VOLUME 17 ISSUE 5 MAY 2012

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Special Focus: Refractive Lens 4 Cover story: Experts discuss premium lenses and PCO8 Managing cataracts with the light adjustable lens9 study shows refractive lens exchange has good safety profile10 Monitoring of phakic iOLs very important11 New measurement tool for presbyopic iOL patients12 Questionnaire shows high spectacle independence with new iOL

Cataract & Refractive 14 study highlights iCL advantages15 iOL power calculation in refractive surgery patients16 Femto-cataract surgery and importance of imaging technology17 iOL calculator aids in axis alignment22 Preoperative counselling important with modest monovision23 study shows applying risk factor method can reduce complications

Cornea 25 Gene therapy for corneal disease 26 Could world blindness be alleviated with bioengineered corneas?28 Potential for presbyopic LAsiK and corneal inlays 29 Avoiding postoperative infections following penetrating keratoplasty

Glaucoma 31 Eye drop exhaustion high on list for medical non-compliance, study shows32 Retrospective study analyses adherence to iOP-lowering medication 33 Updating data could help significantly in fighting blindness

Retina 37 Last call for entries for EURETiNA innovation Award39 steroid implants for intraocular inflammation treatment

Paediatric Ophthalmology 40 Teamwork crucial to help reduce childhood blindness in Africa42 Telemedicine project in india a success

News 43 EsAsO looks forward to two meetings44 Participants in the EsCRs Observership Programme give positive feedback46 Eye Facts looks at Endophthalmitis study misconceptions48 Keratoconus research looks at iCRs implantation

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MAY 2012Volume 17 | Issue 5

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Features 50 Book Review51 Eye on Travel53 Practice Development54 industry News55 JCRs highlights57 EU Matters57 From the Archive 59 Ophthalmologica highlights60 Calendar

Publisher Carol FitzpatrickExecutive Editor Colin KerrEditors sean henahan Paul McGinn

Managing Editor Caroline BrickProduction Editor Angela sweetmanSenior Designer Paddy Dunne

Assistant Designer Janice RobbCirculation Manager Angela Morrissey Contributing Editors howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon schuyler Eisele stefanie Petrou-Binder Maryalicia Post

Leigh spielberg Pippa Wysong Gearóid TuohyColour and Print Times PrintersAdvertising Sales EsCRs, Temple house, Temple Road Blackrock, Co. Dublin, ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org

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

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

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Published byThe European Society of Cataract and Refractive Surgeons

As certified by ABC, the EuroTimes aver-age net circulation for the 11 issues distributed between 01 January 2011 and 31 December 2011 is 32,332.

An article on page 25 in the April issue of EuroTimes Volume 17 issue 4 was incorrectly

accompanied by a photograph of G O Waring III.The correct picture is that of G O Waring IV

(right) who was quoted in the article. Where errors occur it is the policy

of EuroTimes to correct them.

Cover image: This decentralised IOL shows contact of anterior and posterior capsule developing PCO. Image courtesy of Matteo Piovella MD.

by Rudy Nuijts MD, PhD

This month’s issue of EuroTimes is devoted to refractive lens surgery and features a number of thought-provoking and interesting articles on the subject. Our Cover story is a particularly timely look at the issue of posterior capsule

opacification (PCO) after cataract surgery, a complication which has diminished in recent years principally thanks to advances in iOL technology and improved surgical technique.

Looking at the progress made in reducing the incidence of PCO, the major advance has clearly been the knowledge that we should ensure that our intraocular lenses (iOLs) use a 360-degree sharp square-edge optic to act as a barrier to migrating lens epithelial cells. A review of the scientific literature clearly underscores the relationship between the introduction of square-edge iOLs and the corresponding decrease of PCO in our day-to-day clinical practices. Furthermore, we have just completed a review of our Dutch cataract guidelines, and what emerges very clearly is the square-edge design as being the single-most important deterrent to PCO formation irrespective of the lens material.

however, we need to be cautious in asserting the imminent demise of PCO. My own belief, based on clinical observation, is that PCO may well be occurring at a later stage in the postoperative period than we were used to with earlier iOL designs. While there has undeniably been a marked reduction in PCO in recent years, careful study of the Kaplan-Meier survival curves shows that the risk of late-onset PCO cannot be discounted.

The problem, of course, is that many surgeons nowadays do not follow-up their patients that rigorously, so the only information that we have is usually from short-term clinical trials with a maximum of six months or one year follow-up. if we apply the principles of evidence-based medicine, there is a clear lack of longer-term peer-reviewed studies, particularly of more recent iOL designs, that clearly demonstrate the PCO and YAG capsulotomy rates three or four years after surgery. We need the hard data to make informed decisions about lens choice and the risk of PCO formation for our patients.

in my experience, however, if PCO does not occur at the three-year postoperative mark and there is a clear capsular bag behind

the lens, then that patient is very unlikely to be troubled by this particular complication.

With all the emphasis on lens designs, we also need to remember the role of the surgeon in reducing the incidence of PCO. We know now that the single most important factor in this respect is cortical clean-up. The surgeon has to take care to remove as much cortex as possible and carefully clean the equator of the lens to reduce the risk of PCO.

We have also had to rethink some of our old orthodoxies concerning PCO. For instance, it was once widely believed that meticulous cleaning of the anterior capsule was beneficial in decreasing fibrosis and reducing PCO, but it turns out that this is not the case. On the contrary, we discovered that polishing of the anterior capsule is not needed and is counter-productive, because we need the cells of the anterior capsule to generate the shrink-wrap effect with the iOL that has helped to lower the PCO rate.

so i think this example behoves us to be cautious in transferring early science in vitro into clinical relevance with respect to the open capsule designs that are currently being proposed. The technology and concept certainly looks promising, but we need to design some solid clinical trials to learn more about their safety and viability. if the concept proves to be worthwhile, we should probably first start by using a monofocal lens, with a kind of haptic fixation that would create a kind of open bag, to see whether this is beneficial. i think we can certainly look forward to some exciting innovations in the future and hopefully reduce the incidence of PCO even more.

EUROTIMES | Volume 17 | Issue 5

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EDITORIAL Volume 17 | Issue 5

Editorial

RETHINK OLD ORTHODOXIESWe can look forward to some exciting innovations in the future and hopefully reduce the incidence of PCO even more

José Güell

Clive Peckar

Emanuel RosenChairman

ESCRS Publications Committee

Ioannis Pallikaris

Paul Rosen

Medical Editors

International Editorial Board

EUROTIMESESC

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Noel Alpins australia

Bekir Aslan turKEY

Bill Aylward uK

Peter Barry irElaND

Roberto Bellucci italY

Hiroko Bissen-Miyajima JaPaN

John Chang CHiNa

Joseph Colin FraNCE

Alaa El Danasoury sauDi araBia

Oliver Findl austria

I Howard Fine usa

Jack Holladay usa

Vikentia Katsanevaki GrEECE

Thomas Kohnen GErMaNY

Anastasios Konstas GrEECE

Dennis Lam HONG KONG

Boris Malyugin russia Marguerite McDonald usa

Cyres Mehta iNDia

Thomas Neuhann GErMaNY

Rudy Nuijts tHE NEtHErlaNDs

Gisbert Richard GErMaNY

Robert Stegmann sOutH aFriCa

Ulf Stenevi sWEDEN

Emrullah Tasindi turKEY

Marie-Jose Tassignon BElGiuM

Manfred Tetz GErMaNY

Carlo Enrico Traverso italY

Roberto Zaldivar arGENtiNa

Oliver Zeitz GErMaNY

Rudy M.M.A. Nuijts MD, PhD

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The TECNIS® Multifocal Toric 1-piece lens is indicated for primary implantation for the visual correction of aphakia and pre-existing corneal astigmatism in (1) astigmatic adult patients with and without presbyopia in whom a cataractous lens has been removed by phacoemulsi� cation and (2) aphakia following refractive lensectomy in astigmatic presbyopic adults, who desire improved uncorrected vision, reduction of residual refractive cylinder, useful near vision and reduced spectacle dependence across a range of distances. The intraocular lenses are intended to maintain rotational stability after implantation in the capsular bag.

TECNIS® 1-Piece lenses are indicated for the visual correction of aphakia in adult patients in whom a cataractous lens has been removed by extracapsular cataract extraction. These devices are intended to be placed in the capsular bag.

by Howard Larkin

PCO AND THE PREMIUM LENS

Whenever it appears, posterior capsular opacification (PCO) that would be visually insignificant with monofocal

lenses can wreak havoc with diffractive multifocal optics. so much so that Matteo Piovella MD, Monza, italy, reports that about half his multifocal patients experience significant loss of near vision due to mild PCO within six months of implantation. he believes that PCO-related forward light scatter and the resulting loss of visual acuity and contrast sensitivity become intolerable more quickly with multifocal lenses because they already push the limits of acceptable vision quality.

David spalton FRCs, FRCP, FRCOphth, of st Thomas’ hospital, London, UK, agrees. Diffractive lenses such as Alcon’s ResTOR lose up to 20 per cent of incoming light and split what remains, leaving as little as 40 per cent available at near and far focal points, he notes. some newer designs, such as the PhysiOL FineVision trifocal lose less, but still reduce contrast sensitivity.

“With multifocal diffractive lenses, even very small amounts of PCO can have a very damaging effect on patients’ functional vision.”

Dr Piovella’s usual solution is early YAG capsulotomy. “At first the decision was difficult. if the patient was not happy with the lens, the choices were YAG laser or lens exchange. if the YAG doesn’t work, changing the lens with the posterior capsule open is much more dangerous and difficult.”

But as he gained experience, he learned that in most cases a YAG capsulotomy greatly improves near vision, and almost all patients are satisfied with it.

however, YAG capsulotomy does carry risk. it can produce permanent floaters and, rarely, retinal tears or detachments. it may also contribute to lens tilt or decentration, which also creates problems for diffractive multifocals, though Dr Piovella says he has not experienced this.

Because of light loss, multifocal iOLs are also contraindicated in patients who have or are at risk of developing maculopathy, Dr Piovella says. For these patients, and for patients who want to avoid glare and haloes at night, accommodating designs may be a better premium lens choice – though these patients must be counselled that they may need spectacles to read fine print, he says.

But while currently available accommodating iOLs are not as affected by small amounts of PCO, their function is vulnerable to other problems related to lens epithelial cell growth, says Liliana Werner MD, PhD, of the University of Utah, salt Lake City, Us.

“Any remaining anterior LECs in contact with the iOL have the potential to undergo fibrous proliferation; thus anterior capsule opacification is essentially a fibrotic entity. Capsular fibrosis is particularly problematic for ‘accommodating’ iOLs designed to move within the bag.”

Open-capsule designs are promising Post-mortem research shows that lenses with larger areas in contact with the anterior capsule, particularly silicone plate-haptic designs, are more prone to fibrosis and anterior capsule opacification (ACO), Dr Werner notes. Conversely, lenses that hold the anterior capsule edge away from the lens surface, such as the dual-optic Visiogen/AMO synchrony, and lenses that expand the capsular bag without touching either anterior or posterior capsules, have been shown to prevent PCO and ACO in animal models. subsequent clinical studies have confirmed low PCO rates with the synchrony, she adds. Other designs, such as the disk-shaped lens manufactured by Anew Optics are under pre-clinical evaluation.

That finding mirrors Dr Piovella’s early synchrony experience. Of 32 patients implanted, only two, or about six per cent, have required a YAG capsulotomy in the first year, he says. in addition to lower PCO

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Emerging designs may overcome this obstacle to presbyopia correction

EUROTIMES | Volume 17 | Issue 5

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REFRACTIVE LENS

With multifocal diffractive lenses, even very small amounts of PCO can have a very damaging effect on patients’ functional vision

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David Spalton FRCS, FRCP, FRCOphth

If the patient was not happy with the lens, the choices were YAG laser or lens exchange. If the YAG doesn’t work, changing the lens with the posterior capsule open is much more dangerous and difficult

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Matteo Piovella MD

Image shows schematics of the customisation procedure in LALs

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occurrence, the lens also has the advantage of providing contrast sensitivity on a par with a monofocal lens, he adds.

in synchrony clinical trials conducted for Visiogen, George Beiko MD of the University of Toronto, Canada, observed no PCO develop when the lens was placed in eyes with pristine capsular bags that were polished and free of epithelial cells or fibrosis. When placed in younger patients with a fibrous subcapsular component to the posterior capsular bag, the remnant PCO did not increase during the observation period. “i have some thoughts as to why this may be happening but no real explanation. so yes, PCO seems to be less of an issue with dual-optic iOLs.”

One possible mechanism for discouraging PCO may be compression of the bag, and perhaps residual lens epithelial cells as well, Dr Werner says. Mechanical stretch of the bag at the equator by devices such as the capsular bending ring of Nishi and Menapace, and hara’s equator ring is another potential PCO-discouraging mechanism, she adds.

ioannis G Pallikaris MD, PhD of the University of Crete, Greece, having developed the Peripheral Capsule Reconstructor (i-PCR), believes that an expandable ring device, which has the same anatomical shape with the peripheral capsule, and mimics the peripheral lens features, may avoid the PCO and at the same time can be used as a centration device for any type of iOL. in 18 patients with 20 months’ follow-up, no PCO has been observed in the posterior capsule, he said.

Constant irrigation of the capsular bag inner compartment by the aqueous humour could be another factor discouraging epithelial cell proliferation, Dr Werner says. Aqueous humour irrigation would help explain the PCO preventative effect even in eyes where there was no contact between the optic of a disk-shaped iOL under investigation and the posterior capsule. This hypothesis is bolstered by reports that TGF-β2 in the normal aqueous humour inhibits proliferation of both lens epithelial and corneal endothelial cells. According to Nishi, constant irrigation by the aqueous humour also may prevent cytokines that stimulate epithelial cell proliferation, such as interleukin-1, from reaching a threshold concentration, she notes. This finding is

in line with Moran Eye Center research showing that a disk-shaped hydrophilic acrylic lens that avoided optic contact with the capsular bag showed less capsular bag opacification than a conventional hydrophobic acrylic lens contacting the posterior capsule in rabbit eyes, Dr Werner adds.

But modulating, rather than eradicating, lens epithelial cell growth may be the more desirable goal, Dr spalton says. his research implanting iOLs into cultured post-mortem human capsular bags shows that fibrosis occurs when lens epithelial cells are left in the bag, but when they are all obliterated in the fellow eye, the implanted lens wobbles. This suggests that lens epithelial cell growth plays an important role in stabilising current lens designs, and that approaches such as destroying all epithelial cells with lasers or pharmaceuticals may be counterproductive.

Dr spalton is now conducting a study of the impact of cytokine concentration on lens epithelial cells in a human capsular bag model. But while the evidence is preliminary, he believes that lens designs that allow aqueous circulation may be the key to controlling PCO. “i think we are coming into an era of open-bag lenses,” he says.

Accommodation trade-offs While early results with the dual-optic lens look good for both vision quality and modulating PCO, the design does involve trade-offs, and questions remain about it. Chief among them is whether it actually accommodates by moving, and if so, can the effect be reliably replicated in clinical practice.

in controlled studies comparing the dual-optic lens with single-optic lenses designed to accommodate by moving, Dr Beiko has found that the dual-optic on average produced 20/20 uncorrected binocular visual acuity at near, intermediate and far distances, and provided a range of accommodation similar to patients with multifocal implants. The single-optic accommodating lens, though, had little effect on near vision when both eyes were targeted for plano distance vision, and provided no advantage in near vision compared with monofocal non-accommodating lenses targeting a similar amount of myopia.

Dr Beiko notes, however, that the dual-

optic lens trials were conducted with healthy subjects, and the results cannot be extrapolated to the general cataract population, which includes a significant proportion of patients with other ocular pathology. For example, the lens would not be suitable for patients without intact capsules or zonular instability, though such patients may benefit from three-piece multifocals fixated to the iris or sclera.

several reports at meetings have also shown the dual-optic lens moves under accommodative stimulation using ultrasound and other imaging technologies. however, objectively measuring dynamic accommodation would be required to fully clarify if these lenses are actually working, says Pablo Artal PhD, of the University of Murcia, spain. Dr spalton suspects that difficulties conclusively demonstrating dynamic accommodation could be delaying approval of the lens by the Us FDA.

The bulk that may help the dual-optic lens combat PCO also comes with a trade-off – the latest version requires an incision of about 3.75mm for insertion, much larger that the 2.0mm or less for some competing multifocals. This raises the question of how much the greater surgically induced astigmatism that might accompany the larger incision might offset the advantages of lens’ otherwise superior optics compared with multifocal lenses.

Dr Beiko has found that the larger incision can induce up to 1.0 D of astigmatism, but the impact can be minimised by making the incision on the steep axis of the cornea and posterior to the limbus, he says.

“Patients tolerate up to 1.0 D of astigmatism, so there is minimal effect on visual performance. The gain in range of vision with a dual optic iOL far out ranks the minimal increase in astigmatism.”

Dr Piovella reports similar results with 1.0 D being the largest amount of astigmatism induced in his dual-optic cases to date. he also points out that, as with PCO, multifocal diffractive lenses are affected much more by small amounts of corneal astigmatism than monofocal or accommodating lenses. One dioptre of cylinder typically results in two lines of lost vision with a multifocal compared with one line for the dual-optic lens, he says. surgically induced astigmatism also tends to regress over time,

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EUROTIMES | Volume 17 | Issue 5

Any remaining anterior LECs in contact with the IOL have the potential to undergo fibrous proliferation; thus anterior capsule opacification is essentially a fibrotic entity

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Liliana Werner MD, PhD

Patients tolerate up to 1.0 D of astigmatism, so there is minimal effect on visual performance. The gain in range of vision with a dual optic IOL far out ranks the minimal increase in astigmatism

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George Beiko MD

Before and after YAG laser treatment Synchrony channels provide aqueous circulation in the bag avoiding PCO

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REFRACTIVE LENS

Special FocusMatteo Piovella – piovella@piovella.comDavid Spalton – profspalton@gmail.comLiliana Werner – liliana.werner@hsc.utah.eduGeorge Beiko – george.beiko@sympatico.caIoannis Pallikaris – pallikar@med.ouc.grPablo Artal –pablo@um.esco

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and is manageable for even larger incisions. “i have huge experience since 1988 in performing phaco with implantation of 5.0mm rigid iOLs without significant induced astigmatism in over 90 per cent of the cases.”

Other accommodative approaches Another fairly bulky accommodating lens on the horizon is PowerVision’s FluidVision. This lens uses contractions of the ciliary muscles to pump fluid in and out of its optic, which changes the lens’ shape and refractive power, much like the natural crystalline lens. it has achieved shape changes equivalent to accommodation of 5 D in unsighted patients, and is scheduled to enter clinical trials this year.

Pseudoaccommodative lens approaches also show promise. Prof Pallikaris reports achieving up to 2.5 D near accommodation with a hyperboloid iOL designed by the late Otto Wichterle and his collaborators at the institute of Macromolecular Chemistry in Prague, Czech Republic. The rear surface of the hydrogel lens sits against the posterior capsule, which helps block PCO and may allow ciliary muscle contraction and pressure on the vitreous from external muscles to move the lens anteriorly, producing some true accommodation. The large aspheric optic also increases depth of field, facilitating near vision. The smooth surface extending all the way to the edge of the capsule eliminates glare and other dysphotopsias, Prof Pallikaris says.

however, accommodative outcomes are not completely predictable and patients must be trained to make full use of the lens’ potential.

The Oculentis MPlus lens features an asymmetric refractive add zone similar to a bifocal in spectacles that transitions from near to far. While the design does split the image on the retina as other multifocals do, the smaller add zone minimises light loss and tends to localise glare compared with conventional symmetrical designs.

The end of PCO? Another concept for eliminating PCO altogether is the bag-in-lens design pioneered by Marie Jose Tassignon MD of the University hospital of Antwerp, Belgium. The lens features a grooved circular haptic and is implanted by creating concentric capsulotomies in the anterior and posterior capsule, and capturing the edges in the groove. This effectively seals the capsule, giving any remaining lens epithelial cells nowhere to go. Dr Tassignon says that her residents have little trouble implanting the lens and the posterior capsulotomy is often easier to create that the anterior. she continues to develop the lens, and is working with a model that would allow replacing the optic as needed while leaving the haptic in place.

But while the bag-in-lens is immune to PCO, it is subject to soemmerring’s rings, Dr Werner reports. six post-mortem eyes ranging from four to 39 months after surgery showed progressive soemmerring’s build-up, though none obscured the central area delimited by the rhexis openings, she says.

Nonetheless, the complexity of the bag-in-lens, which requires creation of two precisely sized and aligned capsulotomies and risk of vitreous loss, along with the potential for soemmerring’s ring formation are problematic, Dr spalton says. “i think it is an interesting idea but this iOL is unlikely to gain widespread clinical acceptance.”

The need for precision surgery All the premium lenses extant and in

development require precision surgery for proper function. Dr Piovella notes that a perfectly round and centred capsulotomy is essential for the dual-optic lens to move reliably, and this can best be achieved with femtosecond lasers. “This lens and the laser were made for each other,” he says.

The same might be said for multifocal lenses, which are highly sensitive to decentration and tilt, though the theoretical benefits have yet to be demonstrated, Dr spalton says.

And no matter how precise biometry and incisions become, the healing process remains somewhat unpredictable, and refractive outcomes with it. Residual refractive error can be addressed with corneal surgery after lens implants, but new technology may make it easier to change the refractive properties of the implants, says Prof Artal.

Prof Artal is working with Calhoun Vision’s Light Adjustable Lenses not only to correct residual spherical and astigmatic refractive errors, but also to correct higher order aberrations and alter lens asphericity to enhance near vision. The lens is made of a photo reactive material that allows the shape to be adjusted in situ with a special ultraviolet lamp. When the final desired refraction and asphericity is achieved, it is locked in place with ultraviolet light.

By correcting the dominant eye for distance and neutral spherical aberration and the non-dominant eye for mild myopia with negative spherical aberration, J2 near vision and 20/20 far vision with excellent intermediate vision can be achieved. The negative spherical aberration reduces contrast sensitivity and distance vision slightly, but glare and haloes are less than with multifocal lenses, Prof Artal says. The lens adjustments are typically made within a couple of weeks after surgery, allowing for capsular contraction and corneal recovery. The process allows customising the amount of defocus and spherical aberration to patient tolerances and preferences.

“it is like a marriage. The effect of spherical aberration is always in

combination with defocus and you always need to look at the two parameters together.”

The process is precise to within 0.03 microns and 0.25 D. The biggest drawback may be that patients must wear eye protection to prevent sunlight from changing the lens shape until it is locked in, he added.

Femtosecond lasers may also one day be capable of adjusting any type of acrylic lens. A process known as refractive index shaping combined with a diffractive technique known as phase wrapping allows up to 5.0 D of power change in a 50 micron thick lens layer, according to Josef F Bille PhD of heidelberg University, Germany, who is developing the technology for Aaren scientific.

in theory, these customising technologies could be combined in the future with accommodative or PCO-proof designs to allow any type of lens to be customised in situ, Prof Artal says. Diffractive patterns to provide multifocality could be added or subtracted. With adaptive optics technologies to simulate vision, the combination of features could be precisely tuned to patient needs and comfort.

“it’s always about what is best for the patient. The customisable intraocular lens is the future,” Prof Artal believes.

Gross photographs of the disk-shaped lens manufactured by Anew Optics (under pre-clinical evaluation at the Moran Eye Center) The Miyake-Apple posterior view photo from the rabbit eye was taken five weeks postoperatively

The effect of spherical aberration is always in combination with defocus and you always need to look at the two parameters together

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Pablo Artal PhD

The large aspheric optic also increases depth of field, facilitating near vision. The smooth surface extending all the way to the edge of the capsule eliminates glare and other dysphotopsias

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Ioannis G Pallikaris MD, PhD

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The light-adjustable iOL may be the most predictable way of providing optimal visual outcomes to cataract patients who have undergone

previous refractive surgery, according to the results of a study presented by h Burkhard Dick MD, Ruhr University Eye Clinic, Bochum, Germany, at the XXiX Congress of the EsCRs.

“The light-adjustable lens (LAL) in my hands is effective in managing cataracts in eyes that have undergone refractive surgery. it allows the post-implantation correction of up to 2.5 D in sphere and cylinder, and multiple adjustments are possible. That means that patients can check their refractive status in their daily life and then decide if they want an additional improvement or additional myopisation or emmetropisation,” Dr Dick said.

The multicentre retrospective study involved 37 cataract patients who had

undergone previous refractive surgery, he noted. All underwent implantation of the light-adjustable iOL. in 20 eyes the post-implantation adjustment targeted emmetropia and in 17 eyes the targeted refraction was 1.5 D of myopia, for the purpose of monovision, he added.

