated retinal vascular calibre in adults aged 45 to 84 as part of the population-based, cross-sectional Multi-Ethnic Study of Atherosclerosis study. Sure enough, those in the lowest two quartiles of intentional physical activity had a wider retinal venular calibre compared to those in the highest quartile of intentional physical activity, with exception of blacks. Similarly, those in the highest quartile of television viewing time had a wider venular calibre compared to those in the lowest quartile. Wider venular calibre has been shown to be associated with higher cardiovascular risk in previous studies.

Customised gene therapy A new gene therapy trial provides valuable insight into therapeutic strategies for treating patients with Leber Hereditary Optic Neuropathy (LHON). Previous trials have demonstrated proof of concept of this general approach. Researchers from Bascom Palmer Eye Institute screened LHON patients with acute or chronic visual loss in one or both eyes as well as their asymptomatic maternally related family members for ND1, ND4 and ND6 mtDNA mutations commonly associated with the disease. All patients and maternal relatives underwent complete neuro-ophthalmic examinations, automated visual fields, pattern electroretinogram (PERG) and OCT every six months.

The preliminary work showed that RGC survival with dysfunction many months after visual loss may provide a long window of opportunity for intervention and rescue

by AAV mediated ocular gene delivery of a normal ND4

subunit. It would also correct for secondary mutations with expression of the normal ND4 protein, the researchers reported.

This suggests that possible candidates for future gene therapy may include affected patients with mildly reduced retinal nerve fibre layer (RNFL) or carriers with low PERG amplitudes and normal RNFL if the PERG is a predictor of conversion to LHON in these carriers.

AMD anti-VEGF dosing The big questions now with anti-VEGF treatment of AMD involve dosing. A study presented here that compared two dosing schemes – an eight-weekly bevacizumab (Avastin) treatment and a four-weekly ranibizumab (Lucentis) strategy – showed almost equivalent benefit for patients with wet AMD. The data come from a German retrospective analysis of 272 patients with choroidal neovascularisation AMD, who received an initial treatment of either three intravitreal injections of bevacizumab 1.5mg in eight-weekly doses or ranibizumab 0.5mg in four-weekly intravitreal injections.

The poster presentation by Wolfgang F Schrader MD and colleagues at the Universitaetsaugenklinik, Wuerzberg, Germany, noted that the effects seen in the clinic were different than that observed in clinical trials.

“In spite of a better baseline visual acuity and a better initial gain visual acuity, the visual acuity at 12 months and at the last visit was inferior to the bevacizumab data,” said Dr Schrader.

Cross linking safe for endothelium Corneal collagen cross-linking is getting a lot of attention as a potential treatment for keratoconus and ectasia. A new study concludes that the experimental treatment appears to be safe for the corneal endothelium – neither diminishing cell counts or function. A study conducted at the New York University School of Medicine included 23 eyes with keratoconus and 17 eyes with corneal ectasia. A comparison of baseline and one-year postoperative cell counts showed no significant change in cell counts over time.

Coffee may prevent cataracts A report from a lab at the University of Maryland School of Medicine in Baltimore hints that caffeine may offer protection against cataract formation. Hypothesising that caffeine may inhibit the intraocular generation of reactive oxygen species in the lens and consequent damage to the tissue, investigators incubated mice lenses in medium exposed UVA in the presence of kynurenine with and without caffeine. They also conducted in vivo studies by incorporating caffeine with galactose into the diet of rats. In both studies, caffeine was found to be effective in protecting the lens against damage. These effects of caffeine have not been reported before.

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News

EUREQUO

EUREQUO in The Netherlands

Dutch ophthalmologists see the benefits of a European-wide registry

by Dermot McGrath in Paris

T

he roll-out of the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) is proceeding as planned in The Netherlands and has met with a favourable reception there from the majority of ophthalmologists, according to Rudy Nuijts MD, PhD. “We are very pleased with the initial response from Dutch ophthalmologists and the first phase of the implementation of the registry has gone pretty much as planned,” said Dr Nuijts.

Dr Nuijts indicated that part of the reason for the quick uptake of the EUREQUO

registry lies in the fact that cataract surgeons in The Netherlands are already well attuned to the practice of inputting data and keeping records.

“We already have a registry for cataract complications in The Netherlands that was developed about five or six years ago,” explained Dr Nuijts. “This has actually been quite successful in terms of cooperation, as there is an obligation in The Netherlands for surgeons to register their data on surgical complications. However, the means of actually inputting that data and keeping those records was left up to the individual surgeon,” he said.

Given this situation, Dr Nuijts said that

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Sunday 5th September 08.00 – 10.00 Le Palais des Congrès

Introduction

paris 2010

What do we need to know about refractive surgery?

Paul Rosen UK

XXVIII Congress of the ESCRS

EUREQUO, purpose, background & design Mats Lundström SWEDEN What do we need to know about cataract surgery?

Ype Henry THE NETHERLANDS

Presentation of the EUREQUO system Eva Wendel SWEDEN Pause Tools for clinical improvement Susanne Albrecht SWEDEN How can we do better cataract surgery using EUREQUO? Ype Henry THE NETHERLANDS How can we do better refractive surgery using EUREQUO? Paul Rosen UK

Project co-financed from the EU Public Health Programme

Output from the EUREQUO system for benchmarking Mats Lundström SWEDEN Concluding remarks Mats Lundström SWEDEN Do not miss this opportunity to become part of the future.

Come and see the benefits to be gained by you!

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EUROTIMES | Volume 15 | Issue 7/8

the arrival of the EUREQUO registry left the Dutch Ophthalmological Society with a dilemma: should it ditch its current system and start from scratch and ask all its members to adopt EUREQUO, or would it be better to try to fuse the two systems?

Ultimately it was decided to opt for the latter approach, said Dr Nuijts.

“We obviously thought that it made no sense to double the workload by having two separate registries, and the Dutch surgeons probably wouldn’t accept this extra layer of administration. So we took a similar approach to some Scandinavian countries by implementing a system that allows us to integrate our current cataract database into EUREQUO. That has been quite successful – the software is now in place, so we can actually import our national data directly in the EUREQUO database,” he said.

With the cataract component of the registry falling nicely into place, the next challenge was to try to achieve a similar outcome with the refractive data, even though no such registry existed in The Netherlands.

Once again the national ophthalmological society debated the pros and cons of going straight to the EUREQUO registry or of setting up a Dutch-language system along the lines of the cataract database that could then be integrated into the wider EUREQUO system.

“We decided that it would probably be better to have one in the Dutch language and based on the same approach as the one we had developed for cataract surgery registry some years ago,” said Dr Nuijts. “So we had the same software company develop the database using the same analysis parameters as EUREQUO for easier integration into the system. That means that we will be able to put that data directly into the EUREQUO refractive surgery database,” he added.

Dr Nuijts said that the Dutch national society was grateful for the support of the ESCRS in financing and facilitating the process of integrating its national system with EUREQUO and emphasised the benefits that will accrue to all participating ophthalmologists as a result of the initiative.

“It is very much in the interests of our members to have a registry and the great advantage of EUREQUO is that the data will be available over the long term. It means we will have all the advantages of benchmarking between European countries, which is very

EUREQUO European Registry of Quality Outcomes for Cataract & Refractive Surgery

“

We are very pleased with the initial response from Dutch ophthalmologists and the first phase of the implementation of the registry has gone pretty much as planned Rudy Nuijts MD, PhD important because national health authorities are looking more and more carefully at what happens in all these separate European countries. They are looking at the number of cataracts per 100,000 population and how that differs from one country to the other and the reason for that, as well as the complication rates,” he said.

Dr Nuijts said that the initial feedback from his Dutch colleagues has been largely positive.

“Most of the ophthalmologists that I have spoken to think it is a very good initiative.

The penetration rate for cataract is already around 75 per cent to 80 per cent, which is quite high. The refractive surgery side has fewer ophthalmologists involved compared to cataract, but I believe that we will see high penetration rates here too. The other thing is that there are a number of refractive surgery practices or chains here in The Netherlands that have their own registry systems in place, and some of them do very large numbers of procedures. So we need to find a way to facilitate them in order to build a link between their system and the EUREQUO registry to allow the data to be imported,” he concluded.

contacts

Philippe Sourdille - philippe.sourdille@wanadoo.fr

News

RESEARCH

ESCRS research symposia

Update on new implants and diagnostic and surgical devices

by Roibeard O’hEineachain in Dublin

T

he clinical research symposia at the and greater PCO. Rupert Menapace MD, upcoming XXVIII Congress of the Austria, will review the current knowledge ESCRS in Paris will have as their regarding the impact of material and uniting theme ‘New Technology design factors on the incidence of PCO, Applications in Ophthalmic Surgery’ and will refractive predictability and stability; Liliana include presentations from a wide range of Werner MD, US, will present her findings perspectives examining the impact of new concerning IOL design and capsular bag diagnostic technologies and devices on the diameter differences; and Burkhard Dick MD, surgical treatment of refractive errors and the Germany, will review the latest results with prevention and treatment of ocular disease. the light-adjustable IOL. In addition, Gerd As in previous years, the symposia will Auffarth MD, Germany, will examine the provide a platform for lively debate on the experimental and clinical measurements of many controversies which cataract and pseudophakic accommodation and Okihiro refractive surgeons deal with in their daily Nishi MD, Japan, will provide an update on practice, said Phillippe Sourdille MD, France, lens re-filling. who founded the symposia in 1993 and who is “This first session will provide a also a member of the organising committee. comprehensive overview of the clinical results “What is interesting about the clinical of IOL implantation, not only the different research symposia is that their aim is to be factors viewed separately, but the overall result prospective and comprehensive and to provide and their impact on vision,” Dr Sourdille a real live discussion forum which is not really noted. possible for the rest of the meeting. Therefore, The second symposium, chaired by the audience for the symposia, which grows Francois Malecaze MD, France, and every year, is really a very important part of Cynthia Roberts PhD, US, will focus on the these sessions. A lot of excellent questions and Biomechanics of the Cornea and will include propositions come from the audience,” he told reports on several new technologies for EuroTimes in an interview. examining the cornea’s physical properties.

The first of the symposia, chaired by Dr The session will include a presentation from Sourdille and Jorge Alio MD, Spain, will focus Dr Roberts on dynamic corneal surface on New IOL Materials and Micro Design. topography, a presentation by William J • AP crystalens 250x90 4/03/09 9:18 Page 1 During his introduction Dr Sourdille will Dupps, US, on corneal elasticity imaging discuss the relationship of smaller incisions with high-speed OCT, and another by David

Touboul MD, France, on ocular supersonic shear wave imaging. There will also be updates on research into collagen cross-linking for the treatment of keratectasia from Theo Seiler MD, Switzerland, and Renato Ambrosio MD, Brazil. The session is also likely to include some discussion of the safety aspects of collagen cross-linking.

“In this symposium we shall see the new investigations being carried out which will tell us more about the corneal biomechanics.

But we will also have to look at the behaviour of the cross-linked cornea in terms of the penetration of drugs and IOP measurement, so this will be another lively session,” Dr Sourdille said.

