PracticeDevelopment

VOLUME 18 ISSUE 6 jUnE 2013

A pleasant office designwill attract patients

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Cover Story 4 There is plenty to consider and prepare before designing a new office space

Cataract & Refractive 8 Corneal inlay delivers gains in near and intermediate vision9 survey shows lack of guidelines for preventing herpetic eye disease recurrence10 New tools for assessing cataract patients11 Measuring corneal astigmatism with new method could lead to better visual outcomes

Cornea 16 Could trachoma disease become a thing of the past?17 There are many measures patients can take to prevent ocular manifestations of rosacea18 surgeons have many things to consider before using combined procedures19 New treatment for reducing ocular discomfort in patients with dry eye disease

Glaucoma 21 Experts debate combined glaucoma and cataract surgery approach23 Are statins beneficial in patients with open-angle glaucoma?

Retina 24 Phaco and vitrectomy can be beneficial 26 Digital technology devices are good aids for low vision patients27 innovations in rhegmatogenous retinal detachment surgery

Ocular 31 Multidisciplinary team could be more beneficial in assessing vision performance32 Assessing drivers for peripheral field vision important 34 Presenters at AsCRs meeting discuss new technology advances

Global Ophthalmology 36 Planning a successful international mission starts with understanding the destination37 Free drug proves successful treatment for river blindness

News 38 EsAsO retina meeting to be held in Dublin39 Empowering communities in the Democratic Republic of Congo40 Entries welcome for EURETiNA innovation Award

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Features 41 Resident’s Diary44 industry News45 Book Review47 JCRs highlights

Publisher Carol FitzpatrickExecutive Editor Colin KerrEditors sean henahan Paul McGinn

Managing Editor Caroline BrickProduction Editor Angela sweetmanSenior Designer Janice Robb

Circulation Manager Angela Morrissey Contributing Editors howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon schuyler Eisele stefanie Petrou-Binder Maryalicia Post Leigh spielberg

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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

50 Eye on Travel51 Ophthalmologica highlights52 Calendar

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

Building a clinic is often the dream of many ophthalmologists, to give them independence from large hospital organisations and professional freedom. Designing an outpatient clinic or office for an

ophthalmologist will be the subject of one of our keynote Practice Development workshop discussions at the XXXi Congress of the EsCRs in Amsterdam, The Netherlands in October and should be a must attend for anyone planning to build their own facility.

Architect Jaap Dulfer of Architecten aan de Maas, Maastricht, The Netherlands, points out in this month’s Cover story that when developing a new building of any kind, factors such as location, budget and statutory requirements including building codes and use permits are important. he also stresses the importance of ensuring that the building’s function be clearly stated and that spaces be designed to achieve that function.

For ophthalmologists, the aim is to provide efficient, evidence-based eye care, but it is the architect’s role to provide the spatial requirements that are the basis of tangible space and surface, says Mr Dulfer, who designed the recently opened University Eye Clinic Maastricht.

This is a fascinating subject and we hope that by reading our Cover story you will gain some insights into how ophthalmologists and architects can work effectively together to enhance the services to staff and patients. Great design is the key to a smoothly run service which is cost-effective and creates a relaxed working environment.

Amsterdam and Frankfurt On behalf of the EsCRs Practice Development Committee, i would like to invite our friends and colleagues to attend two Practice Development sessions in Amsterdam and Frankfurt this autumn.

The Practice Development workshops will take place on sunday October 6 and Monday October 7 in Amsterdam, The Netherlands and full details of the programme are available on www.escrs.org.

We are also holding a special Practice Development meeting in Frankfurt, Germany from Friday November 1 to sunday November 3. Details of this meeting are being finalised and we will keep you informed coming closer to the event.

Our Practice Development programme is now in its sixth year and thanks to the support of our colleagues in EsCRs and the excellent speakers who have participated in our meeting, the workshops have gone from strength to strength.

i also want to give special thanks to my colleagues on the Practice Development Committee: Jorge Alio, Oliver Findl, Manfred Tetz and Arthur Cummings who have offered excellent advice as to how best we can serve our members in developing the programme.

At our last meeting we agreed that while the programme had been very well received, there was always room for improvement with greater use of counterpoint discussions and also a greater focus on the day-to-day nuts and bolts of running a practice. You will see the results of this new direction at our meetings this year and we look forward, as always, to your participation and feedback.

EUROTIMES | Volume 18 | Issue 6

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eDITORIAL Volume 18 | Issue 6

Editorial

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

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

by Paul Rosen

ROOM TO GROWOphthalmologists and architects can work effectively together to enhance services to both staff and patients

* Paul Rosen FRCS, FRCOphth, is chairman of the ESCRS Practice Development Committee.

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by Howard Larkin

EYE ON DESIGN

There are no doors on the alcoves housing the topographers and other corneal diagnostics at Matthias Maus MD’s sehkraft laser

eye surgery centre in Cologne, Germany. Patients gliding by in the corridors or relaxing to soft music in the lounge can see right in past a semi-transparent curtain of elegant beaded strings.

The arrangement is no accident. it is designed to prevent or alleviate any anxiety patients may feel about LAsiK or other possible eye surgery, says designer Patrick CM schalkwijk of the Cologne architectural firm hell und freundlich. The test equipment is not hidden and mysterious, it is visible and inviting. it is an integral feature of a soothing setting.

“You come in and it is like an oasis, you immediately feel calm. it is about making people feel well and at home,” Mr schalkwijk says.

it also makes patients more likely to go forward with elective surgery, Dr Maus believes. his market research found that fear is by far the biggest obstacle to patients choosing LAsiK, with 80 per cent of 1,500 respondents saying possible complications or quality issues are their biggest concern, compared with just 20 per cent concerned with cost.

so reducing fear was a major design goal when Dr Maus renovated his clinic a decade ago. still, he resisted the curtain concept when it was first proposed by Mr schalkwijk, whose background was mostly in high-end retail design without healthcare experience. After all, he had doors on the diagnostic rooms in his old office, and they were kept closed for privacy.

Except they weren’t, Mr schalkwijk found. During days spent observing clinic operations before developing a design programme, he never saw the doors closed, and the technicians backed him up.

so Dr Maus accepted the change and many other unusual design features Mr schalkwijk proposed. “The goal is to make

the patients comfortable, not to design to the doctor’s taste. The patient is the customer, not the doctor,” Dr Maus says.

A decade later, Dr Maus is still happy he followed his architect’s advice. his clinic charges some of the highest prices in Germany, yet easily weathered the financial collapse that pushed many out of the refractive market. his clinic has been celebrated in design and fashion magazines and visiting surgeons still rave about it. Mr schalkwijk has gone on to build a thriving international healthcare design practice.

The case illustrates how close collaboration between doctor and architect can pay off with an office that is functional and even beautiful on many levels. some steps for achieving a successful collaboration follow.

Basic planning When thinking about your dream office, it’s tempting to jump right to the real estate. But an effective ophthalmology office, surgery centre or

hospital starts with a solid strategic business and service plan – one that’s based in realistic volume and revenue projections.

it’s especially important today as health budgets come under increasing pressure, leaving little room for error in planning, says architect Glenn Dean of Lillibridge healthcare services, a subsidiary of Ventas inc based in Chicago, Us, which owns or operates more than 400 medical office buildings. “You need a qualified consultant who is knowledgeable on reimbursement and what can be expected in the near future to develop a plan.”

Bill Cooler, of Cooler Design inc, based in indianapolis, Us, agrees. “What doctors should come with is an operational model, a budget and a timeline. if they can present that, the architect can work to it,” says Mr Cooler, whose firm specialises in medical office, surgical centre and hospital design, as well as planning and management of facilities and real estate assets.

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Form follows function as close collaboration with architects yields efficient office design

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The Wellington Eye Clinic on the Beacon Medical Campus, Sandyford, Dublin. The extensive glass walling required creative internal architectural design to create a clinical space that relies on dark examination and treatment rooms

The goal is to make the patients comfortable, not to design to the doctor’s taste. The patient is the customer, not the doctor

Our conversion rates go down when LASIK patients are in the same waiting room with medical patients. They want to think about seeing better and talk to other refractive patients. Seeing someone with red eyes might scare them a little

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Mr Dean also advises appointing a strong project manager or champion to oversee architect hiring, design and construction – preferably a physician. “That individual has two roles, one is the authority to make design, budget and operating decisions, and the other is the liaison between the design team and the physicians, nurses, staff, business manager and anyone else who uses the facility. The key to the whole thing is collaboration.”

Licensure Building codes, zoning rules, use permits and environmental regulations apply to all types of building projects. But medical facilities also must comply with a host of rules ranging from specialised licensing codes to community need-based permitting that may be enforced by local, state, regional or national governments, or even public and private insurance plans.

For example, seven years ago Arthur Cummings MD, FRCs, moved his laser refractive clinic from the city centre of Dublin to a medical campus next to a new hospital in sandyford, a predominantly industrial area a few kilometres away well served by roads, buses and trams. since then, refractive lenses and other intraocular work have grown from about 15 per cent of his case load to nearly half.

While the hospital operating suite is just steps away, Dr Cummings, consultant ophthalmologist, UPMC Beacon hospital, medical director, Wellington Eye Clinic, would like to build an operating suite in his office alongside the clinic’s two laser procedure rooms. But in ireland, insurers won’t pay for new operating theatres, so Dr Cummings will wait. “There just aren’t enough self-paying patients to support an operating room in our office right now.”

An architect who understands the regulatory pitfalls, including payment issues, and how to bridge them can keep a project from failing before it starts, Mr Cooler says. “Just a few weeks ago a medical group director told me he was happy he hired us as opposed to the local guy who is not experienced in licensure. he thanked us for making it go so smoothly.”

Space planning and schematic flow Designing a building requires first that its function be clearly stated so that spaces can be developed to achieve that function, says architect Jaap Dulfer of Architecten aan de Maas, Maastricht, The Netherlands.

space planning involves identifying all the functions that will need to be supported in the proposed facility including all types of procedures as well as projected volume, and determining what space is needed to accommodate them. Both work and related logistics processes, such as turning around procedure and operating rooms and maintaining equipment, should be described in great detail, says Mr Dulfer, who designed the recently opened University Eye Clinic Maastricht. “They will have to be laid down in flow charts. spatial requirements can be determined on the basis of these processes in a spatial schedule of requirements. it is important to arrange this in consultation with the architect.”

Flow chart information includes needs for adjacencies; what needs to be next to what. For example, reception should be near exam and procedure rooms, but exam rooms don’t need to be near recovery areas. space and

function plans give a good idea of how much room is needed, and how many rooms of what type are needed. This can lead directly to a preliminary floor plan, but additional information is required to determine all design parameters.

Mr Dean recommends kicking off the planning process with a visioning session that invites participants to talk about what they need and want from their jobs and the facility, and what would improve their performance. he analyses these functions at three levels; national identity, patient identity and facility identity. These provide additional design guidance.

At the national level are quality of care, cost containment and patient outcomes, and any design decisions must address these, Mr Dean says. The patient level covers demographics, what patients need and access to care and technology. This also is a strong

driver of what services are appropriate and how much revenue they can reasonably be expected to produce. Facility identity has to do with how the project is positioned, roughly on a scale from hospital-like to commercial-like.

The physical requirements of intended procedures drive this, with laser refractive tending toward commercial, with carpets and open spaces suitable. On the other hand, operations that require fluid handling may be more appropriate following the hospital model, with tile floors, closed rooms, etc.

Layout and design To get to a functional layout, doctors also need to think in detail about how they want to work and how they want patients and staff to move through the facility. For example, how should corridors be placed, one for both patients and staff, or separate? should separate areas

be designated for refractive patients and patients with more severe pathology? This can have a real impact on practice finances, Dr Cummings says. “Our conversion rates go down when LAsiK patients are in the same waiting room with medical patients. They want to think about seeing better and talk to other refractive patients. seeing someone with red eyes might scare them a little.”

should exam or treatment rooms all be the same? standardised rooms make design and construction more efficient, and can lead to better practice efficiency because they require less movement of patients, Mr Dean says. But Mr Cooler has seen a shift away from standardisation. “The feedback we are getting from practitioners is its okay if rooms are identical, but if it cost more it may not be worth the extra money.”

saving steps can significantly affect practice finances, Mr Cooler says. “One

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clinic manager asked us to minimise the number of steps staff members take to move a patient from reception to treatment room and out with the goal of eliminating one staff position. That can go a long way toward making a new clinic profitable.”

Reviewing plans Mr Cooler advises involving not only physicians but also nurses, technicians and other clinical staff, as well as receptionists and practice managers, in reviewing detailed plans. “in their minds they walk patients through, understanding how they get out of reception and into exam rooms or treatment rooms, going from one room to another or doing multiple tasks in one room. They identify where there may be roadblocks or obstacles and share that with the architect.” Dr Cummings vouches for this approach, which he applied in designing his clinic.

however, bringing too many people into the design process can risk loss of focus or creating expectations about the new space that will not be realised, Mr Dean says. The physician-champion needs to keep the process in line.

Traditionally, 2-D floor plans and drawings were used in the review process, but increasingly, 3-D software provides large-scale renderings and animations that make it much easier for clients to visualise how a space flows and functions, Mr Cooler says. “We had a group of hospital

management students in the other day showing them a design project. One of them asked if they were looking at photos of a completed project – the renderings are that good.”

however, Mr schalkwijk finds that even 3-D isn’t always enough and sometimes builds scale models, which he says most physicians can easily understand. he starts by showing clients 2-D and 3-D drawings, but if they aren’t responding he’ll skip them in favour of models.

Construction review Even so, there’s really no substitute for walking into a real space, Mr Cooler says. he typically schedules bi-weekly meetings with the client leaders during construction to review progress. They may bring along other staff to assess areas such as reception, waiting rooms, storage, iT or records that they will work in.

Mid-course corrections are the norm, but can be minimised with planning. On larger projects, a single exam or procedure room might be fitted and staff brought in to take a look. “They might ask why we mounted a counter or equipment so high. Let’s lower it before we install 10 more,” Mr Cooler says. On very large projects, mock-ups may even be made to test design ideas.

Mr Dean also schedules a series of walkthroughs throughout construction, beginning with an initial tour when studs,

since opening in July 2011, the seven-story Eye Tower of the University Eye Clinic Maastricht in The Netherlands

has drawn rave reviews from patients, doctors, researchers and students alike, says Rudy MMA Nuijts MD, PhD, who heads the cornea service and refractive surgery at the clinic, and Carroll Webers, MD, PhD, chairman of the department. its sleek façade and welcoming interior also have been celebrated in high-profile architecture and art digests.

Most important, the University Eye Clinic Maastricht is enabling a steady increase in patient and procedure volume, they said. With the ageing of the population the department expects more demand for everything from diabetes and age-related retinal services to glaucoma, cornea, cataract and refractive procedures, not to mention routine primary eye care. “The whole point is to be prepared for this growth.”

Clinic volume already exceeds the capacity of the department’s previous cramped quarters, and is on track to achieve a major increase over the next few years, they said. Most patients are still from The Netherlands, but they expect cross-border business may pick up as demand grows.

Element of a larger strategy The Eye Tower’s design is directly related to a broader ophthalmology department strategy to bolster its three major missions – patient care, education and research, they said. Volume is essential for all three.