Fine-tuned refraction Dr Dick pointed out that among eyes targeted for emmetropia, uncorrected visual acuity after adjustment was 0.8 or better in 70 per cent of eyes, 0.63 or better in 90 per cent of eyes, 0.5 or better in 95 per cent of eyes, and 0.4 or better in all eyes. Among 17 eyes targeted for slight myopia with a target refraction of -1.5 D, they had a manifest refraction spherical equivalent after the final adjustment of -1.5 D and a mean uncorrected near visual acuity of J2.

Dr Dick noted that the digital light delivery device used to polymerise the lens material

was very effective in fine-tuning patients’ post-implantation manifest refraction spherical equivalent (MRsE). That is, among eyes targeted for emmetropia, only 15 per cent of eyes had an MRsE within 0.25 of emmetropia before adjustment, compared to 60 per cent after adjustment, he continued.

Furthermore, only 40 per cent of eyes were within 0.5 D of emmetropia before adjustment, compared to 95 per cent of eyes after adjustment, and all eyes were within 1.0 D of emmetropia after adjustment, compared to only 60 per cent before adjustment. Moreover, the mean uncorrected visual acuity improved from 0.5 following implantation to 0.88 after adjustment of the iOL’s refractive power. Their mean best-corrected also improved slightly, from 0.91 after iOL implantation to 0.96 after adjustment.

The refractive predictability of the LAL compares favourably to all of the iOL power calculation formulas currently used for patients who have undergone previous refractive surgery, Dr Dick said. According to a study by Douglas Koch MD and associates, the mean absolute errors with the other iOL power calculation techniques in those patients ranged from 0.57 D to 1.31 D (Wang et al, J Cat Refract Surg  2010;36:1466-1473), he noted. That compares to a mean absolute error of only 0.25 D among the same kind of patients who receive a LAL.

Malleable silicone optic material Dr Dick noted that the optic of the three-piece foldable silicone lens is composed of an unpolymerised silicone matrix polymer, a polymerised macromer, a photo-initiator, and a UV-absorber at the back of the lens. The digital light delivery device induces polymerisation of the unpolymerised silicone, causing a local shrinkage of the lens material.

irradiating the centre of the lens decreases the central curvature, with a resulting hyperopisation of the iOL’s refraction, Dr Dick explained. Conversely, irradiating the periphery of the iOL increases its central curvature, with a resulting myopisation, he added. For a few weeks before final lock-in of the iOL power, patients wear protective eyewear and have the opportunity to experience their vision with the initial refractive adjustment in their day-to-day life. During that trial period they can undergo further adjustments if necessary.

Dr Dick noted that he and his associates first began implanting the LAL in May 2008. As of now, they have implanted over 410 of the lenses. in addition to cataract patients with a history of refractive surgery, they have implanted the iOLs in very long and very short eyes for a customised near add, he said.

he added that he and his associates have been conducting some research into the use of LAL technology for the individual modulation of negative asphericity. Optimal asphericity values can increase depth of focus and improve quality of vision. Future refinements in the technology may make possible the individual correction of higher order aberrations, he continued. An add-on LAL is another possibility, as is a toric version of the lens, which could enhance the fine-tuning of post-implantation cylinder, he said.

Dr Dick noted that even in virgin eyes, iOL calculation is prone to some degree of error. in fact, around two-thirds of cataract patients require spectacles for optimal distance vision after implantation of a standard monofocal iOL, he said. The causes for postoperative refractive error include mislabelling of the iOL’s power, imprecision in biometry and power calculation, and post-implantation movement of the iOL.

in eyes that have undergone refractive surgery there are additional causes of refractive surprises. The factors include mismatches between the corneal radii and the axial length, irregular corneal surfaces, and the biometric abnormalities that are common in long and short eyes. Dr Dick noted that, apart from the predictability the technology provides in difficult cases, the LAL may be particularly suited to post-refractive surgery patients because of their proven willingness to pay a higher price for optimal vision.

“if there is one thing you should remember from this talk it is that the light-adjustable lens technology can treat sphere, cylinder, spherical aberration and presbyopia using one iOL after previous refractive surgery,” he concluded.

H Burkhard Dick – dickburkhard@aol.com

cont

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LIGHT-ADJUSTABLE IOLRefractive adjustability provides greater predictability in post-refractive surgery eyesby Roibeard O’hEineachain in Vienna

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If there is one thing you should remember from this talk it is that the light-adjustable lens technology can treat sphere, cylinder, spherical aberration and presbyopia using one IOL after previous refractive surgery

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H Burkhard Dick MD

9

EUROTIMES | Volume 17 | Issue 5

Refractive lens exchange (RLE) in amblyopic eyes is safe and can improve corrected distance visual acuity (CDVA) in both hyperopes

and myopes, reported Mark Wevill MD, at the XXiX Congress of the EsCRs.

Dr Wevill, specialist eye surgeon, Ultralase Clinics, Birmingham, UK, and visiting lecturer, Aston University, Birmingham, UK, presented results from a retrospective analysis of visual outcomes after RLE in a series of 23 consecutive eyes for which no pathological cause was identified for the amblyopia. Cataract, keratoconus, macular pathology and optic neuropathy were all ruled out, and the amblyopia was either due to strabismus, anisometropia, or had an unexplained aetiology.

All eyes had preoperative logMAR CDVA ≤0.2 (~6/9) and were implanted with the same, single focus iOL (Tetraflex, Lenstec).

There were 12 patients in the series ranging in age from 18 to 64 years, and the 23 eyes included 16 hyperopes and seven myopes. Among the hyperopes, mean sE preoperatively was +4.23 ± 2.03 D and mean logMAR CDVA was 0.2 ± 0.08 (~6/9). At one month after surgery, mean sE was -0.57 ± 1.01 D and mean logMAR CDVA improved to 0.15 ± 0.13 D (6/7.5 to 6/9).

The myopes had a mean preoperative sE of -8.82 ±1.91 D and a mean CDVA of 0.32 ± 0.23 (~6/12). The refractive target was for myopia (monovision) in four of these eyes. One month mean sE was -1.21 ± 0.82 D. LogMAR CDVA improved to a mean of 0.15 ± 0.11.

No eyes in the series lost two or more lines of vision. Among the hyperopes, three eyes lost one line and five eyes stayed the same, while eight eyes gained CDVA, including three eyes that gained two lines and five eyes that gained one line.

in the myopic group, only one eye had a one-line loss of CDVA and one eye remained the same. Four eyes gained two lines and one eye gained one line.

“CDVA improved greatly after RLE in the myopic eyes. They may have some benefit from image magnification, but our sample size is too small to see if the amblyopia was improved or if the outcomes are due to a refractive effect,” said Dr Wevill.

“however, there was also improvement in the hyperopes even though image size is reduced, and seeing that these eyes benefit from the procedure is a good sign,” said Dr Wevill.

he added a few other caveats for interpreting the visual acuity results.

“When assessing visual acuity at one month after surgery, we also have to consider there may be some early capsular changes, especially in younger patients, and cystoid macular oedema still present, especially in older patients. These factors may be limiting CDVA and our patients’ outcomes should tend to improve with time.”

LENS EXCHANGEProcedure has good safety profile and improves visual acuity in majority of hyperopes and myopesby Cheryl Guttman Krader in Vienna

Mark Wevill – mail@wevs.fslife.co.uk

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Special Focus

REFRACTIVE LENS

However, there was also improvement in the hyperopes even though image size is reduced, and seeing that these eyes benefit from the procedure is a good sign

“

Mark Wevill MD

Tetraflex in eye

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EUROTIMES | Volume 17 | Issue 5

in the wake of several phakic intraocular lenses (PiOLs) pulled from European markets due to high complication rates, the few remaining designs provide good refractive outcomes with limited risk of

endothelial cell loss, pupil ovalisation or induced cataracts, presenters told an EsCRs-sponsored symposium at the American Academy of Ophthalmology (AAO) annual meeting. however, problems can still occur even years after implantation, making ongoing monitoring a must for both anterior and posterior chamber iOLs.

Reviewing anterior chamber PiOLs, Francesco Carones MD, Milan, italy, noted that both angle-supported and iris-supported lenses generate good refractive outcomes in high myopes, but also present potential safety issues, especially endothelial cell damage. improperly sized angle-supported lenses may vault too close to the endothelium causing damage quickly, but even properly sized lenses can suddenly provoke rapid cell density loss after years of stability. iris-supported lenses are more difficult to implant, can dislocate, potentially puncturing the iris in addition to damaging endothelium, may cause pupil ovalisation, and may cause pigment dispersion leading to glaucoma. “safety is one of the biggest issues with this device,” Dr Carones said.

Largely because of these problems, just three anterior chamber PiOLs remain on the market in Europe; the iris-fixated Artisan/Verisyse and Artiflex/Veriflex, and the angle-supported Alcon Acrysof Cachet, Dr Carones noted. he reported extensive experience with all three, having implanted about 300 hard Artisan lenses since 2000, 111 flexible Artiflex since 2006, and 70 Cachet lenses since 2009.

Today, Dr Carones generally prefers Cachet because it is easier to implant. The Artisan requires a 6.0mm incision and the Artiflex can be challenging to attach to the iris, he said. however, he still uses Artiflex for cases with significant astigmatism and Artisan where the iris protrudes.

To confirm for himself that the Cachet is safe, Dr Carones conducted his own study. in 29 eyes in 15 patients with a mean refractive spherical equivalent of -9.88 +/-2.71 D, he measured the central and edge clearance as well as lens rotation six months after surgery. All patient had at least 3.3mm anterior chamber depth and normal anatomy, making them good candidates for PiOLs. All iOLs were inserted with a cartridge through a 2.6mm incision, and all surgeries were uneventful.

Measured by high resolution scheimpflug imaging six months after surgery, the mean distance from the anterior iOL surface to the endothelium was 2.11mm, ranging from 1.77 to 2.37mm at the lens centre, and 1.44mm ranging from 1.20 to 1.71mm at the edges – all distances suggesting little interference with endothelium, Dr Carones said. Further, the high correlation between central and peripheral distance suggest that central measurements may be reliable for ongoing clinical assessment of lens stability.

he concluded that currently available anterior PiOLs are effective. Even so, all phakic iOLs, anterior chamber and posterior chamber, are still prone to complications. “i like

to consider them as a kind of temporary solution. All phakic iOLs will need to be removed in the future.”

Posterior PIOLs Posterior chamber PiOLs were introduced by Fyodorov in the 1980s, said Vikentia Katsanevaki MD, PhD, Athens, Greece. in theory, the posterior PiOL is supposed to float above the crystalline lens, but in fact it often touches the lens, leading to cataracts. One design still clinically available, the Phakic Refractive Lens (Carl Zeiss Meditec), is now rarely used because it rests on the zonules, which can lead to contact with the crystalline lens, and dislocation into the vitreous as the zonules weaken, she noted (Martinez-Castillo et al. J Refractive Surg. 2004: 20:773-777).

That leaves the Visian iCL (staar) as the only posterior PiOL in use in Europe, Dr Katsanevaki said. This collagen lens comes in several sizes to fit any size eye, and corrects both myopia and hyperopia. The latest, V4B, also offers astigmatism correction. Compared with earlier versions, this lens has a higher vault, which lowers the risk of cataract to about 0.5 per cent. That compares with reported rates of up to 20 per cent in earlier versions in the 1990s (Chen L et al. J Cataract and Refract Surg 2008; 34:7 1181-1200).

Visual outcomes are excellent. According to a three-year study reported in 2005, 94 per cent of -10 or higher myopes achieving 20/40 or better after surgery and 95 per cent within 2.0 D of intended correction. For those -7.00 or higher, 85 per cent were within 0.5 D. Contrast sensitivity improved in all categories, Dr Katsanevaki said.

The Visian iCL also has shown great promise treating keratoconic eyes.

Nonetheless, implanting posterior PiOLs is tricky, Dr Katsanevaki noted. in most cases, white-to-white measurements correlate well with sulcus size, but in about five per cent it does not. she recommends ultrasound B scans to confirm sulcus-to-sulcus measures to ensure proper lens sizing. she finds the lens safe, at least for short intervals.

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PHAKIC IOLSAfter many failures, remaining designs give good vision, fewer complications by Howard Larkin in Orlando

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REFRACTIVE LENS

This Scheimpflug camera image shows the position of the Cachèt Phakic Lens in the anterior chamber, with the distances between the lens and the endothelium

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Vikentia Katsanevaki – vikentia_katsanevaki@yahoo.grFrancesco Carones – fcarones@carones.com

EUROTIMES | Volume 17 | Issue 5

surgeons must ensure they thoroughly assess functional vision in presbyopic eyes and carefully manage patient expectations to avoid unnecessarily unhappy patients following surgery, Milind Pande FRCs, FRCOphth told

the XXXV United Kingdom & ireland society of Cataract & Refractive surgeons (UKisCRs) Congress. To that end, Pan-Focal Visual Acuity evaluation, a new measurement tool developed by Dr Pande and colleagues at the Vision surgery and Research Centre, East Yorkshire, UK, has shown promising results in helping to ensure the best outcomes for presbyopic iOL patients.

Dr Pande noted that the main questions presbyopia iOL patients have are can they drive, use a computer, mobile phone, shop, read in bed, etc. in standard clinical practice when assessing functional vision in these patients measurements are taken of their photopic distance and near visual acuity, but rarely of their intermediate visual acuity.

“This really is inadequate data to answer these patients’ questions and can result in a mismatch between patient expectations and unhappiness in spite of good uncorrected visual acuity,” he said.

The current measure of functional vision is a defocus curve, which essentially measures visual acuity at different distances by putting in different amounts of defocus on the positive and negative side. however, in order to obtain adequate information on functional vision in both photopic and mesopic conditions, one would need to do both photopic and mesopic defocus curves, which is very time consuming (at least 45 minutes), impractical and subjective. Furthermore, visual acuity requirements of

intermediate and near vision tasks are unknown, he added.To address this, Dr Pande and colleagues devised a new

measure called Pan-Focal Visual Acuity.“The concept behind this was that the legal driving vision standard is a long-established and well-respected standard for photopic and mesopic vision, so we could easily take it on board,” he explained. intermediate vision activities are mainly carried out in photopic conditions, while near vision activities are carried out in both photopic and mesopic conditions, he pointed out. Thus, the new measurement tool serves as a practical clinical measure of visual acuity across standard distance and illumination levels, both corrected and uncorrected vision.

To validate the new system, Dr Pande and colleagues measured 147 eyes of 75 patients more than six weeks postoperatively with almost all variations of presbyopia iOL correction possible. The Pan-Focal Visual Acuity test was used and they were given questionnaires to assess their dependence on spectacles and what their perception of spectacle-free vision was. They were also tested in the clinic on whether they could perform tasks on the laptop, read books etc.

The global validation results showed that if binocular visual acuity is 6/9 or better in all Pan-Focal Visual Acuity measures, patients are able to carry out all tasks without spectacles and the patients themselves feels they don’t need spectacles for any activity.

Individual task performance in terms of the individual task performance, the validation exercise found very good results

for all activities at 6/9 or 6/12 visual acuity except for the laptop performance, which Dr Pande believed was due to variations in the working distance sometimes with the laptop.

“so 6/9 or better pan-focal visual acuity gives you complete spectacle freedom and intermediate visual acuity of 6/9 or better is required for desktop use. The laptop number was variable. Near visual acuity of 6/12 or better is adequate for reading books or newspapers with good light, but near visual acuity of 6/9 or better is needed for reading shiny magazines or telephone directories, especially in dim light,” he reported.

Results from the specific lens choices showed that the monovision and the Crystalens patients tended to perform better on intermediate vision, while multifocal lens patients tended to do better at near vision activities.

in terms of the thresholds required of 6/9 or better, he said surgeons know there is no perfect solution but by characterising each presbyopic iOL option they can then advise patients on what is possible and what is not possible preoperatively, and counsel them and modulate their expectations accordingly.

Dr Pande confirmed he uses the new measurement tool regularly in his clinic, and assesses patients first preoperatively to select the iOL for the first eye.

Then two or three weeks later, he repeats the measure and the second iOL lens for the other eye is then chosen on the basis of this.

“The Pan-Focal Visual Acuity measurement allows us to predict for patients what each lens is capable of. it is a great tool to choose what lens will work for what patient and it is also a great tool to define the boundaries of what each technology is capable of and that really is a key message as until we get to the stage where we have a perfect lens we are always going to have to choose and select,” he told EuroTimes.

Dr Pande reiterated that careful assessment and closely managed patient expectation is vital in ophthalmic clinical practice.

“The Pan-Focal Visual Acuity is really a practical, validated measure of functional vision in presbyopia patients. it allows for objective comparisons of iOLs and the different type of presbyopia eye corrections. it is also an excellent tool clinically to use day in and day out to achieve happy patients,” he concluded.

Milind Pande – mp@visionsurgery.co.uk

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FUNCTIONAL VISIONPan-Focal Visual Acuity - a new measurement toolby Priscilla Lynch in Southport

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EUROTIMES | Volume 17 | Issue 5

A new diffractive iOL (Physiol FineVision) can provide patients with good intermediate vision in addition to sharp near and

distance vision with nearly no change in distance vision under mesopic conditions, said Jerome Vryghem MD, Clinique saint-Jean, Brussels, Belgium.

“The Physiol FineVision, a new diffractive trifocal intraocular lens, provides three useful focal points by combining two superimposed diffractive profiles, one with a +1.75 D addition for intermediate vision and the other one with a +3.50 D addition for near vision,” Dr Vryghem told the XXiX Congress of the EsCRs.

in a prospective study involving 50 eyes of 25 patients who underwent cataract or refractive lens exchange surgery with the implantation of the Physiol FineVision iOL, 87 per cent of patients reported that they had achieved complete spectacle independence. in addition, only 10 per cent spontaneously mentioned seeing haloes around lights at night time and none of the patients reported seeing ghost images.

The patients in the study had a mean age of 70.4 years at the time of surgery and their mean preoperative best-corrected visual acuity was 0.75. All were free of any other ocular pathology and none had more than 1.75 D of astigmatism preoperatively. in all cases Dr Vryghem performed the surgery using temporal 1.9mm microincisions to avoid surgically induced astigmatism.

Sharp acuity over range of distances At two months’ follow-up, the patients’ monocular distance visual acuity had a mean decimal value of 0.89, and was 0.8 or better in 78 per cent of eyes, and 0.5 or better in all eyes. The mean uncorrected binocular distance visual acuity (UCVA) was 1.13, and was 0.8 or better in all patients.

in addition, the monocular uncorrected intermediate visual acuity had a mean value of Parinaud 2.46 (Parinaud 2 = Jaeger 1) at 65cm and was Parinaud 3 (J2) or better in 88 per cent of eyes, and Parinaud 4 (J3) or better in 98 per cent of eyes. Moreover, the patients’ binocular intermediate visual acuity had a mean value of Parinaud 1.7 (which is better than Jaeger 1) and was Parinaud 3 or better in all eyes.

Furthermore, monocular uncorrected

near visual acuity at 30cm had a mean value of Parinaud 1.28 and was Parinaud 2 or better in 96 per cent of eyes, and Parinaud 3 or better in all eyes. Binocular uncorrected near visual acuity had a mean value of 1.06 and was Parinaud 1.4 or better in all eyes.

As regards to refractive predictability, 88 per cent were within 0.5 D of emmetropia. Dr Vryghem noted that the defocus curve showed less of a dip for intermediate vision than with diffractive bifocal iOLs, with an average best distance-corrected intermediate visual acuity of Parinaud 0.86.

Furthermore, although mesopic conditions reduced the mean near and intermediate vision to Parinaud 2.29 and Parinaud 4.16, respectively, it left their mean distance visual acuity virtually unchanged. This is explained by the apodisation of the diffractive steps.

High spectacle independence Dr Vryghem noted that in their responses to a quality of vision questionnaire, 82 per cent of patients said they never use spectacles for near vision, and the remaining 18 per cent said they used them only for reading small letters. Moreover, 92 per cent said they never needed distance spectacles.

As regards photic phenomena, only 10 per cent spontaneously reported seeing haloes, although, when prompted by a questionnaire, 24 per cent said they saw them. in addition, four per cent reported double images but none reported ghost images, difficulties with light transition or glare. The subgroup of patients reporting haloes had a significantly lower mean age than the subgroup without haloes (66 years vs 75 years, p<0.05), Dr Vryghem noted.

When asked if they would be implanted with the same type of lens again, 76 per cent said yes and the remaining 24 per cent said they didn’t know because they had nothing with which to compare it.

“The design of the Physiol FineVision trifocal diffractive iOL adds intermediate vision with no significant decrease in near and distance vision as compared to currently available bifocal iOLs,” Dr Vryghem concluded.

Jerome Vryghem – info@vryghem.be

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EUROTIMES | Volume 17 | Issue 5

The Toric Visian implantable Collamer Lens (TiCL, sTAAR surgical) is an excellent option for correcting moderate to high

myopic astigmatism that successfully outperformed LAsiK in terms of postoperative visual outcomes, according to a study presented here.

“The Visian iCL performed very well in correcting moderate to high myopic astigmatism with one year follow-up,” Kimiya shimizu MD told delegates attending the XXiX Congress of the EsCRs.

“One of the advantages of the iCL is that it is adapted to many patients and the results showed superior visual function compared to LAsiK. in addition, the iCL may also be used as an effective treatment for early-stage keratoconus and for piggyback implantation when required,” he said.

Dr shimizu, professor and chairman of the Department of Ophthalmology at the University of Kitasato school of Medicine, Kanagawa, Japan, said that toric iCLs are a potentially viable solution for patients with corneal astigmatism between 1.0 D and 1.50

D, with an earlier Japanese study of 121 patients indicating that about 73 per cent of iCL candidates were suitable for toric lens implantation.

Dr shimizu noted that the Toric Visian iCL can correct a wide range of spherical and cylindrical errors and is available in spherical powers of -3.0 D to -23.5 D and cylindrical powers from +1.0 D to +6.0 D. The lens has an overall diameter of between 11.5mm and 13.0mm and it is implanted into the posterior chamber through a microincision of 3.0mm.

Dr shimizu’s study included 56 eyes with a mean age of 35.5, a mean spherical equivalent of -10.36 D and a mean manifest cylinder of -2.32. Axis marking was performed at the slit lamp before surgery.

Looking at the results, the safety index of 1.18 was excellent, said Dr shimizu. Changes in snellen lines of best-corrected visual acuity showed a loss of one line in three eyes (six per cent), no change in 19 eyes (40 per cent), with a gain of one line in 18 eyes (38 per cent) and a two-line gain in seven eyes (15 per cent).

in terms of the efficacy index, 100 per cent of eyes achieved 20/40 (0.5 or better) and 86 per cent attained 20/20 (1.0 or better), for an index score of 1.0. Predictability was also very good, said Dr shimizu, with 87 per cent of eyes within 0.50 D and 98 per cent within 1.0 D of intended refraction.

For refractive stability, Dr shimizu said there was no evidence of overshoot or regression over the one-year follow-up period either for sphere or for cylinder. This was in marked contrast to the results obtained using LAsiK.

Underscoring the importance of rotational stability in a toric lens, Dr shimizu said that five eyes in his series experienced a lens rotation of more than 10 degrees.

“Two of those eyes were from a patient who practised a lot of boxing and the rotation was associated with trauma. interestingly the rotations all seemed to occur in the early postoperative period,” he said.

Comparing the performance of the toric iCL in 30 patients to wavefront-guided LAsiK in 24 patients, Dr shimizu said that the iCL outperformed LAsiK in all key parameters tested, even allowing for the fact that there was a higher preoperative spherical equivalent and manifest cylinder in the toric lens group.

six months after surgery, the safety index was 1.28 for toric iCL and 1.01 for LAsiK, with an efficacy index of 0.87 for toric iCL and 0.83 for LAsiK. Predictability was 100 per cent for toric and 71 per cent for LAsiK, while stability was -0.04 D after six months for toric iCL and -0.60 D for LAsiK. The

incidence of higher order aberrations was also found to have increased in LAsiK postoperatively but not in toric iCL implantation. Finally, contrast sensitivity also improved postoperatively in toric iCL compared to LAsiK.

To illustrate the effectiveness of using the toric iCL for early-stage keratoconus, Dr shimizu cited the case of a 38-year-old female patient who was implanted with a -22.5 D sphere and +5.0 D cylinder toric iCL.

“The result was very good indeed. Another advantage of the toric iCL is that it can also be used as a piggyback lens in particular situations,” he said.