The third session is a Joint Symposium with EURETINA, chaired by Marie-Jose Tassignon MD, Belgium, and Sebastian Wolf MD, Switzerland, which will focus on The Role of the Vitreo-Lenticular Interface regarding endophthalmitis, retinal complications in cataract surgery, and lens complications in vitreoretinal surgery.

This is really a remarkable session, the joint symposium really illustrates the broadening spectrum of the ESCRS. We always wanted to analyse all possible consequences of anterior segment surgery on the rest of the eye and now with the joint session we have communication between specialists of the two parts of the eye.

The following session, High Definition Diagnostics and Imaging will be of particular interest to cataract and refractive surgeons, Dr Sourdille noted. Chaired by Thomas Olsen MD, Denmark, and Dan Reinstein MD, UK, it will include presentations by Dr Reinstein, Renato Ambrosio MD, and G Carp MD, South Africa, on new technologies for detecting keratoconus. In addition, Jorge Alio MD, Spain, will discuss the use of new technologies for measuring the angle, sulcus and capsular bag when sizing phakic IOLs. The final symposium, Myth and Reality of Clinical Research? chaired by Manfred Tetz MD and Jean-Jacques Gicquel MD, will examine the role of organisations such as the ESCRS in the promotion of and the dissemination of findings from ophthalmic clinical research. Peter Barry FRCS, Ireland, will discuss the aspirations and accomplishments of the ESCRS, while Eberhardt Zrenner MD, Germany, will review those of the EVI, and Tero Kivela MD, Finland those of EVER. In addition, Harminder Dua MD, UK, will discuss clinical research from his perspective as editor in chief of the British Journal of Ophthalmology.

Pierre-Jean Pisella (Tours) will deal with ethics and feasibility of clinical research.

“We must acknowledge the great work of Peter Barry because with the ESCRS Endophthalmitis Study he really established the ESCRS worldwide as an important research society. We all know what a tremendous lot of work it has been. Certainly we will continue on the path that Dr Barry has opened and the research committee is currently conducting a wide survey of such programmes. Large multi-centred European studies, clinically and prospectively oriented, are vital to our continuous development and influence,” concluded Dr Sourdille.

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29

30

News

EBO European Board of Ophthalmology

EBO exam success

EBOD examination underlines growing impact of European ophthalmic education

by Dermot McGrath in Paris

EBO Awards Ceremony – Successful Spanish, Greek and German Candidates

EUROTIMES | Volume 15 | Issue 7/8

T

hese are busy times indeed for the European Board of Ophthalmology (EBO), which has been active on a number of fronts in recent months.

In May, the highest number of 310 candidates from 27 European countries came to Paris to sit the EBO Diploma (EBOD) examinations, a figure which continues the steadily upward trend of recent years for this prestigious qualification. In addition to the candidates, over 180 examiners travelled from all over Europe to make up the panel of skilled, multilingual EBO examiners, all experts in their various fields.

Held every year in Paris, the EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices.

For Marko Hawlina MD, PhD, FEBO, current president of EBO, this year’s examinations provided grounds for satisfaction for a number of reasons.

“Firstly, it was heartening to see so many candidates come to Paris despite all the problems with the current financial climate and worries about travel disruptions with the volcanic ash. Another source of satisfaction is that the standard seems to have gone up somewhat in recent years and the knowledge of the candidates has improved because more candidates were successful this year than in previous years,” he said.

As in previous years, high attendance was expected from France, Germany, Switzerland, Belgium, The Netherlands and other countries of northern Europe.

A particularly encouraging trend this time around was the increased number of candidates from Spain, Greece, Italy and the countries of eastern Europe, a development that the EBO hopes is a sign of further growth in the near future. From the EBO perspective, the ideal scenario would be to have the EBO examination accepted as a national knowledge test and then for national authorities to add their own formal requirements to enable candidates to attain full accreditation to become specialists in their chosen country, said Prof Hawlina.

“The EBO diploma has always been deemed as a badge of quality for these countries, but not every country has yet included the EBO exam in their qualification system. It would be good if all the residents who passed the exam in Paris could have their efforts acknowledged, at least in part, by their national examining bodies. France, Switzerland, Belgium, The Netherlands, Slovenia and most recently, Austria, have already adopted this approach and have

accepted the EBO exam as the equivalent to their own examination, which is something we would like to see spread to other countries as well,” he said.

Prof Hawlina noted that the higher pass rate in 2010 was achieved despite concerns in some quarters about the introduction of negative marking for the first time in the multiple choice question part of the written examination.

“It was interesting to note that negative marking did not actually impact on the pass rate, so we can conclude that the higher discriminating power of the exam was not achieved at the expense of the pass rate. The idea behind negative marking is to ensure that the answers are based on knowledge rather than wild guessing, although understandably there was a fear among the candidates that this would reduce their chance of passing the exam.

This has not turned out to be the case, as not less but more knowledgeable ones passed,” he said.

Prof Hawlina added that the relatively high pass rate is in part understandable because the demanding eligibility criteria set by the EBO national delegates and programme directors raise the basic knowledge platform of the EBO exam compared to other similar exams.

Another major plus from this year’s EBO gathering in Paris was the influx of new examiners who have decided to play their part in advancing the EBO’s goal of harmonising the standards of ophthalmology education and training across the continent.

“I think the best indication we have that this European atmosphere of collaboration is very much alive is that we had many more applications from examiners than last year. This allowed us to put in place a system where some of the senior examiners could oversee the exam procedures and ensure that everything was conducted to the highest standards, and the new younger examiners could sit in and observe and see how the process works and what will be required of them in the future. It’s a positive mentoring process, so there was some education to the examiners side as well this time and many of them left with really good impressions and are very enthusiastic to return next year,” he said. Prof Hawlina also acknowledged the support of the French Society of Ophthalmology (SFO) which offered logistical support throughout the exam and also Laboratoires Thea, whose support helped to ensure that EBOD was also a pleasant social event in the best traditions of French hospitality.

Looking to the future, Prof Hawlina said that the immediate goals of the EBO are to consolidate the work achieved over the past few years, promoting the

EBO examination and strengthening the EBO’s work in areas such as residents’ and teachers’ observership grants, continuing medical education and expanding the current network of certified training centres and hospitals.

In November, the EBO is scheduled to hold its Extraordinary General Assembly at which elections to the EBO Board will take place.

Prof Hawlina’s term of office as EBO president comes to an end in December 2010, when he will be succeeded by Mr Wagih Aclimandos, a consultant ophthalmic surgeon at King’s College Hospital, London.

However, while Prof Hawlina will be stepping down from the role of commander-in-chief of the EBO, he will still remain actively involved in the Board’s activities and will be able to devote more time to particular EBO activities where he feels he can make a difference.

“After my mandate ends, I become past-president and will sit on the EBO Board for another two years. I have offered support to help in every aspect of the EBO’s work, most notably in trying to accelerate the harmonisation of training in eastern Europe, which has been a longstanding interest of mine,” he said.

One obvious outlet for Prof Hawlina’s experience will be the new Workgroup for Eastern European Education (WEEE) set up by the EBO in January this year, and composed of Board members interested in helping to build bridges between eastern and western Europe.

Looking back over his term as president, Prof Hawlina said that most of the objectives that had been set in the organisation’s strategic plan at the time of taking office have been advanced considerably in the past two years.

In this regard, Prof Hawlina highlighted the assistance of Agenda in setting up a new user-friendly and informative website and streamlining applications and other procedures. He also underlined the important contribution of Danny Mathysen, MSc. in Biomedical Sciences from the Department of Ophthalmology of Antwerp University Hospital, and the Speedwell company from Cambridge, UK, in further professionalising the examination process.

The EBO has now adopted the ICO curriculum as the basis of development of its syllabus, said Prof Hawlina. “Using the platform of the ICO curriculum, we are now in the process of ascertaining European opinion as to what procedures need to be learnt during the residency period in order to construct our new logbook. This will set the baseline upon which we will be able to start constructing recommendations for different medical and surgical fellowships. We have also accredited many didactic courses by the EBO through our ENET programme and also recommended the core source books for candidates to study from for EBOD examination and where the MCQ questions are expected to stem from,” he said.

DG SUHPLXP VROXWLRQ [ (1* Y MPR (8527,0(6 LQGG EUROTIMES | Volume 15 | Issue 7/8

A future initiative will be to further upgrade the profile and position of education in European teaching centres and create an award to appreciate the efforts of outstanding European educators, added to the existing Alan Ridgway award for the highest scoring candidate in the MCQ exam at EBOD. “It was particularly gratifying that Alan Ridgway, former head of the MCQ system, was present this year to give this award,” Prof Hawlina said.

He added that while some goals always take more time than originally anticipated, this was perfectly normal in a voluntary organisation.

“We are all very busy professionals, and the EBO work is extra time that people invest voluntarily in the organisation so we are already more than grateful for all the efforts that they make to raise the standards in the EBO and spread the message,” he said.

A particular source of pride is the recent addition of several new training centres to the growing pan-European network of EBO accredited facilities.

“We have four new centres in France and four in Denmark and new applications have also been received from countries such as Lithuania, Italy and Switzerland. The goal is to have at least one accredited training centre in every European country and we hope we will keep this momentum going to build a strong, truly representative training network across Europe,” he concluded.

“

31

The goal is to have at least one accredited training centre in every European country and we hope we will keep this momentum going to build a strong, truly representative training network across Europe

Marko Hawlina MD, PhD, FEBO President of EBO

To learn more about EBO please visit: www.ebo-online.org

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33

News

YOUNG OPHTHALMOLOGISTS

Paris Highlights

Exciting programme attracts top speakers; 50 bursaries available; new website launched

T

he Young Ophthalmologists Programme on Saturday 4 September will be one of the highlights of the XXVIII ESCRS Congress. The programme is being chaired

by Dr Oliver Findl, Austria, and Dr Charlotta Zetterstrom, Norway and features an interesting mixture of basic and more advanced topics.

“I think the programme is very exciting this year,” said Dr Findl, who is also chairman of the Young Ophthalmologists’ Forum. “We will be discussing problems with small pupils, incisions and capsulorhexis. We will also discuss how to do an anterior vitrectomy and what to take care of in IOL implantation procedures.”

Dr Findl stressed that as well as providing a valuable learning experience for young ophthalmologists the programme should also be of interest to their more established colleagues.

“The discussion on biometry and power calculation is relevant to everybody and we expect to have a lot of interest in the discussions on astigmatism correction and presbyopia correction,” he said.

One of the reasons why the Young Ophthalmologists Programme has been so successful at previous congresses, said Dr Findl, “is that it is a compact oneday programme. We will have a lot of interesting issues for both the beginning but also the slightly more advanced surgeons in training,” he said.

To ensure the success of the programme, Dr Findl and the Programme Committee have been fortunate to draw on the expertise of leading surgeons. “It is important,” said Dr Findl, “that we have different points of views during the programme because we all have different ways of teaching our trainees.

For this reason, each topic has two speakers who will be at the podium simultaneously who will interact with each other to ensure the presentations are lively and engaging.

The speakers are from all over Europe and we also have speakers from the US and India so this should allow us to discuss how training is done in different regions.”

The programme ends with the guest lecture from Dr Theo Seiler, Switzerland who will talk about Cross-Linking.