For patient care, the department has built a referral network by acquiring community eye care practices in The Netherlands and one in Flemish Belgium, they said.

With easy access, short lines and pleasant surroundings, the Eye

Tower “was designed specifically to be inviting to patients,” they said. Entering the hospital, patients turn left for ophthalmology, and straight for everything else, making the clinic easy to find. Common diagnostic tests are grouped together, making check-ups and even preoperative visits for cataract surgery a one-stop affair, with both surgery dates and follow-up appointments made the same day. The Tower is also attractive because it avoids exposing eye patients to the noise, bustle and even infectious diseases often found in general hospital wards.

Volume benefits training by providing enough patients for medical students, residents and fellows to learn and build basic skills, they said. it also helps attract faculty. “if you concentrate only on tertiary care it is very difficult to get enough staff members.” Building features including a 90-seat auditorium with direct video feeds from surgery, and a resident clinic set up to allow supervising physicians to move freely from exam room to exam room without entering the patient waiting area make teaching more efficient and attractive for teachers and students.

Procedure volume, especially cataracts, also generates revenue supporting research and other university activities, they said. And the close placement of doctors’ offices and four dedicated surgical suites greatly increases surgeon productivity.

“With your own surgical theatres just two floors down, you can influence your own logistics and workflow. This shortens turnaround time between cases, and we do at least 50 per cent more in the same time,” they said.

* For more on the design and layout of University Eye Clinic Maastricht’s Eye Tower, visit EuroTimes online at www.eurotimes.org

Efficiency – and attracting patients – at a university clinic

Inside University Eye Clinic Maastricht’s Eye Tower

The Eye Tower

Rudy MMA Nuijts and Carroll Webers

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COMING SOON IN july/auGuSt EuROtIMES...

conduits and other infrastructure are in place. “We can see where the electrical connections and plumbing are roughed in. it is a lot easier to make the change then than when the walls are closed up.” Examples of standard spaces such as exam rooms may also be roughed in for a first look.

Later walks occur after cabinets and other equipment that is difficult to move are installed, Mr Dean says. A final tour is made at the end with a list of all project requirements, including carpeting, paint etc. “We’ve got people who are working the job on a daily basis, but still things get missed.” The doctor-champion signs off after each step.

Future-proofing The pace of technological change also changes needs, Mr Dean notes. indeed, a project with a two-year timeline may schedule equipment that may be discontinued when it is due to be installed, he says. Therefore, offices should be designed to be flexible and “future-proof.”

One way to do so is installing cabling, or conduits to accept a future cable standard in critical areas, Mr Dean says. Rooms that require hard ceilings, such as operating suites, should be next to rooms or corridors with panel ceilings that permit access to the space above the room, or with ceiling hatches. “it’s better to put the infrastructure in first because most people are going to want to make changes sooner than they anticipate.”

Mr Dean also recommends locating “soft space”, such as storage and offices, next to areas that are most likely to require change, usually procedure rooms. That way they can be expanded as needed. Dr Cummings used this approach to expand his laser suites to accommodate femtosecond lasers.

But building in extra space is expensive, Mr Cooler says. he suggests making offices and storage spaces in sizes that can be easily converted to exam or procedure rooms.

But building in idle space is expensive and increases overhead. One solution for leased spaces in buildings not fully occupied is to negotiate rights to expand into adjacent spaces over a period of three to five years. similarly, groups building new offices might lease out extra space for the first few years, and then move in as their practices grow.

What to look for in an architect so building an effective office space is a tall and complex order requiring a great deal of insight into medical needs and expertise in design, construction, regulations and even local cultural norms. so what should you look for in an office architect?

“Experience,” Mr Dean says. “Ask how many projects they have done and talk to peers about what their experience has been. it is a normal vetting process as for any person or service.”

Mr Dean also recommends considering the value that building a good working relationship can add. You will need to work closely, even intimately, with an architect to get the best results. select a few candidates who have the proper experience and who your project manager or champion feels they can work with and have them present based on your preliminary parameters. Then go with who you are comfortable with.

Mr Dulfer brings it all back to collaboration. “When working with doctors, it is vital to listen to and understand what is important to them. And if you are given the opportunity, designing a hospital is exciting and challenging.”

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Cover Story

Matthias Maus – lange@sehkraft.dePatrick C M Schalkwijk – bewerbung@hellundfreundlich.deJaap Dulfer – contekst@gmail.comArthur Cummings – abc@wellingtoneyeclinic.comGlenn Dean – glenn.dean@lillibridge.comWilliam Cooler – bill@coolerdesign.comRudy MMA Nuijts – rudy.nuijts@mumc.nlCarroll Webers – c.webers@mumc.nl

contacts

Our Cover story in July/August will focus on new surgical treatments for glaucoma, especially the new minimally or micro-invasive techniques employing implants such as the istent, the hydrus, the Cypass, the Aquasys and also the trabectome electrocautery device.

With perspectives offered by some of the world's leading glaucoma specialists, the article will trace the evolution of surgical alternatives to trabeculectomy, in light of the latter techniques' known risks for potentially devastating consequences. it will touch on blebless techniques such as selective laser trabeculoplasty, canaloplasty as well as reports from the landmark trabs vs tubes study, leading ultimately to the latest findings obtained with MiGs techniques.

The article will also include discussion of modifications of trabeculectomy that have been developed over the last decade or so and which have been shown to greatly reduce the incidence of such side effects as hypotony, maculopathy and bleb-associated endophthalmitis. Through this perspective, the article will aim to put new minimally invasive glaucoma surgical techniques in their proper context and perhaps provide a window to the future of glaucoma surgery and other iOP-lowering techniques.

New glaucoma treatments

Update

cATAracT & RefracTIve

EUROTIMES | Volume 18 | Issue 6

Unilateral implantation of an aspheric corneal inlay (Raindrop Near Vision inlay [formerly Vue+ and PresbyLens],

ReVision Optics) in the non-dominant eye of emmetropic presbyopes provides rapid, marked improvement in near vision along with very high patient satisfaction, reported researchers at the XXX Congress of the EsCRs.

The transparent, microporous, hydrogel inlay, which measures 2.0mm in diameter and 30 microns thick, is placed under a 150-micron thick femtosecond laser-created flap. it improves near as well as intermediate vision by steepening the central cornea.

Beatrice Cochener MD, PhD, who is an investigator in the multicentre EuroKLEAR trial, presented her perspective on the corneal inlay and outcomes from two studies in North America.

“Unlike other presbyopia-correcting corneal inlays that work by a pinhole or refractive effect, achieving good visual outcomes using this device does not require perfect centration. Additionally stereopsis is unaffected because there is no refractive difference between eyes,” said Prof Cochener, professor and chair, Department of Ophthalmology, University of Brest, France.

“Further follow-up is needed to evaluate long-term efficacy and safety, and we are looking forward to more data from eyes where the inlay procedure is coupled with concurrent or sequential LAsiK to correct ametropia. however, the initial results with the inlay alone and combined with LAsiK are very encouraging.”

Vinod Gupta MD, surgeon, Ultralase Clinics, UK reported positive results from a study of 45 patients and noted that 24 additional patients subsequently received the inlay at his centre with similarly good outcomes.

“For the experienced LAsiK surgeon, the inlay procedure is not difficult to learn, and the only complication encountered has been transitory interface haze in some eyes. however, the haze was successfully managed in all cases with topical corticosteroids and is being mitigated with a new postoperative anti-inflammatory regimen,” said Dr Gupta.

The patients in Dr Gupta’s study were slightly hyperopic on average with low cylinder (mean MsE +0.33 D). Preoperative mean distance UCVA (VAR) was 100 (~20/20) and all had near UCVA worse than N12.

At one month, near vision averaged close to N6 and remained stable thereafter. At last follow-up (range one to six months), all treated eyes had near UCVA of 20/40 or better and 38 per cent saw 20/20 or better.

“With their improved near vision, 100 per cent of patients could read print novels, magazines or instructions, 93 per cent could read newspaper print, and 80 per cent could read the smallest detail markings on tools, which is equivalent to N4 print,” Dr Gupta said.

Mean sE decreased after surgery to -0.5 D and was stable through six months. Distance UCVA in the treated eye decreased to 80 immediately after surgery, but improved to 90 by one month and was stable thereafter.

“The patients remained happy because any loss of distance vision was in the nondominant eye. Binocularly, all patients had distance UCVA of 20/40 or better and 89 per cent achieved 20/20 or better,” Dr Gupta reported.

Prof Cochener presented UCVA data from a series of 27 patients operated on by John Olkowski MD, hawaii, Us, who is an investigator in the Us iDE study of the inlay. Near UCVA was J2 or better in 75

per cent of treated eyes on postoperative day one, reached J1 or better in 90 per cent of eyes by one week, and remained stable to one year based on 12 eyes with available follow-up.

At last follow-up, intermediate vision was improved by an average of about two lines from baseline and was 20/32 or better binocularly in 95 per cent of patients. Distance UCVA was reduced slightly early after surgery, but remained 20/32 or better in 75 per cent of eyes, and all patients maintained 20/25 or better binocular distance UCVA.

“Findings from a study of 20 patients operated on by Enrique Barragan MD, Mexico, show improved performance with near visual tasks in both good and dim light,” Prof Cochener reported.

Prof Cochener also underscored there is strong patient satisfaction with the inlay. she reported that in Dr Olkowski’s series where surveys were completed by patients at each follow-up visit, mean ratings for satisfaction with near, intermediate and distance vision were consistently four or better on a five point scale. Patient satisfaction levels increased over time and at 12 months.

Dr Gupta reported that 96 per cent of patients in his study were satisfied with their outcome. While the remaining four per cent indicated they had hoped for better, 58 per cent said the outcome couldn’t be better, and no one regretted having the procedure.

As with LAsiK, patients should be screened for dry eye preoperatively and are managed with artificial tears postoperatively and punctal plugs as needed.

haze in the interface, developing as a healing response, has been reported. The rate varies across centres, but globally, haze led to inlay removal in very few eyes. Dr Gupta noted haze in six eyes (13 per cent) in his series that was diagnosed at an average of 12 weeks after surgery and diminished after a second round of topical corticosteroid.

“One patient was offered inlay removal but declined because he was happy with his improved reading vision,” Dr Gupta said.

Prof Cochener noted that development of haze is being controlled thanks to the introduction of a new delivery system (EZ Prep) and a more aggressive anti-inflammatory medication regimen. The delivery system preserves cleanliness of the interface while also enabling the ease and speed of inlay placement, and patients are now receiving a four-week tapering course of benzalkonium-free dexamethasone followed by an eight-week course of fluorometholone.

Data from the Dr Olkowski’s series show visual symptoms are not a problem for inlay recipients. Mean scores for difficulty with glare, haloes, blurred vision,

double vision and vision fluctuation were increased slightly from baseline in the first several months after surgery but reached a maximum of only 0.3 to 1.0 (1 = mild) and diminished over time. Responses to additional survey questions confirmed patients had few visual symptoms as well as no decrease in comfort from preoperatively.

Vinod Gupta – vinod@gupta.uk.comBeatrice Cochener – beatrice.cochener@ophtalmologie-chu29.fr

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cORNEal INlaYHydrogel inlay reshapes corneal surface to deliver gains in near and intermediate vision by Cheryl Guttman Krader in Milan

8

Principle of action of the Raindrop Inlay: central elevation of the cornea,

easy release and simple centration of the constricted pupil

The RaindropTM Near Vision Inlay: transparent, highly biocompatible; implanted under a 150µm deep femto-laser flap

Refraction Map (from Tracey wavefront)

The Raindrop Inlay: very small and transparent, 2mm in diameter x 30µm thick

... the initial results with the inlay alone and combined with LASIK are very encouraging

“Beatrice Cochener MD, PhD

The patients remained happy because any loss of distance vision was in the nondominant eye

“Vinod Gupta MD

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EUROTIMES | Volume 18 | Issue 6

A survey of UK corneal specialists reflects the lack of guidelines for the prevention of the recurrence of herpetic eye disease in

patients undergoing cataract surgery, said Rushmia Karim MD, Whipps Cross University hospital, London, UK. Evripidis sykakis MD, from the same hospital, supervised the research.

The results of the survey showed that the great majority of respondents advocated a disease quiescent period of several months before performing cataract surgery, but there was much less agreement regarding antiviral prophylaxis, Dr Karim told the 17th EsCRs Winter Meeting.

“This survey highlights the need for further clinical studies regarding pre-, peri- and postoperative prophylaxis for patients with herpetic eye disease undergoing cataract surgery. At present, there is only anecdotal evidence to support initiation of prophylactic treatment prior to cataract surgery, or for recommendations regarding the timing of drug initiation, dosage and duration of treatment,” she added.

Dr Karim and associates sent a practice-style questionnaire to all members of the

Royal College of Ophthalmologists in the United Kingdom currently registered as cornea consultants. They received 72 replies from the 106 cornea consultants contacted.

The questionnaire consisted of two parts, the first part dealt with patients with cataracts and herpetic eye disease who were not currently receiving acyclovir, and the second part dealt with patients with the two pathologies who were currently receiving the antiviral agent.

Quiescent period necessary Regarding patients not currently receiving antiviral treatment, nearly all respondents recommended a period of several months of disease quiescence before offering surgery. That is, 62.3 per cent of consultants said they would require a quiescent period of three to six months before surgery, 24.6 per cent said they would require a period of more than six months, 10.1 per cent said they would require at least 12 months quiescence, and 0.9 per cent said they would require less than three months.

Opinions were more divided regarding the use of systemic antiviral prophylaxis in patients not receiving such agents, with 58.8

per cent of respondents in favour of and 41.2 per cent against the practice, Dr Karim said. Among those in favour of antiviral prophylaxis, acyclovir was the treatment of choice and 85 per cent said they would start treatment seven days preoperatively.

On the other hand, 72.48 per cent said they would not start topical antiviral treatment and 81.9 per cent said they would not change the steroid regimen from their usual practice in such cases.

Regarding the quiescent period necessary before cataract surgery among patients currently receiving systemic antiviral treatment, 10 per cent of consultants said that they would operate on patients with under three months of quiescent disease, 39.57 per cent said they would require three to six months disease quiescence, 19.1 per cent would require between six to12 months and 8.8 per cent would require over 12 months. Oral antiviral treatment was not increased in 80.9 per cent of replies.

Better guidelines Dr Karim noted that ocular herpes simplex disease is the leading infectious cause of corneal blindness in the developed world. Furthermore, in a UK study, a third of patients with the condition had vision loss severe enough to warrant penetrating keratoplasty. That degree of vision loss occurred after a mean of 6.8 recurrences (Claoué et al, Br J Ophthalmol 1988; 72 ; 530-533).

Ocular surgery is one of many factors which can contribute to the re-activation of herpetic eye disease. The herpetic Eye Disease study Group were able to show in a randomised controlled trial that a

12-month regimen of acyclovir could reduce recurrences of herpetic stromal keratitis by around half, from 28 per cent to 14 per cent, during six months of follow-up (Herpetic Eye Disease Study Group N Engl J Med. 1998 ;339:300-306). however, that study did not concern patients undergoing cataract surgery.