The superior performance of toric iCLs compared to LAsiK was also confirmed in a separate study presented at the EsCRs Congress by Xiaoying Wang MD, PhD, of the EENT hospital of Fudan University in shanghai, China.

Dr Wang’s study compared quality of vision, stability and satisfaction of iCL and toric iCL implantation in one eye and LAsiK/LAsEK in the fellow eye of 26 patients with high myopic astigmatism.

At two years postoperatively, the mean spherical equivalent refraction was -1.25 D in eyes with the iCL/TiCL and -1.12 D in eyes that underwent LAsiK/LAsEK. All eyes with the iCL/TiCL and 78 per cent of eyes with the LAsiK/LAsEK were within 0.50 D of the targeted sE correction at six months.

The mean change in manifest refraction from one week to six months was -0.14 D in eyes with the iCL/TiCL and -1.70 D in eyes with LAsiK/LAsEK. One eye with LAsiK underwent enhancement ablation 12 months after the initial surgery.

For a 4.0mm pupil, the changes in coma, spherical aberration and total higher order aberrations in eyes with the iCL/TiCL were significantly less than those in eyes with the LAsiK/LAsEK. Less night vision problems such as glare and haloes were experienced in eyes with the iCL/TiCL compared to eyes with the LAsiK/LAsEK. Greater patient satisfaction was also reported in eyes with the iCL/TiCL compared to eyes with the LAsiK/LAsEK.

Kimiya Shimizu – kimiyas@med.kitasato-u.ac.jpXiaoying Wang – xiaoyingwang@fudan.edu.cn

cont

acts

ADVANTAGES OF ICLSQuality of vision, stability and patient satisfaction better in eyes with ICL/TICLby Dermot McGrath in Vienna

14 Update

CATARACT & REFRACTIVE

One of the advantages of the ICL is that it is adapted to many patients and the results showed superior visual function compared to LASIK

“

Kimiya Shimizu MD

For a 4.0mm pupil, the changes in coma, spherical aberration and total higher order aberrations in eyes with the ICL/TICL were significantly less than those in eyes with the LASIK/LASEK

Do you have more photos like this?

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EUROTIMES | Volume 17 | Issue 5

The best available techniques for calculating iOL power in patients who have undergone previous corneal refractive surgery can

achieve the required minimal standards for predictive accuracy, but they will not match the predictability which normal cataract patients and their surgeons expect of modern cataract surgery, said Douglas D Koch MD, Cullen Eye institute, Baylor College of Medicine, houston, Texas, Us.

The sources of errors in iOL calculations in eyes that have undergone previous corneal refractive surgery include flawed assumptions in the conventional eye model, the changed asphericity of the cornea, the changed relationship between the cornea’s anterior and posterior curvature, and difficulties in calculating effective lens position, Dr Koch told the XXiX Congress of the EsCRs.

“standard methods of calculating net corneal refractive power assume a refractive index of the cornea of 1.3315, which is in turn based on the assumption that there is a fixed ratio between the front and the back. however, LAsiK and PRK alter the ratio of anterior corneal curvature to posterior curvature, and therefore use of 1.3315 as the standard effective refractive index of cornea is no longer valid,” he said.

Furthermore, he and his associates calculated the actual standardised index of refraction for different types of eyes conducted using the Galilei™ combined placido and dual scheimpflug topography system (Ziemer) the calculated index of refraction was 1.3278 in normal eyes that had not undergone any surgery, 1.346 in eyes that had undergone myopic LAsiK or PRK, and 1.3302 in eyes that had undergone hyperopic LAsiK or PRK – very near the classical Gullstrand eye value of 1.3315 (Wang et al, IOVS 2011; 52:1716-1722).

There is currently a broad range of approaches to correcting iOL calculations for the changes induced by corneal refractive surgery. They fit into three main categories. First, there are those approaches that involve measuring corneal power and then modifying it based on the amount of refractive correction using the clinical history method based on regression analysis as in the case of haigis-l and shammas methods, Dr Koch said.

in the second category are those formulas which use corneal measurements that are obtained when the patient presents for cataract surgery and then modifies them by some fraction of the LAsiK-induced refractive change. The adjustments are made either to the corneal values used in the iOL calculations or in the iOL power after it is calculated in the standard way.

The third category uses no historical data – only measurements obtained at the time of presentation for cataract surgery.

Most methods also use the “double K” calculation described by Jack holladay and Jaime Aramberri, which aim to eliminate errors in effective lens position by using preoperative keratometry for effective lens position and postoperative keratometry for calculating lens power.

New Internet resource in order to help cataract surgeons decide which type of iOL calculation formula to use in eyes that have undergone previous refractive surgery, Dr Koch, Dr Li Wang, and Dr Warren hill have created a new website, the AsCRs iOL calculator, that performs iOL calculations using all of the formulas individually as well as an average value of the calculations.

To make the iOL calculations, the surgeon or technician enters data such as the type of refractive procedure performed, the amount of correction, preoperative refraction and keratometry, and the type of topography device used and the measurements obtained. Once the data are entered, the online program performs the calculations using all of the different formulas. Clicking on the yielded value of each formula provides an explanation of the calculation and its clinical reference.

To evaluate the AsCRs iOL calculator, Dr Koch and his associates conducted a

two-centre study involving 72 eyes of 57 consecutive patients who were undergoing cataract surgery after having undergone myopic LAsiK (Wang et al. J Cataract Refract Surg., 2010;36(9):1466-73). The patients’ ages at the time of cataract surgery ranged from 42 to 77 years and had undergone LAsiK correction of myopia ranging from 0.98 D to 11.21 D.

The researchers found that methods using surgically induced change in refraction and methods using no previous data gave better results than methods using pre-LAsiK/PRK K values and surgically induced change in refraction. For example, the clinical history methods were accurate to within half a dioptre in less than 50 per cent of cases, compared to 57 per cent to 67 per cent with the induced refraction and no previous data groups. The figures for accuracy which were within 1.0 D were only 60 per cent to 69 per cent with the clinical

history methods, compared to 86 per cent to 94 per cent with the induced refraction and no previous data methods.

Dr Koch noted that, although the predictability achieved with the formulas using induced refractive change or no previous data met the proposed UK Nhs benchmark of 85 per cent being within 1.0 D of target and 55 per cent being within 0.5 D of target refraction, the predictability was below that which surgeons have come to expect in the treatment of normal cataract patients.

“We meet those criteria, but i would submit that those criteria are really very loose. Current standards are much higher, and those are the standards we have to give our patients,” he said.

Future advances which may bring iOL calculation in refractive surgery patients up to standard include the development of technologies that will provide a more accurate measure of corneal power and effective lens position, better iOL calculation formulas, new technologies for determining iOL power intraoperatively, and lenses with postoperatively adjustable refractive power, as in the case of the light-adjustable lens, Dr Koch said.

Douglas D Koch – dkoch@bcm.edu

cont

act

POST-LASIK CATARACT PATIENTS IOL calculation after corneal refractive surgery has yet to be perfectedby Roibeard O’hEineachain in Vienna

15

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CATARACT & REFRACTIVE

Current standards are much higher, and those are the standards we have to give our patients

“Douglas D Koch MD

EUROTIMES | Volume 17 | Issue 5

The role of anterior segment imaging in femto-cataract surgery is vital but there is still a long way to go before the perfect imaging system is developed, Ioannis Pallikaris FRCS, FRCOphth,

told a session of the XXXV United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) Congress. Discussing the swift evolution of cataract surgery in recent years, he noted that lower phacoemulsification energy is now used, as are smaller incisions. Adjunctive astigmatic techniques have been developed and IOL designs have improved, while patient state-of-mind and expectations have changed.

However, imaging technology remains key for visualisation and customisation when carrying out femto-cataract surgery, he said. “The image guidance system is a critical part of femto-cataract surgery. It determines the location and dimension of ocular structures and guides the surgeon in customising the placement of laser incisions and lens fragmentation,” said Prof Pallikaris, professor in ophthalmology, Rector University of Crete, Greece.

The ideal image guidance system must be able to generate references for the size and centration of the capsulotomy, determine corneal thickness, and detect the iris boundaries and the posterior surface of the lens.

He reminded delegates that laser cataract surgery poses unique imaging challenges for surgeons. The imaging technology must have superior performance at a wide range of depths from superficial to deep structures, it must be able to image the boundary of the thin and clear posterior capsule, and be able to “see through” opaque lenses. Surgeons also must have 100 per cent confidence in image registration and spatial integrity, he noted.

There are two main ways to image the anterior segment using the technology available today – optical coherence tomography (OCT) and Scheimpflug imaging, Prof Pallikaris explained.

There are a number of different OCT technologies, which is based on the principle of low coherence interferometry where a Michelson-type interferometer is used so back scattered and back-reflected light recombines to produce a coherent interference pattern. Axial position and signal strength of back-scattered tissue is determined by the known reference path length that the light has travelled in the reference arm.

The original time domain OCT has been around for some time, and in this technology the movement of mirror produces an axial scan (A-scan), while lateral scanning produces 2-D. The reference arm moves mechanically and the echo time delays are measured one at a time. The highest resolution is about 18 μm axially and 60 μm laterally in this technology.

In the more recently developed Fourier frequency domain (FD) OCT, the broadband signal is broken into a spectrum using a grating or linear detector array, and depth is determined from the Fourier transform of the spectrum without motion along the reference arm. This system has

a better resolution of 5 μm axially and laterally 15 μm compared to time-domain OCT.

Depending on the system used, Prof Pallikaris said one may observe the anterior/posterior corneal surface, the anterior lens surface, ciliary body, iridocorneal angle, Descemet’s membrane, trabecular meshwork, and Schwalbe’s line. These systems allow assessment of anterior chamber biometry, and corneal and lens thickness.

However, there are limitations to this technology he acknowledged. That aside, Prof Pallikaris said FD OCT is the more accurate and precise form of OCT.

Scheimpflug imaging is an optical system in which the object plane, lens plane, and observation plane are not parallel to each other. The Scheimpflug system images the anterior chamber with a camera at an angle to a slit-beam creating an optic section of the cornea and lens, and the multiple pictures taken in segments can be combined to provide a 3-D image. The advantages of this system are the increased depth of field and image analysis as well as the ability to identify the cataract grade, in order to guided the laser energy to the appropriate level for the emulsification.

Prof Pallikaris discussed the commercial imaging systems that are on the market for refractive surgery. LenSx and OptiMedica use FD-OCT for three-dimensional, high-resolution viewing of ocular structures, while Customlens uses real-time OCT that enables planning (placement of cuts) and monitoring (position of cuts) of the cataract procedure. LensAR, meanwhile, uses a 3-D confocal structured illumination scanning transmitter very similar to Scheimpflug technology.

Prof Pallikaris said there is a long way to go with this type of imaging technology and the industry is likely to produce much more advanced and automatic systems in the future.

Ioannis Pallikaris – pallikar@med.uoc.gr

contact

OPTIMAL IMAGINGEvolution of anterior segment imaging technology will optimise outcomes of femto-cataract surgical proceduresby Priscilla Lynch in Southport

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EUROTIMES | Volume 17 | Issue 5

New software for calculating intraocular lens power using corneal topography and wavefront data and multiple

power calculation formulae can reduce residual total spherical aberrations after cataract surgery. The system allows surgeons to more accurately determine IOL power, asphericity and axis alignment, particularly for patients with irregular corneas or who have undergone previous corneal refractive surgery, Paolo Vinciguerra MD, Milan, Italy, told an ESCRS-sponsored symposium at the American Academy of Ophthalmology (AAO) annual meeting.

Getting an accurate read on corneal power is particularly important for IOL selection, Dr Vinciguerra said.

“If you explode an IOL formula you will find that K values are more important than anything.”

But K values can vary considerably in aberrated or post-refractive surgery eyes, and identifying the correct value to optimise post-implant vision can be especially challenging, he added.

Traditional keratometry determines corneal power by averaging K1 and K2 values derived from only four measurement points, two of which may not even be in the pupil area, particularly if the pupil is decentred or if the patient has a wide-angle cataract, Dr Vinciguerra noted. As a result, the corneal power at the pupil centre and the visual axis is not measured. In cases of wide pupils, the measurement also may not take into account the power change at the periphery.

For normal, regular corneas, the power differences may be negligible and this method works well, Dr Vinciguerra said. But in aberrated corneas the power differences can be substantial. For example, in post-refractive eyes treated for myopia, the traditional method misses the reduced power of the central cornea, leading to a selection of a too-powerful IOL and a hyperopic shift. The reverse is often true for eyes that have been treated for hyperopia.

The IOL-Station software, developed by Nidek in collaboration with Dr Vinciguerra, calculates corneal power more broadly and

precisely. It determines an average corneal power based on 1,000 measurement points derived from topographical scans and biometric data, including pupil size and location. This enables differing corneal power at the pupil centre and visual axis, which are more important to visual outcomes, and across the entire pupil to be taken into account and appropriately weighted for proper IOL power selection, Dr Vinciguerra said.

The software offers several IOL calculation formulae, including Binkhorst, Holladay and Hoffer Q, and can average the results of multiple calculations. Using wavefront and biometric data, it allows calculation of total spherical aberrations and a target residual aberration, which enables matching lens asphericity and toricity to optimise outcomes.

The software generates simulated visual outcomes based on the asphericity of different lens designs, allowing patients to see how they will affect visual quality after surgery. The system also identifies pupil landmarks that can be used in surgery to align toric axes, and prints out guides for use in surgery. Data on axial length, anterior chamber depth, white-to-white measurements, lens hardness and intraocular pressure can be imported from compatible diagnostic and biometric devices or entered manually, and included in a surgical guide.

IOL CALCULATORNew topography-based system optimises residual aberrationsby Howard Larkin in Orlando

Paolo Vinciguerra – info@vincieye.it

contact

Update

CataraCt & refraCtive

If you explode an IOL formula you will find that K values are more important than anything

“Paolo Vinciguerra MD

Don’t Miss Eye Facts, see page 46

XXX Congress OF THE ESCRS

www.escrs.org

XXX C

ongress O

F T

HE E

SCRS

MilanMilan

8-12 September

2012

OTHER HIGHLIGHTSRIDLEY MEDAL LECTURE

CLINICAL RESEARCH SYMPOSIA

Scientifi c Programme Courses and Wetlabs

Congress Registration Hotel Bookings

Available at www.escrs.org:

Saturday 8 September

08.30 – 10.30

IOL POWER CALCULATIONS AND EYE MODELS

Chairpersons: D. Gatinel FRANCE

T. Olsen DENMARK

11.00 – 13.00

IATROGENIC OCULAR SURFACE DISORDERS

Chairpersons: F. Kruse GERMANY

J. Murta PORTUGAL

13.30 – 15.30

IOP LOWERING DEVICES

Chairpersons: P. Sourdille FRANCE

M. Tetz GERMANY

15.30 – 17.30

PROGRESS IN OCULAR CROSS-LINKING

Chairpersons: F. Malecaze FRANCE

M.J. Tassignon BELGIUM

REFRACTIVE SURGERY DIDACTIC COURSE

Saturday 8 September

08.30 – 17.00

YOUNG OPHTHALMOLOGISTS PROGRAMME

Saturday 8 September

09.00 –16.00

Chairperson: O. Findl AUSTRIA

S. Morselli ITALY

VIDEO SYMPOSIUM ON CHALLENGING CASES

Saturday 8 September

16.15 –17.45

Chairperson: R. Osher USA

WORKSHOP ON VISUAL OPTICS

Sunday 9 September

08.15 – 17.45

Chairpersons: I. Pallikaris GREECE

M.J. Tassignon BELGIUM

JOURNAL OF CATARACT & REFRACTIVE SURGERY SYMPOSIUM

Controversies in Cataract and Refractive Surgery 2012

Sunday 9 September

14.00 – 16.00

Chairpersons: T. Kohnen GERMANY

E. Rosen UK

SURGICAL VIDEO SYMPOSIA

Monday 10 & Tuesday 11 September

14.00 – 16.00

M. Lundström SWEDEN

QUALITY OUTCOMES IN CATARACT SURGERY:THE REAL STORY

Sunday 9 September

During the Opening Ceremony, 10.00 – 10.50

SYMPOSIA

Saturday 8 September

11.00 – 13.00

ESCRS/EUCORNEA SYMPOSIUM:CORNEAL NEOVASCULARISATION

Chairpersons: R. Nuijts THE NETHERLANDS

H. Dua UK (EuCornea)

11.00 P. Fagerholm SWEDEN

Mechanisms of neovascularisation

11.15 D. Said UK

Clinical aspects and assessment of corneal vascularisation

11.30 Discussion

11.40 C. Cursiefen GERMANY

The medical management of corneal vascularisation

11.55 L. Fontana ITALY

The surgical management of corneal vascularisation in ocular surface disease

12.10 Discussion

12.20 J. Güell SPAIN

Pterygium and vascularisation: current concepts and therapeutic implications

12.35 B. Seitz GERMANY

Corneal vascularisation in HSV keratopathy: implications for transplantation

12.50 Discussion

13.00 End of session

Saturday 8 September

14.00 – 16.00

ESCRS/EURETINA SYMPOSIUM: CATARACT SURGERY AND MACULAR DISEASE

Chairpersons: P. Barry IRELAND

G. Richard GERMANY (EURETINA)

14.00 S. Wolf SWITZERLAND

Does cataract surgery accelerate conversion to wet AMD?

14.15 F. Holz GERMANY

Prophylactic anti-VEGF therapy in high risk dry and wet AMD at the time of cataract surgery

14.30 Discussion

14.40 J.F. Korobelnik FRANCE Are multifocal IOLs contraindicated in AMD?

14.55 F. Cuthbertson UK

Do blue filter IOLs work?

15.10 Discussion

15.20 F. Bandello ITALY

Diagnostics and treatment in diabetic macular oedema: an update

15.35 M. Wilkins UK The intraocular telescope for AMD

15.50 Discussion

16.00 End of session

Sunday 9 September

11.00 – 13.00

ESCRS/WCPOS SYMPOSIUM:CATARACT AND REFRACTIVE SURGERY IN CHILDREN

Chairpersons: D. Epstein SWITZERLAND

K.K. Nischal USA/UK (WCPOS)

11.00 R. Kekunnaya INDIA

Do study design and surgical technique influence paediatric cataract study outcomes?

11.15 E. Wilson USA

Infant aphakia treatment study

11.30 Discussion

11.40 C. Zetterström SWEDEN Clinical factors affecting target refraction in paediatric cataract surgery

11.55 M.J. Tassignon BELGIUM Which IOLs are best in children’s eyes?

12.10 Discussion

12.20 M. O’Keefe IRELAND

Is there a role for phakic IOLs in the treatment of amblyopia?

12.35 W. Astle CANADA Can the refractive surgeon help? PRK, LASEK and LASIK in children

12.50 Discussion

13.00 End of session

Monday 10 September

11.00 – 13.00

FEMTOSECOND-ASSISTED CATARACT SURGERY: WHERE ARE WE NOW?

Chairpersons: M. Piovella ITALY

P. Rosen UK

11.00 I. Pallikaris GREECE

Imaging and capturing technology: how does it work?

11.15 J. Stevens UK

Delivery systems: How do they function?

11.30 Real world clinical results and complications F. Bucci USA (LensAR)

S. Daya UK (B&L Victus)

B. Dick GERMANY (OptiMedica)

Z. Nagy HUNGARY (LensX Alcon)

12.00 Discussion

12.10 R. Lindstrom USA

When will it work in private practice: what does it take to make it work?

12.25 Discussion

12.35 R. Bellucci ITALY

When and how will it work in public practice?

12.50 Discussion

13.00 End of session

Tuesday 11 September

11.00 – 13.00

INNOVATIONS IN IOL POWER CALCULATION

Chairpersons: T. Kohnen GERMANY

R. Mencucci ITALY

11.00 G. Auffarth GERMANY

The gold standards: IOLMaster 500 and LenStar

11.15 N. Rosa ITALY

IOL power calculation in premium IOLs: part I (accommodative/multifocal)

11.30 Discussion

11.40 J. Aramberri SPAIN

IOL power calculation in premium IOLs: part II (toric)

11.55 W. Haigis GERMANY

IOL power calculation after refractive surgery

12.10 Discussion

12.20 C. Carbonara ITALY

New tools for biometry

12.35 M. Mrochen SWITZERLAND The future: customised eye models

12.50 Discussion

13.00 End of session

Wednesday 12 September

11.00 – 13.00

I AM A PERFECT CATARACT SURGEON. HOW CAN I BECOME BETTER?

Chairpersons: R. Bellucci ITALY

M. Lundström SWEDEN

11.00 D. Spalton UK

How I avoid damaging the capsule

11.15 J. Holladay USA

How I always avoid refractive surprise

11.30 Discussion

11.40 R. Nuijts THE NETHERLANDS

How I avoid inducing astigmatism

11.55 C. Lobo PORTUGAL

How I avoid cystoid macular oedema

12.10 Discussion

12.20 L. Buratto ITALY

How I always avoid patient dissatisfaction with multifocal IOLs

12.35 K. Pesudovs AUSTRALIA

I always evaluate patient benefits after cataract surgery

12.50 Discussion

13.00 End of session

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

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Croma Satellite Meeting

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Cataract Surgery – New Options for Optimizing Outcomes

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Challenging Cataract Cases –The Simple Truths

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NIDEK Satellite Meeting

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Ellex Satellite Meeting

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Evening Symposia Saturday 8 September

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SATELLITE EDUCATION PROGRAMME

13 00 – 14.00

ZEISS Satellite Meeting

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High Speed, High Resolution Anterior Segment Imaging

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13 00 – 14.00

The Place of Dry Eye in Ocular Surface Disease

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Correcting Presbyopia at the Corneal Plane

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13.00 – 14.00

Topcon Refractive

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Evening SymposiaMonday 10 September

18.00

Total Keratoconus SolutionKeraring User Group Meeting

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Intracameral Prophylaxis of Post-Operative Endophthalmitis in Cataract Surgery

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Satellite Education Programme

Lunchtime Symposia Sunday 9 September

13.00 – 14.00

ALCON Satellite Meeting

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Leading Technology in Refractive Surgery

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13.00 – 14.00

Abbott Medical Optics Satellite Meeting

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13.00 – 14.00

Haag-Streit Satellite Meeting

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13.00 – 14.00

Love At Second Sight; How Rayner Sulcoflex® Enhances Pseudophakic Vision

Moderator: M. Packer USA

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13.00 – 14.00

Managing Patient Outcomes Post Cataract Surgery – Focus On Cystoid Macular Edema

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13.00 – 14.00

EVA, A New Dimension in Cataract Technology and Other DORC Anterior Highlights

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13.00 – 14.00

Innovations In Refractive Surgery - Latest Advancements In Excimer And Femtosecond Laser Technology

Moderator: J. Güell SPAIN

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Evening SymposiaSunday 9 September

18.00

ALCON Satellite Meeting

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13.00 – 14.00

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STAAR Surgical Symposium

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Bausch + Lomb Satellite Meeting

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EUROTIMES | Volume 17 | Issue 5

Modest monovision, with just 1.25 D of myopia for the near focusing eye, can provide a presbyopic solution

that is suitable for many types of patients who would find most other strategies unacceptable, said Graham Barrett MD, Perth, Western Australia, Australia.

“We are familiar with the caution that multifocal implants may not be suited to certain individuals. But with modest monovision, architects, engineers, artists and even truck drivers are possible candidates because you can always correct their vision with spectacles if required, for example when driving at night. In addition minor amounts of defocus encountered with astigmatism and PCO and even macular function are not affected to the same degree as they are with multifocal lenses,” Dr Barrett told the XXIX Congress of the ESCRS.

He noted that while modern multifocals can provide the majority of patients with complete spectacle independence, they involve a compromise in the form of reduced contrast sensitivity. Accommodative IOLs provide better optical quality but less predictable near vision, he said.

PresbyLASIK is another strategy to spectacle independence, but it is still not clear how corneal remodelling will affect the results over the long-term, he noted. Similarly, the newer corneal inlays are showing promising results, but proof of their biocompatibility must await longer-term follow-up.

As a result of all these compromises

and caveats, monovision with monofocal IOLs, currently accounts for as much as 50 per cent of cataract procedures in some practices. Monofocal IOLs, in turn, account for 90 per cent of lenses implanted.

However, monovision also has its drawbacks, Dr Barrett said. Conventional monovision involves a myopic defocus of around 2.0 to 2.5 D. Although patients treated this way have approximately the same level of spectacle independence and binocular defocus curve as those implanted with multifocals, they lose a significant amount of stereoacuity.