“This is a very interesting topic for all ophthalmologists,” said Dr Findl, “and we have been very lucky to get Dr Seiler, the EUROTIMES | Volume 15 | Issue 7/8

“

It is a compact one-day programme. We will have a lot of interesting issues for both the beginning but also the slightly more advanced surgeons in training Oliver Findl

pioneer in this field, to deliver the guest lecture.”

The John Henahan Prize for Young Ophthalmologists will also be presented during the programme with the award going to the young ophthalmologist who has written the best presentation on “The Outstanding Memory of My Residency.”

Young Ophthalmologists’ Forum

50 bursaries are available funded by ESCRS through national cataract and refractive societies to assist young ophthalmologists who wish to attend the ESCRS Congress.

Dr Findl said it is also planned to have an informal gathering to allow members of the forum to meet and discuss their common goals and needs which were identified by the focus groups which met at the 14th ESCRS Winter Meeting which was held in Budapest, Hungary. EuroTimes is also planning special coverage of the forum in its special ESCRS Congress highlights issue which will be published in October.

New website The new Young Ophthalmologists’ website has also been launched at www.escrs.org/ youngophthalmologist. The website will include details of the newly launched Observership Programme. Grants of €1000 are available for trainees and residents who wish to observe clinical practice in a hospital or university setting and the website will include a list of participating centres. It will also allow young ophthalmologists to apply online for the grants. Centres interested in offering Observerships can sign up to the programme online.

contact

Oliver Findl - oliver@findl.at

Young Ophthalmologists’ Resource Centre Visit our new website

http://youngophthalmologist.escrs.org to find out more about the new

ESCRS Observership Programme. n

The ESCRS has developed a grant programme to support European trainee ophthalmologists who wish to observe clinical practice in a hospital or university setting.

n

The society is currently seeking interest from centres willing to offer observerships of one-to-two weeks’ duration in cataract and/or refractive surgery.

n

Those centres wishing to participate will be added to a database of centres available on this website.

paris

10

TH

EURETINA Congress

Available at www.euretina.org • • •

2–5 September Le Palais des Congrès

Preliminary Programme Online Registration Hotel Bookings

s 2010

XXVIII Congress of the ESCRS Available at www.escrs.org • • •

Preliminary Programme Online Registration Hotel Bookings

4–8 September Le Palais des Congrès

paris 2010

4–8 September Le Palais des Congrès

XXVIII Congress of the ESCRS

Available at www.escrs.org:

• Congress Registration • Courses and Wetlabs • Scientific Programme • Hotel Bookings

Ridley Medal Lecture Life and Death on the Posterior Capsule David Spalton St Thomas’ Hospital, London

Saturday 4 September 1630 – 1800

Sunday 5 September During the Opening Ceremony, 10.00 – 10.45

A. Agarwal India Mature Cataract with Conversion

Saturday 4 September

‘New Technology Applications in Ophthalmic Surgery’ New IOL Materials and Micro Design

High Definition Diagnostics and Imaging

Chairpersons:

Chairpersons:

T. Olsen denmark D. Reinstein uk

Biomechanics of the Cornea

Myth and Reality of Clinical Research

Chairpersons:

(Joint Symposium with EVER)

F. Malecaze france C. Roberts usa

The Role of the Vitreo-Lenticular Interface

K. Tjia the Netherlands Mature Lens, Zonular Dialysis, Torn Posterior Capsule S. Bhattacharjee India Black Cataract with Suboptimal Pupil and Zonular Dialysis

CLINICAL RESEARCH SYMPOSIA

J. Alio spain P. Sourdille france

Video Symposium on Challenging Cases So Many Complications

Chairpersons:

J.J. Gicquel france (EVER) M. Tetz germany

S. Gupta India Mature Cataract with Dropped Nucleus N. Ray India Anterior Capsular Tear Through Posterior Capsule S.Prasad UK IFIS/LIDRS/IOL Problems D. Pahor Slovenia Intense Coughing P. Biswas India Snapped Haptic A. Elkateb Egypt Haptic Stuck in Cartridge B. Malyugin Russia Peripupillary Membranectomy and Haptic Misbehavior

(Joint Symposium with EURETINA)

A. Chakrabarti India CTR Disasters

Chairpersons:

A. Mearza UK Colored IOL, Uveitis, Explantation

M.J. Tassignon belgium S. Wolf switzerland (EURETINA)

T. Monteiro Portugal Repositioning: Sewing Through Optic C. Tataru Romania Repositioning: Synthetic Zonules R.H. Osher USA When All goes Wrong!

paris 2010

main symposia Saturday 4 September

Monday 6 September

Wednesday 8 September

14.00 – 16.00

11.00 – 13.00

11.00 – 13.00

Myopia: The Lens and the Retina

20/10 in 2010: The 20th Anniversary of LASIK

New Solutions for Presbyopia

Chairpersons:

P. Rosen UK B. Aylward UK (EURETINA)

14.00 J. Jonas germany

Definition and epidemiology of myopia 14.15 C. Hammond UK

Aetiology and genetics: a route for therapy?

14.30 J. Vryghem BELGIUM

Surgical options for correcting myopia 14.45 B. Corcostegui SPAIN

Myopic macular pathology: risks and treatment 15.00 J. Holladay USA

The optics of (high) myopia and lens power calculations 15.15 P. Polkinghorne NEW ZEALAND

Risks and prophylaxis of retinal detachment prior to laser or lens surgery 15.30 Questions and Answers 16.00 End of Session

Chairpersons:

B. Cochener FRANCE V. Katsanevaki GREECE

11.00 M. Knorz GERMANY

Introduction 11.05 J. Marshall UK

Evolution of excimer delivery systems 11.20 L. Buratto ITALY

The mechanical LASIK flap concept and its refinements 11.35 T. Seiler SWITZERLAND

Iatrogenic ectasia

Chairpersons:

D. Epstein SWITZERLAND D. Spalton UK

11.00 A. Glasser USA

Correction of presbyopia: dreams and reality 11.15 O. Findl AUSTRIA

Objective testing of near vision 11.30 J. Alio SPAIN

The corneal way - presbylasik and other excimer strategies 11.45 G. Grabner AUSTRIA

Corneal inlays - will they work this time?

11.50 J. Stevens UK

Customized treatments

12.00 M. Holzer GERMANY

Flapless and painless: can the femtosecond laser really correct presbyopia?

12.05 J. Colin FRANCE

The advent of the femtosecond laser

12.15 R. Bellucci ITALY

The lens approach - CLE and multifocal lenses

12.20 I. Pallikaris GREECE

The future of LASIK

12.30 Questions and Answers 13.00 End of Session

12.35 Questions and Answers 13.00 End of Session

Sunday 5 September

Tuesday 7 September

11.00 – 13.00

11.00 – 13.00

Endophthalmitis

Astigmatism

Chairpersons:

Chairpersons:

P. Barry IRELAND G. Richard GERMANY (EURETINA)

11.00 M. Cormican IRELAND

Bacterial isolates around the world and multiresistant organisms 11.15 P. Montan SWEDEN

The intracameral cefuroxime/moxifloxacin debate: a critical look at the literature 11.30 J. van Meurs THE NETHERLANDS

Endophthalmitis after anti-VEGF injections 11.45 L. Cordoves SPAIN

A comparison of the Endophthalmitis Vitrectomy Study and the ESCRS endophthalmitis studies 12.00 A. Naseri USA

Prophylaxis and cost effectiveness 12.15 E. Feretis GREECE

Vitreous biopsy/intravitreal antibiotics vs vitrectomy: European vs American approach 12.30 Questions and Answers

J. Güell SPAIN K. Vannas FINLAND

11.00 N. Alpins AUSTRALIA

Astigmatism: definition and measurement 11.15 B. Malyugin RUSSIA

Corneal surgical techniques: incisional 11.30 D. Reinstein UK

Corneal surgical techniques: excimer ablation 11.45 T. Kohnen GERMANY

Corneal surgical techniques: ring segments, coagulative procedures 12.00 R. Nuijts THE NETHERLANDS

Intraocular surgical techniques: phakic IOLs 12.15 G. Auffarth GERMANY

Intraocular surgical techniques: pseudophakic IOLs 12.30 Questions and Answers

other highlights Journal of Cataract & Refractive Surgery Symposium Controversies in Cataract and Refractive Surgery 2010

Sunday 5 September, 14.00 – 16.00 Chairpersons:

T. Kohnen GERMANY E. Rosen UK

Refractive Surgery Didactic Course Saturday 4 September, 08.30 – 17.00

Surgical Video Symposia Monday 6 & Tuesday 7 September, 14.00 – 16.00

Workshop on Visual Optics Sunday 5 September, 09.00 – 16.00 Chairpersons: I. Pallikaris GREECE

M.J. Tassignon BELGIUM

13.00 End of Session

13.00 End of Session

Young Ophthalmologists Programme Saturday 4 September, 09.00 – 16.00 Chairpersons: O. Findl AUSTRIA

C. Zetterstrom NORWAY

XXVIII Congress of the ESCRS

4–8 September paris 2010

XXVIII Congress of the ESCRS

EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

4-8 September 2010

PARIS 2010

Lunchtime Symposia (lunchbox included)

Lunchtime Symposia (lunchbox included)

Saturday 4 September

Saturday 4 September

13:00 – 14:00

13:00 – 14:00

Ziemer Refractive Symposium FEMTO LDV & Galilei Room: 252AB

Comprehensive Analyses for Glaucoma and Retinal Pathology: What You Have Been Missing

Moderator: T. Seiler Switzerland

Moderator: P. Buscemi USA

This symposium will present a synopsis of practical experience and clinical results using Ziemer’s FEMTO LDV Femtosecond Surgical Laser and the GALILEI Dual Scheimpflug Analyzer in refractive surgery. It will demonstrate how Ziemer’s state of the art technologies can make a significant difference in obtaining the best possible clinical results in a top performance refractive practice.

E. Midena ITALY F-10 SLO Ophthalmoscope: More than meets the eye

Sponsored by

S. Harroche FRANCE RS-3000 Advanced OCT/SLO System: Ganglion Cell Complex measurement to assess Glaucoma Sponsored by

13:00 – 14:00

Beyond 20/20: The Future of Laser Vision Correction Room: Salle Maillot Faculty: M. Knorz Germany, R. Barraquer Spain, B. Dick Germany

Sunday 5 September

M. Knorz Germany Choosing the Best Ablation Platform

13:00 – 14:00

R. Barraquer Spain Current and Future Applications of the Femtosecond Laser B. Dick Germany Moving Your Patients Beyond 20/20 – Clinical Results

Maximizing Surgical Outcomes: Therapeutic Considerations and Clinical Experiences Room: 252AB Moderator: J.P. McCulley USa J.P. McCulley USa Opening Remarks

Sponsored by

M. Rolando Italy Dry Eye and Visual Acuity

13:00 – 14:00

Innovations in Spectral OCT and Retina Function Testing

J.M. Castillo Spain Management of Ocular Surface in Cataract and Refractive Surgery

Room: 253

U. Pleyer Germany Prevention of Endophthalmitis in Cataract Surgery

Moderator: R. Rosen USA Sponsored by

A Division of OPKO Health, Inc.

