OPH the RECORD Published by Ophtec BV /// 2015 Extra Edition /// #01
Focus on Perfection ArtiLens
Millennial Generation
PLUS: 6 How the Iris Claw Lens was invented
Interview with Prof. Jan Worst
9 Precizon Toric
Results
15 Robomarker
Interview with Dr Alan Brown
20 About Eyes
Test your knowledge and win a sweater!
www.ophtec.com
dear reader We introduce an additional edition of OphTheRecord (mid-year 2015) to celebrate a new generation of innovative and impactful young ophthalmologists from around the world, committed innovative minds with a passion for patients. Looking forward beyond the immediate horizon, this new generation of ophthalmologists will change the world in the face of a looming challenge to service more and aging patients with ever limited resources, by finding new ways to finance improving clinical value with innovation. Ophtec has invested its resources, time and intelligence to address the challenges by bringing innovation to help address un-met needs with clinical value for both incremental and quantum improvements for all segments of the eye/ vision. You will see Ophtec invigorated commitments come to the markets with each New Year. A perfect example of this commitment from Ophtec comes with the innovation and clinical valuable proposition in our Precizon Toric IOL - launched at the ESCRS/Amsterdam 2013. The Precizon Toric addresses one of the biggest challenges with Toric IOLs: optical quality degradation due to rotation and large pupils. The Precizon Toric has proven superior quality of vision under misalignment and large pupils, and is fast becoming the toric IOL of choice.
content 3. ArtiLens Millennial Generation
5 portraits, introduction
4. ArtiLens Millennial Generation
Dr Hye Young Park
6. How the Iris Claw Lens was invented
Interview with Prof. Jan Worst
8. ArtiLens Millennial Generation
Dr Guillermo Amescua
9. Precizon Toric: Results 14. ArtiLens Millennial Generation
Dr Roberto Fernández Buenaga
15. What were you thinking!
Interview with Alan Brown, inventor of the RoboMarker
17. ArtiLens Millennial Generation
Dr Damian Lake
Come experience the innovation from Ophtec and learn more about our future together.
19. ArtiLens Millennial Generation
Jim Simms, Global Director Marketing & Sales
20. About Eyes
Dr Stephanie Rohrweck Test your knowledge
Events & Congresses 2015 / 2016 28-30 May
Algarve
Portugal
CIRP
11-13 June
Leipzig
Germany
DOC
4-5 July
Chennai
India
IIRSI
19-21 July
Tokyo
Japan
JSCRS
5-8 August
Kuala Lumpur
Malaysia
APACRS
20-23 August
Cape Town
South Africa
SASCRS
4-6 September
Barcelona
Spain
WSPOS
5-9 September
Barcelona
Spain
ESCRS
23-26 September
Sevilla
Spain
SEO
1-4 October
Berlin
Germany
DOG
16 October
Groningen
The Netherlands
Artisan Aphakia training
6-8 November
Ilsan Kintex
Korea
KOS
13-14 November
Berlin
Germany
Artisan Artif lex training Germany
14-17 November
Las Vegas
USA
AAO
25-27 November
Brussels
Belgium
OB
5-9 February
Guadalajara
Mexico
WOC
26-28 February
Athens
Greece
W-ESCRS
25-29 March
Taipei
Taiwan
APAO
6-8 April
Maastricht
The Netherlands
NOG
6-10 May
New Orleans
USA
ASCRS
7-10 May
Paris
France
SFO
Colofon OphTheRecord is published by Ophtec BV Interviews: Mathijs Deen; Tekst & Training Amsterdam Marij Thiecke; Concept & Copy, Haren Editor: r.den.besten@ophtec.com Artwork: info@mennoschreuder.nl Print: Scholma Druk, Bedum On the cover: Picture of the ‘Afsluitdijk’ barrier dam between IJsselmeer and Waddenzee, The Netherlands All rights reserved. © Ophtec BV 2015 PO Box 398 | 9700 AJ | Groningen The Netherlands T: +31 50 525 1944 | F: +31 50 525 4386 www.ophtec.com
ArtiLens Millennial Generation
The iris fixated ArtiLenses have been popular for over 30 years now. This is a unique phenomenon in the world of ophthalmology, a world in which new inventions rapidly come and go. Young ophthalmologists are as enthusiastic about the results as the generation before them. OphTheRecord talked to five young ArtiLens users. Meet Hye Young Park, Guillermo Amescua, Roberto Fernรกndez Buenaga, Damian Lake and Stephanie Rohrweck and read their stories.
>> OPH//THE//RECORD 3
ArtiLens Millennial Generation
Dr Hye Young Park
Experienced in cataract and presbyopia more than 11 years.
The only honest lens, ArtiLens, shows your surgery skills by lens positioning on the iris By: Dr Hye Young Park Chief surgeon of Gangnam Seoul Bright Eye Clinic, located in Seoul, Korea It was in November 2012 that I used the Artiflex Lens for the first time. Until that time I had used PC PIOLs (Posterior Chamber Phakic IOLs) since May 2007. I used those lenses in a University Hospital where I worked at that time. There were several reasons why it took long for me to use the Artiflex Lens. First of all, I only had a few chances to learn how to implant Phakic IOLs. Secondly, I had a preconception about using AC PIOLs (Anterior Chamber Phakic IOLs) after hearing from senior doctors that it can cause corneal endothelial cell loss. I had a chance to observe a PC PIOL surgery performed by a head professor, when I was working as a fellow. The surgery did not look that difficult to perform and the CDVA was good. That was the reason why I started to use PC PIOLs. There was no reason to hesitate and the operation turned out to be easy as I expected. There were, however, not many cases due to the high operation cost in a university hospital. That changed in 2011 when I started to work in my current hospital which specializes in refractive surgery. I became very familiar with the implantation technique of PC PIOLs. It only requires easy surgery skills and there was also a belief of satisfied refractive correction even for high myopia.
4 OPH//THE//RECORD
Was Cataract/Cornea Fellow in Asan Medical Center. Was Professors in Gangdong Sacred Heart Hospital, Hallym Univ. Is member of KOS, AAO, ASCRS. Was Editing Executive Director of the Korean Contact Lens Society. Was Editing Executive Director of the Korean Optometry Society. Wrote a book ‘understanding of ophthalmologic disease by clinical cases.