“What we are faced with is a balance between myopic defocus and distance acuity versus the amount of near vision that can be achieved and also the impact on stereoacuity. That is why it is my practice to limit defocus to 1.25 D to avoid asthenopia and preserve contrast and stereoacuity,” Dr Barrett said.

Careful counselling essential Dr Barrett noted that among his patients treated with modest monovision, 92 per cent achieved 20/30 and J4 or better. And despite the fact that only 27 per cent achieve total spectacle independence, patients are rarely dissatisfied with their results.

However, achieving satisfaction requires thorough preoperative counselling of patients in order to make sure they have realistic expectations. To insure that he only treats appropriate patients with monovision, he puts candidates for the procedure through a process he calls the ABCD of modest monovision.

Advising the patients of the alternatives is the first step in the counselling process. Dr Barrett tells his patients that while multifocals provide a greater chance of spectacle independence, monofocal IOLs provide a better quality of vision.

Broaching monovision is the next step, and at this point he explains that monovision provides the same quality of vision as is the case with conventional monofocal IOL implantation, but also adds improved intermediate vision, although they will require reading glasses for some activities.

Choosing the eye with the densest cataract is the next step, and Dr Barrett said he aims for emmetropia in that eye.

After successful surgery in the first eye and if 6/9 or better unaided acuity is achieved, the vision likely to be achieved in the eye with the near focus, can be demonstrated using the recently operated distance eye and a +1.25 D lens in a trial frame, which is the final step before going ahead with the procedure, Dr Barrett said.

Potential pitfalls Dr Barrett said that during his years of practising monovision he has only encountered three cases where the patient’s dissatisfaction was great enough as to require a further surgical intervention. Each of the cases was easily remedied and left the patients very happy with their outcome.

The first case was a patient who came to him following bilateral cataract surgery performed elsewhere. The patient had

an unexpected refractive outcome with a refraction of -3.5 D in the left eye. Dr Barrett performed LASIK on the eye aiming for emmetropia and leaving a refraction of -0.25 D.

The second case was a high myope who also had bilateral cataract surgery elsewhere with an intended monovision outcome. The treatment resulted in one eye being emmetropic the other eye having a refraction of -2.25 D, which the patient found unacceptable. Dr Barrett performed PRK in the myopic eye that resulted in a sphere of -1.0 D and the patient was very happy with that result, he said.

The third case was one of Dr Barrett’s own patients who ended up with a refraction of -0.5 D in one eye and -1.5 D in the other following bilateral LASIK. Retreatment of the more myopic eye resulted in a plano sphere and a satisfied patient, he said.

“I think there are some very important lessons we can learn from these patients. First, the importance in presbyopic treatments of meeting or exceeding patient expectations; secondly, the problematic nature of anisometropia of more than 2.0 D; and thirdly the primary importance of achieving excellent unaided distance acuity in achieving patient satisfaction. The reading add is the icing on the cake but you have to have the cake first and that is your distance vision,” Dr Barrett added.

Dr Barrett noted that while at present patients must choose between total spectacle independence but lower quality of vision with multifocal IOLs and less spectacle independence and excellent quality of vision with monovision, future technologies may help monovision overcome some of those restraints.

“We may need to consider another paradigm which would be to consider the combination of modest monovision with an implant with extended depth of focus. The concept here would be simply to extend the focal range for near vision but retain the other positive attributes of this technique,” he added.

Graham Barrett – barrett@cyllene.uwa.edu.au

cont

act

MODEST MONOVISIONPresbyopic approach with slight defocus in nondominant eye achieves high patient satisfactionby Roibeard O’hEineachain in Vienna

22 Update

CataraCt & refraCtive

Financial planning in an ophthalmology practice Marketing your practice on a budget Beginner’s guide to social media & ranking highly on Google Private equity and ophthalmology

Using EUREQUO outcomes as a business solution Incentivising your sta� Building a practice website

Practice Development

ESCRS ESCRS Practice Development WorkshopsXXX ESCRS Congress, MilanSunday September 9 – Monday September 10

For more information visit www.escrs.org/practice-development

EUROTIMES | Volume 17 | Issue 5

Matching cataract patients to appropriately experienced surgeons based on risk factors reduced posterior capsule

rupture rates by about one-third, Lampros Lamprogiannis MD, of Aristotle University of Thessaloniki, Greece, told the XXIX Congress of the ESCRS.

“Our study focused on how application of the risk factor method can reduce the main intra-operative complication, which is posterior capsule rupture,” Dr Lamprogiannis said.

His clinic (Department of Anterior Segment, 2nd Ophthalmology Clinic, Aristotle University of Thessaloniki, Head: as. professor I.Tsinopoulos) adopted a risk-scoring method based on previous research (Muhtaseb M et al Br J Ophthalmol, 2004 Oct;88(10): 1242-6) that assigns patients points for specific preoperative clinical findings. These include advanced age, pseudoexfoliation syndrome, glaucoma, anticoagulant use, axial length, shallow anterior chamber, hard cataract, phacodonesis and diabetic retinopathy. Cataract surgeons also were divided into three groups – highly experienced, experienced and trainees. Patients with risk scores of four or more were assigned to highly experienced surgeons only, those scoring one to three to experienced surgeons, and those with zero risk factors to trainees. For example, an 83-year-old patient with glaucoma, possible floppy iris, long axial length, a grade four cataract and only one eye scored six on the risk scale.

“He is obviously a patient who should be operated on by a skilled, experienced surgeon,” Dr Lamprogiannis said.

In a study of 388 consecutive patients operated after adopting risk-scoring, the total capsule rupture rate was 3.61 per cent. That compared with 5.53 per cent observed for 1,735 eyes operated previously, when patients were assigned to surgeons more or less randomly or based on a rough estimate of risk. The reduction was statistically significant at p<0.05.

“Our study shows graphically how complications can be reduced and outcomes

can be significantly improved,” Dr Lamprogiannis said.

Improved training Trainee surgeons made the biggest improvement, reducing rupture rates to 4.13 per cent from 7.2 per cent, a drop of about 43 per cent.

“This plays an important role not only in the training but also in the psychology of the training,” Dr Lamprogiannis said.

Grouping six or seven low-risk patients on the surgical schedule for a designated training session helps young surgeons build skill and confidence quicker than pulling trainees into the OR randomly for one case at a time, Paul Ursell MBBS, MD, FRCOphth, of the Epsom and St Helier University Hospital Trust, UK, told EuroTimes. “Repetition is the key. We know our skills fluctuate. After a long break you are not as attuned as if you are doing 10 or 15 cases every day for several weeks.”

While some worry that limiting trainees to uncomplicated cases leaves them unprepared for real-world practice, Dr Ursell believes bringing surgeons along with cases that do not exceed their skill level enables them to focus on the newest challenge as their training progresses. He even extends the concept to parts of the procedure. He starts trainees with the easier tasks of evacuating viscoelastic and inserting the lens on several consecutive cases before moving on to the more challenging phaco and capsulorhexis steps. Having mastered the easier steps, they are better able to focus on the more difficult ones.

Dr Ursell likens the approach to erecting

a building inside a supporting scaffold, which is progressively removed as the structure strengthens. Risk-scoring is an important element. His clinic adopted a method based on risk factors identified by a UK National Health Service study of 55,000 cataract cases (Sparrow JM et al. Eye (Lond). 2011 Aug;25(8):1010-5).

Surgeons tick off risk factors such as small pupils and dense nuclei on a form during examinations. For their first 50 cases, surgeons are limited to scores of zero to one, then for the next 50 from two to four, and are generally considered highly experienced after about 400 cases. It is only after the surgeon has performed over 100 cases that they are allowed to do more complex cases. “Surgeons don’t do procedures beyond their competence. It has reduced complications in our department and increased the confidence of our trainees. It is also safer for our patients.”

Comprehensive quality report In a separate presentation, Jörg Förster, CEO of Eye Hospital Bellevue, Kiel, Germany, reported significantly improved patient satisfaction, post-surgery clinical findings and visual outcomes over three years after implementing a structured quality report for cataract surgeons.

Dr Förster partnered with 44 eye professionals in 2007 to create a quality network. “Our thesis is that increasing quality means learning from the past and from each other. To learn means to analyse data.”

The network created a structured quality report that collects data in three categories: nine subjective findings such as clarity of cornea, five objective measures such as best corrected visual acuity, and five patient satisfaction measures such as satisfaction with nursing care. Data are collected at three follow-up visits. The database now includes nearly 41,000 cases with 114,595 follow-up visits and 1.8 million discrete data items.

For each item, findings are translated into a school note according to the German school note system in which 1 = best and 6 = worst. For example, for cornea quality, no abnormal finding = 1, oedema = 3 and Descemet’s folds = 4. For 13,828 cases, the average quality score for cornea is 1.762 +/- 1.225. For six surgeons, the scores varied from 1.622 +/-1.136 to 2.314 +/-1.376. Results for each category can be summed, as can a total quality score.

Surgeons use the reports to analyse their performance and discuss techniques for improvement. Every month a team of senior surgeons selects a topic for discussion. Topics have included reducing phaco energy, cleaning the chamber angle, post-op medications and behaviour toward patients.

From 2007 through 2010, overall patient satisfaction scores improved 18 per cent, quality in post-surgery findings by 13.3 per cent, and quality of measured findings, including post-op visual acuity, spherical equivalent and IOP, by 6.5 per cent, Dr Förster reported. Total quality improved 10.2 per cent, ranging by surgeon from 5.8 per cent to 31 per cent.

Standard deviation is also useful, Dr Förster said.

“You see one surgeon has some months with very good notes. We have to find out the difference between the months with very good notes and the ones not as good. This surgeon has the highest potential to improve.”

Lampros Lamprogiannis – lamroslamprogiannis@ hotmail.com

Paul Ursell – paul@cataract-doctor.comJörg Förster – jorg.forster@augenklinik-bellevue.de

cont

acts

PERFORMANCE IMPROVEMENTRisk stratification, comprehensive quality scores, boost cataract outcomesby Howard Larkin in Vienna

23Update

CataraCt & refraCtive

Our study shows graphically how complications can be reduced and outcomes can be significantly improved

“

Lampros Lamprogiannis MD

Our thesis is that increasing quality means learning from the past and from each other. To learn means to analyse data

“

Jörg Förster

Repetition is the key. We know our skills fluctuate. After a long break you are not as attuned as if you are doing 10 or 15 cases every day for several weeks

“

Paul Ursell MBBS, MD, FRCOphth

Don’t Miss Eye on Travel, see page 51

MILAN6 - 8 September 2012

www.eucornea.org

3rd EuCornea Congress

Eu C o r n e

a

European Society of Cornea andOcular Surface Disease Specialists

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u C o r n ea

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Dry Eye Disease: The Symptoms and SolutionsFriday 7 September 13.00 – 14.00

INVITED SYMPOSIANew developments in dry eye B. Cochener FRANCE, J. Merayo Lloves SPAIN

Update on infectious diseasesM.J. Tassignon BELGIUM, J. Colin FRANCE

New research in cornea T. Fuchsluger GERMANY

Infl ammationG. Van Rij THE NETHERLANDS, H. Dua UK

Update on keratoconus management F. Malecaze FRANCE, T. Seiler SWITZERLAND

Corneal complications of refractive surgery ROL (refr@ctive.on-line) and SICSSO (Società Italiana Cellule Staminall e Superfi cle Oculare) Symposium

Endothelial cell-based therapies for corneal reconstruction Asia Cornea Society

Anterior lamellar keratoplasty Società Italiana Trapianto di Cornea (SITraC)

Ocular surface reconstruction and keratoprosthesis The Cornea Society

Preparation and preservation of lamellar graftsEuropean Eye Bank Association (EEBA)

Posterior lamellar keratoplasty J. Güell SPAIN, F. Kruse GERMANY

Update on contact lenses European Contact Lens Society of Ophthalmologists (ECLSO)

25

EUROTIMES | Volume 17 | Issue 5

Gene therapy may provide ways to repair damaged corneas and improve the quality of donor corneas, according to Francois

Malecaze MD, CHU Toulouse, Toulouse, France.

“The possible benefits of gene therapy for corneal disease include a reduced need to administer topical treatments, and gene therapy could better target the molecular mechanisms involved in disease making it more effective and more specific,” Dr Malecaze told the XXIX Congress of the ESCRS.

He noted that the technology of gene therapy has been advancing rapidly in recent years and already clinical studies are under way employing gene therapy in the treatment of retinitis pigmentosa. Research is not as far advanced in the gene therapy of corneal disease, but it is catching up, with numerous strategies under development, he added. 

Current research in gene therapy for the cornea is targeting three types of the cells. They are the epithelial cells, for the restoration of corneal surface integrity, the keratocytes of the stroma, to treat corneal opacities, and the endothelial cells to better preserve the endothelium in corneas donated for keratoplasty procedures.

In studies where gene therapy has targeted the epithelium, transfection of genes to epithelial tissue in vitro has been very successful. However, using the same approach in vivo has produced only a very short-lived effect lasting only a day or two.

On the other hand, other research has shown that targeting epithelial stem cells can provide a longer-lasting expression of transfected genes. In studies using different animal models, researchers have been able to excise a small amount of limbal stem cells, transfect the cells in a culture medium with the therapeutic gene and then re-implant the cells in the cornea. The result has been that the progeny of the transfected stem cells migrate to the centre of the cornea (Bradshaw et al, Invest. Ophthalmol. Vis. Sci. January 1999; 40: 230-235).

As regards the keratocytes, Dr Malecaze and his associates have developed a technique for delivering gene therapy to the stroma. It involves injecting a recombinant adeno-associated virus-based vector with a micro-needle. In a study published last

year, using this technique to inject the vector with the MMP14 gene in rabbits’ eyes caused corneal scars to fade and corneal transparency to improve as a result (Galiacy et al, Gene Therapy 2011;18:, 462-468).

Another research team has shown that the gene for the fibrosis inhibiting protein, decorin, can be successfully transferred to stromal keratocytes by applying it topically with an adenovirus (after performing a surface ablation with an excimer laser) again reducing corneal opacity (Mohan et al, Invest. Ophthalmol Vis Sci. 2011; 52: 4833-4841).

Gene therapy for the endothelium is at present primarily aimed at improving the quality of donor corneas. The ex vivo approach seems feasible and helps eliminate some of the safety issues involved with in vivo gene transfer.

In a recently published study, human corneas treated with the anti-apoptotic gene p35 had a lower rate of endothelial cell death and remained viable for 11 weeks. By comparison, untreated corneas only remained viable for seven weeks (Fuchsluger et al, Gene Ther 2011 Aug; 18(8):778-87).

“Thanks to the significant advances in molecular biology, retinal gene therapy has started and significant progress has also been made toward taking the next step to allow for gene therapy of the cornea,” Dr Malecaze concluded.

GENE THERAPYNumerous strategies under investigation now nearing the clinical stageby Roibeard O’hEineachain in Vienna

François Malecaze – malecaze.fr@chu-toulouse.fr

contacts

Update

COrNea

Thanks to the significant advances in molecular biology, retinal gene therapy has started and significant progress has also been made toward taking the next step to allow for gene therapy of the cornea

“

Francois Malecaze MD

26

EUROTIMES | Volume 17 | Issue 5

A bioengineered human cornea substitute may have an important role to play in alleviating world blindness in the not too distant

future, according to Per Fagerholm MD, University Hospital, Linköping, Sweden.

Speaking at the XXIX Congress of the ESCRS, Dr Fagerholm said that the results of a phase 1 clinical study with the biosynthetic cornea remain very encouraging at three years of follow-up, and further refinements in the production of the corneal substitute material may improve results.

“The reason why we do this is that there is a lack of donor corneas world-wide which is immense. There are 10 million people blind from corneal disease. With this cell-free construct you eliminate the risk of infection from donor to recipient and you also eliminate the risk of immune rejection, which accounts for the majority of the 10 per cent of grafts that are lost within two years of transplantation, according to the Swedish National Cornea Register,” Dr Fagerholm said.

The study involved 10 patients, nine with keratoconus and one with a deep corneal scar. All had undergone anterior lamellar keratoplasty involving implantation of the biosynthetic cornea. The biosynthetic material is composed of human recombinant type III collagen cross-linked with water-soluble carbodimides.

Dr Fagerholm noted that at 24 months’ follow-up, the biosynthetic implants remained stably integrated and avascular, and there were no cases of immune rejection. In addition, the epithelial surface barrier was established by two months and remained stable throughout follow-up.

Moreover, corneal sensitivity was as good as or better than occurs with conventional grafts and tear production was sufficient. Furthermore, in-vivo confocal microscopy showed that the growth of nerves into the implant was more rapid and more complete than is the case with conventional corneal grafts. “We saw that the neural fibres reached the centre of the graft, which is something that does not occur in penetrating keratoplasty,” Dr Fagerholm said.

On the other hand although there was a good colonisation of the implant with host keratocytes, it was a little slower than that commonly seen with donor grafts.

Dr Fagerholm noted that at 24 months spectacle-corrected visual acuity was not as good as that achieved in eyes with conventional corneal grafts, and at two years' follow-up had a mean value of only 20/110.

When performing the implantation procedure, Dr Fagerholm and his associates first excised a central deep lamellar button 6.0mm in diameter from the patients’ eyes and replaced it with a custom-shaped biosynthetic lamellar button 6.25mm in diameter and 500 µm in thickness.

They secured the button with six overlying sutures and a bandage lens. Postoperatively, patients received topical therapy with chloramphenicol and dexamethasone for eight to 10 weeks. Sutures were removed at six weeks. In a couple of patients there were problems with re-epithelialisation, which appeared to be suture related. One case of poor re-epithelialisation resulted in corneal melting, he noted.

A decade of research The biosynthetic cornea is a collaborative effort between Dr Fagerholm’s team in Sweden and the Eye institute in Ottawa Canada under the direction of Prof May Griffith PhD. It has so far involved eight years of research, with extensive safety testing and refinement of the biosynthetic material.

The theory behind the recombinant human collagen grafts is based on the observation that when the cornea becomes depleted of keratocytes as a result of intense ultraviolet exposure, as in the case of eyes with UV keratitis, the extracellular matrix is unaffected and the central cornea quickly becomes populated without any loss of corneal transparency.

By mimicking the molecular structure of corneal collagen, the bioengineered grafts serve as scaffolding for the colonisation of the central cornea by keratocytes. The decision to use type III human collagen, which is found in the skin, rather than type I collagen that is found in the cornea, was based on its superior mechanical properties and its lower cost.

The phase 2 study will address some of the complications seen in the phase 1 study.

BIOENGINEERINGRecombinant collagen implants continuing to show promiseby Roibeard O’hEineachain in Vienna

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COrNea

Per Fagerholm – perfa@inr.liu.se

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EUROTIMES | Volume 17 | Issue 5

Presbyopic LASIK and intracorneal hydrogel implants are both viable options for providing some degree of near vision but both types of

approach suffer from the same drawback of a reduction in distance vision in the treated eye, Günther Grabner MD, University Eye Clinic, Paracelsus Medical University, Salzburg, Austria, told a session of the XXIX Congress of the ESCRS.

Dr Grabner noted that the corneal approaches to presbyopia have their pros and cons. For example, presbyopic LASIK has been the subject of clinical research since the late 1980s and in its current forms appears to offer a reversible or at least partially reversible bifocality. On the other hand, it can only provide a limited amount of near vision and there is as yet no consensus as to which of the many available techniques is best.

Corneal inlays, meanwhile, offer a somewhat more reversible means of extending the range of vision in presbyopic patients. However, like presbyopic LASIK, the models currently in use also provide a fairly limited range of near and/or intermediate vision. Moreover, they have been the subject of little in the way of peer-reviewed published research and there is even less information about their longer term safety and efficacy, he said.

Different LASIK approaches Dr Grabner said that there are four main types of presbyopic LASIK ablation profiles. They are the central steep island, the decentred steep island, and the centred steep annulus, and a global optimum, which is a hyperprolate shape optimised for asphericity and radius of curvature.

He noted that a ray tracing computer simulated analysis of those approaches by Tobias Koller MD and Theo Seiler MD, PhD in Zurich, Switzerland showed that the global optimum approach and central steep island approaches were the most promising. The decentred steep island and centred steep annulus produced significantly worse results in terms of both near and distance vision (Koller et al, J Cat Refract Surg; 32: 2118-2123).

“You should probably not use the techniques like the decentred steep island or centred steep annulus ablations, they have some theoretical problems. The techniques with a central zone for near vision with the pupil acting as the driving force, like the Schwind Presbymax and the AMO/VISX

CustomVue, are probably the ones you should consider if you are going to try this technique,” Dr Grabner said.

In a study by Bruce Jackson MD and associates in Ottawa Canada involving 19 eyes that underwent a custom presbyopic ablation with the CustomVue system, the aspheric ablation with the centre optimised for near vision resulted in close to 70 per cent achieving J1 and more than 90 per cent achieving J3 or better in bilateral binocular near visual acuity.

“Bilateral presbyopic LASIK treatments show the best results. If you know how to do it well, the patients are quite satisfied and about 50 per cent will be completely spectacle-free.

You have to expect a loss of one or two lines of best spectacle-corrected distance visual acuity, which is quite a loss. And over time, near vision deteriorates and far vision improves a little bit. Distance vision is not as good in myopes as it is in hyperopes,” Dr Grabner added.

The return of corneal inlays Corneal inlays are lenticules designed to be placed beneath a flap similar to that used in LASIK procedures. They include inlays designed to improve the near focus of the nondominant eye through multifocal optics of the lenticule itself, as in the case of the Flexivue (BioVision),

those that provide a near add through an increase in curvature in the central cornea, like the newest version of the Vue+ inlay, or Presbylens (ReVision Optics) as it is now called, and those, like the Kamra inlay (AcuFocus), which is based on the concept of the pinhole lens.

Dr Grabner noted that the published peer-reviewed data regarding the inlays is very scarce. The most he could find regarding the Flexivue microlens, was an abstract of a study conducted by Ioannis Pallikaris MD in Crete, involving 45 patients, but he expects detailed publications soon. It showed that patients’ mean uncorrected near and distance visual acuity in their treated eye was 0.6. There was also in increase in higher order aberrations.

Regarding the Vue+ lens, Enrique Barragan MD, Monterrey, Mexico, reported his findings in 17 patients with the inlay at the 2010 XXVIII Congress of the ESCRS in Paris. The study showed that at nine months’ follow-up patients gained an average of four lines of uncorrected near visual acuity. However, the uncorrected distance visual acuity in the treated eye was 20/20 or better in fewer than 20 per cent of patients, compared to over 90 per cent of patients before the surgery.

The Kamra inlay is currently the best researched. It is currently the only inlay for which the results appear to have been published in peer-reviewed journals. In addition, more than 8,000 of the inlays have been implanted worldwide, including more than 4,000 of the inlays implanted by Minoru Tomita MD in Japan in conjunction with LASIK procedures.

Moreover, in a recently published study involving 32 patients in whom Dr Grabner and his associates implanted the inlay as part of an international FDA trial, eyes receiving the inlay had a mean gain of 4.6 lines of uncorrected near visual acuity, 98 per cent of patients in the study achieved J3 or better and half achieved J1at 36 months follow-up. In addition they only lost a mean of 0.8 lines of uncorrected distance visual acuity significantly better than any other technique..

“There are some excellent corneal options for presbyopia and in patients with a clear lens, I don’t think you have to go into the eye with all the risks involved,” Dr Grabner concluded.

Günther Grabner – g.grabner@salk.at

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act

PRESBYOPIC TREATMENTSResearch is helping clarify the potential of presbyopic LASIK and corneal inlays by Roibeard O’hEineachain in Vienna

28 Update

COrNea

Uncorrected Distance & Near VA

Kamra inlay

There are some excellent corneal options for presbyopia and in patients with a clear lens, I don’t think you have to go into the eye with all the risks involved

“

Günther Grabner MD

Cour

tesy

of G

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29

EUROTIMES | Volume 17 | Issue 5

Visual outcomes and graft survival are very poor in patients who develop endophthalmitis following penetrating

keratoplasty, according to a study presented by Sonika Gupta MD, New Delhi, India, at the 16th ESCRS Winter Meeting.

The study involved a retrospective review of 258 consecutive penetrating keratoplasties with the aim of determining the incidence of endophthalmitis, its predisposing factors, the microbial spectrum causing the infections, and the visual outcomes and graft survival rates, Dr Gupta said.

The researchers found that there were four cases of post-penetrating keratoplasty endophthalmitis in the series, or 1.5 per cent, over a mean follow-up period of 7.75 months.