13:00 – 14:00

Advanced Optical Biometry for Premium IOL Surgery

J. McCulley USA Fourth Generation Fluoroquinolones: Clinical Experiences J. McCulley USA Closing Comments Sponsored by

Room: 243 Moderator: H. J. Shammas USA Speakers: J. Aramberri Spain, T. Olsen, Denmark, J. Wolffsohn UK Sponsored by

13:00 – 14:00

Impact of New Torsional Technology on Interesting Cases Room: Amphitheatre Bordeaux Moderator: K. Tjia

the Netherlands

Faculty: A. R. Vasavada India, R. H. Osher USA Attendees will observe interesting videos and lively discussions on the impact of torsional technology over a wide variety of challenging cases in cataract surgery. The panel will discuss their experience with the OZil® Intelligent Phaco (OZil® IP) technology on the INFINITI® Vision System.

Individual case presentations will cover topics ranging from phaco-dynamics and fluidics to surgical techniques to overall patient outcome. Look forward to an engaging experience.

Sponsored by

Please note that this is a preliminary programme and is subject to change

PARIS Satellite Education Programme

XXVIII Congress of the ESCRS

4-8 September 2010

Lunchtime Symposia (lunchbox included)

Lunchtime Symposia (lunchbox included)

Sunday 5 September (continued)

Monday 6 September

13:00 – 14:00

13:00 – 14:00

13:00 – 14:00

Croma Satellite Symposium

Carl Zeiss Satellite Symposium

Room: Salle Tuilleries Luxembourg (Concorde)

Room: 243

Surgical Techniques: Injecting the Latest Technologies

Sponsored by

Sponsored by

13:00 – 14:00

13:00 – 14:00

Rayner Premium IOLs: A Road Map to Success Room: Amphitheatre Havane

The Growing and Evolving Role of SLT in Glaucoma Management – Review of a Decade

Moderator: M. Packer USA

Room: 251 Moderator: K. Barton UK

Sponsored by 13:00 – 14:00

Leading Technology in Refractive Surgery Room: 351

M. Latina USA, A. Porta, italy, S. Melamed israel Sponsored by 13:00 – 14:00

Innovative Glaucoma & DMEK Surgery

J. Marshall UK

Room: 242A

Welcome

Moderator: P. Szurman Germany

M.C. Arbelaez Oman

G. Scharioth Germany Glaucolight

M. Tomita Japan

The significance of SCHWIND AMARIS in the largest laser center worldwide (Shinagawa, Japan)

A. Vogel Germany The future in refractive surgery: The SCHWIND SmartTech Laser?

T. Kohnen Germany Evaluation of the SCHWIND SmartTech Laser from a refractive surgeon’s point of view Sponsored by

Moderator: D. Serafano USa D. Serafano USa Personal experience with a new pre-loaded IOL system R. Packard UK Will reducing my incision size improve the quality of my cataract surgery?

R. Nujits the Netherlands The value of correcting astigmatism with IOLs B. Cochener France Latest advancements in correction of presbyopia and astigmatism in one M. Descepola Canada How to successfully incorporate refractive IOLs in your practice Panel Discussion

Moderator: J. Marshall UK

First experiences with the further developments of SCHWIND AMARIS

Room: Amphitheatre Bordeaux

Sponsored by

P. Szurman Germany New DORC Blue’s & New Generation 23G G. Melles The Netherlands DMEK Surgery G. Scharioth Germany Intrascleral Haptic Fixation P. Szurman Germany DMEK Surgery Sponsored by

EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

XXVIII Congress of the ESCRS

EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

4-8 September 2010

PARIS 2010

Lunchtime Symposia (lunchbox included) Monday 6 September (continued) 13:00 – 14:00

13:00 – 14:00

Innovating Premium Cataract Surgery – Optimizing Vision

A Decade of Experience with Selective Laser Trabeculoplasty

Room: Amphitheatre Havane

Room: 251

Moderators: J. Colin France, A. Brézin France

Moderator: J. Marshall UK

J. Colin France Impacting Visual Outcomes by IOL Material and Design

L. Jindra USA Nine-Year’s Experience with SLT as Repeat Therapy (retrospective chart review on 626 eyes)

G. Auffarth Germany New Phaco Technologies: The Impact on Procedure Efficiency and Clinical Outcomes

M. Nagar UK Seven Year’s Experience with SLT

P. Szurman Germany Setting patient expectations with premium monofocal and multifocal IOLs I. Ossma Colombia Innovations in Accommodating IOL technology – Longterm experience with the Synchrony Dual Optic IOL Sponsored by 13:00 – 14:00

Technolas Perfect Vision True Solutions for Presbyopia with Laser Technology Room: Salle Maillot Moderators: M. Knorz Germany, S. Slade USA

TECHNOLAS 520F- Much More than a Femto Laser M. Holzer Germany INTRACOR, 18 month clinical results F. Alonso Spain Personal experience using CUSTOMFLAP L. Hoffart France Managing keratoplasty procedures with the 520F

TECHNOLAS 217P- Capturing the Presbyopia Market J. Castanera Spain

New excimer algorithm for Presbyopia

Breakings News Sponsored by

Please note that this is a preliminary programme and is subject to change

JP. Nordmann France Long-Term Results with SLT as Adjunctive Therapy: The French Experience Sponsored by 13:00 – 14:00

Title Inflammation in Post Cataract Surgery – An Update Room: 351 Moderator: J. Güell Spain Welcome & introduction J. Güell Spain NSAIDs and Corticosteroids - mechanisms, interactions and effects in ocular inflammation U. Devgan usa Pros and Cons of NSAIDs and Corticosteroids in post cataract surgery B. Bodaghi france Clinical use and indications for NSAIDs in ophthalmology J. Güell Spain Concluding remarks This symposium is sponsored by Bausch+Lomb Swiss AG, Switzerland and Croma-Pharma GmbH, Austria.

Register online www.escrs.org/satellites

Evening Symposia Saturday 4 September

Sunday 5 September

Monday 6 September

Cataract and Refractive Live Surgery

Innovations in Refractive IOL and Laser Technology

STAAR Symposium

18:15 Location: Théâtre Mogador (Buses will depart from outside the congress centre at 18:00hrs)

Room: Salle Maillot

18:00 – 18:30 Registration 18:30 – 20:30 Live Surgery Telecast Room: Grand Amphitheatre Surgical Faculty Host Surgeon: L. Buratto Italy T. Akahoshi Japan, L. Cadarso Suárez Spain, P. Crozafon France, M. Weiser France

Moderator: F. Carones

Moderator: D. N. Serafano USA

Faculty: T. Seiler Switzerland, J. Kanellopoulos Greece, A. Cummings Ireland, T. Kohnen Germany

This live surgery telecast will feature the following: Demonstrations of cataract removal techniques using the INFINITI® Vision System and featuring OZil® IP (Intelligent Phaco) software Implants of advanced lens technologies such as AcrySof® ReSTOR® Toric IOL, AcrySof® IQ IOL with the new AcrySert™ IOL delivery system, AcrySof® IQ Toric IOL, AcrySof® ReSTOR® +3.0 D IOL, and the AcrySof® Cachet™ Phakic Lens.

Schedule: Opening Remarks 1st Surgical Case 2nd Surgical Case 3rd Surgical Case 4th Surgical Case 5th Surgical Case

D. N. Serafano USA L. Buratto Italy M. Weiser France P. Crozafon France L. Cadarso Suárez Spain T. Akahoshi Japan

Sponsored by

18:15 – 18:45 Registration 18:45 – 19:45 Symposium (Reception to follow)

Panel Faculty B. Cochener France, O. Moraru Romania, Y. Takhtaev Russia, A. Vasavada India

18:15

Italy

Attendees will learn from some of the industry’s top opinion leaders’ experiences with the newest refractive technology.

Introducing the latest advancements in Alcon refractive technology: AcrySof® ReSTOR® Toric, AcrySof® IQ Toric, and the WaveLight® Refractive Suite comprised of the WaveLight® EX500 excimer and the WaveLight® FS200 femtosecond lasers.

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“To MICS or not to MICS: Still asking the question?”

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Feature

OUT & ABOUT

autumn in paris

Something to satisfy all tastes

by Renata Rubnikowicz

Beyond water lilies This exceptional exhibition encourages us to look beyond the water lilies. By comparing the work of Claude Monet with that of Turner, Rothko and Pollock among others, it makes a case for Monet as an abstract artist as well as an impressionist. The permanent collection at this grand house on the edge of the Parc Ranelagh also shows paintings by Berthe Morisot, Pissaro and Renoir, as well as much of Monet’s most celebrated work and, poignantly, the spectacles Monet wore in his later years and the diagnosis he was given as his eyesight began to fail.

Musée Marmottan-Monet, 2 rue Louis-Boilly, 75016, 11am-6pm Tue-Sun, until 9pm Wed, closed Mon. www.marmottan.com.

Cities of the mind Inspired by architecture, comic-strip artists love to create imaginary cities. This exhibition asks if the inspiration sometimes goes the other way. Mixing future ideas with historical examples, it presents architects’ and cartoonists’ individual visions and the original work that resulted when big-name comic-strip artists – Tardi, Moebius, Bilal and Julliard among them – were each asked to collaborate with an architect. There are more reasons for a visit: the permanent displays here will take you on a tour around the architecture of France with its life-sized models of cathedral and chateau facades and long-vanished shopfronts, and the self-service café has a stunning view of the Eiffel Tower.

The City Drawn: Architecture and Comic Strips, Cité de l’Architecture et du Patrimoine at Palais de Chaillot, 1 place du Trocadéro, 75016, 11am-7pm Mon, Wed, Fri, Sat-Sun, 11am-9pm Thurs, closed Tue. www.citechaillot.fr.

Turning Japanese In a glass building designed by Jean Nouvel, whose Institute du Monde Arabe rises in a sparkling steel tower on the Left Bank, this centre aims to present the latest trends in the best of contemporary arts, including video, photography and fashion. Japanese film-maker and comic Beat Takeshi Kitano aims to debunk our usual view of art. Through paintings, videos, strange machines, gags and games, he pokes fun at contemporary trends, promising a show that’s more like an amusement-park ride than a gallery visit.

EUROTIMES | Volume 15 | Issue 7/8

Gosse de Peintre, Fondation Cartier pour l’Art Contemporain, 261 boulevard Raspail, 75014, 11am-8pm Wed-Sun, 11am-10pm Tue, closed Mon. www.fondation.cartier.com.

Music in flower Towards the end of each summer, the Parc Floral next to the Chateau de Vincennes at the end of métro line 1 resonates to the sounds of music. Each weekend you will find an orchestra tuning up to play a selection of classical pieces as the audience gathers to sit on the grass and listen.

The programmes are varied and often on a Parisian theme – last year’s included “Mozart in Paris” and songs to commemorate the storming of the Bastille.

Parc Floral, Esplanade du château de Vincennes, Route de la Pyramide, 75012, Saturdays and Sundays in August and September, park open 9.30am-8pm, concerts from 4pm. www.parcfloraldeparis.com.

In the dog house Is it true that people grow to resemble their dogs? Or is it that they choose dogs that look like their owners?

There’s a chance to determine the truth in this exhibition of portraits of dogs with their famous owners. The photographer Antoine Schneck follows in an illustrious tradition – Louis XIV commissioned a painting of his favourite hunting dog. Elsewhere in this fabulous museum devoted to hunting and the hunted and spread over two beautifully and wittily restored hôtels particuliers, or grand mansions, in the heart of the Marais, check out the hall of mounted heads to see if you can spot the surprise.