However, problems were identified as the numbers of operations grew. We had to replace lenses due to extreme low or high vaulting. Some patients who had surgeries from other doctors needed to have cataract operations. Problems also rose for astigmatism patients. Although it was possible to correct the astigmatism by LRI or LASEK for those who were not highly astigmatic, there were many patients suffering from dry eye syndrome after LRI or LASEK. In addition, the correction results of the astigmatism by LASEK for those who were 3D or more were not satisfactory enough. Although Toric PC PIOLs exist, their use is compromised because of lens rotation, which causes worse astigmatism in some cases. Moreover, on a more logistic level, we have to order the lenses. This process can take weeks. There is no learning curve for the implantation of the PC Phakic IOLs, but you do need experience in order to choose the right size of the lens. Although sizing problems could be partly solved by getting used to it or purchasing UBM, there is no perfect solution. Those were the major reasons why I started to pay attention to the Iris Claw AC PIOL. I needed a stress-free procedure concerning size, a lower risk of getting cataract, and a complete astigmatism correction. Another reason for choosing the Iris Claw AC PIOL was the need I felt to challenge myself professionally, to try a new operating technique. I thought I had become stereotyped in performing a lot of LASIK, LASEK or ICL operations. I did not have the benefit of a surgical mentor ophthalmologist to teach me how to perform Artiflex, as I was the first person in my hospital to perform Artiflex surgery. After excellent training by OPHTEC Koreaâ&#x20AC;&#x2122;s skilled staff, and by watching YouTube videos about performing Artiflex surgery, I did my first Artiflex and the result was very satisfying. After this, I increased the number of Artiflex surgery cases. Today Iris Claw lenses take 30 to 40 percent of all Phakic Surgeries, because patients with more than 2 diopters of astigmatism usually will have an Artiflex Toric lens. I highly recommend Artiflex surgery except for patients with extremely small eyes (WTW < 11.0mm, ACD (corneal endothelium~phakic lens) < 3.0 mm) and for patients whose corneal endothelium is not healthy enough to perform Artiflex surgery on. With my experience, I came to know that Artiflex surgery will not damage the cornea endothelium cells if the surgery is performed properly and done with confidence.
ArtiLens Millennial Generation
Dr Hye Young Park (right)
Surgeons who use Iris Claw AC PIOLs and PC PIOLs would agree on the fact that surgery with Artiflex and Artisan is not as easy as posterior chamber lens surgery. In the beginning, everything worried me such as where to put the lens between pupil center and cornea center or how much of iris tissue should be used for a successful enclavation. One surgeon who prefers the Iris Claw AC lens to PC lenses once told me that he likes the surgery, because he knows whether the procedure went successfully by seeing the lens. That caused some anxiety.
â&#x20AC;&#x2DC;I am really happy when I see that the lens is located perfectly on the eyeâ&#x20AC;&#x2122; When I had done about 10 cases with Artiflex, Ophtec Korea organized a small symposium where I could meet other expert surgeons. It was a great opportunity for me as I did not yet have a sparring partner with whom I could discuss the Artiflex surgery. When I attended a small group symposium for the second time, I also could exchange my skills and queries for Artiflex with other surgeons. These two sessions helped me greatly in improving my Artiflex skills and, at the same time, building more confidence.
Gangnam Seoul Bright Eye Clinic
Even though I have had a number of experiences with Artiflex surgery, the fact that I can see whether the surgery was successful or not by being able to see the lens position on the iris right after surgery, still causes some anxiety. However, I am really happy when I see that the lens is located perfectly on the eye and that patients with high myopia and more than 3 diopters of astigmatism have a better visual acuity with zero index value. Artiflex and Artisan lenses are honest because the results show the efforts you put in the surgery. With this surgery you can help your patients get back the best possible state of their eyes. You can minimize night glare by placing the lens on targeted position however, it is one of the drawbacks of refractive surgery. I believe that it would be even better for patients when there are consistently more options for sphere and cylinder powers of Artiflex and new products.
OPH//THE//RECORD 5
How the Iris Claw lens was invented Interview with prof. dr Jan Worst
You invented the concept of the Iris Claw lens in Taxila, Pakistan. How did you get in contact with the people of Pakistan? ‘In the seventies I visited the Bascom Palmer Institute in Miami, where I presented a talk on intraocular lens implantation. That is where I met dr Norval Christy, an American, who talked about the Christian Hospital Taxila in Pakistan, where he worked full time. He told the audience that he performed 13.000 cataract operations a year together with a Pakistani colleague. An unlikely high number, but contrary to the opinion of a number of American colleagues, I thought right away: ‘he hasn’t dreamt up such a high number ; it has to be true’. He invited me to come and have a look in Taxila and my first visit was in February 1977. Since then I have been back there a couple of times and I have stayed in contact with the hospital ever since.
‘the iris claw principle with its fixation to the iris has been started in 1978 in Taxila, Pakistan; born out of necessity’
6 OPH//THE//RECORD
What did you experience during the visit with your wife? ‘We knew that it would be pretty primitive, but what we encountered, caused a real cultural shock. We arrived in a regional hospital of moderate size, which was visited by people from far and near for treatment or surgery, which was, according to our standards, performed under rather primitive circumstances. Impressive however was the way they performed cataract operations, in an assembly line on 4 tables.’
Cataract operations in an assembly line
‘We had an enormous desire to help. My wife started immediately to make a list of the most urgent needs of the hospital and she took care of raising funds, so desperately needed, by starting the Foundation Focus (For aid to the curable blind). Later on she convinced the Dutch Government to provide 600.000 guilders for the Taxila Hospital.’ It was in Taxila that you implanted a real iris claw lens for the first time. How did you get the idea of this special design? ‘I continued to perform my surgery and in between, in the back of my mind, I was thinking of what was going on there in Pakistan. Thick postoperative spectacles, prescribed after a cataract extraction, are too expensive for most of these people.’
Interview Prof Jan Worst
Prof Jan Worst and his wife Anneke watching their Pakistan photo album
‘In my own practice I had started to implant intraocular lenses. I used the Binkhorst lens first and later on the Medallion lens, designed by myself; it was fixed to the iris with 2 loops and a suture, first made of perlon and later on of stainless steel. I was not satisfied. It had to be implanted in a simpler way, faster and safer’
‘I was worried as to whether the implanted lens would stay in its proper position while the men were praying. Therefore we tested the situation on one of the patients.