“At present we have no prospective comparative studies that look at the relationship between herpetic eye disease and cataract surgery. And our own Royal College of Ophthalmologists in the United Kingdom has no specific guidelines for patients with hsV [herpes simplex virus] who are going to undergo cataract surgery. There are also no published guidelines in the medical literature in Australia, America or Europe,” Dr Karim said.

she noted that the apparent consensus among UK corneal specialists is that there should be a minimum period of quiescence ranging from three months to one year prior to cataract surgery but consultants are almost equally divided on the use of antiviral prophylaxis. Among those in favour of antiviral prophylaxis all would opt for acyclovir, most likely because it is easily available and cost-effective and because it was the agent used in hEDs trial.

“Our survey’s findings indicate that in patients with herpetic eye disease the cataract pathway is different from the routine cataract surgery pathway that we usually deal with, and i think we do need some prospective clinical studies for this condition,” Dr Karim concluded.

The paper will be published in the June edition of JCRS.

Rushmia Karim – rushmiak@gmail.com

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HSV aND caTaRacTSurvey finds practice variations in prophylaxis against recurrence of herpetic eye disease by Roibeard O’hEineachain in Warsaw

9Update

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EUROTIMES | Volume 18 | Issue 6

There is a growing range of biometry tools and instruments with innovative features designed to allow reliable iOL power calculation in a wide variety of patients, said Claudio Carbonara MD at

the XXX Congress of the EsCRs. “in the early 1980s we used only K readings and the axial

length but now we have a lot of instruments. We have at least five or six new optical biometers, the aberrometers, the Pentacam and some new standalone software,” said Dr Carbonara who is in private practice in Rome, italy.

One of the most recent additions to the cataract surgeon’s diagnostic armamentarium is the Nidek AL-scan, a new optical biometer which comes with the option of customisation with a built-in ultrasound biometer and/or an ultrasound pachymeter.

Dr Carbonara reported that the device is very fast. it performs six different types of measurements in 10 seconds, namely the axial length, the corneal curvature radius, anterior chamber depth, central corneal thickness, white-to-white distance and pupil size.

it also has a signal booster and a signal-to-noise ratio enhancer, which allows it to measure axial length even in eyes with very dense cataracts. For the densest cataracts it has the ultrasound option. Moreover, it has a measurement range of 14mm to 40mm, compared to the 32mm limit of the Lenstar. in addition, unlike the iOL master, its findings are little affected by poor tear film quality. it also has a digital protractor to help with the alignment of toric iOLs.

in a series of 109 eyes of 58 patients, including 12 eyes that had undergone previous refractive surgery for myopia or hyperopia, the instrument produced findings very similar to those of an iOLMaster, Dr Carbonara said. The average difference between the Nidek-AL scan and the iOLMaster measurements was only 0.005mm for axial length with sD 0.039mm and 0.031 mm for anterior chamber depth with an sD of up to 0.125mm. in addition the average differences between the K readings were -0.027 D for the K1 with sD 0.408 D, and -0.180 D for the K2 with sD 0.295 D. The average difference between the axis of astigmatism was 1.524° with an sD of up to 74.316°, Dr Carbonara said.

Another new biometry tool is the Topcon Aladdin, which is an optical biometer and topography instrument. Of all its competitors it is the only one that includes a topographer. it provides complete corneal topography, pupillometry, corneal spherical aberration and axial length measurements in a few seconds: it must be said, however, that the latest version takes a bit more time than the previous one to obtain the same results, leaving the Nidek in first place as the fastest machine (it’s also important to know that Nidek is NOT Windows-based, as opposed to the Topcon Aladdin, which is), he added.

The new device’s keratoscope cone has 24 rings and it can measure axial lengths ranging from 15mm to 38mm. in addition, it has very user-friendly software; it includes the Oculentis formula for toric iOL calculation and includes the sRK/T, holladay, hoffer Q and the haigis formula for the

standard iOL power calculation, as well as the Camellin/ Calossi formula for eyes that have undergone refractive surgery.

in a series of 99 eyes of 53 patients, including eight eyes that had undergone previous refractive surgery, the average difference between the Aladdin and the iOLMaster measurements was only 0.016mm for axial length with sD of 0.048mm and -0.028mm for anterior chamber depth with sD of 0.329mm; as for the K readings, the average differences were between 0.006 D and -0.104 D with sD 0.323 D for K1 and sD 0.301 D for K2. The average difference between the axis of astigmatism was -1.713° with sD of up to 51.042°, Dr Carbonara added.

New aberrometers Aberrometers are also becoming increasingly useful tools in the preoperative assessment of cataract patients. Among the newer devices is Nidek OPD scan, Dr Carbonara said. it combines aberrometry with a wide range of measurements, including topography, autorefraction, keratometry and pupillometry. it also provides a measurement of the angle kappa, which is the difference expressed in millimetres between the visual axis and the pupillary axis.

“in a patient who has a high angle kappa, implanting a multifocal iOL will increase the risk of postoperative phenomena such as blur, astigmatism, double vision, defocus and coma.”

The device provides a predefined clinical summary, depending on the procedure that the surgeon is planning to perform. For example, in the case of cataract surgeries the summary includes the refraction, topography, the pupil size, the pupil position, the degree of astigmatism, the higher order aberrations and the Kappa angle. if the surgeon needs to implant a Premium iOL it can be useful also to check the Wavefront summary and at the Optical Quality summary.

Another aberrometer that can prove useful in cataract surgery patients is the iTrace aberrometer (Tracey), which uses ray-tracing technology. The iTrace has a toric iOL calculator that makes its calculation based on the size and position of the incision and the type of iOL to be implanted. Another of its helpful features is its “Chang Analysis” software, which identifies the source and quantifies the magnitude of the aberrations.

“Knowing the amount of corneal aberrations helps determine whether or not a cataract patient is a good candidate for a premium iOL,” Dr Carbonara commented.

New software Finally, there are many new types of standalone software programs, such as the holladay iOL Consultant – surgical Outcomes Assessment Program, which performs calculations for a wide range of clinical situations including toric iOLs, post refractive surgery eyes, silicone oil-filled eyes. Furthermore, it has a complete database of all types of iOL.

“This software has a fast and easy connection to both the iOLMaster and the h-s Lenstar Ls 900. it extracts the complete patient and iOL information from the iOLMaster database. You have to remember that the iOLMaster does not a make a complete backup of its database,” Dr Carbonara said.

"if you click on the backup button of the iOLMaster it will back up only the patient and iOL data used for the personalisation of the constants. No other data are saved. instead, if you extract the database using the hiC-sOAP software you will be able to access all the data in Excel format as well."

The Nidek iOLstation is another new suite of programs for iOL calculation. Developed by Nidek and Paolo Vinciguerra MD, it has the distinction of being the only software that provides calculations based on the residual spherical aberration desired, using topography and keratometry and internal eye measurements. it also provides a simulation of the quality of vision likely to be achieved postoperatively.

in addition, there is the Eye Pro software for the iPhone and iPad available online at the App store. it provides iOL calculations using the sRK and hoffer Q formulas as well as Double K formulas and the Borasio iOLMaster regression formula for eyes that have undergone previous refractive surgery. The software also includes the BEsst 2.0 formula, based on Pentacam measurements for patients who have undergone either refractive hyperopic or myopic surgery, and a lot of other useful features, such as a toric calculator, a toric misalignment calculator and a corneal-to-spectacle plane converter.

Dr Carbonara also recommended that cataract surgeons occasionally review what he considers to be the “Bible of Biometry” at www.doctor-hill.com, which provides thorough explanations regarding biometry instruments, iOL power calculation formulas and all the information needed to obtain perfect surgical and biometric results.

Claudio Carbonara – carboeye@iol.it

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NEW BIOMETRY TOOlSaberrometers are becoming increasingly useful tools in the preoperative assessment of cataract patientsby Roibeard O’hEineachain in Milan

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EUROTIMES | Volume 18 | Issue 6

A new method of quantifying corneal topographic astigmatism (CorT) has been shown to correspond better to manifest refractive cylinder than other commonly used measures and could

lead to more accurate measurement of corneal astigmatism and ultimately better visual outcomes for patients, according to a recent Australian study.

“Our study showed that when compared to the manifest refraction cylinder, CorT was found to be a better measure of corneal astigmatism than currently used methods such as simulated K, manual K, corneal wavefront or paraxial curvature matching because it is based on more data from a wider area of the cornea,” said Noel Alpins FRACs, FRCOphth, FACs, lead author of the study with James KY Ong BOptom and George stamatelatos BscOptom (see Journal of Cataract & Refractive Surgery Vol. 38, Issue 11, Pages 1978-1988).

Dr Alpins noted that using CorT gives a more accurate measurement of astigmatism of the whole cornea or hemidivision of the cornea, as well as the optimal orientation of the incision, ablation, or toric intraocular lens required for that particular eye. importantly, it also serves to reduce the disparity between different topographers in calculating astigmatism values.

“Corneal irregularity is quantified by several topographers with varied parameters that are not directly comparable to each other. having corneal topographic astigmatism semi-meridian values with topographic disparity provides us with the ability to standardise corneal irregularity assessment between these different topographers,” he said.

Dr Alpins’ retrospective study assessed topographic data in 486 virgin right eyes and 485 virgin left eyes of 498 patients (190 men and 308 women; age 19 to 64 years). 12 right eyes and 13 left eyes were excluded because more than 10 per cent of the topographic data was missing from ring 7 due to upper lid interference, which could have led to unreliable simulated K measurements.

For each Placido ring, an astigmatism value was calculated and the ring astigmatism values were combined via vector summation to create a new measure – CorT. This parameter was then assessed against other commonly used measures of corneal astigmatism using the ocular residual astigmatism (ORA) and its standard deviation (sD) on how closely each measure matched manifest refractive cylinder.

While computer-assisted videokeratography provides multiple concentric Placido rings, most of these rings currently do not contribute to quantifying corneal astigmatism as displayed on simulated K, explained Dr Alpins. “One of the main problems with simK is that it can come up with a significant amount of variability if it is reading an uneven area of the cornea. By contrast, CorT takes more than just one ring of the topographer. it includes all of them – 22, 24 or 26 depending on the topographer – and then takes an average using a vectorial method. By performing an average, if one reading is an outlier, it will be diluted by all the other readings which are much more

accurate. This means that we get a lot less variability and a lot more accuracy with the CorT value,” he told EuroTimes.

While this enhanced accuracy works for all types of cornea, Dr stamatelatos believes that CorT works particularly well for more irregular corneas.

Dr Alpins said that the study clearly demonstrated that CorT provided less variability and greater accuracy than data obtained with manual keratometry, simulated keratometry, corneal wavefront and paraxial curvature matching.

“That is already significant, but we also found that CorT matches the manifest refractive cylinder closer in magnitude and orientation, not just in the spread of the ORA, than the other measures of corneal astigmatism. The reason we chose manifest refractive cylinder as a benchmark is because it is a measure of the total ocular and perceived cylinder and is also used as the reference in prescribing spectacles and performing excimer laser surgery,” he said.

With the initial study of CorT now published in the JCRS, the next step for Dr Alpins and his co-authors is to disseminate the results as widely as possible and ensure that CorT is integrated into the leading topographers on the market.

“We have been introducing CorT at all the major ophthalmic meetings and will be presenting more information and data about it in the coming months,” said co-author Dr stamatelatos.

Dr Alpins and Dr stamatelatos have a financial interest in the AssORT ® outcomes analysis software.

cORNEal aSTIGMaTISMNew method gives more accurate measurement of astigmatism of the whole corneaby Dermot McGrath

contact Noel Alpins – alpins@newvisionclinics.com.au

Update

cATAracT & RefracTIve

The figure displays the difference in orientation between the corneal astigmatism as measured by Sim K and refractive cylinder (R). The corneal topographic astigmatism

(CorT) lines up closer to the refractive cylinder axis than Sim K

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Main SymposiaSaturday 5 October ESCRS/EuCornea SymposiumRefractive Surgery in Risky Corneas: Is it Really Safe for the Patient?

Chairpersons: B. Cochener FRANCE

R. Nuijts THE NETHERLANDS

Sunday 6 October Femtosecond-assisted Cataract Surgery: Euphoria Amid Skepticism and Financial Restraints

Chairpersons: G. Grabner AUSTRIA

Y. Henry THE NETHERLANDS

Monday 7 October Unravelling the Mysteries of Myopia

Chairpersons: D. Epstein SWITZERLAND

G. Luyten THE NETHERLANDS

Tuesday 8 October The Management of High Hyperopia

Chairpersons: J. Güell SPAIN

R. Lapid-Gortzak THE NETHERLANDS

Wednesday 9 October Treating Astigmatism with Cataract Surgery

Chairpersons: O. Findl AUSTRIA

D. Spalton UK

Binkhorst Medal LectureDouglas Koch USA

The Ablated Cornea: What Have We Done?

Sunday 6 October

Ams t e r d a mAm s t e r d a m20 1 3

5 -9 OCTOBER

XXXI congress of the escrs

This year’s programme not to be missed!

Clinical Research Symposia Saturday 5 October

• Treatment of Macular Edema

Chairpersons: P. Barry IRELAND

R. Nuijts THE NETHERLANDS

• Basic Research on the Crystalline Lens and IOLs Restoring Accommodation

Chairpersons: G. Auffarth GERMANY

M. Tetz GERMANY

• Effects of Phakic IOLs

Chairpersons: M. Knorz GERMANY

T. Kohnen GERMANY

• Corneal Stem Cells: A Future for Therapy of Corneal Disease

Chairpersons: H. Dua UK

F. Majo SWITZERLAND

Other Highlights Saturday 5 October

• Refractive Surgery Didactic Course

• Video Symposiumon Challenging Cases

Chairperson: R. Osher USA

• Young Ophthalmologists Programme

Chairpersons: O. Findl AUSTRIA

S. Morselli ITALY

K. Vannas FINLAND

Monday 7 October

• Combined Symposium of Cataract and Refractive Surgery:

Controversies and Ethical Issues in Clear Lens Extraction (CLE)

www.escrs.org

Sunday 6 October

• Journal of Cataract & Refractive Surgery Symposium:

Questions for the Cataract and Refractive Surgeon in 2013

Chairpersons: E. Rosen UK (European Editor)

T. Kohnen GERMANY (European Associate Editor)

• Netherlands Intraocular Implant Club Symposium

Chairperson: R. Nuijts THE NETHERLANDS

• Video Awards Session Chairperson: R. Packard UK

• Workshop on Visual Optics

Chairpersons: I. Pallikaris GREECE

M.J. Tassignon BELGIUM

• Young Ophthalmologists Session: Taking Training into Your Own Hands

Chairpersons: O. Findl AUSTRIA

N. Hirnschall AUSTRIA

T. Rudolph SWEDEN

9445

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Saturday 5 October Lunchtime SymposiaLunchtime symposia includes box lunches

13.00 – 14.00

Technolas Satellite Meeting

Sponsored by

Croma Satellite Meeting

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Ziemer Satellite Meeting

Sponsored by

The Toric Solution: Exceeding Expectations in the Management of Astigmatism

Sponsored by

Abbott Medical Optics Satellite Meeting

Sponsored by

Topcon Satellite Meeting

Sponsored by

Master Your Refractive Outcomes with the LENSTAR LS 900

Sponsored by

Heidelberg EngineeringSatellite Meeting

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Evening Symposia18.15

Staar Satellite Meeting

Sponsored by

Live Surgery:Advancements in Techniques and Technologies

Sponsored by

Refractive Cross-linking: The Future

Sponsored by

Satellite Meeting ScheduleEUROTIMESESC

RS ™

SATELLITE EDUCATION PROGRAMME

Sunday 6 October Lunchtime SymposiaLunchtime symposia includes box lunches

13.00 – 14.00

Alcon Satellite Meeting

Sponsored by

Alcon Satellite Meeting

Sponsored by

Complex Cataract Cases, the Simple Truths

Sponsored by

Croma Satellite Meeting

Sponsored by

Discover Precise Approaches by Experiencing Latest Zeiss Refractive Laser Technologies

Sponsored by

Bausch + Lomb & Croma-Pharma Symposium

Sponsored by

Leading Technology in Refractive Surgery

Sponsored by

DORC goes Anterior: EVA a New Dimension in Cataract Surgery and Other Anterior Innovations

Sponsored by

Ellex Satellite Meeting

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Setting Expectations for Your Cataract Patients with Co-Morbidities: New Technologies that Help You Manage the Cataract and the Disease

Sponsored by

New Frontier of Cataract Diagnosis

Sponsored by

Abbott Satellite Meeting

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Evening Symposia18.00(Buses will depart from the Congress

Centre at 18.00)

Alcon Satellite Meeting

Sponsored by

Monday 7 October Lunchtime SymposiaLunchtime symposia includes box lunches

13.00 – 14.00

Alcon Satellite Meeting

Sponsored by

Technologies and Techniques for Optimizing Corneal Inlay Outcomes

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The Cutting Edge of MICS: Introducing INCISE IOL

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Prevention of Post-Operative Endophthalmitis. What’s New?