Antoine Schneck, the Gallery of Famous Dogs, Musée de la Chasse et de la Nature, 62 rue des Archives, 750003, 11am-6pm Tue-Sun, closed Mon. www.chassenature.org.

The beautiful game

It’s a Football World Cup year and the tournament is being held for the first time in Africa – the continent that has provided many great players for teams in the rest of the world. Reflecting that several national teams in Europe include players of foreign origin in international games and pertinently for Paris, a city of 200 nationalities, this exhibition examines the often contentious connections between football and immigration.

Football and immigration, connected histories, Cité Nationale de l’Histoire de

Geode at Cite des Sciences et de l’Industrie, La Villette

l’Immigration, Palais de la Porte Dorée, 293 avenue Daumesnil, 75012, 10am-5.30pm Tue-Fri, 10am-7pm Sat-Sun, closed Mon, last admission 45 mins before closing. www.histoire-immigration.fr.

The real thing La Villette is one of the fastest changing areas of Paris. La Bassin de la Villette, where the Canal Saint-Martin and the Canal de l’Ourcq meet, has lots of hip, new waterside bars. Not to be outdone, the Cité des Sciences et de l’Industrie at Parc de la Villette has several new displays. The recently opened Tech’galerie promises to renew its exhibits frequently to keep pace with technological developments. You may see the Nano car from India, a humanoid robot made of fabric or play the latest in video games – or they may be replaced by other innovations by the time you visit. But with technology changing so fast, how can you tell the genuine from the fake? The exhibition Contrefaçon looks at counterfeiting in all its forms, be it in medicines, foods, appliances or toys. One thing’s certain: the shiny silver Géode outside the centre will be showing 3D and IMAX films, while in the park itself you may catch the jazz festival which runs for the first two weeks of September each year.

Cité des Sciences et de l’Industrie, 30 avenue Corentin-Cariou, 75019, 10am-6pm Tue-Sat, 10am-7pm Sun, closed Mon. www.cite-sciences.fr.

Jazz à la Villette festival. www.jazzalavillette.com.

Man and his likeness Ever since it opened in 2006, the Musée du Quai Branly has been a huge hit with the public. The building was the first to excite interest – approach one way and you are greeted by a facade of hanging gardens, come upon it from the river and a sinuous path takes you through exotic planting. Inside, the dimly lit galleries and the “music boxes” playing the sights and

sounds of the world beyond Europe evoke the lives of villages and tribes. This year’s big show aims to reveal the meanings hidden in icons and totems, with displays of 160 objects from five continents.

La Fabrique des Images, Musée du Quai Branly, 37 quai Branly, facing the Passerelle Debilly or 206 and 218 rue de l’Université, 11am-7pm Tue, Wed and Sun, 11am-9pm Thur, Fri and Sat, closed Mon. www.quaibranly.fr.

The past seen from Europe How many of us feel that we “should” visit the Louvre, but are overwhelmed by its sheer scale and riches? One way to overcome this is to have a specific focus – like that provided by the special exhibition Antiquity Rediscovered, which examines the neoclassical trend of the 18th-century and the innovative ways the artists of the day such as Houdon, Piranesi, Blake, David and Canova responded to Europe’s rediscovery of its ancient heritage.

Musée du L’Antiquité Retrouvée: L’Art Européen Entre Antique et Réinventions, 1720-1790, Louvre, enter via the Pyramid, Cour Napoléon, 75001, 9am-6pm daily, until 10pm Wed. www.louvre.fr.

Joystick challenge In its unlikely home of an old church on the edge of the Marais, the Musée des Arts et Métiers has made a temple to the great French names of invention and application, such as Foucault, Renault, Blériot and Peugeot. While gathering all machinery and some more modern technology into its halls, it does not ignore more recent innovations. Alongside the biplanes and old motor cars, in September you can see its latest exhibition on the video games of yesterday, today and tomorrow.

Musée des Arts et Métiers, 60 rue Réamur, 75003, 10am-6pm Tue-Sun, until 9.30pm Thurs, closed Mon. www.arts-et-metiers.net.

contacts

Kfir Azoulay - KAzoulay@lumenis.com

Feature

outlook on industry

making laser history

Lumenis Vision developed the first argon photocoagulator and SLT now studying selective retina therapy (SRT) and offers systems that improve practice efficiency and clinical workflow

by Howard Larkin

S

ince pioneering the first argon laser photocoagulator in 1970, Lumenis Vision has been at the forefront of ophthalmic laser development.

“The history of Lumenis is intertwined with the history of ophthalmic lasers,” says Kfir Azoulay, director of global marketing and product development for the company, whose ophthalmology business is headquartered in Santa Clara, California, US. Company breakthroughs – multicolour lasers, the laser indirect ophthalmoscope, photoactivators for photodynamic therapy and selective laser trabeculoplasty – have revolutionised treatment for ocular diseases ranging from glaucoma to macular degeneration to diabetic retinopathy to secondary cataracts. Combining different lasers on the same platform and developing new guidance technologies have made treating patients easier and more efficient.

To date, it is estimated that more than 30 million patients have been treated with Lumenis ophthalmic lasers worldwide, and more than 10 million can see today who might not have. And with combined 2009 revenues of $226m, Lumenis is the largest manufacturer of laser-based medical products in the world.

It’s a position the firm isn’t prepared to relinquish, Mr Azoulay says. “Being the market leader today does not necessarily guarantee that one will be the leader tomorrow. You have to anticipate and respond to customer needs.” That means not only developing innovative clinical technologies, but also such that are minimally invasive, cost-effective, smart and intuitive to use – and offer superb technical support after the sale.

“Our philosophy revolves around product excellence, physician education programmes, patient information materials, and ongoing clinical and technical support,” Mr Azoulay adds. “The relationship doesn’t end with the physician buying a product from us. It starts there.”

One of Lumenis’ hottest items among Europe’s ophthalmologists is its selective laser trabeculoplasty (SLT) system for glaucoma. Lumenis sold as many of the systems in the first quarter of 2010 as in all

Don’t miss Book Review, see page 47 EUROTIMES | Volume 15 | Issue 7/8

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of 2009 in Europe, Mr Azoulay reports.

“Patients treated with SLT may not require medications to control their glaucoma or the number of medications required to control their glaucoma may be reduced,” notes Mark Latina MD, who developed the procedure. “This can simplify the patient’s medical regiment and cost, thereby improving patient compliance.”

The technology is also quickly growing in popularity in India, China, Africa and other developing areas where the need for glaucoma treatment is rising with incomes and life expectancy, but the cost of longterm dependence on prescription drugs is an issue. “SLT provides glaucoma patients with better access to treatment in both developing and industrialised countries. In the long-term this can reduce vision loss in this population of patients, and help to reduce the high healthcare and other social expenditures due to blindness,” Dr Latina adds. More than 2,000 Lumenis SLT systems are now installed worldwide.

Mr Azoulay believes Lumenis’ support is also a factor in its continuing SLT success.

“There are other manufacturers with SLT systems on the market, but when you buy from Lumenis you get the benefit of thirdgeneration SLT technology. Furthermore, our customers gain immediate access to the largest network of SLT users worldwide, receive product upgrades & updates, clinical support and a long list of other benefits which are exclusive to Lumenis SLT users.

In addition, as the company that invented and developed this technology, our SLT systems are designed to meet clinically recommended SLT protocols that we helped define, which helps guarantee optimal clinical outcomes.

Mr Azoulay adds that because Lumenis maintains support offices around the world, it can respond quickly to physician service needs. “Wherever you are, we can usually respond in real time.”

Improved design improves treatment With a full-time

ophthalmologist on its board, Lumenis is committed to anticipating and meeting the everyday needs of ophthalmologists, Mr Azoulay says. This is reflected in advanced designs that are both user and patient friendly.

One such device is the InSight, an advanced laser delivery system integrated with a slit lamp biomicroscope for diagnosing and treating various retinal diseases. InSight uses what Lumenis calls “Co-Linear” technology to place illumination and laser delivery on the same axis for performing pan retinal photocoagulation or macular or other retinal grid therapy.

Rather than requiring the physician to move the light and then separately aim the laser for each spot, a special micromanipulator mounted on the joystick moves the laser with the illumination beam so it is simultaneously aimed at whatever area of the retina the doctor is examining, thus simplifying and accelerating treatment. The system is now being introduced country by country in Europe, Mr Azoulay says. “We are doing it in an organised manner so we can meet supply requirements.”

Similarly, Lumenis offers the Selecta system, which combines SLT, photocoagulation, and photodisruptor capabilities, enabling doctors to treat glaucoma, retina and secondary cataracts with a single device, reducing equipment footprint and capital costs. Combining these technologies also can come in handy when more than one laser is needed for a treatment, Mr Azoulay notes. For example, an iridotomy can be achieved using the photodisruptor module and the treatment site can be coagulated with green laser to prophylactically reduce any potential bleeding. This can be done without moving the patient, thereby optimising

Our philosophy revolves around product excellence, physician education programmes, patient information materials, and ongoing clinical and technical support Kfir Azoulay the procedure. The three types of lasers are available individually as well, with multicolour photocoagulators available to target specific retinal chromophores.

Selective retina therapy progresses In development is selective

retina therapy, which is currently undergoing a large-scale prospective trial for treating diabetic macular oedema at Tel Aviv Medical Center under the leadership of Prof Anat Loewenstein MD. Similar to SLT, SRT targets melanin-containing cells. In particular, SRT targets melanin in the retinal pigment epithelium – which is implicated in many retinal pathologies – without destroying surrounding tissues including photoreceptor cells. “I think Lumenis SRT technology represents significant potential over conventional lasers, as it selectively targets the RPE layer without damaging the highly-sensitive neurosensory retina layer; thereby avoiding scotomata in the treated areas,” Prof Lowenstein explains.

Early tests have proven SRT effective for DME and central serous chorioretinopathy without producing blind spots as traditional photocoagulation often does. However, the technology is not yet clinically available, Mr Azoulay notes. “We are fine-tuning it. Our goal is to introduce technologies only after they are thoroughly clinically tested. It is too early to say when it will be on the market, but we will keep our customers informed, and there will be more information at upcoming meetings.”

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Feature

industry news Recent developments in the vision care industry

Product Update

Regulatory News CE Mark for latest ICL products

Staar Surgical has received CE Mark approval for a range of product improvements to the Visian Implantable Collamer Lens (ICL). The expanded CE approval includes myopic ICLs at -18.0D to hyperopic ICLs at +10.0D without interruption, as well as Visian Toric ICLs up to 6.0D of cylinder for the entire range. The approval also allows expansion to quarterly dioptric increments for ranges between -3.0 D and +3.0 D. The company can now also offer the Hyperopic Toric ICL. Taken together, this change more than doubles the current Visian addressable market in Europe, the company says. n www.staar.com

FDA nod to femto cataract surgery

IOLMaster® 500

Selecting the right IOL to meet individual patient expectations is more crucial than ever, according to Carl Zeiss Meditec.