The age of the patients varied from 33 years to 68 years and the complication occurred in three men and one woman. The predisposing factors included contaminated donor tissue in two cases, wound dehiscence in one case, and loose suture removal in one case. In addition, the donor cornea was stored in McCarrey-Kaufman medium in all four cases.

The microbial pathogens isolated from the vitreous aspirates included culture-positive streptococcus in two cases, staphylococcus in one case, and aspergillus in one case.

Two eyes received intravitreal vancomycin 1mg/0.1ml and ceftazidime 2.25mg/0.1ml, one received amphotericin B, and one underwent pars plana vitrectomy.

The outcomes were failed grafts in two eyes, phthisis bulbi in one eye and a visual acuity of 20/80 in one eye.

Dr Gupta noted that the incidence of endophthalmitis was unusually high in her case series. Published case series show an incidence ranging from 0.8 per cent to 0.77 per cent. Possible reasons for the high incidence may be related to the difficulty of obtaining good donor tissue in her part of the world, she said.

In addition, all four eyes were aphakic, which means that vitreous incarceration was a possible risk factor. There may have also been inadequate compliance with treatment and follow-up after surgery. Furthermore, the only antibiotic in the type of storage media used was gentamicin.

The microorganisms responsible for the infection were resistant to gentamicin in both cases where contaminated donor tissue was the predisposing factor.

Dr Gupta noted that the finding of contaminated donor tissue as the causative factor of endophthalmitis in half of cases was similar to other case series reported in the literature. The same was true of the visual outcomes the patients in this series.

An unusual finding was aspergillus as the infective agent in one case. In fact, in other case series the incidence of rim cultures positive for fungal contamination was only one or two per thousand. There is at present no evidence whether antifungal prophylaxis will present such infections, Dr Gupta said.

On the other hand, she stressed that there are several measures that can be taken to prevent post-keratoplasty endophthalmitis. They include the routine screening of donor rim tissue and the treatment of all patients with prophylactic intraoperative and postoperative broad-spectrum antibiotics. She added that early detection of the complication is essential for achieving optimum outcomes.

“In our set-up, detection and treatment of complications like endophthalmitis is delayed due to inadequate compliance with follow-up after surgery. Early diagnosis and aggressive intervention is mandatory to salvage the eye,” she said.

PREVENTIONBetter tissue screening may help avoid postoperative infectionsby Roibeard O’hEineachain in Prague

Sonika Gupta – dr_sonika2003@yahoo.co.uk

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31

EUROTIMES | Volume 17 | Issue 5

In addition to considering adherence, which is often poor for patients using topical glaucoma medications, ophthalmologists should also consider

bottle exhaustion and refill rate when individualising therapy, Daniel B Moore MD told the 2011 annual meeting of the American Academy of Ophthalmology.

About one-quarter of glaucoma patients surveyed at the University of Washington Eye Institute reported running out of eye drops before they were allowed to refill them at least once a year, with about eight per cent running out five or more times. Patients with visual acuity of 20/60 or less, no medication insurance, and those requiring an interpreter during medical visits were significantly more likely to report exhausting eye drop supplies on a regular basis.

“About eight per cent of patients in our study routinely exhausted eye drops early, making this an important cause of medical non-compliance,” Dr Moore said.

The cross-sectional non-randomised study involved 241 consecutive glaucoma patients with prescribed topical glaucoma therapy in both eyes who were stable, self-administered drops, and had no therapy changes in the prior three months. Interviewers administered a brief survey at office visits, asking subjects how many medications they took, how often they thought they ran out, and why they thought they ran out. Median age of study participants was 67.7 years; 53 per cent were male; and mean visual acuity and Humphrey visual field index were logMAR 0.135, or about 20/30. Mean duration of treatment was 7.6 years, and the mean number of drop bottles was two.

Overall, 72.9 per cent reported not running out of drops, while 10.8 per cent said they ran out once or twice a year, 7.1 per cent three or four times a year, 2.1 per cent five to seven times a year, 1.2 per cent eight to 11 times, and 5.0 per cent ran out always. Of those who reported running out, insufficient amount in the bottle was the leading reason given at 28.1 per cent, followed by more than one drop coming out at 21.9 per cent, inability to hold the bottle steady at 12.5 per cent, can’t see tip of bottle at 10.4 per cent. Drop size, bottle problems, missing the eye and miscellaneous reasons were also reported.

Poor visual acuity was the most significant risk factor. Dr Moore hypothesised that poor vision inhibits hand-eye coordination and may result in poor aim and drop size control. He noted that research has shown both are issues in topical medication adherence.

The relationship between the need for an interpreter and adherence is more complex, Dr Moore suggested. While research shows that in the US, non-English speaking patients may not seek medical attention until poor vision is apparent, one study also shows that they have higher compliance with clinic visits as open-angle glaucoma suspects. An analogous increase in medication adherence may help explain more-frequent bottle exhaustion in this population, he suggested. However, the study did not examine compliance rates among patients who did not report frequent bottle exhaustion.

Lack of insurance has frequently been associated with lower therapy adherence. Medication costs are a significant barrier, particularly among patients from less-affluent backgrounds, Dr Moore noted.

Age, sex, years of eye drop use, number of eye drops and bottles, presence of arthritis, number of co-morbid medical conditions and indices of visual fields were not significant risk factors in this study. The guidance this study contributes is valuable, but further research is needed to confirm or generalise the findings, Dr Moore said.

EYE DROPsPoor vision, no insurance, language problems increase risk of running outby Howard Larkin in Orlando

Daniel B Moore – dbmoore@u.washginton.edu

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Update

GLAUCOMA

About eight per cent of patients in our study routinely exhausted eye drops early, making this an important cause of medical non-compliance

“

Daniel B Moore MD

A five-year retrospective study of nearly 18,000 glaucoma patients by a large US health system found that most patients are either highly adherent or highly non-adherent with prescribed

IOP-lowering medication, and that these patterns of behaviour are usually evident in the first year of treatment.

The results suggest that efforts to improve glaucoma medication adherence should target specific groups and individual patients, Jason Jones PhD of the Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, US, told the 2011 annual meeting of the American Academy of Ophthalmology (AAO).

Using glaucoma drop prescription refill data, Kaiser Permanente researchers calculated a medication possession ratio, or MPR, for each patient as a proxy for medication adherence. An MPR of 1.0 indicates the patient had enough medication for 100 per cent adherence with prescribed doses during the period while 0.0 indicates no medication at all on hand.

The study found a pronounced bimodal distribution in adherence behaviour during the second year of treatment. At the high end, 5,556 patients, or 31 per cent, had an MPR of 0.8 or more, meaning they had access to 80 per cent or more of the medication prescribed for the period. The peak for this group was about 95 per cent, suggesting close to daily adherence for many patients. On the low end, 4,732 patients, or 27 per cent, had MPRs of less than 0.2, indicating they had possession of less than 20 per cent of prescribed glaucoma medications. The peak for this group at just over zero per cent suggests that many patients took no drugs at all, possibly increasing their risk of glaucoma progression.

Another 31 per cent of patients had MPRs between 0.2 and 0.79, with the distribution skewed slightly toward higher possession ratios. Eleven per cent were not included because they left the study group during the year. The overall mean MPR was 0.52 and the median 0.57, consistent with prior publications but not useful indicators of adherence given the nature of the distribution.

However, “any interventions should consider the fact of the bimodal nature of compliance, and suggests specific targeting of patients,” Dr Jones said.

Broad population study The study included 17,679 glaucoma patients aged 18 or higher who were diagnosed and started medication within 90 days between 2005 and 2009, had no previous glaucoma diagnosis or surgery, and had both medical and prescription insurance coverage through Kaiser Permanente until the follow-up period ended or they had glaucoma surgery. Patients’ mean age was 66 years, with 51 per cent female. Mean length of follow up was three years, with 4,510 patients followed for five years. They include all qualifying incident glaucoma cases identified during the period among about 3.5 million patients Kaiser Permanente serves in Southern California.

Since Kaiser Permanente delivered most medical services to these patients supported by comprehensive electronic

health records, the researchers were able to track most interventions, including prescription filling behaviour, not only for ophthalmology, but for all medical services used by the entire study population. The primary focus was on IOP-lowering medication adherence in year two of treatment. Potential correlates of adherence, including demographics, co-morbid conditions, health service resource utilisation, adherence with medications for other conditions and glaucoma MPR year-to-year were examined to identify possible predictors of high or low adherence.

By far the most powerful predictor of second-year glaucoma medication adherence was first-year adherence as measured by MPR, with an area under the receiver operating characteristic curve (AUC) of 0.95 (p<0.001). Similarly, year two and year five MPR were strongly related at AUC=0.67, suggesting that adherence behaviours are established early and persist, Dr Jones said.

More ophthalmology outpatient visits in the first two years also predicted better year two adherence, with AUCs of 0.61 and 0.64, respectively.

“The results of this study, as with others, point out that continuing to see their doctors is related to patients’ medication adherence but not nearly as strongly as their prior medication adherence behaviour,” Dr Jones said.

Members of the high adherence group also showed a slightly higher use of outpatient services overall in year one. Conversely, members of the low adherence group showed higher inpatient use in year one, logging 1.33 days per member for the year, compared with 0.75 per member per year for the high adherence group.

Among demographic factors, higher age, female gender and white race were weak predictors of better adherence. Half of those in the low adherence group were 65 or younger, compared with 38 per cent in the high adherence group, while 48 per cent of low adherers were female compared with 54 per cent of high adherers, and 47 per cent of low adherers were white compared with 52 per cent of high adherers.

Overall, the glaucoma population has a high incidence of co-morbid conditions, including hypertension in 65 per cent, diabetes in 29 per cent, chronic pulmonary disease in 17 per cent, cancer in 12 per cent and renal disease in 13 per cent. On average they took seven to eight non-glaucoma medications in six to seven classes. But while the prevalence of particular co-morbidities were similar between the high and low adherence groups, the low adherence group was more likely to have a higher co-morbidity burden, despite generally being younger.

“Adherence to IOP-lowering medication is weakly associated with adherence to other chronic medications or use of other medical services. Ophthalmologists should focus efforts on groups and individuals that have demonstrated low adherence, and stress the importance of treating glaucoma independently of other chronic diseases,” Dr Jones concluded.

EUROTIMES | Volume 17 | Issue 5

Jason P Jones – Jason.p.jones@kp.orgcontact

GLAUCOMA ADHERENCELower age, higher co-morbidity burden, at higher risk for medication non-complianceBy Howard Larkin in Orlando

32 Update

GLAUCOMA

marking pattern

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33

EUROTIMES | Volume 17 | Issue 5

There is an urgent need for updated data concerning the rates of glaucoma surgery around the world, and particularly in

lower-income countries where the disease is most prevalent, according to Kaweh Mansouri MD.

“At the moment intraocular pressure is the only modifiable risk factor for glaucoma, a disease which has been recognised by the World Health Organization as being the second leading cause of blindness worldwide and the first irreversible cause of blindness. Surgery is so far the ultimate treatment option and one of the weaknesses that we face in glaucoma is a general lack of epidemiological data which is the cornerstone of public health action and policy,” he said.

Dr Mansouri, a senior fellow at the Hamilton Glaucoma Center, University of California, San Diego, US, proposed using a new metric to gather data concerning glaucoma surgeries worldwide. Known as the Glaucoma Surgical Rate (GSR), this metric is the total number of surgeries performed in a country in a one-year period per one million people.

Presenting data collected from 37 countries that responded to the survey, Dr Mansouri noted that the GSR in these countries ranged from single digits in low-income, high-prevalence, developing countries to over 1,000 in Portugal.

“The data presented covers a total of 1.6 billion people or about one-fifth of the planet’s population. The lowest rates so far are from low income but high prevalence countries most affected by this disease. Based on these findings we would appeal to the World Glaucoma Association to coordinate collection of data as this would really be a significant step in fighting glaucoma-related blindness in the world,” he said.

Dr Mansouri’s survey revealed some interesting disparities in glaucoma surgery rates within and between regions. In the European region, for instance, the GSR varied from as high as 1,022 for Portugal to just 85 in the Netherlands. Similarly in the American region, the United States of America recorded the highest glaucoma surgery rate of 292 surgeries per one million population per year compared to a GSR of only 17 for Brazil. He added that other

reasons for the significant disparities in data may be differences in definition or coding of interventions as well as in the quality of data collection between countries. The paucity of data from the sub-Saharan African region, the region with the highest prevalence of glaucoma, was evidenced by the fact that only two countries, Ghana, with a GSR of 7.01 and Ivory Coast with a GSR of 2.85, responded to the survey.

Looking at the data in more detail, Dr Mansouri noted a correlation between the number of ophthalmologists in a country and the number of glaucoma surgeries performed.

“This is pretty much as we might expect, but there are some notable exceptions to the rule. For instance Georgia and Pakistan have a similar GSR rate as Serbia which has almost five times more ophthalmologists per head of population,” he said.

A correlation was also found between the wealth of a country, as reflected by its GDP, and the number of surgeries performed, again with some notable exceptions. The Netherlands, for instance, performs less glaucoma surgeries than Lithuania which has a significantly lower GDP, said Dr Mansouri. In general, however, a clear trend emerged where the vast majority of low-income countries, defined by having a GDP of less than 3,000, also tended to have a GSR of less than 100.

“The new GSR metric might be useful to facilitate epidemiological research and comparison between countries and it seems that a GSR of 100 or close to 100 might be a useful target for public action,” concluded Dr Mansouri.

UPDATING DATACo-ordinating collection of data would be significant step in fighting blindnessby Dermot McGrath in Paris

Kaweh Mansouri – kamansouri@ucsd.edu

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GLAUCOMA

The data presented covers a total of 1.6 billion people or about one-fifth of the planet’s population

“Kaweh Mansouri MD

MAIN SESSIONS

MAIN SESSION 1THURSDAY 6 SEPTEMBER 11.30 – 13.00OCULAR TUMOURSChairpersons: N. Bornfeld GERMANY,J. van Meurs THE NETHERLANDS

MAIN SESSION 2FRIDAY 7 SEPTEMBER 08.00 – 10.00PVR AND RETINAL DETACHMENTChairpersons: D. Charteris UK, D. Wong HONG KONG

MAIN SESSION 3FRIDAY 7 SEPTEMBER 14.00 – 16.00IMAGINGChairpersons: W. Drexler AUSTRIA, S. Wolf SWITZERLAND

MAIN SESSION 4SATURDAY 8 SEPTEMBER 08.00 – 10.00DRY AMDChairpersons: P. Lanzetta ITALY, U. Schmidt-Erfurth AUSTRIA

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E. Stefansson ICELAND

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MAIN SESSION 7SUNDAY 9 SEPTEMBER 08.00 – 10.00INNOVATIVE VITREORETINAL SURGERYChairpersons: B. Aylward UK, S. Rizzo ITALY

MAIN SESSION 8SUNDAY 9 SEPTEMBER11.00 – 13.00MANAGEMENT OF DIABETIC MACULAR EDEMA: WHAT YOU NEED TO KNOWChairpersons: F. Bandello ITALY, J. Cunha-Vaz PORTUGAL

08.00

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15.00

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MAIN SESSION 1Ocular Tumours

MAIN SESSION 2PVR and Retinal

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KREISSIG LECTURE

AMSTERDAMRETINA DEBATE

MAIN SESSION 3Imaging

US RETINASOCIETY

ITALIANRETINA SOCIETY

EVICR.NET+EUROVISIONNET

SYMPOSIUM

COURSE 10How to Read

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COURSE 11New Strategies in

Ocular Trauma

FRENCH/ISRAELISYMPOSIUM

ARVOSYMPOSIUM

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COURSE 16Managing Diabetic Macular Edema:

Pearls and Pitfalls

COURSE 12Proliferative

Diabetic RetinopathyFREEPAPERS

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COURSE 17Tips and Tricks in Minimal-Invasive

Vitrectomy

COURSE 13Management of

Intraocular Tumors

COURSE 18Retinal imaging: Revolutionising

Retinal Therapeutics

COURSE 14The Role of the

Vitreous in Retinal Disease

FREEPAPERS SHORT

PAPERSSHORTPAPERS

SHORTPAPERS

COURSE 9Surgical Approach to the Vitreoretinal

Interface

COURSE 8Bimanual Surgery in Small Incision

Vitrectomy (23g-25g-27g)

LUNCH BREAK

COURSE 7Current

Management in Uveal Melanoma

SURGICALSKILLS

COURSES

RESEARCHSYMPOSIUM

OPENINGCEREMONY

WELCOME RECEPTION

UVEITISCOURSE

COURSE 2What, When and How:

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EUROLAMSYMPOSIUM

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OCT Imaging: Indications, Features,

Consequences

RETINALDETACHMENT

COURSESURGICAL

SKILLSCOURSES

THURSDAY 6 SEPTEMBER

FRIDAY 7 SEPTEMBER

SILVER(LEVEL 2)

SILVER(LEVEL 2)

RED 1/2(LEVEL 1)

RED 1/2(LEVEL 1)

BLUE 1(LEVEL 1)

BLUE 2(LEVEL 1)

BLUE 1(LEVEL 1)

BLUE 2(LEVEL 1)

WHITE 1(LEVEL 2)

WHITE 1(LEVEL 2)

WHITE 2(LEVEL 2)

WHITE 2(LEVEL 2)

YELLOW 3(LEVEL 1)

YELLOW 3(LEVEL 1)

GREEN 3(LEVEL -1)

GREEN 3(LEVEL -1)

COFFEE BREAK

LUNCH BREAK

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NOVARTIS SATELLITE MEETING

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ASIA PACIFIC VR SOCIETY

SYMPOSIUM

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CEREMONY

COURSE 15Diseases Involving

VR Interface

Closing Date for Applications:

31 May 2012www.euretina.org/innovation

07.00

08.00

09.00

10.00

11.00

12.00

13.00

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15.00

16.00

17.00

18.00

08.00

09.00

10.00

11.00

12.00

13.00

GENERALASSEMBLY

MAIN SESSION 4Dry AMD

MAIN SESSION 5Retinal Vein Occlusions

SPANISH VITREORETINAL

SOCIETY

FREEPAPERS

COFFEE BREAK

COFFEE BREAK

JOINTSYMPOSIUM

EURETINA/ESCRS

MAIN SESSION 6Neovascular AMD

FREEPAPERS

COURSE 19Steroids in

Retinal Therapy

FANCLUB

COURSE 22Vitreoretinal

Complicationsof Cataract Surgery

WCPOS JOINT SESSION

The Child’s Retina –Different Perspectives

WCPOS JOINT SESSIONPaediatric Uveitis

GERMAN RETINAL SOCIETY

SYMPOSIUM

COURSE 23Understanding AMD:Genetics, Prevention,

Pathophysiology

COURSE 24Uveitis:

Standard Diagnostic and Therapeutic

Procedures

ITALIANBIO-ENGINEERING

SOCIETY

FREEPAPERS

COURSE 25Laser Therapy in Retinal Disease:

Indications & Procedures

US MACULA SOCIETY

COURSE 20Managing

Complications inVitreoretinal Surgery

COURSE 21Fluorescein and

ICG-Angiography - Interpretation & Diagnosis

of Macular Diseases

MAIN SESSION 7Innovative

Vitreoretinal Surgery

MAIN SESSION 8Management of Diabetic

Macular Edema: What you need

to know

RETINAWSSYMPOSIUM FREE

PAPERS

OPEN SESSIONScreening for

DiabeticRetinopathy

COURSE 28Simple Approach to PVR Management

FREEPAPERS

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COURSE 26Management of Retinal Vascular

Occlusion

COURSE 27Electrophysiology:

Principles and Practice

SUNDAY 9 SEPTEMBER

SATURDAY 8 SEPTEMBER

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

FREEPAPERS

SILVER(LEVEL 2)

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RED 1/2(LEVEL 1)

RED 1/2(LEVEL 1)

BLUE 1(LEVEL 1)

BLUE 1(LEVEL 1)

WHITE 1(LEVEL 2)

WHITE 1(LEVEL 2)

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WHITE 2(LEVEL 2)

AUDITORIUM(SOUTH, LEVEL 3)

AUDITORIUM(SOUTH, LEVEL 3)

GOLD(SOUTH, LEVEL 2)

COFFEE BREAK

LUNCH BREAK

ALCONSATELLITE MEETING

D.O.R.C.SATELLITE MEETING

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BAYERSATELLITE MEETING

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37

EUROTIMES | Volume 17 | Issue 5

The EURETINA Innovation Award was established with the goal of supporting and encouraging innovation in retinal medicine.

The closing date for entries is 31 May, so if you wish to take part in this exciting initiative, you will need to act quickly. A cheque for €20,000 will be presented to the overall winner with the runner-up receiving €10,000. Already there has been an impressive range of entries and the competition to win this award promises to be even tougher than the inaugural award in 2011.

Last year, the biggest challenge facing the judges was the selection of the shortlist of potential winners because the standard was so high. It is hoped that this year’s entries will once again allow EURETINA to promote the first-class work being carried out in retinal research in Europe

EURETINA is sponsoring the award as the society believes that it is important that it should support and reward retina specialists who develop novel and innovative ideas relevant to the field of retinal medicine. The ultimate aim is to support initiatives that will help to deliver new market applications for the benefit of patients with retinal disorders.

Major progress has been made in promoting innovation in retinal research in recent years, but EURETINA believes that this area needs to be developed to a greater extent than is the case at present. While research can advance scientific knowledge it is also important to consider the practical and commercial application of that research.

The Judging Panel for the award will consider a number of factors before deciding on the eventual winner and runner-up. These include the novelty or “inventiveness” of the

research, the feasibility and scalability of the innovation and the scale of the market need for the product that might be developed from the research. Potential for commercial success and intellectual property potential will also be considered.

2011 winners Last year’s first prize was awarded to Prof Martin Rudolf of the University of Lübeck in Germany. He won the Innovation Award for his work on the prevention and treatment of macular degeneration by reducing pathological lipid deposition and inflammation in the eye.

According to Prof Rudolf this is a new therapeutic AMD approach involving the removal of neutral lipid accumulation from Bruch’s membrane, basal deposits and drusen. This approach focuses not only on one biological factor but an entire AMD critical alteration and the whole downstream effects associated with that.

Second prize went to Prof Eberhart Zrenner of the University of Tübingen for his research demonstrating how subretinal electronic implants can restore basic visual function in blind retinitis pigmentosa patients. The aim of this research is to restore useful visual process by implanting a subretinal electrode implant in patients that are blind from utter retinal degeneration, and to give them back the possibility of recognising or localising objects and achieving self-sustained mobility.

n Further information about the EURETINA Innovation Award 2012 can be found at http://euretina.org/Innovation/about-innovation.asp

MAjOR PROGREssEURETINA Innovation Award aims to encourage research in retinal medicine

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It is hoped that this year’s entries will once again allow EURETINA to promote the first-class work being carried out in retinal research in Europe

Don’t miss Book Review, see page 50

Prof Einar Stefansson, chairman of the EURETINA Innovation Award judging panel, presents last

year’s first prize to Prof Martin Rudolf

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EUROTIMES | Volume 17 | Issue 5

Steroid implants currently under development show promise in the treatment of intraocular inflammation with an improved

side-effect profile compared to implants currently in use, said Baruch D Kuppermann MD, PhD, University of California, Irvine, California, US at the 11the EURETINA Congress.

“The most important concept with these drug delivery systems is that very small amounts of drug can be used very effectively to treat disease for a prolonged period of time. So systemic exposure is limited, as well as the need for repeated injections,” Dr Kuppermann said.

The first intravitreal steroid implant to be marketed was the Retisert (Bausch + Lomb). The implant is sutured to the eye wall using a 3.5mm pars plana incision. It contains 0.5mg fluocinolone acetonide, which it releases at a rate of approximately 3.0 to 5.0 micrograms per day and is designed to last up to three years.

In a preliminary clinical trial comparing the implant’s efficacy at four dosages, 0.59mg, 2.0mg, 3.0mg and 6.0mg, the lowest dosage, which was expected to have nearly no effect, turned out to be very effective, Dr Kuppermann said.

The FDA granted approval for the implant’s use in uveitis. However, they held back on approving the agent for diabetic macular oedema (DME) because, despite the

low amount of drug it delivered, it had very significant side effects, chiefly cataract and intraocular pressure elevation.

He noted that nearly all the patients with the implant in the FDA trial developed cataracts. Although that might be acceptable for uveitis patients, the situation is more debatable in the case of patients with DME, he said. But of much greater concern was the implant’s effect on IOP, with 40 per cent of eyes needing filtration surgery to control the IOP, he pointed out.

“That became a concern, acceptable perhaps in uveitis patients, considering that the alternative is steroids or other toxic drugs, but for diabetics this was deemed not a fair trade-off in diabetic macular oedema, so the company decided to pass on the diabetic indication,” he added.