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Orbis Satellite Meeting

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NeXt Generation of LENTIS® premium IOLs

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IRIDEX MicroPulse™ Laser Therapy Satellite Meeting

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Ams t e r d a mAm s t e r d a m20 1 3

5 -9 OCTOBER

XXXI congress of the escrs

Satellite Meeting Schedule

Update

cORneA

EUROTIMES | Volume 18 | Issue 6

Trachoma is endemic in about 50 countries, including much of Africa, parts of india and southeast Asia, and even in remote regions of China and Australia. As many as eight million

people have impaired vision and half of these have advanced disease, with inward-turned eyelashes threatening their corneas.

“Trachoma is the most common infectious cause of worldwide blindness, the leading cause of preventable blindness and until recently the second commonest cause of worldwide blindness after cataract,” Robert M Feibel MD, professor of clinical ophthalmology at Washington University school of Medicine, st Louis, Missouri, Us, told the 2012 American Academy of Ophthalmology meeting.

Yet from a historical perspective, trachoma is on the ropes – so much so that the World health Organization has declared that the global elimination of trachoma as a blinding disease by 2020 can be achieved, Dr Feibel noted. since 1981, the worldwide population estimated to have active trachoma infections has fallen more than 90 per cent, from 500 million to 40 million.

improved public sanitation and personal hygiene in developing areas combined with targeted medical and surgical intervention are behind the gains, Dr Feibel said. in a few years, they might finally knock out an infectious menace that has pummelled humanity since ancient times.

Greek for ‘rough’ Caused by Chlamydia trachomatis, acute infectious trachoma is a disease of small children, Dr Feibel said. With repeated infection, as is common, it becomes a chronic cicatricial disease in adults, with secondary entropion, trichiasis and corneal scarring, often leading to blindness.

References to trachoma date back to 2700 BC in ancient sumerian and Chinese civilizations, Dr Feibel said. Ebers’ papyrus, the oldest known medical text, dating from 1500 BC, documents the importance of trachoma in ancient Egypt.

“This text describes trichiasis and muco-purulent discharge, and 10 per cent of its prescriptions relate to topical ocular medications.”

The ancient Greeks and Romans also recognised trachoma as a chronic, blinding disease described by hippocrates, who treated it medically and surgically. “The word trachoma comes from the Greek word for rough, describing large follicles in the palpebral conjunctiva,” Dr Feibel said.

indeed, the treatments they devised were scarcely improved upon for thousands of years, during which trachoma shaped human history, and prompted development of ophthalmology as an independent specialty.

Trachoma invades Europe in the late 18th century, trachoma, then called ophthalmia, was so prevalent in north Africa that Egypt was known as the land of the blind, he said. When French and British armies invaded in 1798, they contracted ophthalmia and carried it back to Europe.

“in the next century, the Egyptian ophthalmia had greater impact on civilian and military affairs than any other disease since the bubonic plague.”

During the Napoleonic wars from 1798 to 1815, major outbreaks were seen in European armies. Blinded soldiers were sent home in large numbers, igniting epidemics in civilian populations.

“The disease was so unexpected, so severe and so widespread that it sparked a revolution in public health and medical care,” Dr Feibel said.

Large hospitals were devoted to ophthalmia cases, including Moorfields in London. Thousands lost their sight and public asylums were erected.

Ophthalmology also thrived. The resources devoted to ophthalmia and the invention of the ophthalmoscope in 1850 helped transform ophthalmology from a branch of surgery into a specialty of its own.

More important, public health initiatives, including securing clean water and eliminating open sewers and garbage heaps, took hold. sanitation brought trachoma and many other diseases under control decades before the infectious organisms causing them were identified, he said.

indeed, through the mid-19th century, environmental factors, such as dust or heat, or possibly moisture, were commonly thought to cause ophthalmia. "The British physician, John Vetch, in 1807, was the most important doctor to insist that the disease was transmitted by the conveyance of purulent material from the infected to the healthy eye. The recognition that trachoma was contagious proved an important step in controlling the spread of this disease," Dr Feibel said.

Based on symptoms described, early 19th century ophthalmia almost certainly included infectious keratoconjunctival diseases ranging from the relatively harmless Koch-Weeks’ to gonococcal infections that destroyed the cornea and sometimes the entire globe within weeks, he said. The name trachoma was applied later in the 19th century. But bacteria wasn’t proven the cause until the 1930s. indeed, Chlamydia trachomatis wasn’t isolated until 1957.

Antibiotics Despite progress in sanitation, trachoma remained a worldwide pandemic well into the 20th century, he said. in 1897, it was the first contagious disease designated by the Us as cause to deny entry to persons into the Us from foreign countries. immigrants were examined for trachoma and for decades, it was the leading cause of deportation.

There was no effective treatment, Dr Feibel said. Copper sulphate was used to suppress infection, diseased conjunctival follicles were expressed with roller forceps, or scraped or excised, which was effective in only about 20 per cent of cases.

The breakthrough came in 1938, when Fred Loe MD showed that oral sulphonamide antibiotics cured 90 per cent of cases.

“The tedious medical therapies, and painful and disfiguring surgeries were immediately obsolete,” he said.

Today, the same factors that eliminated trachoma in the developed world are working in the developing world, Dr Feibel said. The current strategy is called sAFE, for surgery, Antibiotics, Facial cleanliness and Environmental change. But for eyelid surgery and antibiotics to work, cleanliness is essential.

Rising standards of living are bringing about environmental changes, including access to clean water and proper waste sanitation, he said. People are taught personal hygiene, including not sleeping together and washing faces and hands. Then, antibiotic treatment can treat and prevent active infection, breaking the reinfection cycle, allowing surgery patients to recover.

“Tremendous progress has already been made. With sustained effort and funding, these campaigns might end the 5,000 year history of blinding trachoma,” Dr Feibel said.

Robert M Feibel – feibelr@gmail.com

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ElIMINaTING TRacHOMa after 5,000 years, end of ‘Egyptian Ophthalmia’ may be in sightby Howard Larkin in Chicago

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Active follicular trachoma

Cicatricial trachoma

Trichiasis and corneal scarring from trachoma

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EUROTIMES | Volume 18 | Issue 6

Ocular rosacea is an underdiagnosed and potentially blinding condition that requires a long-term treatment strategy,

said Jesús Merayo Lloves MD, Oviedo, spain, at the 17th EsCRs Winter Meeting.

Rosacea is a chronic skin disease that occurs most frequently in Caucasians between the ages of 30 and 60. in the Us alone it affects 13 million people. in 80 per cent of patients there is ocular involvement. however, skin manifestations of rosacea are present in only 10 per cent of patients with ocular rosacea, Dr Merayo Lloves said.

The typical symptoms are similar to those in eyes with dry eye and include foreign body sensation, photophobia, pain, itching, redness and watering eyes. Clinical signs include erythema, telangiectasia and irregularity of lid margins, and meibomian gland dysfunction.

Ocular rosacea involves the cornea in 13 per cent of cases, and five per cent require keratoplasty procedures. Five per cent end up with a visual acuity below 20/200.

Inflammatory response The condition is a “photo-aggravated inflammatory disorder” that involves altered immune responses leading to vascular and inflammatory abnormalities. Known predisposing factors include a patient’s genetic background, infection with h pylori, infestation with D Folliculorum and seborrhoea. Ocular rosacea causes a loss of the ocular surface’s lipid layer which leads to an evaporative dry eye condition, which in turn increases the osmolarity of the eye and triggers an inflammatory response. The mechanism involved in rosacea conjunctival inflammation resembles a type iV hypersensitivity reaction.

There are a range of preventive measures that patients can take to prevent ocular manifestations of rosacea. They include the avoidance of things that induce ocular inflammation or increase the risk of dry eye. Therefore, corneal surgery is contraindicated, as are contact lenses. Ocular rosacea patients should also avoid exposure to toxic environmental factors, tobacco smoke in particular. There are nutritional options, such as omega 3 fatty acids, vitamin

supplementation and antioxidants that could in theory be of benefit.

Treatment includes the adoption of scrupulous lid hygiene by the patient, the use of warm compresses, lid massage, lid cleaning and lubricants. Tetracyclines also appear useful, not so much for their antibiotic effects as for their apparent immunomodulatory effects. however, there have as yet been no studies comparing the agents with placebo. For severe dry eye associated with rosacea Dr Merayo-Lloves recommends the use of haematic derivatives, particularly autologous plasma rich in growth factors (PRGF) according with the data presented in his observational study.

Breath test The treatment of associated diseases such as h pylori infection and Demodex mite infestation are essential. Diagnosis of the condition is possible by means of a urea breath test, when that test is negative, a biopsy may provide a more definitive answer. Treatment of h Pylori infection in ocular rosacea patients is the same as in the treatment of cases of gastric ulcer and consists of a seven-to-10-day regimen of amoxicillin, clarithromycin and omeprazole.

Demodex infestation can be diagnosed through microscopic examination of a patient’s eye lash. Treatments for the condition include topical ivermectin eye drops. There are also formulas that can be composed at any pharmacist consisting of metronidazole and permethrin, as well as shampoos and oils containing tea tree oil.

“Ocular rosacea is an under-recognised potential blinding disease. Usually it is in relation with severe dry eye and if surgery is performed on an inflamed eye it could eventually end in a disaster. Long-term treatment and patient education about avoiding aggravation could keep the eye with no active inflammation. Research is focusing in biomarkers for correct diagnosis and trials for new treatments. At present it is underdiagnosed, despite its potential to cause blindness,” Dr Merayo-LLoves concluded.

OcUlaR ROSacEaSight-threatening condition often missed by ophthalmologistsby Roibeard O’hEineachain in Warsaw

Jesús Merayo-Lloves – merayo@fio.as

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18

EUROTIMES | Volume 18 | Issue 6

Corneal Collagen crosslinking (CXL) has been adopted by physicians worldwide as a first-line treatment for progressing keratoconus, however, its presumed synergism with other treatment

modalities has yet to be proved, said David Touboul MD, ChU Bordeaux, France.

“We do not know a lot about combined corneoplastic treatments for keratoconus. Robust validation studies with long-term follow-up are not always the rule in the world of collagen cross-linking innovations,” Dr Touboul said at the 17th EsCRs Winter Meeting in a presentation he co-authored with the late Joseph Colin MD.

some of the combinations now in use include intracorneal ring segments plus collagen cross-linking, photorefractive keratectomy (PRK) plus collagen cross-linking, and intracorneal ring segments plus PRK plus collagen cross-linking. Microwave keratoplasty is another emerging technology which may be useful in combination with collagen cross-linking in the treatment of keratoconus.

Although these combined procedures are likely to work synergistically, it remains difficult to weigh the impact of each component of combined treatments because of intrinsic confounding interactions.

Among the confounding factors are those which affect the course of keratoconus, such as the stabilisation that occurs with age, the presence or absence of atopy and its associated eye rubbing, tear film fluctuation and epithelium remodelling.

Furthermore, every corneoplastic procedure for keratoconus can lead to a corneal stabilisation and a refractive improvement. intracorneal ring segments induce a redistribution of stress that flattens the cornea and reduces the irregular curvature, making the eye more amenable to treatment with contact lenses.

Collagen cross-linking mainly serves to stiffen ectatic corneal tissue and thereby halt the progression of keratoconus. however, it also induces a reduction in corneal curvature and may also induce changes to the stroma's refractive index.

Topography- or wavefront-guided PRK can reduce also corneal irregularity and can fine-tune the postoperative refraction after implantation of intracorneal ring segments and prior to collagen cross-linking to halt the keratoconus.

There are numerous factors that can influence a surgeon's decision whether or not to use a combined procedure in a keratoconus patient. They include the patient's tolerance or otherwise of rigid contact lenses, the degree of ametropia, the severity of keratoconus and corneal thickness.

however, studies published to date have yet to establish how much each treatment adds to the other when used in combination. What also remains to be determined is whether collagen cross-linking and intracorneal ring segment insertion, though safe on their own, are safe when used in combination.

Dr Touboul noted that in an unpublished study which he and his associates carried out involving 34 eyes that

underwent ring segment insertion and collagen cross-linking simultaneously, uncorrected and best-corrected vision improved by a mean of three lines. in addition, the maximal keratometry value decreased by a mean of 4.0 D.

Furthermore there were no instances of epithelial problems and there was no change in endothelial cell counts. in addition, when viewed by confocal microscopy the corneal stroma's healing response to collagen cross-linking was identical to that in eyes that underwent cross-linking alone. however, there were extrusions of the ring segments at three and 12 months' postoperatively in two eyes.

Dr Touboul noted that performing intracorneal ring implantation and collagen cross-linking on the same day has the advantage of involving only one surgery for the patient. however, it is best reserved for very predictable cases and highly progressive cases. in more challenging cases and those that are no longer progressing it is better to first implant the ring segments and a few months later perform cross-linking if the implants have produced a good result.

Collagen cross-linking can also be combined with PRK, but literature on the combination is sparse and results have only been published for 400 eyes, 325 of which were from a study by John Kannelopoulos MD in Athens (Kannelopoulos et al, J Refract Surg 2009; 25:S812-8. Doi: 10.3928/108159X-20090813-10). The results of the study were encouraging although some patients did not have significant reductions in their higher-order aberrations, Dr Touboul said.

he also cautioned that cross-linking performed after PRK, as in the Athens protocol, has some additional safety issues. The ablation of Bowman's membrane means that the riboflavin will penetrate more deeply into the stroma. There has been one report in the literature of a tendency for more persistent haze in eyes following the combined procedure (Kymionis et al. Invest Ophthalmol Vis Sci. 2010 Oct;51(10):5030-3). Reducing the duration of exposure riboflavin may reduce the incidence of that complication.