“With automatic and non-contact measurement of the patient’s eye, the new IOLMaster 500 offers the fastest and easiest way of calculating the right IOL for each patient,” said a company spokeswoman. “As a complete workstation for user-friendly biometry and totally reliable IOL selection, the IOLMaster 500 represents the latest generation of optical biometry that is specially designed to meet the needs of a modern cataract practice. The guiding principles behind its development are precision, simplicity and outcomes,” she said.

The company said the IOLMaster® 500 incorporates a long heritage in the recording of highly precise measurement data.

“With the IOLMaster 500, this level of clinical confidence is easier to achieve than ever: In the new dual measurement mode, multiple axial length and keratometry readings are captured largely automatically, with a simple push of a button,” said the spokeswoman.

The company also said that providing all measurements needed for state-of-the-art IOL power calculation has always been the hallmark of the IOLMaster as a comprehensive biometry solution.

“The IOLMaster 500 re-defines simplicity. Its redesigned graphical user interface yields more data with fewer clicks. The optional Sonolink ultrasound connection provides an optimal workflow even for those few cases where an optical axial length reading is not possible,” said the spokeswoman.

The IOLMaster 500 software offers a range of recognised formulas for the automatic calculation of the targeted IOL power.

The long clinical experience with the IOLMaster is reflected by the Users’ Group for Interference Biometry (ULIB) website. For virtually all common IOL types, the ULIB database contains lens constants optimised specifically for the IOLMaster. “And the IOLMaster 500 allows these constants to be further refined and personalised,” she said. n For more information on the IOLMaster 500 visit www.meditec. zeiss.com/iolmaster or www.iolmaster-online.zeiss.com.

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LensAR has received 510(k) clearance from the US FDA for use of the LensAR Laser System for anterior capsulotomy during cataract surgery. The LensAR Laser System integrates propriety ocular measurement and 3D laser scanning technologies with a femtosecond laser.

The LensAR system is being designed to allow physicians to perform several of the steps in cataract surgery (capsulotomy, lens fragmentation, precise astigmatic corrections and unique clear corneal incisions) in a single laser procedure, the company says. However, the FDA so far has only cleared the LensAR system for anterior capsulotomy. n www.lensar.com

Crystalens 0.25 approval

The US FDA has expanded its approval of the Crystalens AO (Bausch + Lomb) to include quarter dioptre increments. Quarter dioptres will be available immediately for the Crystalens AO for the models AT50AO and AT52AO in the ranges of 18-22 dioptres.

The company plans to offer a wider dioptric range by the end of the year. n www.crystalens.com

New fluoroquinolone drop approved

Allergan has reported US FDA approval for Zymaxid™ (gatifloxacin ophthalmic solution) 0.5 per cent. The topical fluoroquinolone is approved for the treatment of bacterial conjunctivitis caused by susceptible strains of Haemophilus influenzae, Staphylococcus aureus,

Company News

Dr Tamayo and Presbia

Gustavo E Tamayo MD has become the latest high profile ophthalmic surgeon to join the medical advisory board of Presbia, a company developing the Flexivue™ corneal inlay optical micro-lens solution for presbyopia.

Dr Tamayo, director of the Bogotá Laser Refractive Institute, Bogotá, Colombia, holds several patents for the treatment of presbyopia, irregular astigmatism and phacoemulsification surgical procedures. In addition, he has authored almost 100 medical journal articles, 11 book chapters and has lectured worldwide. The medical advisory board includes Prof Ioannis Pallikaris

Staphylococcus epidermidis, Streptococcus mitis group, Streptococcus oralis, and Streptococcus pneumonia.

The product is the highest concentration of gatifloxacin ophthalmic solution on the market in the US. It is formulated with the preservative benzalkonium chloride (BAK). n www.allergan.com

New solution from Abbott

Abbott has announced that it has received the European CE mark for Complete RevitaLens, a multipurpose solution for disinfection of soft contact lenses. The company says that the Complete RevitaLens Multipurpose Disinfecting Solution delivers high quality disinfection and comfort for the patient, with the convenience of a one-bottle multipurpose solution.

The solution was developed in partnership with the Brien Holden Vision Institute (formerly Institute of Eye Research) in Australia. According to the company, the new solution provides high microorganism kill rates, removes proteins and lipids from the lens surface, effectively kills Acanthamoeba and Fusarium; and reduces corneal staining. n www.abbott.com

CE for Keraflex

Avedro has announced that its Vedera™ System for performing the Keraflex® procedure has received the European Union’s CE Mark. The Keraflex procedure is a non-invasive, incision-less ophthalmic procedure for flattening the cornea. The company asserts that because Keraflex thermally remodels the cornea without the removal of any tissue, the procedure offers the unique ability to induce refractive change without weakening the cornea’s biomechanical integrity. In its European clinical trials for the correction of myopia and the treatment of keratoconus, a progressive disease of the cornea, Avedro has investigated a two-step procedure whereby Keraflex provides corneal flattening to achieve refractive correction and concomitant collagen crosslinking stabilises the cornea. The company plans to immediately begin commercialisation of the Keraflex procedure throughout Europe and Asia. n www.avedro.com

MD, PhD, as chairman, and Dr Jorge L Alio of Madrid, Spain, and Dr Kerry K Assil of Beverly Hills, California. n www.presbia.com

Bausch acquires Zirgan

Bausch + Lomb has acquired assets and US rights for Zirgan (ganciclovir ophthalmic gel 0.15 per cent), from Sirion Therapeutics. The topical anti-viral was approved by the US FDA in 2009 the treatment of acute herpetic keratitis. Zirgan selectively targets the replication of herpes simplex virus DNA. It has a low corneal toxicity profile to provide patients with comfort and relief, the company says. n www.bausch.com

Feature

eu matters

Prescribing incentives

EU court supports cheaper drugs

by Paul McGinn

T

he European Court of Justice has ruled that national health systems and public health insurers can offer ophthalmologists and other physicians financial incentives to persuade them to prescribe cheaper drugs.

Although the landmark decision applies specifically to pharmaceuticals, the principle adopted by the EU’s highest court may lay the groundwork for European health systems to offer incentives to ophthalmologists to use cheaper medical devices, including IOLs. The court’s ruling followed a lawsuit by the Association of the British Pharmaceutical Industry against the UK’s Medicines and Healthcare Products Regulatory Agency. In the lawsuit, the association argued that EU law prohibited regional health authorities within the National Health Service from offering financial incentives to induce doctors in England and Wales to prescribe cheaper drugs.

The association based its lawsuit on the Medicinal Products Directive. The directive, which was introduced by the European Union in 2001, is law in all 27 EU countries. Among other things, the directive prohibits the offering of money or benefits in kind to doctors or pharmacists to promote prescription drugs.

The British association, which represents more than 70 pharmaceutical companies in the UK, argued that the medical products directive banned such a scheme because it would interfere with the objectivity of doctors in prescribing appropriate drugs for their patients. The UK schemes at issue in the case primarily involved the offering of financial

Journal Watch

Appropriate steps In reply to the association’s arguments, the British medicines regulatory agency countered that the Medicinal Products Directive was adopted to prevent commercial organisations from influencing the judgement of doctors when prescribing medicinal products and that it did not affect the right of EU countries to take appropriate steps to reduce the costs of their health services.

In its decision, delivered in late April, the Court of Justice agreed with the British medicines agency.

“In general terms, the health policy defined by a Member State and the public expenditure devoted to it do not pursue any profit-making or commercial aim,” the court wrote.

“Since a financial incentive scheme such as the one at issue in the main proceedings forms part of such a policy, it cannot be regarded as falling within the commercial promotion of medicinal products.

by Sean Henahan

Prism Power

Many symptoms of traumatic brain injury (TBI) could be reduced or eliminated with prism lenses to correct visual misalignment. A study of 43 patients with TBI found that correction of vertical heterophoria appeared to ameliorate many post-concussive symptoms including headache, dizziness, nausea and neck pain. Overall, the use of prismatic eyeglass lenses to realign the images and reduce or eliminate eye muscle overwork led to a 71.8 per cent reduction of patients’ symptoms. While it was known that vision was affected by TBI, it appears that the vision abnormalities caused by the TBI are causing the other post-concussive symptoms, the researchers note.

JE Doble et al., Physical Medicine and Rehabilitation, “Identification of Binocular Vision Dysfunction (Vertical Heterophoria) in Traumatic Brain Injury Patients and Effects of Individualized Prismatic Spectacle Lenses in the Treatment of Postconcussive Symptoms: A Retrospective Analysis”, April 2010, Volume 2, Issue 4, Pages 244-253.

EUROTIMES | Volume 15 | Issue 7/8

incentives to general practitioners to entice them to prescribe certain cheaper statin drugs to reduce cholesterol.

Easy eye test for MS

Using optical coherence tomography to measure retinal thinning appears to be a promising method for early diagnosis of multiple sclerosis. Investigators followed 299 patients with MS for six months to 4.5 years. Patients underwent eye exams and OCT measurements every six months. These studies showed that progressive retinal nerve fibre layer thinning occurred as a function of time in some patients with MS, even in the absence of optic neuritis. The retinal thinning was associated with clinically significant visual loss. These findings support the use of OCT and low-contrast acuity as methods to evaluate the effectiveness of putative neuroprotection protocols, the researchers noted.

LS Talman et al., Annals of Neurology, “Longitudinal study of vision and retinal nerve fibre layer thickness in multiple sclerosis”, 2010;67:749-760.

“The very nature of the task of those authorities is to supervise public health, for which they assume political responsibility and they are thus in charge of evaluating the therapeutic value of the medicinal products which they authorise to be marketed.

“In those circumstances, it is permissible for those authorities, in the exercise of the responsibilities which they assume, to determine, on the basis of evaluations of the therapeutic qualities of medicinal products by reference to their cost for the public budget, whether, in order to treat certain conditions, certain medicinal products containing a given active substance are, from the point of view of public finances, preferable to other medicinal products containing a different active substance, but falling within the same therapeutic class.”

The court added, an EU country must “be able to verify that the financial incentive scheme implemented by the public authorities is based on objective criteria and that there is no discrimination between national medicinal products and those from other Member States.”

Public and transparent In addition, EU countries must ensure that such schemes are public and transparent and “make available to healthcare professionals and professionals in the pharmaceutical industry the evaluations establishing the therapeutic equivalence of the active substances available belonging to the therapeutic class covered by that scheme,” the court said.

In coming to its decision, the Court of Justice also noted that patients were protected from the adverse effects of inappropriate prescribing by EU governments through public health agencies, whose job it is to enforce the duty of physicians to prescribe drugs only when they were needed and in a correct manner.

“First, a prescribing doctor is required, from the point of view of professional conduct, not to prescribe a given medicinal product if it is not fitting for the therapeutic treatment of his patient, despite the existence of public financial inducements for its prescription,” the court noted.

“Second, all doctors are authorised to practice only under the supervision of the public health authorities, which the latter carry out either directly or indirectly by appointing professional organisations to that effect, such as, in the UK, the General Medical Council. In performing their task of supervising and monitoring the activity of doctors, the public authorities or delegated professional organisations are authorised to provide doctors with recommendations relating to the prescription of medicinal products, without such recommendations being able to prejudice the objectivity of prescribing doctors.”