Implant easier on eye However, there is now a smaller implant, The Iluvien (Alimera) also using fluocinolone acetonide, which appears to have a less severe effect on IOP, Dr Kuppermann said. The implant is injected into the eye, rather than sutured into the eyeball, using a 25-gauge injector, he noted. It contains roughly half the amount of drug as the Retisert. There are two versions of the implant, one with a high dose of 0.5 micrograms per day that lasts for 18 months and the low dose 0.2 micrograms per day, which lasts for 24 to 36 months.

A clinical trial involving patients with DME, the Fluocinolone for Macular Edema (FAME) study, showed that at both dosages of the Iluvien implant around a third of patients gained 15 or more letters, compared to only 17 per cent of patients receiving standard of care. Moreover, although 75 per cent of patients developed cataracts, only five per cent requires filtering surgery, compared to 40 per cent with the Retisert implant.

Another implant is the I-Vation from SurModics, a titanium-based helical coil designed for delivering triamcinolone acetonide, is screwed into the pars plana. However, this implant is something of an orphan because although in clinical trials it met most of its treatment goals, in terms

of reduced retinal thickness and improved visual acuity, one patient with the implant developed retinal detachment and another developed endophthalmitis. In addition, about a third of patients needed to be on glaucoma drops and all developed cataracts.

“This drug delivery system is on hiatus right now looking for another home,” Dr Kuppermann said.

Meanwhile, Allergan has acquired a biodegradable dexamethasone implant, the Ozurdex, originally developed by Oculex. Unlike the Retisert and the Iluvien implants, it does not leave an empty husk behind once the drug is used up. Instead, as the drug is released, the implant’s polymer, polylactic glycolic acid, biodegrades to lactic acid glycolic acid, water and carbon dioxide.

“What attracted Allergan to purchase this company is that by varying the proportion of drug to polymer and the composition of the polymer it is possible to have a highly programmable drug delivery system so they are looking at brimonidine and other drugs as well in these polymer based systems,” Dr Kuppermann said.

In the PLACID trial, which compared laser alone to laser in combination with six monthly injections of Ozurdex, the implant performed significantly better than laser alone throughout 12 months of follow-up. In addition, only 15 per cent of eyes required IOP-lowering medication.

Another completely different approach under development by a French Company called Novagali, is to inject dexamethasone in a pro-drug form. The pro-drug’s chemical structure, dexamethasone palmitate, is relatively inert in the aqueous and the vitreous and is therefore less likely to affect the lens or the trabecular meshwork. However, in the retina it breaks down and becomes active. A Phase I, Open-Label, Dose-Escalation Clinical Study is under way.

Baruch D Kuppermann – Bdkupper@uci.edu

cont

act

sTEROID IMPLANTsMethods for delivering steroids may have reduced side effectsBy Roibeard O’hEineachain in London

39Update

RETINA

A GLOBAL VIEW OFOPHTHALMOLOGY AT

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Our new mobile website is designed for tablets and smartphones and includes content from the print edition of the magazine.

Over the coming months we will be enhancing and improving the digital version to help meet your needs.

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“The most important concept with these drug delivery systems is that very small amounts of drug can be used very effectively to treat disease for a prolonged period of time”

40

EUROTIMES | Volume 17 | Issue 5

Ophthalmologists and associated eye care professionals need to adopt a more flexible, district-based model with a strong emphasis on teamwork in order to address the changing

epidemiology of childhood blindness in Africa and other developing regions, Paul Courtright PhD told delegates attending the World Ophthalmology Congress.

“With the changing epidemiology we need to take on different approaches such as developing more effective tertiary facilities and building stronger partnerships across all eye care support services,” he said.

Dr Courtright, co-director of the Kilimanjaro Centre for Community Ophthalmology (KCCO) of the Good Samaritan Foundation in Moshi, Tanzania, noted that while child eye health in the past was usually based on single interventions, the reality now is that children’s needs in terms of eye-care are more complex and involve many different people at different points of time with different pieces of equipment.

“We often look at childhood blindness as being a case of making an intervention and then stepping away and saying that our job is done. That is not true anymore. We really need to look at our programmatic approaches to take into account our interaction with these children throughout their entire childhood,” he said.

In terms of planning, Dr Courtright said that a district-based approach based on the actual needs of the population is the most effective means of reaching the maximum number of children.

“We have to look at the Child Eye Health Tertiary Facility (CEHTF) as a kind of a hub around which the population can build spokes to ensure that the children can be reached within those communities with tertiary as well as primary and secondary eye-care services,” he said.

Once the hub has been established, it is vital to implement a strong population-based approach, based on the available data and evidence to guide ophthalmic services on the ground, said Dr Courtright.

“It is always very tempting to say that we have this lovely hospital and the services are there. However, if we don’t take a population-based approach the lovely hospital might be there but it will not be used as needed. There is a lot of good research that is going on and a lot of valuable data out there, so we need to use that information more effectively to make sure that those children have access to our services,” he said.

The key to building an effective hub lies in adopting a team approach to servicing the ocular health needs of the local population, said Dr Courtright.

“We absolutely have to adopt more of a partnership approach that really brings into play those personnel involved in education, rehabilitation, low-vision and so forth. Particularly important is the role of the childhood blindness and low vision coordinator, because that person is the key to making sure that all the various components of the team are properly harmonised and work well together,” he said.

Finally, Dr Courtright highlighted the importance of the child and the family being made an active partner in the healthcare process.

“In the past we tended to view children as recipients and we were there to provide a service. Now we have to bring the child and the family into the participant process. What this requires, in particular, is high-quality counselling. Parents have a very significant role in assisting their children and they need a lot of counselling at multiple time points to ensure that their child can utilise the best possible services,” he concluded.

Paul Courtright DrPH – pcourtright@kcco.net

contact

TEAMWORK CRITICALNew approaches needed for reducing burden of childhood blindness in developing countriesby Dermot McGrath in Abu Dhabi

Update

PAEDIATRIC OPHTHALMOLOGY

Particularly important is the role of the childhood blindness and low vision coordinator, because that person is the key to making sure that all the various components of the team are properly harmonised and work well together

“

Paul Courtright PhD

Elizabeth Kishiki (KCCO childhood blindness and low vision coordinator) working with a child with low vision at a school for the blind

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Rose (Masai girl prior to cataract surgery)

Rose (after cataract surgery)

“The key to building an effective hub lies in adopting a team approach to servicing the ocular health needs of the local population”

www.wcpos.org

registration openprogramme overview available online

KEYNOTE LECTURES SATURDAY 8 SEPTEMBER 12.00 – 12.30

WHAT’S NEW AND INTERESTING IN PEDIATRIC EYE TUMORS?

Jerry Shields USA

Director of the Oncology Service at Wills Eye Institute and Professor of Ophthalmology, � omas Je� erson University, Philadelphia, USA

SUNDAY 9 SEPTEMBER 09.00 – 10.00

FORTY YEARS OF CLINICAL STRABISMOLOGY: LESSONS AND EXPERIENCES

Emilio C. Campos ITALY

Professor & Chief of Ophthalmology at the University of Bologna S.Orsola-Malpighi Teaching Hospital, Italy

Joint symposia with ESCRS, EURETINA and EuCorneaWorkshops and over 30 scienti� c sessions.

EUROTIMES™

SATELLITE EDUCATION PROGRAMME

Clarity Medical Systems Satellite SymposiumSaturday 8 September 12.45 – 13.45

Sponsored by:

Ocular Surface Impairment in Paediatrics: New OutcomesSunday 9 September 12.45 – 13.45

Sponsored by:

www.wcpos.org

Satellite Education Programme

PROGRAMME INCLUDES:

A telemedicine project to combat retinopathy of prematurity (ROP) in Indian infants has met with significant success and

could serve as a useful model for future efforts in developing countries, according to Anand Vinekar MD, FRCS.

Addressing the World Ophthalmology Congress, Dr Vinekar, head of the Paediatric Vitreo-Retina Department at Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India, said that the true incidence of ROP is not reflected in the currently available statistics.

“The World Health Organization says that India and other middle-income countries are facing the ‘third epidemic’ of ROP. Extrapolating government data, every two hours in India three babies have reached the threshold for treatment. Up to 22 per cent of childhood blindness in India has a retinal cause, and ROP is the most important of these causes, especially when we consider that the disease is preventable,” he said.

There are a number of different reasons for this pending epidemic, said Dr Vinekar, including high birth rates, high rates of pre-term births and a dearth of screening and treatment programmes due to lack of awareness, skilled personnel and financial constraints. Ironically, the improvement in survival rates in developing countries has also played a part in the resurgence of ROP.

“Neonatal care practices have improved a great deal in India over the past decade and babies who would not have survived before in small towns are surviving in greater numbers. But while that has improved control of mortality and morbidity issues, somewhere along the line ROP is not given the prominence it merits. So usually by the time that the child reaches the retinal specialist, he or she is probably already legally blind,” he said.

Dr Vinekar said it was vital to refute some of the myths surrounding ROP in order to implement more effective strategies. The first myth, he said, stems from paediatricians who usually report that they have never seen a child going blind from ROP.

“Studies have shown, however, that the paediatricians never saw these blind babies

because they never reached them in the first place. In addition broader guidelines are needed to ensure screening for at-risk infants,” he said.

The second myth cited by Dr Vinekar is that ROP does not develop in babies who have not been given supplemental oxygen.

“This is an old concept and while oxygen plays a role it is not a causative factor. Between 11 per cent to 24 per cent of babies that never receive oxygen may still develop ROP and we need to remember that there are at least 27 studied factors classified as risks for ROP,” he said.

Another myth is that babies weighing more than 1,500 grammes at birth do not need to be screened, said Dr Vinekar.

“As we showed in data pooled from six districts in southern India, applying the US or British cut-off rate of 1,500 grammes meant that between 18 per cent to 23 per cent of severe ROP cases were missed. So Western guidelines should not apply to middle income countries and India when it comes to birth weight, and this is especially true when we look at rural areas” he said.

Another prevalent myth is that gestational age is as important as birth weight as ROP screening criteria, said Dr Vinekar.

“This may be fine in urban areas but cannot be applied in a rural setting where a variety of factors make it almost impossible to date the pregnancy. Therefore basing an entire screening programme on post-conceptional ages is sure to cause problems. This is why we need to stick to birth weight as a criteria for ROP screening, since every baby gets weighed immediately or soon after birth,” he said.

Triple ‘T’ philosophy Dr Vinekar said that the Karnataka Internet-Assisted Diagnosis of ROP (KIDROP) has been extremely successful in saving the sight of babies that would otherwise have gone blind from ROP. The network is based on the triple ‘T’ philosophy, said Dr Vinekar – tele-ROP, training of peripheral ophthalmologists and ophthalmic assistants and talking to neonatologists, paediatricians and gynaecologists.

Dr Vinekar and colleagues have trained teams of technicians to use a RetCam to take wide-field digital fundus images of infants in over 50 rural and semi-urban neonatal care centres spread over 12 districts in the state of Karnataka. The portable RetCam (Shuttle) is easily transferable between hospitals and clinics. They have also developed a comprehensive Tele-ROP platform that allows image transfer from the outreach sites to be viewed and reported remotely by the expert on his smart phone (iPhone in 2009) or PC. Over 25,000 imaging sessions have been completed to date.

“Some time ago we were named one of the largest tele-ROP networks in the world and we now screen in about 53 hospitals over 12 districts. We estimate that 4,258 babies have been screened so far by the programme, and 436 of them have been treated for ROP,” he said.

The cost-effectiveness of the programme has been a major argument in persuading the Indian authorities to support tele-ROP in the first public-private partnership for childhood blindness in India, said Dr Vinekar. At the congress, Dr Vinekar presented a study wherein the KIDROP model was compared with three alternate strategies of screening for ROP in rural areas and showed that a single RetCam per zone was the most cost-effective strategy.

“If we estimate that these 436 infants that were treated would contribute a per capita income of Rs 40,000 annually for a lifetime of 65 years, which is the average life expectancy in India, that is a total of Rs 1.13bn. That amounts to a federal saving of about $25.2m for an investment of $0.7m, which are the kind of figures that make sense to the Government when we try to solicit their support,” he said. The programme has now entered into a public private partnership with the Government and is set for a phased expansion into other states of the country.

EUROTIMES | Volume 17 | Issue 5

42 Update

PAEDIATRIC OPHTHALMOLOGY

Infants sharing limited resources in rural neonatal centres

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SNeonatal care practices have improved a great deal in India over the past decade and babies who would not have survived before in small towns are surviving in greater numbers

“

Anand Vinekar MD, FRCS

ROP sCREENING IMPROVEsTelemedicine success story in the fight against ROP blindnessby Dermot McGrath in Abu Dhabi

Anand Vinekar – anandvinekar@yahoo.com

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Don’t Miss Industry News, see page 54

43

EUROTIMES | Volume 17 | Issue 5

These are exciting times in Lugano with two major meetings planned for October and November 2012. The first event is the Live Surgery

Symposium which will discuss “New trends in anterior segment surgery”.

José L Güell MD, Spain, chairman of the Scientific Committee for the meeting, said the symposium was a new event for ESASO and it was planned to hold it every year from now on at the school’s campus in Lugano, Switzerland.

“This year we will be discussing some specific hot topics,” he said. “Among the topics are Femtosecond Laser Assisted Anterior Segment Surgery, New Toric and Multifocal IOLs and Keratoconus Management.”

Prof Güell said one of ESASO’s main activities was the holding of week-long educational courses in Lugano and the symposium was an important part of that programme. “I think this will be a very good meeting and we have an excellent scientific programme,” he said.

Prof Güell said students attending the course would learn the latest concepts in the management of keratoconus and the use of femtosecond laser technology for both corneal and cataract surgery. “We will also have good case reports on the use of intraocular lenses,” he said. “Students will also be able to see some live surgery cases.”

Full details of the programme are available on: www.esaso.org/live-surgery-symposium-2012.

AMD and Retina Congress The 12th International AMD and Retina Congress will be held in Prague, Czech Republic, from 2-3 November, 2012, and will feature a scientific programme which includes plenary sessions, panel discussions, case studies and meet-the-expert sessions delivered by distinguished speakers from Europe and other continents. In addition to this programme, a scientific poster exhibition is planned and the best poster presented at the congress will be nominated by the Scientific Committee. Other highlights will be the 3rd ESASO Graduate Award Ceremony and the 3rd XOVA Award Ceremony, supported by Novartis.

“This is a major meeting on the international ophthalmology calendar and we have a different venue every year,” said

Francesco Bandello MD, chairman of the Scientific Committee for the congress. “We are delighted to be holding the meeting in Prague this year as it is very important to us to open up our meetings to our eastern European colleagues,” he said. “It is also important to point out that this is an independent meeting organised by ESASO and the independence of our scientific programme is very important,” said Prof Bandello.

Last year’s congress in Lisbon, Portugal was attended by over 1,100 delegates and already more than 800 delegates have registered for the Prague meeting. “I am confident,” said Prof Bandello, “that the success of former meetings will be repeated this year.”

Surgical topics “Our focus will be on the diagnosis and treatment of retina and macular diseases,” said Prof Bandello, “and this year we have an exciting new addition to our programme.

“At previous meetings we have concentrated on medical retina, but this year’s meeting will also have sessions devoted to surgical topics,” he said. “We will also have some exciting news about the development of new compounds that could change the approach to some retinal diseases.”

n Full information on the congress is available at: www.esaso.org/12th-international-amd-and-retina-congress.

TWO MEETINGsEsAsO looks forward to symposium in Lugano and AMD, Retina congress in Prague

Francesco Bandello – cancellieri.laura@hsr.itJosé Güell – Güell@imo.esGabriella Skala – gabriella.skala@esaso.org

contacts

ESASOc/o Università della Svizzera italiana (USI)Via Giuseppe Buffi 136904 Lugano, SwitzerlandTel. +41 (0)58 666 4629Fax +41 (0)58 666 4619Email info@esaso.org www.esaso.org

Prague, Czech Republic2 – 3 November 2012

Register today!

12th InternationalAMD and Retina Congress

Lugano, Switzerland5 – 6 October 2012

Live surgery symposium:

New trends in anterior segment surgery

Meet and discuss with distin-guished speakers from all across the world

• Plenary Presentations• Panel Discussions• Case Studies• Meet-the-Expert Sessions• Poster exhibition• Poster Award• Graduate Award Ceremony

and gain CME credits!

FacultyR. Bellucci, L. Buratto, A. Caporossi, B. Cochener, H. Dua, J.L. Güell, F. Hafezi, S.B. Hannush, F. Kruse, F. Malecaze, Z. Nagy, R. Nuijts, R. Pinelli, S. Shimmura, D. Tan

08_1202_01 ESASO_Anz_EUT_120x300_RZ.indd 1 2.4.2012 20:45:22 Uhr

News

ESASO

Among the topics are Femtosecond Laser Assisted Anterior Segment Surgery, New Toric and Multifocal IOLs and Keratoconus Management

“

José L Güell MD

Anand Vinekar – anandvinekar@yahoo.com

EUROTIMES | Volume 17 | Issue 5

In 2010, in a major new initiative, the ESCRS decided to set up an Observership Programme for young ophthalmologists. The programme is designed for ophthalmologists who are starting their surgical

training, or already in surgical training, and is under the direction of Oliver Findl MD, MBA, chairman of the ESCRS Young Ophthalmologists’ Forum.

A number of the young ophthalmologists who have taken part in the programme say their experiences have been very positive and following the completion of their observerships, they sent their feedback on the programme to ESCRS.

An excellent experience Romanian ophthalmologist Corinna Cracium who did her observership with Prof Jorge Alio at the Vissum Institute in Alicante, Spain, said her visit was very enjoyable and she enjoyed a valuable learning experience.

“At Vissum, I met an extraordinary team led by Prof Alio,” Dr Cracium said. “He and everyone else there were very nice to me, very kind and helpful and responded to every question that I had. I had the opportunity to observe refractive and cataract surgeries and also to participate in consultations. The team in Vissum are also involved in research and do a lot of clinical studies, which is very important for a good practice. Prof Alio is an excellent teacher and his clinic is a very good choice for anyone who wants to learn practical and theoretical ophthalmology,” she said

Research and trials Another young ophthalmologist who visited the Vissum Institute was Constantin Mihai.

“There is a very well organised team at Vissum, including medical and administrative personnel,” said Dr Mihai. “I observed several cases and surgeries in the areas I am most interested in which are refractive surgery, corneal transplantation and cataract surgery. What impressed me a lot is the fact that there is huge amount of effort and time allocated for research and clinical trials. I think this is very important,” said Dr Mihai.

Practice skills Jasna Pavicic-Astalos from Croatia worked under the supervision of Prof Marko Hawlina at the Ophthalmology Clinic, University Medical Centre Ljubljana, Slovenia.

“Prof Hawlina and all his colleagues were very helpful and kind,” said Dr Pavicic-Astalos. “They are used to foreign students coming to take part in the Observership Programme because at the time I was there, a few more young ophthalmologists from Lithuania and Cuba were working on their projects. Every morning we had a meeting discussing patients and interesting cases. After that, I went to surgery and followed a current day programme. I was able to talk with my colleagues about cataract surgery or other fields of ophthalmology. I also spent three days observing plastic surgery and I learned a few new surgical approaches for eyelid problems,” he said.

Observing surgeries Olesya Ziyatdinova from Russia did an observership at the Institute of Vision and Optics, University of Crete, Greece, under the supervision of Prof Ioannis Pallikaris and Prof George Kymionis.

“I observed surgeries like PRK with mitomycin, t-PTK-PRK, femtosecond LASIK and corneal collagen crosslinking with Riboflavin,” said Dr Ziyatdinova. “In the near future, I am going to start refractive surgery at our clinic in Kazan.

“This was great a learning experience and this programme has also enriched my life with the wonderful experience of visiting Crete. The ESCRS Young Ophthalmologists’ Observership Programme is a perfect way of increasing the exposure levels of young doctors,” she said.

Variety of approaches Greek ophthalmologist Dimitrios Kardaras was an observer at the Hanusch Hospital, Vienna under the supervision of Dr Oliver Findl.

“There were two operation rooms with a constant flow of surgical cases that I had the chance to observe,” said Dr Kardaras. “I observed a variety of scientific approaches in cataract surgery, as well as alternative strategies. The opportunity to make comparisons between different techniques, styles and instruments will help me in the future to make more informed decisions about my own procedures.

“In addition, I became familiar with modern IOL, like Toric IOLs and Multifocal IOLs, and I was delighted to be introduced to procedures that I had never observed, like cornea endothelium transplantation and techniques that Prof Findl uses in complicated cases like IOL iris-fixation,” he said.

n For information on the ESCRS Observership Programme, visit http://www.escrs.org/Youngophthalmologist/grant-information.asp

POsITIVE FEEDBACK Young ophthalmologists and their mentors taking part in the EsCRs Observership Programme say it is a valuable addition to the EsCRsby Colin Kerr

44 News

OBSERVERSHIP

Dr Olesya Ziyatdinova (left) with staff at the Institute of Vision and Optics, University of Crete, Greece

A number of the young ophthalmologists who have taken part in the programme say their experiences have been very positive and following the completion of their observerships, they sent their feedback on the programme to EsCRs

EUROTIMES | Volume 17 | Issue 5

Jorge Alio, Vissum Institute, Alicante, Spain

Marko Hawlina, Ophthalmology Clinic, University Medical Centre Ljubljana, Slovenia

Prof Ioannis Pallikaris, Institute of Vision and Optics, University of Crete, Greece

Oliver Findl, Hanusch Hospital, Vienna, Austria

Despite the fact that ophthalmology is a surgical discipline, surgical training of residents is insufficient. In a number of European countries, no intraocular

surgery is included in the residency training, whilst postgraduate fellowships hardly exist. As surgery training is essential, one-month observerships, as offered by ESCRS, are excellent for trainees to gain insight into modern surgical techniques. Trainees are shown the optimal ways for a smooth start with a steep learning curve. Wetlab experience, also available at our centre, is important to get familiar with the microscope, phaco machine operation and IOL implantation.

When the trainees get to the point where they are ready to start operating on patients they may use the approach to operate from “back to the beginning”, which means that they start with the OVD removal and IOL implantation followed by I/A and nucleus segment removal, and then proceed to nucleus division, and in the end, to capsulorhexis and incision. This technique, introduced to us by Takayuki Akahoshi a number of years ago, allows for the residents to gain confidence with easier steps first and allows for a much less stressful start because if the incision and capsulorhexis are not done well, the whole procedure may be in jeopardy.

It is a great pleasure to be participating in the ESCRS Observership Programme.

Our clinic has long-standing experience with foreign fellows in several types of training

projects. These fellows come mainly from the Middle Eastern countries.

The interaction with young fellows coming from other countries is always welcome and the recent presence of young ophthalmologists from northern countries was refreshing.

In addition to what they learn from us during their stay, there are a lot of things that we also learn. Networking of our own young physicians is also important and scientific and personal friendships developed during these visits can be very helpful for both sides in the future.

And, of course, there is no better ambassador for our institute in other countries than a satisfied young physician who spent a productive period with us.

“When we set the programme up we decided to look at short observerships for a few days or a week at most in different

European centres. We also asked participating centres to draw up a short curriculum and to give our observers the opportunities to see patients in a clinical setting.

Many young ophthalmologists will go on for further education and training outside of their own countries. The ESCRS Observership Programme will give them a chance early in their education to see how ophthalmology is practised in different settings. We have different cultures and different

health systems and we should try to broaden our horizons and learn from seeing other systems, other surgeons and other techniques.

The ESCRS Observership Programme is a rewarding experience not only for the observer, but also for the inviting department. For the surgeons involved, teaching is enriching. It is also enriching for the trainees in the department since they make international contacts with peers.

We can always learn from each other – not only concerning diagnostic and treatment strategies, but also from the logistics of running an operating theatre, an outpatient clinic or an entire department.

45

We have been receiving young ophthalmologists as visitors for short periods of time under the auspices of the ESCRS. These visits

have been most fruitful for us and have opened opportunities.

Those applying for this type of observership position from the ESCRS are highly motivated and have leadership qualities. In all cases, they have been integrated in our practices, and in spite of the language barrier, they have been interacting with patients and with our staff and the doctors.

In some cases, they have even participated

in studies and have co-authored papers. This interaction is very positive because it expands the horizons of our colleagues and other healthcare professionals working with us. We maintain a close relationship and friendship with many of those who visit us and when we visit their countries, we are privileged by their hospitality.

The ESCRS Observership Programme should be reinforced in the future. As a professional and scientific society, one of the ESCRS’s most important roles is to expand the community of European ophthalmologists based on training and professional exchange.