First model of the Iris Claw lens
I still have slides of the situation, where we used the local open air garage. The patient took his bent position on the bridge.
‘I had discovered that iris tissue, sometimes trapped in the slots of the Medallion lens, didn’t cause a problem at all! A serendipitous discovery! In the Netherlands I started to experiment. Various models were made with a claw on one side’. ‘And then, one day while I was sitting in Taxila together with Norval Christy, I started to drill holes in blanks as a preparation for the claws. Then, for the first time I made 2 holes on either side of the blank optic and made the slits for the fixation in the iris. That is how I made the first iris claw lenses. I polished them on the side of a matchbox, cleaned them properly and sterilized them in caustic soda, being the usual wet-sterilization method in those days. During the following days I implanted a few lenses and investigated the suitability of this new design.’
Examination in open air garage
While standing under the bridge I could control the position of the implanted lens with my ophthalmoscope and observed that the lens remained perfectly in its proper place. The iris claw lens proved to be a super system!’ ‘Back in the Netherlands I have still refined the concept somewhat. However, the iris claw principle used in all designs of Artisan and Artiflex lenses has been started in 1978 in Taxila, Pakistan; born out of necessity’
OPH//THE//RECORD 7
ArtiLens Millennial Generation
Dr Guillermo Amescua
Ophthalmologist at Bascom Palmer Eye Institute in Miami, USA
Ophthalmic passion in Miami Dr Guillermo Amescua merrily rides the ophthalmic innovation tidal wave By: Marij Thiecke Dr Guillermo Amescua has been an ophthalmologist for the Bascom Palmer Eye Institute in Miami, Florida since 2010. His professional passions are easily summed up: fixing the worst of the worst in anterior chamber eye conditions in a dedicated innovative team, and training future colleagues to improve ophthalmic eye care, both in the US and in Latin America. The catch in fulfilling passions is, as ever, in the execution. Not for Amescua: ‘I work in a truly amazing institute that boasts a history that I already feel proud of. The innovative atmosphere is tangible, and I trust that in a few years’ time, the scholarly efforts we undertake now will make a difference for patients in the US and in Latin America.’
‘Ophthalmology in general is buzzing with innovation’ Dr Guillermo Amescua started medical school in Monterrey, Mexico, at the Tecnológico de Monterrey, a world renowned institute. With over 90,000 students, branches can be found throughout Latin America. This private university boasts excellent exchange programs with US medical schools. Amescua: ‘When I got acquainted with the US academic system through such an exchange program, I knew that studying in the US would suit my goals very well. I got accepted at excellent training programs (Cole Eye Institute and University of Pittsburgh Eye Center), and ended up here in Miami as a cornea fellow because Miami suits my goals the best. First, I love the innovative character of the institute – progress is on everyone’s mind. Also, the support of my mentors - I name Victor L. Perez, Sonia Yoo and Carol Karp, but I could name so many others - has always been inspiring. Thirdly, on a more personal level, the proximity to Latin America also played a role: a big part of my heart still lies in Mexico.’
8 OPH//THE//RECORD
Specialties: Cataracts and Intraocular Lens, Uveitis, Corneal and External Diseases, Corneal Transplant Surgery, Ocular Surface Diseases, Keratoprosthesis, LASIK and Laser Vision Correction.
Rocky road ‘My specialties are ocular surface diseases, keratoprosthesis, and cataract surgery. As a top ophthalmic institute, we often receive patients who have travelled a rocky road filled with corneal inflammation, rejection or failure of corneal transplant, and other ocular horror stories. In some cases, a cornea transplant with artificial material is the only option. I love fixing complex problems, having this whole precious organ in front of you, delicately manipulating structures, adding artificial or human donor material so that a patient has his or her vision restored or enhanced. As a result, I perform a lot of complex surgery, and about twice each month I conduct keratoprosthesis surgery, in a dedicated medical bio-engineering team so that our patients get the best treatment available.’ Alternatives ‘Ophthalmology in general is buzzing with innovation, and rapidly evolving towards the development of increasingly refined tools and procedures. In Miami, we aim to contribute in several ways in securing better vision. For instance, our team currently studies alternatives for the treatment of corneal blindness and other inflictions that in the future might work better than today’s cutting edge tools. Our team – in which my colleague Jean Marie Parel is a driving force - also conducts research into the merits of photodynamic therapy to kill organisms that conventional anti-microbial treatments are unable to reach. Alternatives for antibiotics have our attention by default, because we are building up more and more resistance. Moreover, in many developing countries the scarcity of antibiotics (and medical care in general) is a threat to public health. It would be premature to suggest we discovered a way around antibiotics in the treatment of fungal ulcers or other corneal infections, but our study so far seems promising but with lots of work to do!’ Wish list So, my wish list for a bright ophthalmic future includes the development of highly bio-compatible material with characteristics that enable better tissue integration. At some point, it would be amazing to perform regular intraocular pressure monitoring with artificial corneas. As yet, this is a bridge too far. Also, I would like to see more refined ophthalmic fellowship programs in Latin America. I am currently part of a group that focuses on better eye care training for Latin America. The people at Ophtec are included in this discussion, as their aphakia lens would be a great addition to both the US and all the Latin American health systems, among other things. We’re working on it!’
Precizon Toric: Results ™
>> PRECIZON™ Toric Model 565
‘Transitional Toric surface’
Lens type:
One piece IOL, In the bag fixation
Body:
6.0 mm | Transitional Conic Toric | Biconvex
Material:
Hydrophilic Acrylic
Overall Ø:
12.5 mm
Angulation:
0˚
A-Constant:
Explained by Fred Wassenburg, Director Technology & Operations. In ‘standard’ toric IOLs on the market, the aspherical correction has not been implemented in an optimal way, resulting in a less optimal image. When designing the Precizon Toric, we calculated the curvature of the side with the toric cylinder in relation to the other side of the IOL. This way the curvature is constantly changing over the surface of the IOL. It results in a transition of the radius and
118.0 (A Scan) 118.5 (IOL Master; SRK T) | 118.7 (IOL Master; SRK II)
in this way the dioptric power remains constant along the total surface of the lens. The value of Precion Toric is that the lens has a broader vision zone. It maintains the same dioptric power at all points on the lens surface, independent of the pupil size, decentration or tilting of the lens. The lens behaves better in case of misalignment or some rotation as compared to ‘standard’ toric lenses.