Full details of the case, titled “Association of the British Pharmaceutical Industry -v- Medicines and Healthcare Products Regulatory Agency,” are available from the European Court of Justice website at: www.curia.eu.

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Feature

JCRS Highlights Journal of Cataract and Refractive Surgery

JCRS Symposium Controversies in Cataract and Refractive Surgery 2010 Sunday, September 5, 2010

14:00-16:00 Chairs: Emanuel S. Rosen, MD, FRCSEd Thomas Kohnen, MD, FEBO Presbyopia Treatment: Cornea or Lens n

n

Accommodating and/or Multifocal IOL Gerd U. Auffarth, MD

PresbyLASIK or Implant Richard L. Lindstrom, MD

Astigmatism Management in Cataract and RLE Surgery: Toric IOL or Corneal Incisions n Incisions

Louis D. Nichamin, MD n Toric IOL

Rudy M. Nuijts, MD, PhD

Pediatric Refractive Surgery n Pro’s

Michael O’Keefe, FRCS n Con’s

Elie Dahan, MD, MMedOphth

Phakic IOL n Anterior Chamber José Güell, MD n Posterior Chamber Roberto Zaldivar, MD

During the XXVIII Congress of the ESCRS, Paris, France

Comparison of central corneal thickness measuring techniques

Measuring central corneal thickness (CCT) is a key part of refractive surgery.

It also plays an important role in obtaining accurate intraocular pressure measurements, and assisting in the detection of endothelial disease and graft failure after penetrating keratoplasty.

However, several measuring methods are available using different technologies.

Researchers at the Grewal Eye Institute conducted a study comparing sequential Scheimpflug imaging, spectral-domain anterior segment optical coherence tomography (AS-OCT), and ultrasound pachymetry in 150 normal, keratoconic, and post-LASIK eyes. In normal eyes, CCT was statistically significantly higher by ultrasound pachymetry than by Scheimpflug imaging and AS-OCT. In keratoconus eyes, ultrasound pachymetry produced statistically significantly higher measurements than Scheimpflug imaging and AS-OCT. In post-LASIK eyes, ultrasound pachymetry measurements were also significantly higher than by Scheimpflug imaging and AS-OCT. Scheimpflug imaging and AS-OCT produced similar measurements in all groups. The researchers conclude that CCT measurement results should be interpreted in the context of the instrument used. n DS Grewal et al., JCRS, ‘Assessment of central corneal thickness in normal, keratoconus, and post-laser in situ keratomileusis eyes using Scheimpflug imaging, spectral domain optical coherence tomography, and ultrasound pachymetry’, Volume 36, Issue 6, Pages 954-964.

Scanning electron microscopy showed cells and cell debris on the segments explanted by extrusion, a clean surface on the ICRS explanted for refractive failure, and bacteria (cocci) in the case of proven infectious keratitis. The researchers were encouraged by the lack of inflammatory reaction in cases other than those involving extrusion. n C Ferrer et al., JCRS, ‘Causes of intrastromal corneal ring segment explantation: Clinicopathologic correlation analysis’, Volume 36, Issue 6, Pages970977.

FS LASIK comes of age

The femtosecond laser LASIK flap creation has been available for nearly 10 years. Since the early femtosecond laser models were introduced, considerable progress has been made in improving flap geometry and limiting complications of LASIK performed with the laser.

This has led to increasing popularity of LASIK performed with the femtosecond laser. Indeed, independent sources now estimate that 30 per cent to 50 per cent of LASIK procedures in the US in 2008 were performed using a femtosecond laser. The approach is also gaining adherents in Europe and elsewhere.

The current issue of JCRS offers a comprehensive review of common considerations in the management and complications of femtosecond laser– LASIK flap construction. n MQ Salomão and SE Wilson, JCRS, ‘Femtosecond laser in laser in situ keratomileusis’, Volume 36, Issue 6, Pages1024-1032.

Reasons for ring explantation

Intrastromal corneal ring segments (ICRS) are employed as a reversible refractive treatment for keratoconus patients. Researchers in Spain reviewed eight years of experience to determine the main causes of explantation and the relationship with the microscopic findings on the implant surface. They identified 58 cases in 47 patients where explantation was performed. The main cause was extrusion (48.2 per cent), followed by refractive failure (37.9 per cent), keratitis (6.8 per cent), and corneal melting and perforation (6.8 per cent).

Thomas Kohnen Associate Editor of JCRS

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

Don’t miss Bio-Ophthalmology, see page 49 EUROTIMES | Volume 15 | Issue 7/8

Feature

Book review

Straddling the divide

academic philosophy. Rather, it’s a call for recognising that the actual technique of any A little more than 50 years ago, the English medical practice is an art, requiring patience, novelist and physicist, CP Snow, coined a degree of apprenticeship, and dexterity. the term ‘two cultures’ to describe how the David F Chang, in his introduction to the arts and sciences have grown apart from volume under consideration here, writes one another in our modern world. Snow that it is a remarkably exciting time to attributed the two cultures phenomenon to be a cataract surgeon, with technological the increasing specialisation of academia advances arriving at an extremely rapid and to the highly technical direction of rate. Uniting these technological advances the academic discourse among artists and and ever increasing scientific knowledge scientists. with the art of surgical practice is the aim of Medicine has always attempted to Agarwal and Lindstrom’s book. straddle the two cultures divide with skilled The book begins with a chapter by Amar practitioners bringing the best scientific Agarwal, titled “MICS: From Phakonit to knowledge to bear on the art of everyday Microphakonit.” Refreshingly for a book of practice. However, medicine is no stranger this type, Agarwal takes a highly personal to the two cultures divide as we have approach. He disclaims responsibility for witnessed a trend toward greater and greater the invention of phakonit, as “this invention dominance by the scientific of approach to (as do all inventions and discoveries) came patients and disease at the expense of the as a message to me from the Almighty holistic view of medical practice. and so the invention is His and only His.” This is not a plea for medical students to This note of humility is struck throughout study novels and paintings, or for trainee Agarwal’s account of what lead to the first faros_245x150_EuroT_e 6.5.2010 11:17 Uhr with Seite 1 ophthalmologists to immerse themselves surgery phakonit.

This introductory in the abstruse verbiage of modern chapter also serves to remind us that all

scientific progress is situated in very human stories, and even those who may not share his faith will surely agree with Agarwal that something greater than the individual is discernible in these individual stories of discovery.

The main text is divided into four sections – an introductory one, one on machines and instrumentation, one on microincisional cataract surgery techniques, and one on the microincisional lenses and complication management. The contributors are from a range of international centres in India, Canada, the US, Colombia, the UK, and Mexico.

A plethora of new and improved technologies are dealt with by the various authors. The book is an extremely comprehensive one, in which the extensive and indeed foundational experience of the editors is brought to bear. Anterior segment surgeons, cataract surgeons, ophthalmologists and those in ophthalmological training will all benefit from it as an excellent source of reference and advice.

books editor: Seamus Sweeney publication: Microincisional Cataract Surgery – The Art and Science Editors: Amar Agarwal and Richard Lindstrom Published by SLACK Incorporated

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

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EUROTIMES | Volume 15 | Issue 7/8

47

ISTANBUL 15 th ESCRS Winter Meeting in conjunction with TOS Cataract & Refractive Surgery Society

18 â&#x20AC;&#x201C; 20 February 2011

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49

Feature

bio-ophthalmology

Targeting photoreceptor cell death restores visual function and preserves retinal tissue in retinitis pigmentosa

C

ollaboration between researchers at the University of Florida and the University of California has produced the restoration of visual function in an animal model of autosomal dominant retinitis pigmentosa.

The American research is the first of its kind to employ an anti-apoptotic gene therapy approach focussed on over-expressing “BiP” – a protein chaperone known to be involved in cellular stress signalling.

Retinitis pigmentosa is the collective term for a group of ocular disorders with a prevalence of between one in 3,000 and one in 7,000. The term “retinitis pigmentosa” describes a range of retinal dystrophies in which degeneration of the retina is characterised by a loss of photoreceptors and a clinical observation of retinal pigment deposits. Initial symptoms include night blindness and a slight detection of peripheral visual field defects in dim lighting. As the disease progresses, night blindness becomes more obvious and often driving at night should be avoided. Patients gradually become more aware of the loss in peripheral vision.

Fundus examination can reveal the presence of bone spicule shaped pigment deposits in the mid periphery in addition to attenuation of retinal arterioles. In its later stages, patients will frequently have problems moving about independently due to further constrictions in the visual field that lead to tunnel vision. Reading becomes difficult and often there is a flat electroretinogram recording. The disease continues to progress slowly, sometimes to complete blindness.

Over 80 distinct mutations in the rhodopsin gene can give rise to autosomal dominant retinitis pigmentosa. One of the most common errors is a proline to histidine substitution at position 23 (Pro23His) of the gene. The mutated P23H rhodopsin is unable to adopt a functional three dimensional protein structure which leads to retinal degeneration in both humans and animal models.

Current thinking suggests that the mutated P23H protein causes significant stress in the cell’s endoplasmic reticulum triggering a series of biochemical events that lead to “apoptosis”.

Apoptosis is a genetically controlled mechanism of cell death in which the cell activates a specific set of instructions which EUROTIMES | Volume 15 | Issue 7/8

lead to the deconstruction of the cell from within. Such cell death contrasts markedly with the more familiar mechanism known as necrosis. Necrosis occurs when a cell is injured mechanically or receives some shock whereby it is unable to continue carrying out the activities of life.

Though the end result of both apoptosis and necrosis are the same, that is, the death of the cell, the mechanisms leading to such death are crucially different. Whereas necrosis is characterised by swelling, rupture, leakage and inflammation, apoptosis appears as a more deliberate and choreographed affair. Cells dying by apoptosis replace swelling with shrinkage and rupture with an elegant packaging of cellular contents into a convenient size for disposal. There is no leakage of cellular material and no inflammation. The remaining fragments of an apoptosed cell are neatly and quietly disposed of by either neighbouring healthy cells or by the body’s household staff – the macrophages.

Against that background, researchers have questioned what pathways connect the primary genetic mutation, such as P23H, to the final outcome of apoptotic cell death.

While a generalised answer remains elusive, findings by the researchers in California and Florida suggests that the P23H protein, unable to fold correctly, leads to retention of mis-folded P23H in the endoplasmic reticulum, activating what is known as the “unfolded protein response” or UPR. The study’s lead researcher described the UPR as “a signal transduction cascade that detects and alleviates protein folding stress in the endoplasmic reticulum caused by physiological demands or environmental variation.” Details of the researchers’ findings appear in Proceedings of the National Academy of Science (2010;107:59615966).

According to the researchers, the alleviation of the stress is mediated by a number of transmembrane proteins which either produce protective stimuli to reduce translation and clear mis-folded proteins or, if restoring homeostasis is not possible, alternate signalling promotes pro-apoptotic signals that guide the cell towards controlled cell death.

An important player in all of these biochemical gymnastics is a chaperone protein known as “BiP/Grp78”. BiP is

stimulated into activation by the UPR it may buy precious time – time which can pathway which itself is triggered by the extend photoreceptor survival and thereby stress in the endoplasmic reticulum brought extend visual function. If such results can about through mis-folded P23H rhodopsin. provide even an additional six months A combination of cell and animal work of useful vision, then it may represent a have shown that BiP can protect cells from significant gain for patients. apoptotic cell death and the current work by the American research groups was designed % ADRP caused by known genes to investigate if this could be achieved in a P23H model of retinitis pigmentosa.