Visit our website http://youngophthalmologist.escrs.org

Young Ophthalmologists’Resource Centre

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.

to fi nd out more about the new ESCRS Observership Programme.

EUROTIMES | Volume 17 | Issue 5

In a previous article (EuroTimes, Volume 17, Issue 3, March 2012) we clarified misconceptions that early “postoperative” antibiotic drops were excluded in the ESCRS Endophthalmitis Study.1 Discussion here

further addresses critiques that larger patient numbers would have produced statistically significant results for topical drops vs. controls, and minimised differences between drops and intracameral injection. A quick review of basic pharmacokinetic and pharmacodynamic (PK/PD) principles that underlie antibacterial actions may quell further confusion on this issue.

To address whether greater patient numbers would have changed study results, we can analyse two scenarios basic to this argument from a pharmacodynamic point of view. Because the literature confirms that increasing the preoperative antibiotic drop frequency, when povidone-iodine is also used, offers no advantages, only two scenarios or time-frames remain for debate: the three immediate postoperative drops in study Group C vs. controls, and again, the three postoperative drops vs. intracameral injection (Group B).

Scenario 1: While study Group C showed a trend, differences over controls did not reach statistical significance.1 This implies that the immediate postoperative drop intervention did not significantly impact postoperative endophthalmitis rates.

Because intraoperative bacterial contamination is linked to the patient’s own ocular surface flora, and sterilisation of conjunctiva is rarely achieved preoperatively, a risk does remain that bacteria may enter the eye during cataract surgery. Frequent topical drops given immediately after surgery (eg, Group C) deliver only low antibiotic levels to the aqueous humour (AH), as abundantly shown in previous clinical studies that measured AH levels after intensive drop regimens. Furthermore, because of high interpatient variability after drops, clinicians cannot be certain what levels are actually achieved in any given patient.

Nevertheless, one can interpret even the relatively “high” AH levels anticipated in ESCRS study Group C,2 through PK/PD parameters associated with bacterial eradication. The table above compares peak AH levels and calculated AUCs after topical drops and intracameral injection.

Target values for peak/MIC ratios for fluoroquinolones (FQ) fall near 10, and desired AUC values near 50-100.3 The table shows initial AH antibiotic levels after drops are low, although initial peak/MIC ratios may exceed 10

for some microorganisms. However, due to AH turnover, the concentrations over time (AUC) are inadequate, being well below target values of 50-100. Any increase in patient study numbers would not override such pharmacodynamic fundamentals.

Scenario 2: To diminish study differences between intracameral injection and frequent topical drops, again, analysis of AH peaks, and calculated AUCs would be fundamental. The table shows that intracameral injection delivers approximately 1,000 times higher AH antibiotic levels than do topical drops. This translates into much higher calculated AUCs (and related parameters such as AUIC, T>MIC) bringing the estimated AUC after a cefuroxime 1mg intracameral injection into the range of 4,000 mg•hr/L, about a thousand-fold higher than AUC after the FQ drops.

While target AUC values for fluoroquinolones are well described, the action of cephalosporins and other antibiotics are also tied to the AUC. For beta-lactams, including cephalosporins, the key pharmacodynamic parameter is exposure time above the MIC, (AUIC – area under the inhibitory curve, and T>MIC)). Therefore, it is an oversight to focus only on achieved antibiotic peaks (Cmax) as a predictor of antibiotic effect. In vitro studies show that even extremely high concentrations of FQ required substantial amounts of time to achieve bacterial kill.4

Intracameral injections deliver high, immediate antibiotic levels to the AH, without interpatient variability. Because of these high initial levels, concentrations remain above bacterial MICs for longer periods of time, which translates into the higher AUCs and AUICs necessary to eradicate bacteria.

Patient study numbers are not tied to these recognised PK/PD fundamentals and dismissing their role in fighting bacterial infection likely results only in futile argument.

Antibiotic prophylaxis is aimed primarily at eliminating bacteria that enter the eye during cataract surgery. There should be little confusion over which regimen – intracameral injection or topical drops – delivers the highest antibiotic levels directly to the anterior chamber.

Other factors such as inoculum size and bacterial virulence also impact the risk for serious infection. Poor wound healing or surgical complications may permit surface

contaminants to enter the eye postoperatively during wound healing; under these conditions, ongoing surface antisepsis is a separate matter.

Nevertheless, to eradicate bacteria entering the eye during cataract surgery, there can be little doubt that the intracameral injection delivers higher antibiotic levels over time, levels that are impossible to achieve with clinical topical drop regimens. Fundamental principles of PK/PD support clinical findings of the ESCRS study. Increasing patient numbers in study groups would not alter the basic principles of bacterial eradication already well established within the scientific community, all wishful thinking aside.

References 1. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons.

Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cat Refract Surg 2007; 33: 978-88.

2. Sundelin K, Seal D, Gardner S, et al. Increased anterior chamber penetration of topical levofloxacin 0.5% after pulsed dosing in cataract patients. Acta Ophthalmol. 2009;87:160-165.

3. Odenholt I, Cars O. Pharmacodynamics of moxifloxacin and levofloxacin against Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae and Escherichia coli: simulation of human plasma concentrations after intravenous dosage in an in vitro kinetic model. J Antimicrob Chemother. 2006;58:960-965.

4. Callegan MC, Novosad BD, Ramadan RT, et al. Rate of bacterial eradication by ophthalmic solutions of fourth-generation fluoroquinolones. Adv Ther 2009;26:447-54.

* Susanne Gardner, Pharm. D, is a specialist in ocular antiinfectives and ocular pharmacokinetics with a background in academics, research and publishing.

Susanne Gardner – susanne.gardner@gmail.com

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STUDY MISCONCEPTIONSFundamentals of science unaltered by ESCRS Endophthalmitis study patient numbersby Susanne Gardner

46 News

EYE FACTS

a. Data from Reference 2, Sundelin et al., duplicating ESCRS study Group C dosing;b. Extrapolated from Reference 1, using 1mg cefuroxime dose and AH volume of 0.25ml;c. MIC values obtained from ESCRS Study data and Seal D, et al. J Cat Refract Surg 2008;

34:1439-50;d. Using calculated, estimated AUC, 0-1.5 hr. from available data.

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To address whether greater patient numbers would have changed study results, we can analyse two scenarios basic to this argument from a pharmacodynamic point of view

“Susanne Gardner

“Intracameral injections deliver high, immediate antibiotic levels to the AH, without interpatient variability”

©2011 Novartis AG Date of preparation: July 2011 SYB:EUR:12/11:HC

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Keratoconus is a progressive disease of the cornea. It is characterised by steepening and paracentral thinning, more

in the corneal apex, with distortion of the corneal surface resulting in irregular astigmatism.

Intrastromal corneal ring segments (ICRS) are indicated in patients with keratoconus with low vision with spectacles or contact lenses, or intolerance to contact lenses as a way to delay or avoid corneal grafting. The main advantages are reversibility, stability and security, since it is an additive intrastromal procedure which adds “corneal tissue”, that does not require intraocular manoeuvres.

The definition of the location of the intrastromal corneal rings and its dimensions has varied widely, with unpredictable results, with an apparently similar keratoconus achieving good and bad results with one or two ring segments1. There are several types of intrastromal ring segments on the market. The Keraring are triangular rings of PMMA (polymethylmethacrylate) available in two models (SI-5 and SI-6) with thickness from

150 to 350 µm with 50 µm increments. The SI-5 model, with an isosceles triangular shape and truncated at the apex in 40 µm, has an optical zone of 5mm; the SI-6, with a scalene triangular shape and truncated at the apex in 120 µm, has 5.5mm or 6mm OZ and both can have 90, 120, 150, and 210 degrees of arc length. This variety allows multiple combinations and, theoretically, an implant better targeted to each patient.

SA.ANA classification For comprehension of the topographic and refractive results obtained with the intrastromal rings’ implantation, a database was created compiling 3,450 eyes implanted between January 2004 and December 2009, from nine Iberian surgeons. This study culminated in the creation of the SA.ANA classification, which is based on a simple and fast algorithm, based on two criteria: symmetry and axiality. The rings can be symmetrical (two similar rings) or asymmetrical (two different rings or a single ring), axial (on the flat axis) or non-axial (axis away from the flat one in at least 30°), which composes the acronym

SAANA (Symmetric, Asymmetric, Axial, Non-Axial). The position of the rings is obtained from this classification, identifying the type of ectasia. The axis of the coma is also considered in the choice of the location of the ring. While in markedly asymmetric ectasias (AA1 and AA2) the coma axis is usually coincident with the flat axis, in intermediate ectasias (SNA, ANA 1,2 and 3) it is closer to the steepest axis. In these cases, the choice could fall on the axis of the coma or on an intermediate axis between the comatic and the flat axis, depending on the values in question. In asymmetric SA.ANA categories (AA1, AA2, ANA1, ANA 2 and ANA3) one or two rings are implanted according to the topographic cylinder. The thickness of the ring segment is still limited by the corneal pachymetry in the area of the implantation.

Thirty eight eyes (23 patients, 15 men and eight women) aged between 22 and 65 years (37.6 ± 10.10) were evaluated. The mean follow-up time was 6.2 months (SD= 5.2; range three to 27 months). The inclusion criteria were contact lenses intolerant keratoconus, transparency of the central cornea, minimum pachymetry of more than 400 µm and thickness on the area of the incision exceeding 450 µm.

All procedures were performed under topical anaesthesia. The incision was made on the steepest topographic meridian and the tunnel performed at 70 per cent of the corneal thickness. Since the introduction on the market we used preferentially 6mm diameter ring segments. The intracorneal ring segments were implanted easily immediately after the laser. A hydrophilic contact lens was applied in all patients and

removed on the first postoperative day (see image).

The mean spherical equivalent changed from preoperative -3.55 D (SD 2.72, range -7.75 to +4.50) to -2.33 D (SD 2.87, range -8 to + 5.5) in the postoperative period, and this reduction was statistically significant (P= 0.003). The mean decrease in cylindrical power after the surgery was 1.0 D, from 3.38 D (SD 1.38, range +0.5 to +6.0) to 2.38 D (SD 1.73, range 0 to +8.0). Similarly, topographic astigmatism showed a significant decrease from 3.34 D (SD 2.47, range +0.3 to +8.4) to 1.44 D (SD 1.72, range 0 to +5.2) (P= 0.04). The mean BCVA (logMAR) improved from preoperative 0.42 (SD 0.2) to postoperative 0.22 (SD 0.14) (P< 0.0001). Twenty seven eyes (71.1 per cent) gained at least two lines of vision, 15 eyes (39.5 per cent) gained three or more lines of vision, seven eyes (18.4 per cent) showed no change in BCVA and no eye lost vision.

Innovative approach The mean coma aberration showed a reduction (third-order component Z3) from 0.0034 to 0.0025 (P= 0.055). The preoperative and postoperative aberration coefficient changed from 2.47 to 2.58.

The SA.ANA classification was AA1 in 27 of the 38 eyes, ANA1 in four eyes, SA on three eyes, AA2 in two eyes and SNA1 in two eyes.

The visual discomfort in patients with keratoconus and with transparent cornea comes from myopia, astigmatism and high order aberrations (HOA), particularly the coma2. In fact, the results of stromal rings implantation are worse in keratoconus with high comatic default, comatic axis clearly distinct from the astigmatic axis and irregular patterns of keratoconus2.

In conclusion, the introduction of intrastromal corneal ring segments with the femtosecond laser based on a classification that considers the keratoconus in its multiple facets (refractive, topographical and aberrometric) is an innovative approach, based on the pathophysiology of the disease and extremely promising in treatment of keratoconus. The results presented in this study are very encouraging, however, further studies are needed, with longer follow-up and greater number of patients, to refine the SA.ANA classification and create clearer guidelines in relation to astigmatic versus aberrometric correction.

References 1. Murta, J N, et al. Intracorneal rings (intacs) for the correction of keratoconus. European Society of Cataract and Refractive Surgeons, Paris 2004.

2. Alfonso Sanchez, J F, et al. Normograma de Implante de Segmentos Intracorneales mediante laser de femtosegundo para la correccion refractiva del queratocono. Oviedo : Instituto Oftalmologico Fernandez-Vega, 2009.

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EUROTIMES | Volume 17 | Issue 5

News

rESEArCh

KERATOCONUS RESEARCHICRS implantation with the femtosecond laser for the treatment of keratoconus – results according to the new SA.ANA classification by Joaquim Murta PhD Dept of Ophthalmology, University Hospital of Coimbra, Portugal

Slitlamp photograph on the first postoperative day after Keraring implantation of 6mm diameter and 150° arc length

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PhD

“The main advantages are reversibility, stability and security, since it is an additive intrastromal procedure which adds “corneal tissue”, that does not require intraocular manoeuvres”

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EUROTIMES | Volume 17 | Issue 5

One of the main problems with textbooks on surgical technique is that they too often “tell” rather than “show”. Certainly, reading long descriptions of a particular procedure can help us develop a fundamental understanding of how the procedure should be performed. However, at a certain point, the specifics need to be illustrated for the reader so that (s)he can delve into the details, details that might end up making the difference between a successful procedure… and referral to a vitreoretinal colleague. Some fine points can be very difficult to transfer to the reader. Precisely, how large should a capsulorhexis be compared to the pupil diameter? Where, in relation to anterior segment structures, should the phaco tip be held during vertical chopping? And where should the helper instruments like the chopper and sweep be positioned in relation to the phaco tip? Clearly, text descriptions can only go into so much detail before images become necessary to bridge the gap between theory and practice.

In the “Illustrative Guide to Cataract Surgery: A Step-by-Step Approach to Refining Surgical Skills,” images form the core of the information provided. Edited by Dr Amar Agarwal and Dr Soosan Jacob, both of Chennai, India, and published by Slack Incorporated, this illustrated guide goes through the fine points of cataract surgery, both standard and complex. Realising that surgical photographs can be difficult to understand due to suboptimal lighting, reflections, air bubbles and media haziness, the authors have redrawn each photograph in a simple, unadorned format that is simple to comprehend. Additionally, purchase of the book entitles the reader to view cataract surgery videos on the accompanying, password-protected website.

The book is divided into four sections. Section I: Phaco Surgery covers the standard cataract surgery and its many variants. Each step is illustrated and described in the accompanying legends. Knowing that each individual step can be performed using several different techniques as well as with distinct instruments, the authors cover each of these as well. For example, the main port can be constructed using a uni-, a bi-,

or a triplanar technique; the capsulorhexis technique is shown using a cystitome and forceps; nucleus removal is shown in its various incarnations.

Section II: Microincision Cataract Surgery is a very focused section describing both coaxial and biaxial techniques, with a short explanation of their relative “pros” and “cons.”

Section III: Challenging Cases will be of particular interest to residents or fellows nearing the end of their training, or surgeons looking to either brush up on their own trusted technique or considering trying a new one. This section discusses mature cataracts, iris hooks, the Malyugin ring, posterior polar cataracts and subluxated cataracts. A great deal of attention is given to the management of cases with small pupils. Later in the section, the treatment of the subluxated lens is described using several tools.

Of course, this would all be unduly optimistic without Section IV: Complications. What to do with a torn rhexis, how to manage iridodialysis and how to react upon rupture of the posterior capsule – step-by-step instructions for the some of the most dreaded intraoperative complications.

The editors might have considered referring to other authors’ work more frequently than to their own, as this would strengthen the evidence in favour of a particular technique. Nevertheless, this book is appropriate for medical students who are observing cataract surgery in the operating room; ophthalmology residents during their cataract rotation; and instructors of cataract surgery in training centres, who might make good use of the techniques described and the images provided.

Eye Chat with Oliver Findl

Exclusive on www.eurotimes.org

Eye Chat features exclusive interviews with the major opinion leaders in ophthalmology.

The podcasts are intended to give up-to-date information on the latest news and innovations in the fi eld.

They also offer instructions to young ophthalmologists on how they should deal with challenging cases.

Scan this QR code to gain access to EuroTimes podcasts

Oliver Findl

Rudy Nuijts

“ Astigmatism correction and cataract surgery

Cataract surgeons now have a number of options for correcting astigmatism, ranging from the scalpel to laser to intraocular lenses.In this month’s Eye Chat, Dr Oliver Findl discusses the advantages and disadvantages of these approaches with Dr Rudy Nuijts, Maastricht University Hospital, the Netherlands.

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Images necessary for learning

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

BOOKS EDITORLeigh Spielberg

PUBLICATIONILLuStratIve GuIde to CataraCt SurGery: a Step-by-Step approaCh to refInInG SurGICaL SkILLS

EDITORED BYdr amar agarwal and dr Soosan Jacob

pubLIShed by SLaCk InCorporated

EUROTIMES | Volume 17 | Issue 5

Temple of emotions Milan's legendary football stadium, Stadio Giuseppe Meazza (San Siro) has been home to AC Milan since 1926. Since 1947 – in an ecumenical sporting gesture – it has also been home to rival Inter Milan.

Designed by Ulisse Stacchini, architect of Milan's Central Station, the stadium is modelled on a steep-sided English football stadium with a capacity of over 80,000 spectators. Usually called “San Siro,” after the neighbourhood in which it’s located, the stadium acquired its official name, Stadio Giuseppe Meazza, in 1980. Meazza played for both teams in the course of his career and was a two-time World Cup winner.

You will see why San Siro is also called the “Temple of emotions,” when you attend a match; the atmosphere is as legendary as the stadium. To join the good-natured, partisan spectators, buy a ticket on-line or at the gates. Bring picture ID; your name will be printed on the ticket and checked at the entry.

If you can’t attend a match, take the guided tour of the museum and stadium. Bilingual tours, in English and Italian, are scheduled every day, except match days, from 10:00 to 17:00. The half-hour stadium tour assembles at Gate 14, Via Piccolomini 5; a tour leaves roughly every 20 minutes. Just show up and you will be included in the next group. A guide will show you not only the stadium but

also the pavilion where, for €400, a VIP can view the game in comfort. You will also be able to visit the “behind-the- scenes” areas, too, including the locker rooms.

In the museum, take your time mulling over the myriad trophies acquired by AC Milan and Inter Milan through the years, plus memorabilia of their famous players. There’s a stand where you can acquire the blue and black souvenirs of Inter Milan or the red and black mementos of AC Milan.

San Siro is not easy to reach by Metro or tram. If you come by taxi, be prepared to phone for one for your return.

MiCo’s “Red Carpet” service will arrange a ticket for an AC Milan game plus a pre-game aperitif and light dinner at the AC Milan hospitality centre. Pickup and return to your hotel are included. To book, visit www.micmilano.it, and click on the Red Carpet tab.

Comet sustains energy MiCo is the venue for the XXX ESCRS Congress, 8-12 September 2012 and also the EURETINA, WCPOS and EuCornea congresses. Situated in the heart of Milan and incorporating the old Milan Convention centre, “MiCo” was completed in 2011 at a cost of €64m. Designed by Mario Bellini, it has quickly become one of the most prestigious congress destinations in Europe.

The building’s outstanding visual feature is its extraordinary roof. Officially described as the “Comet,” an aerial view also suggests

a river, a glacier or even an exhausted giant seagull. However it is described, it makes the building a model of self-sustainable energy. Covering 15,000 square metres, it was designed to support enough photovoltaic panels to provide electricity not only for the congress centre itself but for the surrounding areas as well. The Comet usually requires only about 400 metres of panels for its own needs.

The roof also serves to unify the structures under it. These include the totally refurbished, pre-existing exhibition halls, the new extensions, and Milano Convention Center – which was already the largest congress complex in Italy. MiCo provides seating for up to 18,000 people and 54,000 square meters of exhibition space.

Colour-coding has been used to simplify navigation through the vast interior which extends over five floors, two of them underground.

Exciting architecture apart, MiCo offers a unique attraction for congress delegates. Its “Red Carpet” concierge service organises “dream events” for a delegate's leisure time in Milan. Activities capitalise on the city's special attractions and range from driving a Lotus around the Monza racetrack to a full-day, escorted wine tour. Everything can be booked online at: www.fmc-redcarpet.com/en.

MiCo stands at the gateway to City Life Fiera Milano, the urban redevelopment project on the site of the old Milan fairgrounds. The scheme incorporates residential and office development, retail space, and a museum – all built around a central park enlivened by canals. When completed, it will feature three skyscrapers, one of which will be the tallest building in Milan. The 50-storey structure was designed by Japanese architect Arata Isozaki.

A villa to love The film, Io sono l'amor, (I Am Love), stars not only Tilda Swinton as a wealthy Russian woman living in Italy, but the villa, “Necchi Campiglio,” as the stylish Milanese villa in which she lives. Designed by architect Piero Portaluppi, the villa was constructed between 1932 and 1935 for the Necchi sewing machine family. The Fascist Republican Party requisitioned the villa in 1943 for use as its headquarters.

After the war, the villa was reclaimed by the owners, who hired Tomaso Buzzi to “soften” the original decor. In 2001, the villa was bequeathed to Italy’s National Trust, and it opened as a museum in 2008. Architectural highlights of the still largely Art Deco villa include the veneered staircase, garden room, leather paneling in the dining room and sumptuous library ceiling.

Villa Necchi Campiglio is located at Via Mozart, 14, 20122 Milano. Telephone: +39 02 76340121. Open Wednesday to Sunday, 10:00 to 18:00. Last entrance at 17:30.

A STADIUM TO REMEMbERMilan’s great buildings, new and old, are well worth a visit for delegates attending congresses hosted in the cityby Maryalicia Post

51Update

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AC Milan dressing room

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Feature

pRACTICE dEVELopmENT53

EUROTIMES | Volume 17 | Issue 5

For €300 (early registration) ophthalmologists and healthcare professionals working in the ophthalmic industry can have access

to one of the top business brains from the world-renowned London Business School.

Keith Willey Bsc, MBA is presenting a Masterclass at the ESCRS Practice Development Weekend in Dublin which takes place from October 5-8 in the Royal College of Surgeons in Ireland.

As an added bonus, the registration fee will gain delegates admission to a series of workshops from other top marketing and management consultants. A gala dinner is

also included with the registration fee.This will be the second ESCRS Practice

Development Weekend hosted by the ESCRS outside its main congress following last year’s inaugural event in Dublin. One of the challenges facing ESCRS in developing its Practice Development Programme is to cater for ophthalmologists of all ages from different countries. “Ophthalmologists are a diverse group but as soon as they launch their own private practices they share many important challenges,” said Prof Willey, who will present his workshop on Saturday October 6. “Success as an entrepreneur

requires an understanding of the nature of entrepreneurship and the imagination to pursue an enterprise beyond what they can support with their current skills, organisation and finances,” he told EuroTimes.

Prof Willey said his ESCRS Masterclass aims to provide the impetus, insights and framework for ophthalmologists to plan a successful future. “Above all it provides surgeons and their practice managers with a way to develop their own commercial judgement based on an understanding of business and the special considerations affecting an owner-managed entity,” he said.

Practice building On the opening day of the Practice Development Weekend on Friday October 5, Arthur Cummings of the Wellington Eye Clinic and Kris Morrill of Medeuronet will give a workshop on Building Refractive Practices. “Cataract-age patients increasingly approach cataract surgery with an expectation for outstanding visual results following surgery; which means that cataract surgeons and their staff need to ensure that they match those expectations,” said Ms

Morrill. “This workshop will discuss the areas where surgeons should focus in order to make this happen,” she said.

Social media The final workshop, which is on social media, takes place on Sunday October 7. “Social media is a relatively new marketing channel and its use in mainstream healthcare, while limited, is growing faster than almost any other media channel. Today Internet users spend three times more minutes on blogs and social networks than on email,” workshop presenter Rod Solar of LiveseySolar Practice Builders said.

Mr Solar’s workshop will show delegates how to use social media such as Facebook, Twitter, LinkedIn, YouTube, Flickr and Blogging in order to increase marketing effectiveness, increase customer satisfaction and reduce marketing costs.

* Early Bird Registration is now open. For more information visit: www.escrs.org/practice-development/dublin2012.

bUSINESS SKILLSThe second ESCRS Practice Development Weekend takes place in Dublin in October

new perspectives in dry eye

The force of aTTracTion in Dry eye

Be prepared for a new and unique cationic emulsion that goes directly to the ocular surface

EUROTIMES | Volume 17 | Issue 5

Capsulorhexis forcepsIn cooperation with Prof Gerd U Auffarth of the University of Heidelberg Eye Clinic, Geuder has developed a new MICS Double Cross-Action Capsulorhexis Forceps.