Also under investigation are triple procedures that combine intracorneal ring segments, PRK and collagen cross-linking. One recent study involved 45 eyes and 40 patients. simultaneous PRK and cross-linking a minimum of six months after intracorneal ring segment insertion resulted in a significant improvement in both corrected and uncorrected vision at six months. Furthermore, no patient lost lines of corrected distance visual acuity. in 11.1 per cent of eyes mild haze persisted at 12 months after treatment. (Kremer et al, J Cataract Refract Surg. 2012 ;38(10):1802-7.)

Keraflex® (Avedra) is a recent addition to the refractive surgeons' armamentarium which may also prove useful in the treatment of keratoconus. it is a procedure that involves the use of microwave energy to cause an annular shrinking in the cornea's paraxial area to produce a central flattening, and then locking the changed refraction into place using collagen cross-linking.

contact David Touboul – david.touboul@chu-bordeaux.fr

cOMBINED TREaTMENTSNumerous factors influence a surgeon’s decision whether or not to use a combined procedure by Roibeard O’hEineachain in Warsaw

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19

EUROTIMES | Volume 18 | Issue 6

A new system called LipiFlow® (Tearscience), designed to remove obstructions in the meibomian gland through the

application of heat and gentle pulsatile pressure, appears to increase the lipid content of the tear film and reduce ocular discomfort in patients with evaporative dry eye disease, said Matteo Piovella MD, Centro Microchirurgia Ambulatoriale, Monza, italy.

“This new system provides an effective and efficient means of treatment for meibomian gland dysfunction and evaporative dry eye. For patients with meibomian gland dysfunction, this treatment should be considered prior to laser-assisted refractive surgery or advanced technology lens implantation in order to optimise the tear film and thus optimise surgical outcomes,” Dr Piovella told the 17th EsCRs Winter Meeting.

in a study that involved 40 eyes of 21 patients with meibomian gland dysfunction (MGD) and dry eye syndrome, treatment with the Lipiflow system brought about a reduction in symptoms and an increase in the thickness in the lipid layer of the tear film, as quantified by the LipiView® interferometer (Tearscience), in all patients by one month.

Meibomian gland obstructions The LipiFlow device clasps the eyelid with an inner portion that applies heat to the inner eyelid and an outer portion that applies pulsatile pressure to the outer eyelid. The treatment is an in-office procedure that takes 12 minutes and is designed to liquefy and evacuate meibomian gland obstructions. The LipiView interferometer operates on the principle of broad-spectrum white light interferometry, and quantifies the lipid content of the tear film in terms of interferometric colour units (iCU).

“The interferometer that the Tearscience system uses to determine tear film quality gives you a simple result that you can quantify and this helps you determine what the best treatment for the patient will be. The interferometer also gives you the opportunity to detect any difference between the tear film before and after treatment as regards the meibomian gland production,” Dr Piovella said.

Patients reported no discomfort or pain during or after treatment. in addition, the mean pre-treatment iCU score is increased by 45.75 per cent from 46.05±13.68 to 67.12±23.65 at one month post-treatment. Furthermore, expression of the meibomian gland using a standardised technique provided further evidence of improved meibomian gland functionality.

Dr Piovella noted that studies show that MGD is present in up to 90 per cent of eyes with evaporative dry eye. MGD results in a reduced secretion of meibum which, in turn, decreases the lipid layer thickness of the tear film. That, in turn, results in an increase in evaporation, which decreases the thickness of the tear film’s aqueous layer. The expression of obstructions to the gland can restore its function, he said.

“This treatment only takes 12 minutes and it is free of complications. it allows the patient to return to daily life on the day of the treatment and the efficacy of the treatment has been shown to last up to 18 months before needing to be repeated. The weak point is that it is very expensive which might prevent it from being widely used,” Dr Piovella concluded.

New treatment system improves quality of tear film and quantifies the change by Roibeard O’hEineachain

contact Matteo Piovella – piovella@piovella.com

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MEIBOMIaN GlaND

Eyelid margin before (top) and one week after (bottom) Lipiflow treatment: Meibomian glands excretory ducts show a

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gLAucOmA21

EUROTIMES | Volume 18 | Issue 6

Combined and sequential phacoemulsification and trabeculectomy both have their advantages and disadvantages, but there is a growing consensus that there are specific indications for both

approaches, according to two discussants in a debate on the topic held at the 17th EsCRs Winter Meeting.

“The number of patients needing surgery for both cataract and glaucoma is likely to increase as life expectancy increases. People have also come to expect a better quality of life and many would prefer treatment of both their glaucoma and cataract in one procedure rather than two,” said Tomasz Zarnowski MD, chair of ophthalmology, Medical University Lublin Poland.

One of the disadvantages of the combined phacoemulsification and trabeculectomy approach is that it is inferior to trabeculectomy alone in terms of iOP reduction, as several studies have demonstrated. For example, in one well-conducted trial, the mean iOP fell by only 6.7 mmhg in eyes that underwent the combined procedure, compared to 11.4 mmhg in eyes that underwent trabeculectomy alone (Lochhead et al, Br J Ophtalmol 2003:87: 850-852).

On the other hand, he noted that a study he and his associates conducted indicates that much of the benefit gained from first performing trabeculectomy alone will be lost if the patient later requires a cataract procedure. The study showed that in 50 patients who had previously undergone trabeculectomy, cataract surgery resulted in a mean increase in iOP of 2.0 mmhg at six months, one year and 18 months.

“it's not just a matter of pressure, but also the morphology of the bleb which deteriorates and flattens after phaco in eyes that have undergone previous trabeculectomy,” Dr Zarnowski said.

Patient selection The ideal candidate for a phacotrabeculectomy procedure would be an older patient aged around 80 years with fairly advanced glaucoma and significant nuclear cataract. The cataract should be an otherwise simple case, with a wide pupil, a good conjunctiva and preferably the eye should have not undergone previous surgery.

The surgeon performing the procedure should be skilled in both glaucoma and cataract surgery. Those who feel they lack the necessary expertise should probably just perform the cataract procedure and refer the patient on for the glaucoma surgery. The centre where the patient undergoes the surgery must also be capable of undertaking the demanding follow-up such cases require.

he noted that in a study he and his associates conducted involving 75 eyes of 64 patients who underwent one site-phacotrabeculectomy plus mitomycin C, more than 90 per cent of patients maintained a 30 per cent reduction in iOP at five years' follow-up,

The mean number of iOP-lowering medications patients were using fell from 1.6 before surgery to 0.59 at 12 months follow-up. however, by five years the number of medications needed rose to a mean of 1.15.

Combined approach One reason to consider a sequential approach in eyes with glaucoma and cataract is that cataract surgery alone provides a sufficient iOP reduction in some cases, especially those with angle closure glaucoma and those with early stage of primary open angle glaucoma, said Ewa Mrukwa-Kominek MD, PhD, Department of Ophthalmology, Medical University of silesia, Katowice, Poland. she noted that in a study she and her associates conducted involving patients with primary angle-closure glaucoma who underwent phacoemulsification, mean iOP fell from a preoperative value of 19.7 mmhg to 15.5 mmhg. in addition the mean number of iOP-lowering medications the patients required fell from 1.9 to 0.5.

“Cataract surgery not only eliminated pupillary block, but also attenuated any anterior positioning of the ciliary process,” Prof Mrukwa-Kominek said.

in eyes with open-angle glaucoma, cataract surgery reduces iOP by 1.0 to 3.0 mmhg. in her own research phacoemulsification was at its most effective in lowering iOP among those that had the highest iOP.

That is, those with the highest preoperative range of iOP, 21.0 mmhg to 30 mmhg had a mean reduction of 27 per cent in iOP at the end of the study. By comparison, those with iOP of 15 mmhg to 17 mmhg Mercury had only 10 per cent reduction in iOP. Eyes of pseudoexfoliation also had a greater than average drop in iOP following cataract surgery.

Patients in whom glaucoma surgery alone would most likely be the best option are those with a high amount of optic nerve damage and visual field loss but without significant lens opacity, she said.

she noted that the consensus of the World Glaucoma Association is that cataract patients with mild-to-moderate

glaucoma that is adequately controlled with one to two drugs should undergo phacoemulsification alone.

however, those with advanced glaucoma and early to mild-to-moderate cataract should undergo trabeculectomy first followed by cataract surgery a minimum of six months later. Uncontrolled glaucoma or controlled glaucoma requiring more than two drugs together with cataract patients can be an indication for phacotrabeculectomy.

“A careful history with thoughtful and thorough clinical assessment with the aid of emerging technologies and carefully planned surgical steps and a fully informed consent process will increase the chance of a satisfactory outcome for the majority of patients,” Prof Mrukwa-Kominek added.

GlaUcOMa aND caTaRacT

by Roibeard O’hEineachain in Warsaw

combined and sequential procedures both have their indications

Glaucoma patient with hard cataract and small stable visual field damage required cataract surgery first

Shallow anterior chamber in close angle glaucoma patient with hard cataract (a); AS-OCT before (b) and after cataract removal (c)

Tomasz Zarnowski – zarnowskit@poczta.onet.plEwa Mrukwa-Kominek – emrowka@poczta.onet.pl

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23

EUROTIMES | Volume 18 | Issue 6

Does treatment with cholesterol-lowering statin drugs reduce the risk for developing glaucoma? A review of a large patient database suggests the answer may be yes. Joshua D stein MD,

Ms and colleagues recently reported findings from a study they conducted which supports the notion that statins may be beneficial in patients with open-angle glaucoma (OAG). The findings along with additional evidence from population-based studies and the basic science literature, provide justification for undertaking a prospective interventional study to investigate a role for statins in OAG management [Ophthalmology 2012;119:2074-81].

Dr stein and colleagues from the University of Michigan, Ann Arbor, evaluated associations between statin treatment and risks of OAG development and disease progression using data from enrollees in a large managed care network with members throughout the Us. They identified approximately 524,000 patients age 60 years or older who had hyperlipidemia and received eye care between 2001-2009. About 316,000 of those patients had at least one prescription for a statin, of which some 93,000 also received a non-statin lipid-lowering medication, and about 21,000 patients were prescribed a non-statin only during their time in the plan. in multivariable regression analyses, after adjustment for sociodemographic factors and medical and ocular comorbidities, they found a statistically significant, duration-related effect of statin treatment on the risk for developing OAG, with the risk decreasing 0.3 per cent for every additional month of statin treatment. in addition, every additional month of statin treatment conferred a 0.4 per cent decreased risk for both progression from a diagnosis of glaucoma suspect to OAG and for requiring medical treatment for OAG.

statin treatment did not affect the likelihood of OAG patients requiring glaucoma surgery, leading the authors to suggest that statins might be protective in earlier stages of glaucoma rather than later in the disease course. Treatment with non-statin lipid-lowering drugs had no effect on the risks for developing OAG or progression from glaucoma suspect to OAG, suggesting that the beneficial effects of statins are not simply related to lowering of cholesterol.

Based on the results, Dr stein and co-author David C Musch PhD, MPh, submitted a clinical trial planning grant to the Us National Eye institute and received funding to create the infrastructure for a multicentre randomised controlled trial that aims to provide better understanding of whether or not statins may prevent the progression of OAG. “While there is mounting evidence that statins may be beneficial for OAG, it would be premature for eye care providers to change their practice patterns just yet because statins, like all medications, have side effects,” said Dr stein, assistant professor of ophthalmology and visual sciences, University of Michigan.

“We hope the randomised controlled trial we are spearheading will provide us with sufficient evidence to confidently make recommendations about whether statins

are beneficial in patients with OAG,” he told EuroTimes. The University of Michigan researchers were motivated to

study associations between statins and OAG after coupling their earlier finding that hyperlipidemia reduced the risk of OAG development [Ophthalmology 2011;118(7):1318-26] with evidence that statins may be beneficial in patients with other diseases involving the nervous system.

“The stroke Prevention by Aggressive Reduction of Cholesterol Levels trial found a reduced risk of cerebrovascular events in atorvastatin users, and in other studies, statins reduced the risk of ischemic stroke, multiple sclerosis and even Alzheimer’s disease,” said Dr stein.

“since the optic nerve and retinal nerve fibre layer are extensions of the nervous system, we hypothesised that statins might also be beneficial in reducing the risk of glaucoma. Considering our earlier work showing hyperlipidemia was associated with a reduced risk of developing OAG, we undertook another analysis to better understand whether it was the condition of hyperlipidemia or the medications used for its treatment that was responsible.”

Protective mechanisms since they found non-statin medications did not reduce glaucoma risk, Dr stein and colleagues postulate that the protective effects associated with statins are not explained simply by cholesterol reduction. Complementary basic science research has identified several pathways by which statins may help protect against OAG. These include upregulation of nitric oxide synthase, resulting in vasodilation and increased retinal/choroidal perfusion that could protect the retinal nerve fibre layer and optic nerve from glaucomatous damage. statin effects on rho kinase and/or myosin ii adenosine triphosphatase activity may increase aqueous outflow, leading to reduced iOP. There is also evidence from experimental models of cerebral and retinal ischemia that statins have neuroprotective effects, which might be mediated through reduction in glutamate-mediated cytotoxicity and anti-apoptotic activity. “A well-designed, randomised controlled trial to better understand whether statins are beneficial in patients with OAG will also help determine whether the benefit is the result of iOP-lowering or an iOP-independent mechanism, such as improved blood flow to the optic nerve and/or neuroprotection,” he said.

“Our retrospective study had several strengths, including its large, nationwide sample, multiple years of longitudinal follow-up, the ability to adjust for a number of confounding factors and the fact that medical and pharmacy data were obtained from healthcare records. however, we had no glaucoma-related clinical information such as levels of iOP or visual field loss, and our analyses did not consider changes in serum lipid fraction levels. These data will be collected in the prospective clinical trial we are developing and analysed to see how their changes correlate with statin use and glaucoma progression.”

Potential protective benefit of statin treatmentby Cheryl Guttman Krader

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24

EUROTIMES | Volume 18 | Issue 6

The question of whether patients with cataract who require vitrectomy should undergo a combined procedure remains a contentious one, according to speakers at a debate held at the 17th EsCRs Winter

Meeting. Taking the view that the lens was an obstacle to vitrectomy procedures, simonetta Morselli MD, san Bassano hospital, Bassano del Grappa, italy, argued that removing the lens during the vitreoretinal procedure was the best option.

“Phacovitrectomy is a safe and effective procedure because it provides visibility of the retina and facilitates inner limiting membrane peeling. however, it is an educational process for the anterior and posterior segment surgeons,” she said.

she added that combining pars plana vitrectomy and cataract surgery may be especially indicated in elderly patients because they are highly prone to the development or progression of cataract after pars plana vitrectomy.

Dr Morselli noted that cataract formation occurs after pars plana vitrectomy in around three-fourths of patients over the age of 60 years of age but in only a very low proportion of patients younger than 40 years.

she cited a study carried out by Gisbert Richard MD and his associates in hamburg. The prospective interventional series involved 230 consecutive patients with a mean age of 65 years who underwent combined pars plana vitrectomy and cataract surgery. The indications for vitrectomy included idiopathic epiretinal membranes in 160 patients and epiretinal membranes secondary to a range of conditions including diabetic retinopathy, previous retinal surgery, branch retinal vein occlusion uveitis and trauma in 70 patients. At mean follow-up of 1.5 years 82 per cent had an improvement in their visual acuity after surgery, seven per cent remain unchanged and 11 per cent had a reduction in their visual acuity.

in the diabetic retinopathy patients, mean visual acuity improved in 73 per cent of eyes and the retina was reattached in 90 per cent. There was residual peripheral retinal detachment in the remaining 10 per cent. Complications included posterior synechiae in 13 per cent, iris capture in three per cent and vitreous haemorrhage in 10 per cent.