1.020 (IOL Master; Haigis aO) | 0.400 (IOL Master; Haigis a1) 0.100 (IOL Master; Haigis a2) 5.26 (IOL Master; Hoffer-Q pACD) 1.51 (IOL Master; Holladay 1 sf) Available Powers:
+1.0 D to +34.0 D (0.5 increments) Cylinder 1.0 D to 10.0 D (0.5 increments)
Refractive index:
1.46
IOL Spherical Aberration:
360˚ | 0 µm
VIDEO
Precizon Toric IOL Scan code or visit: www.youtube.com/ophtecbv Playlist: Precizon Toric
OPH//THE//RECORD 9
Precizon Toric: Results
Results presented during Dr J. Cazal, Spain
Precizon Toric: Management of immidiate post-op rotation. Take home message: • Create a 5-mm anterior capsulorhexis contacting the optic 360º. • Remove all viscoelastic from behind the IOL. • Do not hyperinflate the capsular bag with BSS. • Gently tap the optic to ensure contact between the capsular bag and the optic.
Dr T. Ferreira, Portugal
Visual outcomes with the new Precizon Toric IOL in a multicenter clinical trial. Conclusions: Visual results • 90% eyes UDVA > 0.8 • Excellent VA Refractive results • 95% eyes within ±0.50 D target • Excellent predictability
Rotational stability • 94% eyes <5° misalignment • Excellent rotational stability • Tolerance misalignment.
Dr S. Hamada, UK
Safety and Efficacy of Precizon Toric IOL Implantation. A Prospective Study. Conclusions: • An ideal toric IOL, • Safe, • Stable in the capsular bag, • Minimal rotation has no significant impact on the astigmatic correction, • Effective.
Prof. M. P. Holzer, Germany
Preoperative specifics and experiences with the Precizon toric IOL. Summary: Precizon Toric IOL: • Majority of patients show corneal astigmatism that would require toric IOL implantation. • Preoperative precise diagnostics important for correct IOL calculation. • Intraoperative correct positioning of IOL important for good visual outcomes. • Precizon toric IOL easy to handle with good visual outcomes. • No postoperative IOL rotation necessary in own patient cohort.
10 OPH//THE//RECORD
Precizon Toric: Results
the ESCRS 2014
>> Scan the QR codes or
visit www.youtube.com/ophtecbv Playlist: Precizon Toric
Prof. Myoung Joon Kim, Korea Tolerance of Toric IOLs to Rotation.
Conclusion: • There are many steps that can cause misalignment of an IOL. Precizon toric gives more forgiveness.
Dr T. Monteiro, Portugal
Precizon Toric IOL – a new concept of precision for astigmatism management after cataract surgery. Conclusions: • Ideal IOL design: - S shaped, - Independence from AC morphology and width. • Best material biocompatibility: - Hydrophilic Acrylic, - Low PCO. • High range of correction trough small incision. • Innovative IOL power distribution.
Prof. F. Ribeiro, Portugal
Precizon Toric pupil independence for night vision and aberrations. Conclusions: • Proven efficacy, • Proven stability, • Pupil independent spherical power, • Pupil independent cylindrical power.
Dr M. Sbordone, Italy Precizon Toric.
Conclusions: • IOL Stability: (very good - demonstrated!). • Post-Op Results: Optimal quality of vision, aberration free for any pupil diameter. • Easiness to Implant: Soft to introduce, stable as soon as introduced. • Injector: Easy to manipulate, insertion pushing or screwing.
OPH//THE//RECORD 11
Precizon Toric: Results
Evaluation of Precizon Toric optic,
by means of intraoperative Wavefront aberrometry (ORA system) By Dr Erik Mertens
Objective
Calculation for designing Transitional Conic Surface
Evaluation of a new toric IOL optic by means of intraoperative wavefront aberrometry (ORA system): the effect of IOL misalignment on cylinder reduction. Study conducted by: Erik L. Mertens, MD Medipolis Eye Center, Antwerp, Belgium
Introduction
Axis Shift Remaining Astigmatism from Preoperative
Remaining Astigmatism Magnitude as a Percentage of Preoperative Magnitude
Rotation of Toric IOLs have been well documented. It has been shown for every degree of rotation off intended axis 3% of effect is loss.
Efficiency Loss
150%
129%
125%
100%
100% 68%
75% 52%
50%
45˚ 40˚ 35˚ 30˚ 25˚ 20˚ 15˚ 10˚ 5˚ 0˚
a
Dpt
0
20.0
22.5
20.3
45
21.0
67.5
21.7
90
22.0
35%
25% 0%
141%
7.2˚ 0˚
5˚
14.5˚
10˚1
5˚
38.5˚
22.1˚
20˚
Residual error of the axis
25˚
30˚
35˚
40˚
45˚
Rotation of Astigmatism 40.0˚
37.5˚
Power and asphericality calculated in 8 meridians. Every anterior axis compensates the aberation of the posterior axis. The diopter power is calculated per meridian resulting in a constant power from the center of the lens to the edge.
35.0 ˚ 30.0˚ 25.0 ˚
Precizon™ Toric Power
22.5˚
Standard Toric
(Transitional Conic Surface) 90˚ 120˚
150˚
Toric axis
-150˚
5˚
10˚1
5˚
20˚
Residual error of the axis
25˚
30˚
35˚
40˚
45˚
The traditional approach to addressing toric IOL misalignment has been through design modification of haptics to maximize stability. The Precizon™ Toric (Ophtec BV, Groningen, the Netherlands) with transitional conic surface is the first toric IOL to address prevention of common rotation errors with both an enhanced haptic design for improved stability, and also improve optic designed to allow tolerance of misalignment errors.