“The design of the branches which lie over one another makes the forceps ideal for small clear-cornea incisions of down to 1.6mm,” said a company spokeswoman. “The double cross-action mode of function gives the surgeons more freedom of movement in the anterior chamber, promoting effective capsulorhexis. This new and innovative technique is more gentle to the edge of the incision and prevents the iris from being pinched, particularly in cases of intraoperative Floppy Iris Syndrome (IFIS),” according to Geuder.n www.geuder.com/crossactionforceps!

54 Feature

INduSTrY NEWSRecent developments in the vision care industry

Commercialisation agreement for OcriplasminThromboGenics NV has entered into an agreement with Alcon for the commercialisation of Ocriplasmin in all markets outside the US. As a result of this deal, ThromboGenics will concentrate on commercialising Ocriplasmin in the US where it plans to build its commercial and medical organisation to support the product’s anticipated launch within the next 12 months.

“Under the terms of the agreement with Alcon, ThromboGenics will receive an up-front payment of €75m. The company is also entitled to a further €90m in potential near-term milestone payments. Additional milestones bring the potential total of up-fronts and milestones to €375m,” said a company spokesman. “In addition, ThromboGenics will receive royalties on net sales of Ocriplasmin that are commensurate with a product that has successfully completed Phase III development and that has been filed for regulatory approval,” he said.n www.thrombogenics.com

FDA clearance for SPECTRALIS Anterior Segment ModuleHeidelberg Engineering GmbH has announced that the United States Food and Drug Administration (FDA) has granted clearance for the new SPECTRALIS Anterior Segment Module (ASM).

“The SPECTRALIS Anterior Segment Module paves the way towards digital gonioscopy,” said Sanjay Asrani MD, associate professor of ophthalmology, Duke University Eye Center. “Glaucoma surgeons will further benefit from the enhanced depth imaging (EDI) OCT capabilities of SPECTRALIS when assessing filtering blebs and anterior chamber angles.”n www.heidelbergengineering.com

Artisan 25th anniversary OPHTEC is celebrating the 25th anniversary of the implantation of the first Artisan lens for myopia. “Its clinical success has continued to prove it is one of the world’s safest, most effective IOL designs, with the broadest applications of any IOL design – phakic, secondary, paediatric and trauma designs,” said a company spokesman. n www.ophtec.com

FDA clearance for FEMTO LDV Z ModelsZiemer Ophthalmic Systems AG has announced that the FDA has granted clearance for the new femtosecond platform, the FEMTO LDV™ Z Models.

A company spokesman said FEMTO LDV Z2, Z4 and Z6 – are powerful platforms for performing a broad variety of procedures in ocular surgery. “We are looking forward to presenting the products and their unique features to the US audience,” says Graham Hodge, managing director for Ziemer USA Inc. All models are now available for sale in the US.n www.femtoldv.com

LED light sourceOertli say that precision work in the vitreous body makes it absolutely necessary that skin and tissue structures in particular can be shown with as much contrast as possible. “To do so, the new highly advanced Goodlight®LED light source designed by Oertli provides an optimum solution. Goodlight®LED enables excellent viewing and combines the advantages of healthy light with those of the latest LED technology. Goodlight®LED is available with any Oertli OS3 (dual light source) and farosTM,” said a company spokesman.n www.oertli-instruments.com

New surgical lights Dräger is expanding its range of LED lights with Polaris 100 and 200. The integrated LEDs (light emitting diodes) deliver a homogeneous light with a spectrum similar to that of natural daylight, said a company spokeswoman. “These new OR lights feature the well-proven classic round design of the Polaris family with circular handles on the top which allows non-sterile personnel to position the light heads easily. Sterile personnel can adjust the lights by using a sterile central hand grip, “ she said.n www.draeger.com

SCHWIND installs 1,000th eye laserSchwind has announced the installation of the 1,000th SCHWIND laser system for the treatment of visual defects, the SCHWIND AMARIS 750S. “In reaching the number 1,000, we have achieved yet another milestone in the history of our company. This is a great motivation for us to continue to expand our strong market position,” said CEO Rolf Schwind.

55

EUROTIMES | Volume 17 | Issue 5 ad-EUR-1-2 hoch-1202v2-pva RZ.indd 1 29.02.12 13:43

Reducing postoperative astigmatismAs cataract surgery techniques have improved over the years, so too have the criteria for success. The development of astigmatism-correcting IOLs and lenses that treat presbyopia in particular demand precise refractive outcomes. Yet postoperative astigmatism continues to challenge surgeons and their patients. Naturally, astigmatism cannot be managed effectively without reliable preoperative measurements of the cornea. In this issue, Kobashi et al. (pages 648–654) investigated the precision of corneal astigmatic measurements with current devices, including keratometers, topographers, and other imaging modalities, eg, Scheimpflug or ray-tracing devices. The study highlights some of the current issues with preoperative measurement. Incision manipulation is a common method for treating astigmatism, but surgeons disagree on where to place these incisions, how to measure them, and what the long-term effects are. Wang et al. (pages 660–665) report short- and long-term effects of astigmatic manipulation seen even with microincisional lens surgery. These three studies highlight the fact that measurement and manipulation of astigmatism has improved significantly but still needs our attention. With more advanced and standardised diagnostics to determine and measure astigmatism (eg, anterior and posterior corneal surface, lenticular components) and more standardised surgical methods (eg, femtosecond laser to create the incision), the astigmatic component of lens surgery will be even more predictable, controllable and reliable in the near future.n T Kohnen, JCRS, “Astigmatic manipulation

with modern small-incision intraocular lens surgery (editorial)”, Volume 38, Issue 4, 563.

The pseudophakic eyeOlsen and colleagues describe a method for back-solving the power of an intraocular lens (IOL) in situ based on laser biometry and ray-tracing analysis of the pseudophakic eye. This study comprised 767 pseudophakic eyes with an IOL power ranging from -2.00 to +36.00 D. Preoperatively, the corneal radius was measured with conventional autokeratometry and the axial length (AL) with optical biometry. After surgery, the position of the IOL was recorded using laser interferometry. Based on the postoperative refraction and the biometric measurements, a ray-tracing analysis was performed back-solving for the power of the IOL in situ. The analysis was

performed assuming pupil diameters from 0.0 to 8.0mm with and without correction for the Stiles-Crawford effect.

The prediction error showed no bias with IOL power or with AL. The calculated IOL power depended on the assumed pupil size and the Stiles-Crawford effect. However, the latter had a modulatory effect on the prediction error for large pupil diameters (>5.0mm) only. The researchers conclude that the optics of the pseudophakic eye can be accurately described using exact ray tracing and modern biometric techniques.n T Olsen et al., JCRS, “Ray-tracing analysis of

intraocular lens power in situ,” 641-647

Quantifying long-term wound healingWhat are the long-term wound-healing changes in clear corneal cataract incisions? US researchers used Fourier-domain optical coherence tomography (OCT) in a series of eyes that had phacoemulsification one day to 180 months previously. The incision midpoint was measured with OCT. They found that Descemet’s membrane detachment occurred in 37.1 per cent of eyes one day postoperatively and in 4.5 per cent of eyes at one to three months (P=.005). It was absent after three months. Posterior wound gape appeared in 85.7 per cent of eyes at one day and in 31.8 per cent at one to three months (P<.001); it was absent after three months. Posterior wound retraction appeared in 33.3 per cent of eyes at two to three weeks, in 75.0 per cent at one to three years, and in 90.5 per cent after three years (P<.001). The mean wound retraction was 120 μm, which was 7.5 per cent of the radial incision length.n L Wang et al., JCRS, “Healing changes in

clear corneal cataract incisions evaluated using Fourier-domain optical coherence tomography,” 660-665.

Review

JCrS hIghLIghTSJournal of Cataract and Refractive Surgery

Thomas Kohnenassociate editor of jcrs

FURTHER STUDYBecome a member of ESCRS to receive a copy of EuroTimes and JCRS journal

PRACTICE DEVELOPMENT WEEKEND

Practice Development

ESCRS

Register online: www.escrs.org/practice-development/dublin2012/

FRIDAY 5 OCTOBER

Building Refractive PracticesKris Morrill, Medeuronet, FranceArthur Cummings, Wellington Eye Clinic, Ireland

n Refractive outcomesn Communication to patients and sta� n Public relations to the community and referral networkn Valuing procedures and pricing

SATURDAY 6 OCTOBER

Practice Development MasterclassStrategies and Tactics for a Successful PracticeKeith Willey, London Business School, UK

n Strategies and tactics for a successful practicen Planning for a successful futuren Commercial judgmentn Sharing success and failure

SUNDAY 7 OCTOBER

Social Media In ActionRod Solar, LiveseySolar Practice Builders, UK

n Determine social media’s purpose in your businessn Speak with your target audience e� ectivelyn Generate consistently valuable contentn Engage your community appropriately

ROYAL COLLEGE OF SURGEONS IN DUBLIN, IRELANDFRIDAY 5 OCTOBER – SUNDAY 7 OCTOBERDELEGATE FEES (INCLUDING GALA DINNER IN MERRION HOTEL, DUBLIN)

EARLY REGISTRATION (20 JULY 2012) €300LATE REGISTRATION €350

EUROTIMES | Volume 17 | Issue 5

Ophthalmologists may be able to avoid paying royalty fees for background music they play for patients in their private offices

and clinics, under a new ruling by the EU’s highest court.

The potential savings follows a judgment by the European Court of Justice that an Italian dentist was not obligated to pay royalties for background music for his private dental patients. The court ruled that the payment of royalties did not arise because the playing of background music for private patients did not constitute “communication to the public”.

In its judgment, handed down on March 15, the Court of Justice ruled that a dentist who plays background music tracks “free of charge in his dental practice, for the benefit of his clients and enjoyed by them without any active choice on their part, is not making a ‘communication to the public.’”

As with all court decisions, however, ophthalmologists should consult with a lawyer to establish whether they may be able to take advantage of the judgment in their own country and avoid or reduce any royalty payments for the music they play in their private offices and clinics.

The Court of Justice case arose from a dispute between a dentist in Turin and the Societa Consortile Fonografici (SCF). The Italian-based SCF acts as a collecting agency to manage, collect and distribute the royalties of music producers.

The dispute followed the failure of negotiations between the SCF and Association of Italian Dentists. The SCF and Association had attempted to conclude a collective agreement to set an appropriate royalty fee for association members for any “communication to the public” of the background music they played in their private professional practices. In the industry, music tracks are often referred to as “phonograms”.

Background music After negotiations failed, the SCF, in June of 2006, brought an action before the Turin District Court against a local dentist, Dr Marco Del Corso. In its lawsuit, the SCF sought a declaration that Dr Del Corso should pay royalty fees for the playing of background music in his private dental practice in Turin.

The SCF based its lawsuit on its

interpretation of national, EU and international law governing the payment of copyright royalties to performers. Under the 2001 EU Directive on the Harmonisation of Certain Aspects of Copyright and Related Rights in the Information Society, EU countries are obliged to “provide authors with the exclusive right to authorise or prohibit any communication to the public of their works.” The directive also requires EU countries to “provide for the exclusive right to authorise or prohibit” the communication of their works to the public.

In addition to the EU directive, the SCF relied on Italian copyright law, which provided that music performers and producers “shall be entitled to receive remuneration for the use for profit of the phonograms, by means of cinematography, radio and television broadcasting, including communication to the public, via satellite, at public dances, in public establishments and on the occasion of any other public use of the phonograms themselves.”

In his defence, Dr Del Corso argued, among other things, copyright laws did not apply to his broadcast of music in his practice because the law only referred to the broadcast of music to the public in public places. On that basis, he argued that a private dental

practice could not be classified as a public place, unlike public health facilities.

In 2008, the Turin District Court dismissed the SCF lawsuit for a number of reasons: there was no communication for profit, the type of music played in the practice did not influence the patients’ choice of dentist, and the dental practice was private and, as such, could not be equated with a public place or place open to the public.

Not part of treatment SCF appealed against that judgment to the Court of Appeal in Turin.

Because the Appeal Court was unsure about whether the broadcasting of phonograms in private professional practices constituted “communication to the public,” it referred the case to the Court of Justice for a preliminary ruling.

The Court of Justice held that the term “public” within the meaning of the 2001 Directive “refers to an indeterminate number of potential listeners, and, in addition, implies a fairly large number of persons.” The court also relied on existing legal concepts employed by such world legal bodies as the World Intellectual Property Organisation. According to that organisation, the concept “communication to the public” exempted the

broadcasting of music “to specific individuals belonging to a private group.”

Having considered the legal principles surrounding the definition, the court then examined the facts before it. “As regards the patients of a dentist such as the one in the case in the main proceedings, it must be observed that they generally form a very consistent group of persons and thus constitute a determinate circle of potential recipients, as other people do not, as a rule, have access to treatment by that dentist.”

The court also found that “in the case of the patients of a dentist, the number of persons is not large, indeed it is insignificant, given that the number of persons present in his practice at the same time is, in general, very limited.”

The court also noted that there was little to be gained financially by the dentist in broadcasting the music tracks because “a dentist who broadcasts phonograms, by way of background music, in the presence of his patients cannot reasonably either expect a rise in the number of patients because of that broadcast alone or increase the price of the treatment he provides. Therefore, such a broadcast is not liable, in itself, to have an impact on the income of that dentist.”

In addition, the court noted that the playing of music tracks did not by any definition, form part of their treatment. “The patients of a dentist visit a dental practice with the sole objective of receiving treatment, as the broadcasting of phonograms is in no way a part of dental treatment.”

n For more details about the case, SCF Consorzio Fonografici -v- Marco Del Corso, visit the European Court of Justice website at www.curia.eu.

bACKgROUND MUSICOphthalmologists who broadcast music in a private clinic may be able to avoid paying usual copyright royalty feesby Paul McGinn

57Feature

Eu mATTErS

From the ArchiveSteps to smooth out folds and striae

I f simple lifting of the corneal flap does not reduce folds and striae seen in association with LASIK procedures, then a combination of de-epithelialiation, stretching and suture fixation will, say German researchers.

“Although folds and striae are evident in refractive surgery, they rarely affect visual acuity. However, folds that do reduce visual acuity should be treated in the early postoperative stage to avoid additional complications and further worsening of vision,” said Thomas Kohnen, MD, Frankfurt University Eye Clinic.

Dr Kohnen and colleagues analysed three individual cases presenting with folds. He reviewed the results at the annual meeting of the DGII (German-Speaking Organisation of Intraocular Lens Implantation and Refractive Surgery).

* Reprinted from EuroTimes Volume 7 Issue 5 May 2002

Where do you go for questions on:• Fluid in interface years after LASIK• Loose zonules• MRSA endophthalmitis• Prevention of epithelial ingrowth with flap lifts• IOL target for captured optic

These are just some of the hundreds of everyday issues and questions ASCRS members discuss on eyeCONNECT. It’s where members tap into the awesome knowledge base of the ASCRS community for quick answers to pressing problems. eyeCONNECT gives members the assurance that they’re making the best choices possible. And it’s available only through ASCRS – the ONE society focusing exclusively on cataract and refractive surgery.

The power of the ASCRS community. Can you afford to practice without it?

• Late onset corneal haze after PRK• YAG capsulotomy in the ASC

EyeCONNECTLogin

Subscribe to ASCRS’ eyeCONNECT today andconnect with colleagues in a worldwide virtual community.

Visit www.eyeCONNECTIONS.org and click the Discussions tab.Login (using the same user name andpassword as for the ASCRS website), click “My Subscriptions,” choose the list(s)you wish to subscribe to, the deliverymethod, and click “save.”

Not yet a member of ASCRS? Visit www.ASCRS.organd join online today.

Click the “Membership” tab.

EUROTIMES_March 2012 ads_Layout 1 3/2/12 9:47 AM Page 2

59

EUROTIMES | Volume 17 | Issue 5

Wina €1,000 travel bursary to the XXX ESCRS Congress

For more details seewww.escrs.org/milan2012/programme/henahan-prize.aspClosing date for entries: 4 June 2012

The

John

Hen

ahan

Pri

ze 2

012

The Trials and Tribulationsof a Young Ophthalmologist

EuroTimes Writing CompetitionCall for Entries

Update on Coats’ diseaseCoats' disease is rare condition of uncertain aetiology which can be difficult to diagnose in its early stages, according to recent review of the literature on the topic. An idiopathic, progressive condition, it is characterised by retinal telangiectasia and exudates which can cause retinal detachment. Its diagnosis can be challenging because it has features in common with many other retinal disorders. However, retinoblastoma is by far the most important lesion to rule out. There are several well-established treatment modalities for Coats’ disease, starting with laser photocoagulation and cryotherapy, for mild to moderate stages of the disease, to vitrectomy, for the advanced stages. In recent years, various investigators have used anti-VEGF agents as adjuvant therapy with variable results.

(Ghorbanian et al, Ophthalmologica 2012; DOI: 10.1159/000336906).

Uveal melanoma and enucleationOverall mortality and metastasis-free survival are not significantly lower in uveal melanoma patients who undergo proton beam radiotherapy than they are in patients who undergo enucleation, according to the results of a retrospective non-randomised study. The study involved 132 consecutive patients with stage T3 and T4 choroidal melanoma. At five years’ follow-up, the cumulative all-cause mortality, melanoma-related mortality and metastasis-free survival there was no statistically significant difference between the two treatment groups. Moreover, 74 per cent of patients treated with proton beam radiotherapy retained their eyes at five years’ follow-up. Furthermore, best corrected visual acuity was 0.1 or better in 47.5 per cent of the retained eyes at 12 months’ follow-up, and in 32 per cent of the retained eyes at 60 weeks’ follow-up.

(Mosci et al, Ophthalmologica 2012; DOI: 10.1159/000334401).

New microcatheter for drug deliveryThe results of a prospective study indicate that a new microcatheter can provide a safe and effective means of delivering steroids and anti-VEGF agents to the submacular suprachoroidal space in eyes with advanced age-related macular degeneration (AMD). The study involved 21 eyes of 21 patients with choroidal neovascularisation

(CNV) secondary to advanced, exudative AMD. All underwent a single injection of a combination of bevacizumab and triamcinolone into the submacular suprachoroidal space using the new microcatheter. In all cases the researchers were able to perform the injection successfully and atraumatically without any serious intraoperative or postoperative complications such as suprachoroidal haemorrhages. The study’s authors noted that direct drug delivery to the choroid can potentially increase local tissue drug levels and drug efficacy for the treatment of AMD and other diseases associated with CNV.

(Tetz et al Ophthalmologica 2012; DOI: 10.1159/000336045).

Good and bad polymorphismsPolymorphisms in the gene for the receptor for advanced glycation end products (RAGE) can increase or reduce the odds of retinopathy developing in patients with diabetes mellitus, according to a meta-analysis of research conducted to date. The meta-analysis of studies derived from PubMed and Web of Science (up to August 31, 2011) included six articles investigating the -429T/C polymorphism, seven investigating -374T/A polymorphism and five investigating Gly82Ser in patients with diabetic retinopathy. An estimation of pooled odds ratios showed that there was a positive correlation between the RAGE -374T/A polymorphism and retinopathy in patients with Type 2 diabetes, but there was a negative correlation between the -374AA allele and retinopathy in Type 2 diabetes. The analysis also indicated that the RAGE Gly82Ser polymorphism may increase the risk of diabetic retinopathy in Asian populations.

(Yuan et al, Ophthalmologica 2012; DOI: 10.1159/000335628).

Review

ophThALmoLogICA

José Cunha-VazEDITOR OF OPHTHALMOLOGICA,The peer-reviewed journal of EURETINA

Reference

CALENdAr oF EVENTSDates for your Diary

Advertising Directory: ARC Laser Ag: Pages: 8, 15; Abbot Medical Optics: Page: 3; Alcon: Page: 13, 47, IBC, OBC; Alsanza Medizintechnik and Pharma GmbH: Page: 25; Angiotech: Page: 10; ASCRS: Page: 52, 58; Carl Zeiss Meditec: Pages: 31; Croma-Pharma GmbH: Pages: 12, 55; DORC International BV: Page: 26; ESASO Lugano: Page: 43; Hoya Surgical Optics GmbH: Page: 7; Katena Products Inc.: Page: 32; Keratoconus Solutions: Page: 27; Medicel AG: Page: 11; Medicontur International SA: Page: 36; NIDEK: Page: 17; Oculus Optikgerate GmbH: Page: 37; Oertli Instruments AG: Page: IFC; Santen Inc.: Page: 53; Surgistar: Pages: 29, 33; VSY Biotechnology: Page: 9; VuExplorer Institute: Page: 16.

May May

JuneJune June

June

July

September

November February

September

October October

September September

20122012 2012

2012

2012

2012

2012 2013

2012

2012 2012

20122012

9th Congress of Slovenian Society of Ophthalmology32nd Symposium of Ophthalmologists of Slovenia and Croatia28-30 Portoroz, SLoVENIAwww.zos2012.si

11th Aegean Summer School in Visual Optics26-28 CrEtE, GrEECEwww.ivo.gr/summerschool

Aegean Cornea XI29-1juLy CrEtE, GrEECEwww.aegeancornea.gr

2nd Joint International Congress Refr@ctive on-line and SICSSO 28-30 roME, ItALywww.rolandsicsso.org

ARVO Annual Meeting6-10 fort LAudErdALE, fL, uSAwww.arvo.org

UKISCRS Cornea & Cataract Day 201214 LIVErPooL, uKwww.ukiscrs.org.uk

10th SOI International Meeting23-26 MILAN, ItALywww.sedesoi.com

16th Afro Asian Congress of Ophthalmology & 5th Mediterranean Retina Meeting13-16 IStANbuL, turKEywww.afroasian2012.org

ISER 2012XX Biennial Meeting of the International Society for Eye Research22-27 bErLIN,GErMANywww2.kenes.com/iser/pages/home.aspx

3rd EuCornea Congress6-8 MILAN, ItALywww.eucornea.org

12th EURETINA Congress6-9 MILAN, ItALywww.euretina.org

AAO•APAO Joint Meeting10-13 ChICAGo, IL, uSAwww.aao.org

17th ESCRS Winter Meeting15-17 WArSAW, PoLANdwww.escrs.org

UKISCRS – XXXVI Annual Congress27-28 brIGhtoN, uKwww.ukiscrs.org.uk

VI Congress of the Latin American Society of Cataract and Refractive Surgeons4-6 buENoS AIrES, ArGENtINAwww.congresos-rohr.com/alaccsar2012

8th International Symposium on Uveitis19-22 hALKIdIKI, GrEECEwww.ISU2012.org

Modern Technologies in Cataract and Refractive Surgery – 201225-27 MoSCoW, ruSSIAwww.mntk.ru

XXX Congress of the ESCRS8-12 MILAN, ItALywww.escrs.org

2nd World Congress of Paediatric Ophthalmology and Strabismus7-9 MILAN, ItALywww.wcpos.org

2012 2012

60

June2012

25th International Congress of German Ophthalmic Surgeons14-17 NurNbErG, GErMANywww.doc-nuernberg.de

10th EGS Congress17-22 CoPENhAGEN, dENMArKwww.eugs.org

DuoTrav EUROTIME 270x320.indd 1 06/02/12 17:01

How do you design a phakic lens to last?

1. For further information concerning this lens and/or the surgical procedure, please refer to the package insert.

© 2012 Novartis 3/12 PHA171D-EU

A phak ic lens l ike no other

Proven safety

Unique lens design

Excellent visual outcomes

Trusted heritage

Engineered for excellence™

Start with innovative engineering.

Introducing the AcrySof® CACHET™ Lens.An innovative, angle-supported design. A proven lens material. Crafted

together, they provide a proven clinical solution for the challenges of

maintaining endothelial cell density and avoiding pupil ovalization.1

The AcrySof® CACHET™ Lens gives opportunity to your patients with

moderate to high myopia to improve their vision.

EuroTimes 5/1/12

78383 PHA171EU ET.indd 1 3/22/12 1:13 PM

How do you design a phakic lens to last?

1. For further information concerning this lens and/or the surgical procedure, please refer to the package insert.

© 2012 Novartis 3/12 PHA171D-EU

A phak ic lens l ike no other

Proven safety

Unique lens design

Excellent visual outcomes

Trusted heritage

Engineered for excellence™

Start with innovative engineering.

Introducing the AcrySof® CACHET™ Lens.An innovative, angle-supported design. A proven lens material. Crafted

together, they provide a proven clinical solution for the challenges of

maintaining endothelial cell density and avoiding pupil ovalization.1

The AcrySof® CACHET™ Lens gives opportunity to your patients with

moderate to high myopia to improve their vision.

EuroTimes 5/1/12

78383 PHA171EU ET.indd 1 3/22/12 1:13 PM