The advent of 23 gauge vitrectomy has made combined sutureless phaco vitrectomy a more attractive option since both parts of the procedure use small self-sealing wounds. it therefore has the potential to reduce surgical trauma and thereby reduce postoperative inflammation leading in turn to a faster postoperative recovery.

Good candidates for 23-gauge sutureless phaco vitrectomy include eyes of vitreous haemorrhage macular pucker macular hole. Bad candidates for combined sutureless phaco vitrectomy include eyes with blue or thin sclera, eyes that have been traumatised.

Dr Morselli noted that to be successful, the cataract surgery must be atraumatic in order to avoid any corneal oedema, which could reduce visualisation. Complications occurring during cataract surgery may lead to problems during vitrectomy.

Useful barrier Barbara Parolini MD, istituto Clinico, santa Anna, Brescia, italy contended that the lens should be left in place as a physiological barrier during vitrectomy procedures. “i do agree that the lens is in fact in the way of the vitreoretinal surgeon. it is much easier to perform a vitrectomy without the lens. however, there are disadvantages of combined surgery, they are technical logistical and clinical,” she said.

The technical disadvantages include the potential loss in visualisation as a result of corneal oedema, the iOL’s optics, or viscoelastic residue. in logistical terms it can lead to reduced reimbursement for hospitals and physicians and it also may provoke the resentment of those who specialise in anterior segment surgery.

But most important are the clinical issues. several studies have shown that combined phacoemulsification and vitrectomy procedures induce more inflammation than either procedure on its own. The combined procedures are also more likely to induce glaucoma than separate procedures.

Dr Parolini said that what concerns her most about the combined procedure is the increased rate of cystoid macular oedema it appears to induce. she noted that in two retrospective studies she carried out, the incidence of cystoid macular oedema was nearly twice as high among those who underwent a combined cataract and vitrectomy procedure compared to those who underwent vitrectomy alone.

in the first retrospective series, which involved 193 patients who underwent epiretinal membrane peeling, the rate of postoperative cystoid macula oedema was 14.4 per cent among those who underwent a combined procedure compared to a rate of only 7.8 per cent among those who underwent vitrectomy alone. in the second study, the rate of cystoid macular oedema among the combined procedure group was 12 per cent, compared to only eight per cent among those undergoing vitrectomy alone.

“Treatment of these cysts is very difficult. They do not respond to nonsteroidal anti-inflammatory drops, to oral steroids, steroid drops or subconjunctival drops. We’ve had reasonable results with prednisolone 10mg steroid drops or intra-vitreal Ozurdex,” Dr Parolini said.

she noted there are some cases where it is necessary to have the lens out of the way to perform vitreoretinal surgery. They include cases of macular hole and those where the surgeon performs a peripheral retinotomy. however, performing both procedures at once may be too strong of a shock for the retina to withstand in some cases.

“We induce too much inflammation if we do both procedures at the same time. Therefore, the recommended sequence is to remove the cataract first, allow the eye to recover and then perform the vitrectomy,” she concluded.

Simonetta Morselli – simonetta.morselli@gmail.comBarbara Parolini – parolinibarbara@gmail.com

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PHacO aND VITREcTOMYPros and cons of combined procedure debated at 17th EScRS Winter Meetingby Roibeard O’hEineachain in Warsaw

When disaster strikesDr Oliver Findl talks to Dr Paul Rosen about how to prepare for complications in eye surgeries

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EUROTIMES | Volume 18 | Issue 6

Digital technology in the form of portable devices such as tablets and e-readers are increasingly showing promise as a way to

help patients with low vision problems. in a study published in Eye, Canadian

researchers found the iPad with its larger display screen and high contrast ratio, was superior to the sony eReader in terms of reading speed among age-related macular degeneration (AMD) patients. But, paper won out over both devices when it came to ease of use. Brand names aside, the key appears to be having a large display screen, higher contrast through use of back lighting, and the ability to display text in large fonts that meet a patient’s needs.

“i think the interest for low vision patients is that some of these new technologies may enable them to read with greater ease and speed. Patients can adapt these devices to their own personal deficits by modifying font size, brightness and so on,” said Thomas sheidow MD from the University of Western Ontario.

The findings come from a prospective study of 27 patients with AMD. The study compared the reading speed of patients when they used each of three devices: an iPad, a sony eReader and paper.

Patients recruited for the study all had stable, wet AMD in one or both eyes and would benefit from low vision aids, Dr sheidow said. Participants were an average age of 78 years old, and visual acuity in the eye with stable wet AMD ranged from 20/25 to count fingers (CF).

After clinical assessment, each underwent tests for reading speeds. standardised texts validated through the hahn method for reading speeds were used, and different content was placed on the iPad, the e-reader and the paper. The font chosen for the text on all three devices was New Courier, was mono-spaced and had serif-type font – which has been shown in other studies to be more ‘readable’ than other fonts by patients with AMD.

The text sizes used varied between patients and reflected the degree to which their disease affected acuity. Text sizes chosen were size 12, 16, 24, 32, 50 and 80 for the standard print group. The font sizes were made to be physically the same on both digital readers by use of a microcaliper and reflected the spectrum of

print that would be seen from newsprint to large print books.

The average reading speed on paper was 113.2 words per minute (WPM), 110.6WPM on the eReader, and 117.1WPM on the iPad. Patients with lower vision tended to read more slowly, in general. Patients tended to read the most quickly using the iPad with a text size of 24 or greater. But, they tended to read text on paper more quickly than that on the e-Readers no matter the text size. Patients found paper the easiest to use.

“Often for patients of the AMD population, newer technologies require a learning curve before they feel comfortable with them. i think this was one of the reasons for the paper being the easiest – they know it the best and no new skills need to be developed,” Dr sheidow said.

Tablets and apps could be of use to the ophthalmologist too. in a study presented at the international Orthoptic Congress (iOC) last autumn, Dr Nadia Northway, an orthoptist and lecturer at Glasgow Caledonian University, scotland presented a study investigating the effectiveness of the isight app – an iPad app for measuring visually acuity (VA).

here, a total of 35 children and 36 adults underwent VA testing using isight plus conventional testing (using the Kay picture test and the Bailey Lovie chart respectively). There was no statistical difference between the iPad measures and conventional eye charts in the adult or the children's groups.

Generally, isight results showed higher acuity in preschool children than the chart and the test took longer to conduct, in part because the young participants were restless, she said.

Dr Northway noted that some adults complained of blur when the iPad screen was set to 100 per cent brightness. Correlation to the chart measures and compliance improved when the screen brightness was set to 50 per cent. The researchers concluded that the iPad app was accurate when compared to results from the charts, and suggest isight would be a good tool for parents to use to assess their children’s vision. When it comes to apps, though, she said to approach with caution. Many of the available apps have not undergone scientific scrutiny, she cautioned.

lOW VISIONTablets and e-readers may be of use to ophthalmologists and their patientsby Pippa Wysong in Toronto

contact Thomas Sheidow – sheidowt@me.com

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Update

ReTInA

EUROTIMES | Volume 18 | Issue 6

Pars plana vitrectomy (PPV) has become such a popular approach to the repair of rhegmatogenous retinal detachment that surgery

trainees today are often not even taught the alternative of scleral buckling.

However, according to Marc Veckeneer MD, vitreoretinal specialist at the Rotterdam Eye Hospital, surgeons who believe that this trend represents progress are misleading themselves because they are overlooking a fundamental issue, which is that functional and anatomic outcomes of PPV procedures today are no better than they were 20 years ago.

A recently published meta-analysis comparing outcomes of scleral buckling and PPV procedures for uncomplicated rhegmatogenous retinal detachment (RRD) [Soni et al. Ophthalmology 2013 Mar 16, Epub ahead of print] confirms that PPV has not been proven to yield better results than scleral buckling, Dr Veckeneer said.

Taking into account that many eyes undergoing PPV today are straightforward detachment cases with a good visual prognosis, contemporary functional outcomes for RRD repair could actually be worse using the PPV approach rather than the original methods of scleral buckling, he told EuroTimes.

“The newer sutureless small-gauge vitrectomy procedures clearly are associated with a benefit of improved patient comfort. Ultimately, however, we would hope that they would provide better anatomic and functional results,” Dr Veckeneer said.

“Unfortunately, it seems that the availability of high-tech vitreoretinal procedures and enthusiasm for their use is prompting some surgeons to ignore their expense and trade-offs while not even considering alternative, potentially less invasive solutions.”

The drawbacks of PPV Dr Veckeneer’s interest in these issues was raised as he undertook historical research for a thesis project on the outcomes of vitreoretinal surgery. He believes that a lack of improvement in functional and anatomic outcomes using newer vitrectomy techniques may be explained by the fact that the procedure is not as “minimally invasive” as some surgeons think. Whereas the ocular surface impact of the procedure may be

reduced, the intraocular portion remains, and its use in eyes with straightforward retinal detachments may be introducing unnecessary risks that compromise vision.

“Our advanced vitreoretinal surgery procedures were developed to salvage complex cases that would have otherwise been abandoned, such as eyes with post-traumatic detachment and dense vitreous haemorrhage. With the advent of small-gauge surgery, these techniques are being used in eyes that are not severely diseased and that could be easily managed using much less invasive procedures,” he explained.

Take for example younger patients with a retinal detachment. In these eyes where the aetiology of the detachment usually involves blunt trauma or high myopia, posterior vitreous detachment is usually absent. Therefore, vitrectomy is

not necessary, and surgery via an external approach using drainage and retinopexy, with or without a scleral buckle can be successful.

“Regardless of the size of the entry incision or whether one is using newer vitrectomy systems featuring faster cut rates, the act of removing vitreous from the eye remains the same, and that has implications for early and late complications involving functionally relevant tissues,” said Dr Veckeneer.

He explained that induction of a posterior vitreous detachment during vitrectomy carries a high risk of additional trauma to the retina. In addition, removing vitreous causes cataract development making PPV an unattractive repair option for a simple retinal detachment in a younger, pre-presbyopic patient.

A fresh focus At the Rotterdam Eye Hospital, Dr Veckeneer and colleagues have been taking a systematic approach to innovation in RRD surgery. Their research aims to understand retinal physiology in disease and health along with the aetiology for factors limiting postoperative anatomic success and functional recovery as a basis for developing novel targeted solutions. These new concepts are evaluated in controlled trials.

Aiming to mitigate the risk of inadvertent scleral penetration during scleral buckling, they investigated securing the explant material with cyanoacrylate glue instead of sutures and found it was a safe and effective technique. Research focusing on the relationship between blood-ocular-barrier breakdown and the development of proliferative vitreoretinopathy led to studies of strategies for minimising the intraocular inflammatory insult, including preoperative subconjunctival steroid treatment and performing delayed laser retinopexy instead of cryotherapy at the time of scleral buckling surgery.

Understanding that persistent subretinal fluid after RRD surgery delays recovery and may limit the final visual outcome, a modified surgical drainage technique was developed to evacuate the fluid more completely and prevent its persistence. However, the development of methods for early restoration of the attachment between the neuro-retina and the RPE should be a critical aim for future research.

“Within a few hours after a retinal detachment, there is a severe reduction in the physiological adhesion of the retina to the pigment epithelium that will remain so for days or even months after re-attachment.

This fundamental issue remains largely unaddressed in our current therapeutic approach,” said Dr Veckeneer.

“A solution to this problem would allow detachment repair surgery that is truly less invasive, without buckling or vitrectomy. With future pharmacological advances in the field of neuroprotection, true progress with improved functional outcomes can be expected. In the meantime we must consider the fact that the broad application of technological novelties in micro-incisional vitreous surgery may not be the road to better outcome of RRD repair.”

RETINA DETACHMENT REPAIRAt the Rotterdam Eye Hospital, doctors are taking a systematic approach to innovation in rhegmatogenous retinal detachment surgeryby Cheryl Guttman Krader

27Update

RETINA

Despite important technological advances since its introduction more than three decades ago, pars plana vitrectomy has so far not yielded better outcome for uncomplicated RRD (Reproduced with permission from Dr Heinrich Heimann)

“The newer sutureless small-gauge vitrectomy procedures clearly are associated with a benefit of improved patient comfort. Ultimately, however, we would hope that they would provide better anatomic and functional results”

Marc Veckeneer – veckeneer.icare@gmail.com

cont

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Cour

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of M

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Veck

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26–29 September 2013

10 Main Sessions

30 Instructional Courses

5 Surgical Skills Courses

19 Free Paper Sessions

Leading Societies from around the globe will offer delegates a thoroughly international insight into medical and surgical retina.

For full programme listing and to register go to

www.euretina.org

EURETINA LectureLeonidas Zografos SWITZERLAND

Radiotherapy in Ocular Oncology

Kreissig LectureMark Blumenkranz USAEvolving Concepts in Innovation and Academic Technology Transfer in Retina: Digital Medicine and the Lessons Learned in Silicon Valley

WorldRetina

DaySATURDAY SEPTEMBER

28

This initiative, sponsored by EURETINA, was introduced in 2011 to support and encourage innovation in the fi eld of retinal medicine.

Applications for novel and innovative ideas relevant to the fi eld of retinal medicine are invited for review by a Judging Panel.

1st Prize of €20,000 2nd Prize of €10,000Prizes will be awarded on Friday 27 September 2013at the 13th EURETINA Congress, Hamburg, Germany.

INNOVATION AWARD 2013SCIENCE & MEDICINE

INNOVATION AWARDSEURETINA3rd

The competition is open and entries will be accepted until 8 July 2013.

www.euretina.org/Innovation

This initiative, sponsored by EURETINA, was introduced in 2011 to support and encourage innovation in the fi eld of retinal medicine.

Applications for novel and innovative ideas relevant to the fi eld of retinal medicine are invited for review by a Judging Panel.

1st Prize of €20,000 2nd Prize of €10,000Prizes will be awarded on Friday 27 September 2013at the 13th EURETINA Congress, Hamburg, Germany.

INNOVATION AWARD 2013SCIENCE & MEDICINE

INNOVATION AWARDSEURETINA3rd

The competition is open and entries will be accepted until 8 July 2013.

www.euretina.org/Innovation

EURETINA is delightedto announce

the 2nd Retina Race

Date: Saturday 28 September, 06.30

Location: Planten un Blomen Park (beside CCH Congress Centre)

Registration Fee: Ð30 in aid of Orbis

For more information

www.euretina.org

26–29 September 2013

10 Main Sessions

30 Instructional Courses

5 Surgical Skills Courses

19 Free Paper Sessions

Leading Societies from around the globe will offer delegates a thoroughly international insight into medical and surgical retina.

For full programme listing and to register go to

www.euretina.org

EURETINA LectureLeonidas Zografos SWITZERLAND

Radiotherapy in Ocular Oncology

Kreissig LectureMark Blumenkranz USAEvolving Concepts in Innovation and Academic Technology Transfer in Retina: Digital Medicine and the Lessons Learned in Silicon Valley

WorldRetina

DaySATURDAY SEPTEMBER

28

This initiative, sponsored by EURETINA, was introduced in 2011 to support and encourage innovation in the fi eld of retinal medicine.