12 OPH//THE//RECORD
0˚
-30˚
-120˚
-60˚ -90˚
Spherical equivalent
90˚ 120˚
60˚
150˚
30˚
180˚
0˚
Power
60˚
30˚
Toric axis
180˚
-150˚
0˚
-30˚
-120˚
-60˚ -90˚
Spherical equivalent
Precizon Toric: Results
Clinical Study Goals To intraoperatively compare the effect of misalignment of the Precizon™ and Lentis toric (Oculentis GmbH Berlin Germany) intraocular lenses (IOLs) on refraction by means of the ORA system and to compare postoperative outcomes.
Precizon Toric vs Lentis Toric IOL Cylinder Loss Per Degree Of Rotation
Prospective, randomized, comparative study in which patients with cataract and pre-existing corneal astigmatism underwent routine cataract surgery with bilateral implantation of a toric IOL model. Intraoperative wavefront aberrometry (ORA system) was used to assess the effect of IOL misalignment on cylinder reduction after which the lenses were rotated to the intended axis and surgery was completed.
Cylinder Loss Lentis Toric IOL
Method and Materials Emmetropia was targeted. Intraoperative refraction was measured at 10°, 5° and at 0° misalignment using the Optiwave Refractive Analysis (ORA) system wavefront aberrometer (WaveTec Vision Systems, Aliso Viejo, CA, USA). Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction and IOL misalignment were evaluated 1 month postoperatively. Postoperative IOL misalignment was assessed using a KR-1W Wavefront analyzer (Topcon, Tokyo, Japan).
Precizon Toric vs Lentis Toric IOL Cylinder Loss Per Degree Of Rotation
Cylinder Loss Lentis Toric IOL
Analysis Toric IOL implantation in 10 eyes in each subgroup resulted in an average of 1,6° rotation with the Precizon IOL and an average of 2,2° with the Lentis Toric IOL. For every degree of error in a toric IOL’s rotational misalignment, there is a 3.3 percent decrease in the correction of astigmatism. If a toric IOL is misaligned by 10 degrees, the astigmatism will be 33 percent under-corrected. If the toric IOL is misaligned by 30 degrees, there will be no astigmatism correction. As indicated in previously published papers, we found the same under correction with misalignment with the Lentis Toric IOL by deliberately misaligning 10° and 5°. Surprisingly we did not have the same results with the Precizon™ IOL. By misaligning Precizon™ 10° the under correction was on average 18% instead of the expected 33% as measured with the ORA and the average under correction with 5° misalignment was 9% instead of 15%
Conclusion The new toric optic IOL Precizon™ gave similar results in terms of rotation one month postoperatively but performed significantly better in astigmatism correction and was less sensitive to misalignment in respect to the Lentis Toric IOL. Longer follow-up and a larger series is needed to support this findings.
Reference This data submitted to ESCRS/2014
Degrees of misalignment
10° rotation
5° rotation
Precizon™ under correction loss of effect
18%
9%
Lentis Toric IOL under correction loss of effect
33%
15%
For more information please contact: info@ophtec.com
EXAMPLE: Effective Loss of Cylinder Power Precizon™ @ 10°
Lentis IOL @ 10°
Precizon @ 5°
Lentis IOL @ 5°
4D cy IOL
.72D loss
1.32D loss
.36D loss
.6D loss
10D cy IOL
1.8D loss
3.3D loss
.9D loss
1.5D loss OPH//THE//RECORD 13
ArtiLens Millennial Generation
Dr Roberto Fernández Buenaga Consultant Ophthalmic Surgeon at Ramón y Cajal Hospital, Madrid and Private Clinic: Vissum Corporation, Madrid. Specialties: Refractive, cataract and cornea surgery.
When the Artiflex is implanted properly, the patient is perfect the day after Dr Roberto Fernández Buenaga is trainer during the official ArtiLens implantation course in Madrid in 2015. He has spoken about his ArtiLens experiences in the Ophtec booth during the ESCRS 2014 and will do so again in 2015. by: Mathijs Deen Dr Roberto Fernández Buenaga is the only child of an optometrist from Santander, Spain. From early childhood, he saw his father making people happy, and he thought: I want to do that too. But when he grew older, becoming an optometrist alone was not enough for Roberto. He was drawn to medicine in general and especially to surgery. So he aimed for medical studies and the specialization ophthalmology. Much to his father’s delight. ‘He was very happy,’ Roberto remembers.
‘I can guarantee the patient will be perfect the day after’ He started his medical studies in Pamplona, and after his graduation, he passed the general exam for specialization with top grades. Because of his excellent results, he could do his ophthalmology training at the most desired of all hospitals: Ramón y Cajal Hospital in Madrid. Ramón y Cajal Hospital is widely considered one of Spain’s best institutes of ophthalmology for every aspect of the eye. So its graduates have been trained very well all-round.
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‘I liked the cornea,’ Roberto recalls, ‘so after my basic ophthalmology training I was very fortunate to move to Alicante and work with Professor Jorge Alió. His reputation in cornea, cataract and refractive surgery is one of the best. The work felt like a four year fellowship. It was great.’ At present, dr Roberto Fernández Buenaga is back in Madrid, at Ramón y Cajal Hospital, which is a public health institute, where he works during the morning. In the afternoons, he works in a private clinic: Vissum Corporation. ‘I like the private clinic because it gives me the opportunity to do refractive surgery,’ Roberto says. ‘Refractive surgery is not performed in the public health system because it is considered cosmetic. As far as IOLs go, dr Roberto Fernández Buenaga has adopted the preference of his teacher, Professor Jorge Alió. ‘He showed me the reasons why he prefers the ArtiLens family, and I consider these advantages so important that have to fully agree. To name one: of all the lenses I know, Artiflex has the lowest risk for developing cataract, which is always a risk with posterior chamber phakic lenses. If one implants the wrong size of lens and the vault (distance of the posterior chamber phakic IOL to the crystalline lens) is too small, cataract may develop. Or glaucoma, when the distance is too big. ‘This problem doesn’t exist with the Artiflex or Artisan,’ Roberto Fernandez points out. ‘I tell my colleagues that, when the Artiflex is implanted properly, I can guarantee the patient will be perfect the day after.’ Being an ophthalmologist has not disappointed Roberto over the years. For him, it all boils down to restoring the vision of the patient, and that remains very satisfying. Even though it can be a bit of a burden when you notice that the work never leaves your mind. ‘When you have a patient with a complicated condition and the stakes are very high, you can’t simply shrug it off when you leave the clinic. Even after working hours, or in the weekends, my thoughts tend to wander to this patient and his or her problem. That is how it works with me, anyway. It depends on what kind of person you are, I suppose.’