Using an adeno-associated virus engineered to carry the DNA sequence for BiP, the researchers sub-retinally injected the experimental therapeutic into 15-day-old P23H models. Following three months of monitoring, the researchers were able to show that BiP was elevated by up to 26 per cent above controls and that electroretinogram analysis showed a rescue of retinal activity. Treatment with Separate research from the University of Texas has BiP appeared to reduce apoptotic signalling reported that 14 mutations in aggregate account for 28 by up to 42 per cent within a month of per cent of the ADRP cases examined which equates to approximately five per cent of all RP injection while the a-wave and b-wave scotopic electroretinogram had increased by 115 per cent and 97 per cent at month three, respectively.

The results of the research provide encouraging data from which larger studies are now possible including studies using Gearóid Tuohy different models of retinal degeneration Smurfit Institute to determine if the mutation independent of Genetics approach to targeting the secondary effect of Trinity College Ins_easyPhaco_120x120_EuroTimes Seite 1 apoptosis is viable. While such an approach 6.5.2010 11:21 Uhr Dublin does not target the primary genetic lesion

Courtesy of Gearóid Tuohy

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Feature

eye on travel

Paris is the ticket

From 21st century La Defense to 14th century Chateau de Vincennes, Paris Metro line 1 is the way to go

by Maryalicia Post

La Defense Conceived as a business park, La Defense, with its iconic Grande Arche, has become, since its inauguration in 1989, a tourist attraction in its own right. A sampler of contemporary architecture, the area also boasts “Europe’s largest shopping centre,” on 11 hectares of parks and gardens, with elaborate fountains and 60 modern sculptures, including the works of Calder, Miro and Richard Serra.

Designed by Danish architect Johann Otto von Sprekelsen, the arch is a giant hollow cube spanning an open space large enough to accommodate Notre Dame Cathedral. Two panoramic lifts make the 110-metre ascent to the “Toit” in 66 seconds. Make the ascent to visit the computer museum, where over 200 pieces are displayed, documenting the computer’s evolution since World War II. Exhibits include an early computer so large you are invited “to come inside”, as well as the first desktop and first laptop. There is also a reconstruction of a teenager’s bedroom of 1980, complete with the equipment that he would have needed to download one song in 24 hours.

The Grande Arche itself is a prolongation

of the “historic axis” that starts at the Louvre pyramid, continues through the Carrousel Arch, the Place le la Concorde, and the Arc de Triomphe. From the viewing terrace in front of the arch you can take in a spectacular vista that includes not only the axis, but the Seine valley and the grapevine that will give its first harvest in 2010.

After the computer museum, give your eyes a workout in the adjacent Dimitri Remanence gallery. The Warhol-like paintings of Dimitri, a French artist from Nancy, demonstrate the phenomenon of retinal persistence.

Le Toit de la Grande Arche is open seven days a week from 10:00 to 19:00 from October through March and until 20:00 during the rest of the year. There’s a “water ballet” at the AGAM Fountain Monday to Friday from 17:00 to 19:00 and Friday and Saturday at 20:30. Download an audio guide to La Defense to your MP3 player from www.ladefense.fr.

Chateau de Vincennes There is something undeniably exotic about emerging from the Metro right at the foot of a castle; you need only cross a drawbridge

Paris (almost) without Picasso Nothing substitutes for the Picasso Museum, which is closed until 2012.

There are, however, two suggestions to help fill the gap.

Quai Branly Museum The architect Jean Nouvel designed this modernist museum that opened in 2006. It houses a collection of 3,500 examples of indigenous culture assembled from the Musee de l’Homme and the Palais de la Porte Doree.

The exhibits follow a geographical trail that ranges from Oceania to Asia, Africa to America and not surprisingly, many of the artifacts bring Picasso to mind; it was an African mask exhibition in Paris in 1907 that inspired him to explore abstract representation.

There are no rooms or internal walls at the

QBM, where a gently sloping ramp winds up through the exhibition space. Glass display cases seem to be scattered in a dimly-lit forest, emphasising the “discovery” aspect of the experience. The museum’s wildlooking garden strikes an adventurous note, too. Architect Nouvel organised the space “around the symbols of the forest, the river and the obsessions of death and oblivion.”

An elegant restaurant – Les Ombres (reservation only) – overlooks the Seine and the Eiffel Tower. There’s a pleasant café in the garden and an interesting museum shop, too.

Quai Branly Museum: Open on Tuesday, Wednesday and Sunday from 11:00 to 19:00 and on Thursday, Friday and Saturday until 21:00. Closed on Mondays. Full details available at: www.quaibranly.fr.

Medieval Tower, Chateau de Vincennes

over a wide stone-lined moat to enter the grounds of the Chateau de Vincennes. Now the last stops at the Eastern end of Metro number 1, this was the residence of French kings until Louis XIV moved the court to Versailles. It is complete with a medieval keep and dungeon and its own Sainte Chapelle built to house a fragment of the crown of thorns now kept in Paris.

Damaged in a storm at the end of 1999, restoration of the chapel took 10 years. It has recently reopened to the public.

The Chateau began as a Royal hunting lodge in 1150 and was enlarged

The Orangerie The home of Monet’s famous Water Lily series reopened in 2006 after six years of reconstruction and a long delay caused by the discovery of part of a 16th century wall during the construction of an underground gallery.

After much controversy, a 10-metre section was preserved and incorporated into the design of the building. The new gallery now houses the Walter-Guillaume bequest of Impressionist and post-Impressionist paintings (including 10 Picassos). When the upper floor, where they were previously displayed, was removed from the Orangerie, natural lighting was restored to the two oval salons each hung with four of Monet’s enormous water lily paintings: four represent dawn, four represent dusk. It’s a tranquil experience to sit in one of these rooms. Light filters through roof panels shifting with the time of day and the movement of the clouds changes the mood of paintings that Monet

Modern Tower, La Defense

and modified over the centuries. The picturesque 50-metre high tower was constructed in 1337, making it the tallest medieval fortified structure in Europe. Take a tour of the dungeon, one of whose prisoners was the Marquis de Sade. The Chateau is now the headquarters of the French Historical Service, which maintains a museum in the dungeon.

The Chateau is open every day from 10:00 to 17:00. For details, visit www.chateaudeincennes.fr.

Water Lilies by Claude Monet

himself described as “landscapes of water and reflection.”

The Orangerie is open every day from 09:00 to 18:00. Closed on Tuesdays. For details, visit: www.musee-orangerie.fr.

Paris is the venue for the 10th EURETINA Congress from 2 - 5 September and the XXVIII Congress of the ESCRS from 4-8 September, 2010. For further details visit www.euretina.org and www.escrs.org EUROTIMES | Volume 15 | Issue 7/8

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Program Chairs Edward J. Holland, MD Stephen S. Lane, MD Program Planning Committee David F. Chang, MD Eric D. Donnenfeld, MD Herbert P. Fechter, MD Roger F. Steinert, MD Keith A. Warren, MD Faculty Vincent P. de Luise, MD Terry Kim, MD W. Barry Lee, MD Nick Mamalis, MD Nancey K. McCann Stephen A. Obstbaum, MD E. Ann Rose Jonathan B. Rubenstein, MD R. Doyle Stulting Jr., MD, PhD â&#x20AC;Śmore to come!

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Reference

Calendar of events Dates for your Diary

July

August

2010

2010

9-11 Aegean Cornea X www.aegeancornea.gr

CRETE, GREECE

18-23

MONTREAL, CANADA

ISER 2010, XIX Biennial Meeting of the International Society for Eye Research www.kenes.com/iser

September 2010

9-11 MUNICH, GERMANY

28th Annual ESOPRS Meeting www.esoprs2010.org

September

EDINBURGH, SCOTLAND 12-16 SIDUO XXIII Congress

2010

www.siduo2010.org

12-17 Madrid, Spain

paris, France

2-5

9th European Glaucoma Society Congress www.oic.it/~egsmadrid2010/

4-8

16-20 beijing, china

25th Congress of the APAO in combination with the 15th National Congress of the COS www.apao2010beijing.org

10th EURETINA Congress XXVIII Congress of the ESCRS www.euretina.org www.escrs.org

24-26 Alexandroupolis, Greece

4-6

9-12

12-14

5th International Congress on Glaucoma Surgery ICGS www.oic.it/icgs2010/

The International Symposium on Ocular Pharmacology and Therapeutics – ISOPT ASIA

www.isopt.net

11

Vilnius, Lithuania 20-22 XIII Baltic Ophthalmologicum Balticum www.fob2010.com

October 2010

6-9 CRETE, GREECE

European Assocation for Vision and Eye Research 2010 www.ever.be

chicago IL, usa 16-19 American Academy of Ophthalmology www.aao.org/annual_meeting

HAMBURG, germany 21-24 23rd International Congress of German Ophthalmic Surgeons www.doc2010.de

28-31CHANDIGARH, INDIA

2011

2011

MACAU, CHINA

EyeAdvance 2010 www.eyeadvance.com

February

January

Delhi, India

13-15 MUMBAI, INDIA

3rd Greek University Congress of Ophthalmology www.unieyecongress.gr/2010/

December 2010

www.presbymania.com

10th Annual Conference of Uveitis Society of India & Moorfields Uveitis Course www.usi2010.in

November 2010

GENEVA, SWITZERLAND 7PRESBYMANIA 2010

Vienna, Austria

2nd International course on ophthalmic and oculoplastic reconstruction and trauma surgery www.ophthalmictrainings.com

18-20 TURKEY

ISTANBUL,

15th ESCRS Winter Meeting www.escrs.org

BELGRADE, SERBIA

3rd International Symposium on Macular Disease www.milosklinika.com

March

April

3-6 Barcelona, Spain

6-10

2011

2nd World Congress on Controversies in Ophthalmology (COPHy) www.comtecmed.com/cophy

11-12

Alicante, Spain

ARI Monographic 2011 - “The best and most updated information about Lens, Cataract and Refractive Surgery” www.alicanterefractiva.com

25-30

San Diego CA, USA

ASCRS/ASOA Symposium and Congress www.ascrs.org

EUROTIMES | Volume 15 | Issue 7/8

May Mar del Plata, Argentina

19th Argentinian Ophthalmology Congress www.oftalmologia2011.com.ar

Advertising Directory Abbott Medical Optics Page: IFC Alcon Pages: 27, OBC ASCRS Pages: 25, 32, 51

September

2011

2011

26-29 11th EURETINA Congress www.euretina.org

Bausch + Lomb Page: 29

DOC Page: 14

Nidek Page: 19

Carl Zeiss Page: 15

Eye Technology Page: 26

Oculus Page: 6

Lumenis Page: 9

Oertli Instrumente AG Pages: 47, 49

Croma Pages: 11, 31

2011

London, UK

Rayner Intraocular Lenses Limited Page: IBC VSY Page: 3

16-17 vienna, 17-21austria 2nd EuCornea Congress www.eucornea.org

vienna, austria

XXIX Congress of the ESCRS www.escrs.org

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