Applications for novel and innovative ideas relevant to the fi eld of retinal medicine are invited for review by a Judging Panel.

1st Prize of €20,000 2nd Prize of €10,000Prizes will be awarded on Friday 27 September 2013at the 13th EURETINA Congress, Hamburg, Germany.

INNOVATION AWARD 2013SCIENCE & MEDICINE

INNOVATION AWARDSEURETINA3rd

The competition is open and entries will be accepted until 8 July 2013.

www.euretina.org/Innovation

This initiative, sponsored by EURETINA, was introduced in 2011 to support and encourage innovation in the fi eld of retinal medicine.

Applications for novel and innovative ideas relevant to the fi eld of retinal medicine are invited for review by a Judging Panel.

1st Prize of €20,000 2nd Prize of €10,000Prizes will be awarded on Friday 27 September 2013at the 13th EURETINA Congress, Hamburg, Germany.

INNOVATION AWARD 2013SCIENCE & MEDICINE

INNOVATION AWARDSEURETINA3rd

The competition is open and entries will be accepted until 8 July 2013.

www.euretina.org/Innovation

EURETINA is delightedto announce

the 2nd Retina Race

Date: Saturday 28 September, 06.30

Location: Planten un Blomen Park (beside CCH Congress Centre)

Registration Fee: Ð30 in aid of Orbis

For more information

www.euretina.org

Saturday 28 September Morning Symposia 10.00 – 11.00

Alcon Satellite Meeting

Sponsored by

Issues and Advances in the Treatment of Wet Age-Related Macular Degeneration withAnti-VEGF Therapy

Sponsored by

Lunchtime Symposia Boxed lunch included

13.00 – 14.00

NIDEK Symposium

Sponsored by

Issues And Advances in the Treatment of Myopic Choroidal Neovascularization with anti-VEGF Therapy

Sponsored by

EYLEA®: A New Option for the Treatment of CRVO

Sponsored by

EVA, the New Innovation in Vitreoretinal Surgery

Sponsored by

Argus II Retinal Implant, The First Approved Treatment for RP: 25 Years of Experience Reaching the First 100 Patients

Sponsored by

Friday 27 September Morning Symposia 10.00 – 11.00

Alcon Satellite Meeting

Sponsored by

Lunchtime Symposia Boxed lunch included

13.00 – 14.00

EYLEA® in wAMD: What Have we Learned and What Can we Expect?

Sponsored by

Bausch & Lomb Satellite Meeting

Sponsored by

New Advances in Retinal Imaging

Sponsored by

Topcon Satellite Meeting

Sponsored by

Evening Symposia 18.15

Issues and Advances in the Treatment of Diabetic Diabetic Macualr Edema with Anti-VEGF Therapy

Sponsored by

SATELLITEEDUCATIONPROGRAMME

13th EURETINA Congress26– 29 September 2013

Thursday 26 September Lunchtime Symposia Boxed lunch included

13.00 – 14.00

Allergan Satellite Meeting

Sponsored by

Bausch and Lomb Satellite Meeting

Sponsored by

ad-versario-classic-ET-1-2 hoch-1304v2-pva.indd 1 29.04.13 13:35EUROTIMES | Volume 18 | Issue 6

In an ideal world optometrists and ophthalmologists should work as part of a multidisciplinary team instead of standalone practitioners in assessing

vision performance, visual acuity and in particular driving ability, Martin O’Brien FCOptom, Association of Optometrists of Ireland told a meeting on traffic medicine.

“Unfortunately optometrists are often just seen as people who sell glasses rather than as eye-care professionals who perform thorough eye examinations, which is one of our primary roles,” he told the meeting.

He said a key strength of optometrists is their skills in the assessment of visual function as opposed to the diagnosis of disease given the limitations of the Opticians Act, and this has become more relevant as new driving vision guidelines look more at individual visual function rather than classifying disabling conditions rigidly.

Mr O’Brien said the eye exams carried out by optometrists are much more detailed than the simple Snellen eye chart exam.

“The ability to read letters on a test chart doesn’t translate very well into the skills of driving. With issues like twilight, poor contrast, age; or conditions like cataracts, vision can deteriorate and these are some of the things that are looked at in the new driver vision guidelines that have been launched in Ireland,” he explained.

Mr O’Brien added that it has now been recognised that the driver’s field of vision should also be assessed. If there are any suspicions of contrast sensitivity and glare issues they too must be assessed.

“The true importance of a driver’s visual field has not been emphasised up until now and it should play a greater role in visual assessment for driving, as stressed by the guidelines” he noted. It is very important the GPs are aware that there are several groups of patients where the confrontation test is not a suitable assessment of visual field.

Visual acuity The minimum visual acuity required for driving in the new Irish guidelines is 6/12 (0.5). Mr O’Brien maintained however that this basic measurement doesn’t explain very much about the patient’s vision, particularly why their vision is at the level it is when tested and whether it is going to deteriorate in the future.

“So, for example, was their vision better originally and has it deteriorated in the

period before the test? If it has gotten rapidly worse from something progressive like cataracts or macular degeneration then it is likely their driving vision is not going to be legal within a short space of time,” he pointed out.

He said if there are medical issues that are causing visual deterioration the pathology has to be checked out and a thorough visual assessment taken. This is one area where general practitioners, optometrists and ophthalmologists should be working together to ensure that there are proper protocols established to ensure drivers have a pathway to follow. Then it should be noted if the patient will need to be retested again after a certain period of time, like one year, three years, 10 years, etc. as allowed for in the Medical Fitness to Drive guidelines.

Essentially an eye exam is a ‘snapshot’ in time and it will change as people age, he said. Moreover, the age of a person’s first driving licence at 16 or 17 years of age coincides with the period in the late teens where myopia can start to develop. This means that a person’s eyesight can be a lot poorer in their early 20s, which raises concern about driving vision if given a 10-year licence, he added.

Mr O’Brien pointed out that patients themselves can be poor at determining if they will need another assessment of their driving vision or about seeking a test or treatment as deterioration can be very gradual.

“Studies from the UK and Ireland show that between one in six and one in 10 drivers on the road fail to meet the visual standard and a significant number of them are not even aware they don’t meet the standard,” he revealed.

For drivers who use glasses or contact lenses there are issues such as vanity and not equating driving with being a difficult visual task. This means many do not use their vision correction appliance when driving.

Mr O’Brien said that he would like to see optometrists forging closer links with the ophthalmology community to develop protocols in managing a range of visual issues.

DRIVER VISIONOptometrists want closer links with the ophthalmology community to develop protocols by Priscilla Lynch in Dublin

31Update

OCULAR

Martin O’Brien – radharcjournal@gmail.com

contact

EUROTIMES | Volume 18 | Issue 6

The importance of peripheral field vision is underestimated in relation to the ability to drive, but new ways of testing allow ophthalmologists to more accurately assess patients, reported Ananth

Viswanathan FRCOphth at a meeting on traffic medicine.Dr Viswanathan, Moorfields Eye Hospital, London, UK,

spoke about how best to assess and monitor visual field loss and its implications for safe driving at the meeting in the Royal College of Physicians of Ireland.

He reminded the meeting that a single error while driving can have devastating consequences, hence the importance of ophthalmic clinicians ensuring patients are visually fit to drive.

While visual acuity obviously plays an important part in driver vision, the level of peripheral vision also plays a vital role in the ability to safely drive, he said.

Studies have now shown that visual field loss leads to an increased risk of crashes, but many patients do not realise their visual field vision has been impaired and their driving ability subsequently affected, Dr Viswanathan, who is also chair of the UK Honorary Medical Advisory Panel on vision disorders and driving, told the meeting.

Patients with glaucoma are at particular risk of field of vision decline, and this needs to be noted in relation to their driving ability, he maintained. While patients with glaucoma may retain reasonable visual acuity they may not be able to see other cars, bicyclists or pedestrians that are outside their central field of view when driving. Contrast sensitivity and glare and driving at night-time can also cause significant issues for this cohort.

The first study to compare accident rates for drivers who have advanced glaucoma with normal-vision drivers found that the glaucoma group had about twice as many accidents. This study, which was conducted in Japan using a driving simulator, supports that potential drivers should pass a visual field test to ensure adequate peripheral vision before a licence is granted or renewed. The research was presented at the 116th Annual Meeting of the American Academy of Ophthalmology last year.

However screening of these patients is a key issue given that in many countries they only have to pass basic visual acuity tests to qualify for a driving licence, while routine visual testing in busy ophthalmic practices does not necessarily provide the relevant information, and established specific visual field testing is not sensitive enough, Dr Viswanathan explained.

Testing field of view He discussed the limitations of established visual field tests such as the useful field of view (UFOV). While validated for driving examination, the UFOV was not designed with driving in mind. It is not validated in the visually impaired, has only been validated by its developers and is an unrealistic test, comprising of briefly presented stationary stimulus arrays, Dr Viswanathan reported.

He said having questioned whether it is possible to merge bilateral monocular field tests to more accurately predict the binocular field in drivers, it has now been proven this can be done very successfully.

Studies, including those done by his own group, have shown that the use of the integrated visual field (IVF) test is an excellent method for screening driver vision, particularly for glaucoma drivers, Dr Viswanathan said.

Studies have shown that the IVF technique is best at representing the central binocular visual field in patients with glaucoma. The IVF has also been shown to be more relevant than the commonly used binocular Esterman visual field test (EVFT) in measuring patients’ self reported problems with performing daily tasks and general mobility.

The IVF is seen to be more sensitive to identifying patients with a field of vision that is incompatible to safe driving, as it uses accurate threshold data rather than a simple ‘yes or no’ dot based equation, he said. This means the height of the hill of vision can be mapped, which is useful in monitoring disease progression on a functional basis, Dr Viswanathan added.

It also generally has good agreement with the Esterman test, he noted.

“Having compared the tests in practice we feel confident after the results that no one with a potential issue would slip through the net using the IVF.”

Additionally, the IVF has been positively rated for predicting the future likelihood of a person losing his or her driving licence by assessing visual field status at baseline and visual field deterioration rate at two years, Dr Viswanathan elaborated. This is a very useful and valuable diagnostic tool, given the growing ageing population.

Concluding, Dr Viswanathan said the IVF provides an accurate field of vision screening method that can be easily incorporated into practice and can help identify the need, or not, for medical intervention and allow the preparation of patients for possible driving licence loss.

FIELD OF VISIONStudies have now shown that visual field loss leads to an increased risk of crashesby Priscilla Lynch in Dublin

32 Update

OCULAR

Ananth Viswanathan – mammie.ndoko@moorfields.nhs.uk

contact

Having compared the tests in practice we feel confident after the results that no one with a potential issue would slip through the net using the IVF

“Ananth Viswanathan

Ams t e r d a mAm s t e r d a m20 1 3

5 -9 OCTOBER

XXXI congress of the escrs

Go towww.esont.orgfor abstract submission, registration, hotels& programme

During the

EUROPEAN SOCIETY

OF OPHTHALMIC NURSES

& TECHNICIANS

ESONTMeeting

5 -7 OCTOBER

EPOS/WSPOSEuropean Paediatric Ophthalmological Society /

World Society of Paediatric Ophthalmology & Strabismus

PAEDIATRIC SUB SPECIALTY DAY

WEDNESDAY 9 OCTOBER 201308.30 – 17.15

During XXXI Congress of the ESCRS 5–9 October 2013 Amsterdam RAI,

Amsterdam, The Netherlands

Immediately preceding The 39th Meeting of EPOS in Leiden, The Netherlands from 11–12 October 2013

www.wspos.orgfor Registration and Hotel Bookings

A View Through the Child’s Eyes

SESSION I: Paediatric ocular surface disease

D. Bremond Gignac FRANCE

Incidence and management of BKC in children?

H. deConinck BELGIUM

The use of steam goggles in BKC in children

A. Mataftsi GREECE

Punctal plugs in children: are they safe?

M. Fernandes INDIA

Microsporidia and exotic infections in children

W. Moore UK

Keratitis: common and not so common causes

P. Nucci ITALY

Limbal vernal kerato-conjunctivitis

S. Jones UK

What is the normal tear break up time in children?

S.Hamada UK

Can we use Avastin in children with corneal NV’s?

A. van der Lelij THE NETHERLANDS

Cross-linking in children

SESSION II: Visual rehabilitation of the aphakic child

Chr. Lloyd UK

My choice for a secondary IOL in the presence of capsular support

N. Schalij-Delfos THE NETHERLANDS

Choices for IOL implantation when there is inadequate capsular support

M. Sminia THE NETHERLANDS

The use of the iris claw IOL for the correction of aphakia

N. Ziakas GREECE

Retroplacement of the secondary IOL in children

J. Murta PORTUGAL

Can we implant infants safely?

Tj. de Faber THE NETHERLANDS

Clear visual axis after surgery for Pseudo-Peters / PHPV

D. Granet USA

Visual rehabilitation of the child with JIA and aphakia

C. Vervaet THE NETHERLANDS

10 Essentials about the paediatric CL

C. Luchansky USA

Using BIFOCAL CL’s in the aphakic child

C. Frambach THE NETHERLANDS

Paediatric CL’s: how to handle the parents

SESSION III: Novel therapies in glaucoma: can we use them in children?

Lj. van Rijn THE NETHERLANDS

The role of axial length in the decision to operate on paediatric glaucoma

K.Nischal UK/USA

Trabectome

C. Eggink THE NETHERLANDS

An illuminated microcatheter for 360 trabeculotomy

M. Tekavčič Pompe SLOVENIA

Aphakic and pseudophakic glaucoma

S. Biswas UK

Endoscopic cyclophotocoagulation vs high frequency ultrasound guided cyclophotocoagulation

E. Gajdosova UK

Goniotomy for aphakic glaucoma

E. da Silva PORTUGAL

The role of nanoparticles in pediatric glaucoma

V. Sturm SWITZERLAND

Hints and tricks about OCT use in paediatric glaucoma

VIDEO VENTURE

10 videos of 5 minutes each showing a sign or surgical experience of a classical or unusual nature. The audience will be asked to vote on best video.

Organisers: Nicoline Schalij-Delfos, Marije Sminia, David Granet, Ken K Nischal

Update

OCULAR

EUROTIMES | Volume 18 | Issue 6

Tough economic times along with government mandates to insure all US residents and use of electronic medical records are affecting every US ophthalmologist. But eye care technology

continues to advance, and the profession is rising to the challenges, presenters told the 2013 Symposium of the American Society of Cataract and Refractive Surgery.

“These are confusing and complex times in ophthalmology,” said incoming ASCRS president Eric D Donnenfeld MD. More government intervention, electronic medical records and increasing patient expectations are among the issues US ophthalmologists face.

ASCRS is addressing these challenges head on with new educational programmes, Dr Donnenfeld said. These include a new residents mentoring programme to help ensure ophthalmologist are trained in advanced technologies including toric and presbyopia-correcting intraocular lenses (IOLs) and laser refractive procedures. New education programmes are also under way in glaucoma and corneal surgery. New content is delivered online through a revamped ASCRS website (www.ascrs.org).