What were you thinking! Interview with Dr Alan Brown, inventor of the RoboMarker By: Marij Thiecke
Dr Alan Brown Ophthalmologist at Surgical Eye Care, Wilmington, USA Founder of Surgilüm
Meet Dr Alan Brown. As an ophthalmologist, he strives to help people see better and as an inventor, his aim is to innovate state-of-the-art (medical) instruments. Brown’s personal and professional drive, mixed with a steep learning curve in entrepreneurship, recently led to the founding of the medical device company Surgilüm. Brown: ‘At Surgiüm, we aim to create cool, beautiful and intuitively functional instruments that stand out in the crowd. Conceptually and visually they have to present a clear-cut answer to current surgical frustrations. Their added value should be huge. We have a file drawer with over 100 concepts; the RoboMarker is only the beginning.’ The smart, sleek, self-leveling RoboMarker could revolutionize corneal marking as we know it. With a CE-Mark well under way, Ophtec takes great pride in a new collaboration with Surgilüm.
‘This will allow patient to live better, happier lives of superior vision’ At the 2014 Boston ASCRS conference, Ophtec delegates were immediately impressed with Surgilüm’s first creation, the RoboMarker. In fact, the RoboMarker was considered one of the top 8 eye surgery innovations of the ASCRS conference. Alan Brown illustrates how a genuine frustration can catapult a concept like the RoboMarker into existence: ‘The whole corneal marking process has proven to be confusing and complicated. Traditional methods for marking the eye include either a pendular marker or a gentian-violet pen, both having their drawbacks: pendular markers are allowed for accurate markings, but those markings never last very long. Gentian-violet pens are prone to error because they are applied with the surgeon ‘eye balling’ the
proper location on the eye, and have the subsequent issues of smeared ink marks. Furthermore, in both of these techniques I had to wait for an instrument to come out of the autoclave, which can delay surgery. When it comes to the level of comfort for your patient, previous marking instruments were intimidating due to the swinging hanging pendular weights, or bubble levels. Unfortunately, their level of accuracy varied since the marking process depended on so many instruments and steps.’ Responsibility Brown resumes: ‘Patients trust us with their vision using a procedure that affects them for the rest of their lives. We owe them the best technology to give them the best possible result. This thought is equally important during the designing and developing process of the RoboMarker. Because we spend so much time and money on the latest technology to measure corneal astigmatism; we look the patient in the eye and tell them they will pay a lot of extra money to have this astigmatism corrected. How then can we meet them at surgery with a carpenter’s bubble level or a medieval swinging pendular weight, or worse, our cell phone with an attached marker? They have trusted us with their eyes and paid us handsomely. Just think about it.’ Cool Brown resumes: ‘So, I was clearly fed up with the corneal marking process and started deconstructing and rethinking the critical factors that determine a perfect cornea mark: ‘We knew we needed to create a corneal marker with superior accuracy, so we incorporated 2 hidden pendular weights and 2 high precision ball bearings. We needed to have the patient in a comfortable marking environment so we gave our patient a fixation light. Moreover, we had to make a beautiful instrument that looked like it fell out of the medical >>
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The Inventor / Ophthalmologist
VIDEOS Basic model of the Robomarker, made with a simple pen with a LED-light, a ball bearing and two felt marker points on a plunger.
bay of a passing spaceship, so I went through over 50 iterations to land the design of a mini jet engine. I have to smile when I go to mark the patients preoperatively and their families remark ‘What is that device? It is so cool!’. That is what we strive for, an instrument that inspires the confidence of the patient towards their surgeon and the results they desire.’ Jet engine ‘The RoboMarker aha-moment was caused when I mashed up a simple pen with an LED light, a ball bearing, and two felt tips on a syringe plunger to create an illuminating pendulum marker.’ It was this first concoction of readily available utensils that further ignited the 3-year creative and entrepreneurial road to the RoboMarker. Brown: ‘The RoboMarker was eventually transformed to look like a small jet engine, with a sterile dry-ink disposable tip that leaves a mark for up to 2 hours. The two high-precision ball bearings ensure a perfect mark. In addition, the RoboMarker doesn’t intimidate the patient, as there is no dangling pendulum. Also, the fixation light mimics the way other procedures are measured in the office, adding to patient comfort and more reliability.’ Aha-moment ‘Rethinking has been something I’ve done all my life, and I must say that I can’t take pride in this ability to create and innovate. I believe this is just what my Creator packed in my suitcase. Ideas just pop into my head. It is like finding a rough gem along a plowed field. You can’t take credit for stumbling along and finding a rough gem; you just cut and polish it to the point that others see its beauty. I love to learn, especially by taking things apart
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and turning them into something new. My upbringing provided a great medium for innovation. My father, an army man, was sent to France as part of NATO, so much of my youth was spent abroad. I had no American television and pre-cooked toys on which to waste my time. From a huge spare-part box with accumulated engineering surplus, I amused myself with inventing new things during my childhood. The feeling I got from my original heartbeat-o-meter at the age of 7 (which didn’t work, but that is beside the point), still hits me when I experience a new ‘aha moment.’ Nothing really changes the joy of innovation’. Passion It had been a long, winding, and adventurous road that Alan Brown traveled before manning the Surgilüm booth at the 2014 Boston conference: ‘In the past, I would invent and present my idea to a big company and hope they would license that idea. I had many say that an invention was wonderful, yet no one would ‘take me to the dance’, so I decided to become a manufacturer and set up my own booth at the major meetings. In essence, like Ophtec many years ago, I went to the dance by myself and now the bigger companies are asking me to dance with them. During this process, a major encouragement came from Bill Link, a household name in the eye innovation industry. Dr Link took me out to breakfast, listened to my invention inventory, and encouraged me to venture out on my own. It is very rewarding to have taken the risk to do so, and having a very positive response that has given me the freedom to offer new innovations on my schedule, no longer depending on other companies to get my product to market. It was especially rewarding to have an established company
Dr Alan Brown Inventor of the RoboMarker™ www.youtube.com/ophtecbv playlist: Robomarker
like Ophtec appreciate Surgilüm and the RoboMarker because Ophtec had similar humble beginnings and has grown to become a powerhouse in eye surgical products.’ Think tank Brown: ‘Performing surgery on a frequent basis aids in generating and accelerating new ideas, and having the opportunity to help individual patients is very rewarding. At the same time, ophthalmology is a field that still needs innovation and I see that my work for Surgilüm will take up more and more time. Surgilüm will be known, I hope, as a major think tank where bright engineers, medical doctors, and creative minds alike can thrive in creating beautiful inventions that will improve surgical outcomes and patient happiness. So when I met the good people of Ophtec, I was almost immediately struck by their similar passionate approach towards innovation. For instance, their Precizon toric IOL lens is a brilliant idea. I am certain that it will integrate very well with the RoboMarker in order to give our patients the best possible eyesight. Ophthalmology is both rewarding and challenging. Working together with a well-known family business that is equally passionate in that respect, and also sees itself as an incubator for innovation in a field where so much can be done, feels very satisfying.’ Brown summarizes: ‘We are very grateful that Ophtec has included the RoboMarker in a family of products to improve patients outcomes and happiness. With the Cassini topographer to map astigmatism and the RoboMarker to mark the correct astigmatic axis, the superior results of the Precision Toric are a given, and will allow patient to live better happier lives of superior vision.’
ArtiLens Millennial Generation
Dr Damian Lake Consultant Ophthalmologist and Lead surgeon for the Corneal,Refractive and External Diseases Service at Queen Victoria Hospital, East Grinstead,UK
Precizon Toric IOL: a bright marriage of concepts Dr Damian Lake focuses on enthusiastic ophthalmic innovation by: Marij Thiecke The tangible tradition of passionate innovation in ophthalmology is slowly but certainly passed on to a new generation of pioneers. Mr. Damian Lake can be seen as a down to earth yet innovative trendsetter in this respect. Operating from the famed Queen Victoria Hospital in East Grinstead (UK) he divides his time between ‘regular’ cataract procedures and (severe) trauma cases that demand a customized solution. The Precizon Toric IOL has been under his scrutiny for 7 months now, and a study will be published later this year. Lake: ‘The preliminary results are very satisfactory – 100% happy patients. Nevertheless, my educated guess and my scholarly fantasies lead me to believe that, 25 years from now, we will frown upon today’s approach towards surgery and medicine as a whole. I think that there will be more and more emphasis on prevention, that surgery will be less invasive as a rule, and that our approach towards medical challenges will be more customized at the cellular level.’ ‘To boldly go where no ophthalmologist has gone before’ certainly holds – well, up to a point – for Mr. Damian Lake. Educated at the University of Glasgow Medical School (‘A long way from home but worth the trip’), Lake felt inspired to pursue a career in eye surgery from a pleasant mash up of fond Star Trek memories (just remind yourself of Dr ‘Bones’ McCoy and his futuristic, sleek instruments) and the inspiring surroundings at Glasgow Medical School.
Dr Damian Lake shared his Artiflex experience during the booth-speaker presentation at the ESCRS 2014.This presentation can be found on OPHTEC’s YouTube channel.
Lake: ‘It’s not that we were in a Dead Poets Society environment continuously, but my professors were so inspiring – they truly helped light the fire inside me to look for the unanswered questions. Also, the fact that I suffer from a harmless Obsessive Compulsive habit that I share with most of my colleagues – the sort of minute meticulousness that is inhibiting in other industries – helped in narrowing down and determining my career path.’ Pilots Mr. Lake’s professional home base is the world renowned Queen Victoria Hospital. The illustrious history of this hospital explains why an enthusiastic hunger for innovation is every professional’s starting point, combined with, among other things, excellent patient care. Lake explains: ‘Initially, this institute was an average ‘cottage hospital’. But along came the Second World War with all its casualties. The hospital became a designated burns unit for pilots, because so many suffered from massive burns when they were shot down. Often, they suffered severe visual trauma and required ocular rehabilitation. After the war the unit flourished into a greenhouse for innovation, with an outstanding cornea bank.’ Enthusiasm Lake continues: ‘I have been practicing ophthalmology here since 2007, and the decade long tradition of dedicated innovation in eye care is very much tangible every day. We get the complicated cases, and work enthusiastically towards solutions that make our patients’ lives better through better vision. For instance, we have been making great progress in the past 10-15 years in retrieving epithelium stem cells in our laboratories, thus improving the vision of sufferers of conditions such as the Stevens-Johnson Syndrome, or of patients who accidentally or intentionally had a disastrous encounter with chemicals. Innovation in anti-rejection methods are one of our focal points as well. As is the work my colleague does in restoring eye lids through cutting edge plastic surgery: the healthy blink of an eye is so important in keeping the eye moist, in the distribution of nutrients. Having a working eyelid once more can make a huge difference for some of our patients.’ Happy patient, happy doctor Suffering from an accident that could leave you blind, is a different starting point than gradually developing cataract. Lake: ‘With my trauma patients, focus is mostly on damage control and on seeing anything at all, maybe, some day. Whereas cataract surgery nowadays is, for me, striving for a straight A in vision. My patients are demanding, so working with the best material available is paramount: >>
OPH//THE//RECORD 17
ArtiLens Millennial Generation
Damian Lake during surgery
a happy patient is a happy doctor. About 20% of the cataract patients I see, also have a considerable amount of astigmatism. In England, the standard procedure in curing cataract with astigmatism is the insertion of a monofocal lens and limbal relaxing incisions (LRI’s) to reduce astigmatism. I do think this procedure will become obsolete before long, because the incision is more variable than inserting a lens, and only works with low level astigmatism. This unpredictability is not within the narrow margin I strive for, as some patients will by nature react more vigorously than others to this procedure’
‘working with the best material available is paramount’ Content Mr. Lake and his direct colleague have been using the Toric Precizon IOL for about 7 months now as an alternative. Lake: ‘I think it is very wise to combine a cataract and astigmatism procedure, and this lens so far does what it promises. Moreover, it has a solution for the problems I encounter with other options. The results are very promising. First and foremost, all 35 patients so far have indicated that they are very content with the end result: they see better and in most cases don’t need glasses to correct astigmatism. From a medical point of view, the outcome is predictable and better. Also the procedure is much simpler. For instance, I love the
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DualTec kit that comes with the lens; its design is very well thought through, also from an ergonomic point of view. Of course, the alignment of the lens is essential. You don’t want the lens to propeller in your patients’ eyes, you don’t want rotation of a lens that has been carefully inserted because it would impair vision. With the Precizon, the risks are minimal because the haptics are designed in such a way that rotation is kept to less than 5%. Moreover, a little rotation won’t result in poorer vision because of the transitional conic toric surface.‘ Marriage So, does the Precizon Toric IOL deserve the predicate ‘perfect’? Lake: ‘Of course not. As Salvador Dali said: ‘Have no fear of perfection – you’ll never reach it.’ I think that I will certainly have fond feelings towards the procedures I perform today, but at the same time I know that 25 years from now, surgery will be a whole different story. It’s not that I think I will have the capacities or equipment of a Dr ‘Bones’ McCoy, but nevertheless, today’s surgery will probably appear brutal and medieval when I retire in a few decades. I see a marriage of micro-endoscopic procedures, virtual reality displays for surgery, of natural bio-engineered replacements that will be instantly welcomed by our bodies instead of rejected as artificial prosthetics, and especially of large scale prevention programs for all sorts of ailments. Our knowledge is added to on a daily basis and sharing that knowledge has become the new standard. It’s combining all those flashes of inspiration that will help define the medical future. Until then, Ophtec does a fine job in keeping innovation going.’
ArtiLens Millennial Generation
Dr Stephanie Rohrweck Consultant Ophthalmic Surgeon ‘Clínica Baviera - Instituto Oftalmológico Europeo’ Castellón, Spain
German ophthalmologist in the Mediterranean A scholarship grant brought her to work and live in Castellón, Spain by: Mathijs Deen Dr Stephanie Rohrweck wanted to become a medical doctor for as long as she can remember. Even when she was only a little girl in the German village Lennep, close to Cologne, she was fascinated by illness and healing. Her father worked as a physicist at Cologne University, her mother was a primary school teacher. Nowhere in her family was a doctor to be found. Still her enthusiasm was awakened every time when in biology classes the human body and all its mechanisms, workings and mysteries were discussed. To master it all, to gain insight, and if necessary, to operate; that became her goal in life. This childhood dream never went away, and when she enrolled in the University of Cologne for her medical studies, she pictured herself working as a surgeon in traumatology one day.
‘I consider this a very delicate gift, every time again’ Then fate took over. During her studies, in 2005, she received a scholarship grant for a semester in Valencia. She enjoyed Spain so much (the systematic and thorough study-program, the happy people, the warm weather, and above all: the sea) that she decided to come back after her graduation and apply for her specialization in the Hospital La Fe in Valencia. In Spain, in order to apply for a specialization position, every applicant has to pass an entrance exam. The better the result of this exam, the broader the range of specializations that the applicant may choose from. And Stephanie did well, really well. In fact: she could choose what she wanted, every specialization was open for her. She oversaw the field and the possibilities and she decided to take a different turn from the path that had always seemed so clear to her.
As a surgeon, one can operate, of course, and she still longed to do just that. But as an ophthalmologist, one can do so much more than operate. One accompanies the patient from beginning to end, one rarely sends him or her off to a colleague for extra tests outside one’s field, and operating on an eye is very meticulous and beautiful. ‘My conclusion was: ophthalmology is the most all-round, versatile form of medical practice,’ Stephanie says. ‘On the face of it, the eye only seems to be a small organ, but when you take all the extra’s into account, it is in fact very comprehensive, very big.’ So Stephanie trained to become an ophthalmologist, in the Hospital La Fe, finishing a Phd in E.N.T. - which she already started during her studies in Cologne - on the side (Doing a Phd in a field different from your specialization is a common practice in Germany.) She still enjoyed Spain and planned to stay after her studies. The language was a problem in the beginning, but she mastered it, and now it is like a near native language for her. ’But it is still hard to fully grasp a football match on radio,’ she confesses. ‘During the last World Cup, when I listened to the games in my car between home and work, it sometimes was not clear to me if the German team was actually losing or winning’ (They were winning). After completing her specialization in Valencia, the Clinica Baviera invited her to work in their clinic in Castellón. In Hospital La Fe the refractive surgery is not a part of the regular ophthalmology curriculum. So her new employer trained her for 6 months to laser eyes and to implant lenses. And now she is living her dream and operating for a living, in warm and friendly Spain, in a city on the Mediterranean coast. No wonder she feels privileged. ‘The eyesight is - in the mind of many patients - the most important part of their body and of their visible personality,’ she says. ‘So when they offer their most precious organ for treatment, it is always with dread for the outcome on the one hand, but with trust in me on the other. I consider this a very delicate gift, every time again.’ And sometimes the outcome of an operation is like a miracle for the patient. She remembers an exceptional case in which a patient came to her with a dioptre of -23. She implanted an Artisan lens and the eyesight was fully recovered. ‘For out of the ordinary cases like very high dioptres or astigmatism, for me the Artisan is a very safe and predictable treatment option,’ she observes. ‘The lenses are of very high quality and, very important, they are fixated, which in case of toric lenses, is a must.’ OPH THE RECORD 19
About eyes Test your knowledge
Fill in the correct answers in the diagram below. The letters in the gray squares spell out a new answer. Send your answer, together with your: name, function, hospital/clinic name, city + country to magazine@ophtec.com and win a sweater (10 winners).
1. 11.
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10.
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8. 7.
1. What is the name of this old cataract treatment? 2. Who is the inventor of the ArtiLens? 3. What is the name of this toric IOL? 4. What is Europe’s most important ophthalmic Congress? 5. What is the title of the 1981 James Bond movie? 6. Who invented the IOL? 7. This captain suffers an eye injury.
What is his name?
8. What is the name of the inventor of the Phacomachine? 9. Mention another name for ‘Onchocerciasis’ 10. What is the name of this optical implant? 11. What is OPHTEC’s home town?
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6.