“There is extraordinary greatness in our profession. Cataract and refractive surgery have never been safer or more effective,” Dr Donnenfeld said. “We are all bound by the passion to advanced surgery, to improve the vision and quality of life for our patients and to abolish all forms of blindness. With dedication and perseverance, together we can accomplish these noble goals.”

Accommodating IOLs emerge Accommodating IOLs, including dual optics, liquid optics, injectable lenses and even liquid crystal electronic devices, are becoming a reality, said Nick Mamalis MD in the 2013 ASCRS Binkhorst Lecture. Range of accommodation and long-term function and biocompatibility are major development questions now being examined.

Indeed, Louis D 'Skip' Nichamin MD, medical director of the Laurel Eye Clinic, Brookville, Pennsylvania, US, reported in a separate session that four patients in South Africa were implanted with the first foldable model of a fluid-based accommodative IOL as the meeting opened. The patients were doing well, but it was too soon to test their visual acuity and accommodation with the Fluidvision IOL, though patients implanted with an earlier non-foldable version of the lens in 2009-2010 achieved good distance vision and an average 5.0 D of accommodation using the push-down test, in line with PowerVision’s design parameters for the lens. Dr Nichamin is a scientific advisor for PowerVision.

Light adjustable lenses and new materials that could improve lens efficiency are also in development, said Dr Mamalis. “The future is bright in the area of intraocular lenses and in providing our patients with the best possible vision. I am excited to see what we will be talking about 20 years from now.”

Femto-cataract surgery maturing Advances in femtosecond laser lens fragmentation are dramatically reducing the amount of ultrasound energy needed to remove cataracts of nearly all types, according to several presenters.

In his last 200 femto-cataract cases, 91 per cent required no phacoemulsification energy at all, said H Burkhard Dick MD PhD, University Eye Hospital, Bochum, Germany. That’s down from 41 per cent in an early comparable group of 200 patients in which 41 per cent needed no phaco, and an intermediate group of 200 in which 62 per cent needed none. The reductions were statistically significant.

Improved lens fragmentation grids and surgical techniques led to the first improvement, while refinements of phaco probe tips and machine settings, and surgical instruments contributed to the second gain, Dr Dick said. All groups included consecutive patients with cataracts grade 1 through 4 and pupils of 6.0mm or more operated by a single surgeon. Mean LOCS-III grades for the groups were 3.5 for the early and 3.4 for the intermediate and late groups.

Pavel Stodulka MD, PhD of Gemini Eye Clinic, Czech Republic, reported success removing grade 1 to 3 cataracts without any ultrasound at all using a twin laser approach. After femtosecond laser lens fragmentation a coaxial photolysis laser probe was used in place of a phaco probe. In 10 eyes, a mean of 35 probe laser pulses were required to remove cataracts, and a mean endothelial cell loss of 6.8 per cent were observed. Dr Stodulka believes that laser probes are viable for cataracts up to grade 3, but questioned their use for harder nuclei.

Retinal restoration At the innovators session, Daniel V Palanker PhD of Stanford University, US, presented a photovoltaic retinal prosthesis that could restore vision to the blind. Multiple modules of 0.8 x 1.2mm in size are implanted in the subretinal space in place of lost photoreceptors, providing thousands of pixels, compared with 60 in current implant devices. The photovoltaic array is also completely wireless, each pixel converts light shining on it into electric current to stimulate the nearby neurons. However, the device requires brighter than typical ambient light, so a set of video goggles displays the incoming images using pulsed near-infrared light projected into the eye. In vitro, the device elicited signals in retinal ganglion cells similar to those produced by normal retina in response to light, and has produced cortical signals in rats with both normal and degenerated retinas, Dr Palanker said.

ASCRS 2013 REVIEWMoving to a future of financial challenge and technology advancesby Howard Larkin in San Francisco

34

Eric Donnenfeld – ericdonnenfeld@gmail.comNick Mamalis – nick.mamalis@hsc.utah.eduLouis D ‘Skip’ Nichamin – nichamin@laureleye.comDick Burkhard – dickburkhard@aol.comPavel Stodulka – Stodulka@lasik.czDaniel Palanker – palanker@stanford.edu

contacts

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EUROTIMES | Volume 18 | Issue 6

Treating patients in underserved regions is among the most rewarding activities in ophthalmology. Yet there’s always

a risk not only for your prospective patients, but for you as well.

“You have to understand the risks of working in an unfamiliar environment and take steps to manage them before you go abroad,” said Brad H Feldman MD, who chairs the American Academy of Ophthalmology’s Young Ophthalmologist International Subcommittee, and directs the Wills Eye Global Initiative, based in Philadelphia, Pennsylvania, US.

Careful preparation and diligent follow-up are essential not only to ensure you can safely and ethically achieve your service goals. Risk assessment and planning also help preserve your own health and safety, presenters told the AAO annual meeting.

Planning a successful international

mission starts with understanding your destination, especially your hosts’ objectives for your visit, said Hunter Cherwek MD, who is a member of ORBIS International’s Medical Advisory Committee, and medical director – strategic markets for Alcon Laboratories, Fort Worth, Texas, US. That includes not only the medical needs and systems, but also the culture, laws, availability of medical support, and any security risks a given location may present.

For first-time international volunteers, Dr Cherwek recommends signing on with an established organisation. It will have relationships in the host country and will know how to prepare, including the necessary steps for in-country credentialing and licensure. Get your travel visa early, and carry with you a letter of invitation from your host stating your destination, their local contact information and the purpose of your visit.

Talk with your local sponsor about the capabilities and practice patterns of the local medical establishment, Dr Cherwek said. If possible, he likes to admit patients before and after surgery to ensure adequate care and next-day follow-up. He also recommends following up with local physicians by Skype and email after the trip.

Lack of certain medicines and/or support equipment such as pulse oximeters and heart monitors may also limit the scope of surgery that can safely be done, Dr Cherwek noted.

“It’s ill-advised to put a patient under general anaesthesia without properly monitoring the patient’s vital signs and having the support of experienced anesthetic staff.”

Medical facilities are also often needed for your team members as well, Dr Cherwek said. “Ask your hotel, travel insurance company or embassy what hospital to use. People often have to go to the hospital in the middle of the night. They go through the day thinking they can gut it out, but at 2am, they need help and that is not the time to begin looking for a hospital.”

Dr Cherwek recommends walking through the facilities you will use on the first day, and listening to how the staff functions. Familiarise yourself with any equipment you will be using such as microscopes or phaco devices before you begin patient care. Also ensure that sterilisation procedures are adequate or try to use disposable instruments.

Also, show respect and pay attention to local customs, such as changing footwear before going in the OR and not wearing scrubs outside the operating room, Dr Cherwek added. Photography can be a particular issue. Always ask permission from your host, patients and their families before taking pictures.

Personal health and safety It’s impossible to care for patients if you aren’t healthy yourself, Dr Feldman said. A complete check-up with your primary care physician and dentist, including updating vaccines for tetanus and hepatitis, are essential.

Depending on where you are going you may also need vaccinations against local diseases, such as yellow fever. Many countries require proof of vaccination for entry, so start the process early. Resources on specific immune prophylaxis are available from the World Health Organization (www.who.int/ith/en/) or the US Centres for Disease Prevention and Control (http://wwwnc.cdc.gov/travel/default.aspx), Dr Feldman said.

Also pack a first aid kit. If you’re going to a remote rural area, it may need to be more extensive, Dr Feldman noted. If you are doing surgery, consider bringing HIV prophylaxis in case of needle stick injuries.

If you have your own personal medicines, bring extras. They should be packed in a labeled container with a prescription to avoid problems at customs. Also bring extra glasses and contacts if you wear them.

Once you arrive, take care when travelling, Dr Cherwek said. Avoid travelling at night, in uncovered vehicles or alone. “Your greatest risk is not Ebola or some exotic disease, it is the roads. Several times, I have been involved in helping people in accidents and it is incredibly scary.”

Dr Cherwek also cautions against unsafe hotels. Look for hotels with latches on doors, in-room safes if possible and a front desk manned 24 hours a day. And please be careful when you go out - it is best to travel in groups, have a contact list with you, know where you are going and ideally have a local SIM card in your phone.”

“You really can be a target because your language, the way you look and act really stand out.”

Financial concerns To avoid being scammed into a costly purchase, know the conversion rate to the local currency in advance, Dr Feldman said. If you can, bring enough cash to get you through the first 24 to 48 hours.

Tell your bank card and credit card issuers where you will be and for how long so your cards will not be refused. Also find out what fees will be charged for credit transactions and ATM withdrawals.

Know whether your cell phone is CDMA- or GSM-based and check it for compatibility within the national system by calling your carrier. Also ask the carrier about fees for data usage, texting and voice services, and whether you will be able to use a SIM card on your particular phone while abroad, Dr Feldman added.

“An e-mail download could end up costing you $20. You could come back with a $1,000 phone bill.”

Please don’t bring in expired medical devices or drugs, Dr Cherwek said.

Malpractice coverage is also a growing concern. Find out if your policy covers you abroad. If not, many carriers will sell you short-term coverage. However, be aware that most coverage will only cover lawsuits filed in your home country and not in foreign courts, Dr Feldman said.

Medical evacuation insurance is also a good idea, Dr Cherwek said. “I’ve had to have staff members evacuated several times. It can easily run up to $100,000 without insurance.”

Finally, keep notes on your experience and use it to plan for the next volunteer programme, Dr Cherwek said. “The best thing you can do is prepare. Ninety per cent of sailing errors are made before you leave the dock.”

Brad H Feldman – drfeldman@phillyeye.com

cont

act

AT RISK OVERSEASSafe international practice requires careful preparation and follow-upby Howard Larkin in Chicago

36 Update

GLOBAL OPHTHALMOLOGY

37

EUROTIMES | Volume 18 | Issue 6

Since 1987, millions of people with onchocerciasis (river blindness) in 35 countries have received more than one billion doses of Merck’s

Mectizan (ivermectin) free of charge. As a result, disease transmission has been interrupted – meaning no new cases have been identified – in four of six affected countries in Latin America and nine regions in five African countries.

“This is a mammoth success,” Hugh R Taylor MD, FRANZCO, of the University of Melbourne School of Population Health, Australia, told the American Academy of Ophthalmology annual meeting. It was accomplished through a partnership among private firms and non-governmental agencies with national governments.

Merck was the chief private firm, which pledged to donate ivermectin free to anyone with onchocerciasis for as long as needed. The World Health Organization, the World Bank, regional development banks, NGOs including the Carter Centre and national governments collaborated under direction of the Mectizan Expert Committee to distribute the drug and train workers to administer it in more than 117,000 local communities.

The model’s impact has since reached well beyond treating river blindness, Dr Taylor said. “This was the first of these large public-private partnerships that we have seen so much more of with HIV-AIDS, malaria and TB. They have become almost the norm for handling infectious diseases.”

Onchocerciasis is spread by biting black flies that breed in fast-moving water, making it particularly troublesome in fertile river delta areas. Flies pick up microfilaria, or first-stage larvae, of the parasitic nematode Onchocerca volvulus from infected humans. The parasite develops into a new form in the flies, and re-enters humans through fly saliva.

Once in humans, the larvae develop into adult roundworms, usually in a nodule beneath the skin. Females can measure up to one metre in length, with two large uteri taking up 90 per cent of this. Each produces thousands of microfilaria that are released into the body. These microfilaria and symbiotic organisms they carry are highly inflammatory both alive and dead. In the cornea they produce punctate

keratitis and sclerosing keratitis, and in the retina oncho chorioretintis, any of which can produce blindness.

Initially, an estimated 28 million people had onchocerciasis with 200 million more at risk, predominantly in sub-Saharan Africa, “the poorest of the poor,” Dr Taylor said. As of 2010, an estimated 18 million had the disease with about 500,000 visually disabled of which 270,000 are blind, according to WHO.

Previous attempts to contain onchocerciasis include spraying to suppress the black fly vector, which was partially successful in West Africa, but raised other environmental issues. Diethylcarbamezine (DEC), a pharmaceutical developed in World War II, killed the worms, but often caused severe allergic reactions. Suramin was administered in six weekly injections, and was effective against fatal sleeping sickness. But it carried about a one per cent mortality rate so it was not generally used for onchocerciasis, which is not fatal.

Ivermectin required just one oral dose repeated annually to contain onchocerciasis by killing microfilariae, leaving adult worms alive and less fertile. With Merck’s donation and the easier logistics of handling oral medications and training community members to administer them, eliminating the disease became possible.

“This is possibly the single biggest success in global public health in the last quarter of the last century,” Dr Taylor said.

RIVER BLINDNESSEnd in sight for onchocerciasis after one billion donated doses of ivermectinby Howard Larkin

Hugh R Taylor – h.taylor@unimelb.edu.au

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EUROTIMES | Volume 18 | Issue 6

2013 is the official year of The Gathering in Ireland, a homecoming and reunion for Irish families living abroad who will

come home to join their friends and relatives. But not only will the Irish have something

to celebrate. ESASO, too, has something to be proud of as this is the organisation’s fifth anniversary. Although the two celebrations are different, they share some things in common.

ESASO Fellowships 2013 ESASO and The Gathering Ireland 2013 are both proud to have inspired so many people and launched so many unique activities, events and projects.

The invitations to apply for a full-year international Fellowship with ESASO have recently been released and the interviews will take place in early July. During the same month, a major new programme will be launched for cataract surgeons, The ESASO Short Term Visiting Fellowship in collaboration with the L.V. Prasad Eye Institute (LVPEI) in Hyderabad, India.

A special hands-on training in cataract surgery will be held during four weeks each month. More information will follow soon.

AMD & Retina Congress On 25-26 October 2013 ESASO expects to welcome 900 or more surgeons to the beautiful Irish capital city of Dublin to discuss the latest findings and innovations in retina and AMD.

It is the 13th time that specialists from all over the world will come together to discuss cases, studies and share latest innovations in this fast moving specialty.

Since the onset of the anti-VEGFs treatment in 2006, the congress has grown in interest and importance. It was only four years ago when ESASO took over the organisation of the meeting to transform its structure. Since then, the organising and scientific committees have modified the meeting steadily following their vision and the vision of an independent school. They started to concentrate on the structure of an instructional congress where the delegates

participate actively in the programme.“This year’s scientific programme is

created with the advent of photodynamic therapy that represents a revolution in the treatment of wet AMD, with the aim to spread among the retina specialists the new clinical and therapeutic information that the new treatment will carry on,” said Prof Francesco Bandello, chairman of the Scientific Committee.

During the meeting of the Scientific Committee in Budapest in April, new ideas and activities were discussed which will be implemented during the upcoming meeting. “Expect the 13th international AMD and Retina Congress to be even more interactive and instructive,” said Prof Bandello.

Delegates will participate in sessions on diabetic retinopathy and on retinal vascular occlusion. The sessions will start with brief introductions of clinical cases on the state-of-the-art treatment and then leading experts will discuss these cases with the audience.

There are sessions planned where the problems of the long-term treatment of wet AMD is faced and the three anti-VEGFs in use will be compared. Thus, critical discussions on comparative clinical cases will fire up the debates with the final aim to learn how to best use medications.

Instructional Courses on OCT, on new imaging techniques and on sub-threshold laser will be presented. Finally the delegates will have the choice to participate in two exciting ESASO-Style debates, where two experts will lead cross-fire discussions on a given topic.

Although each congress stands and falls with its scientific programme, it is important to mention that ESASO will be proud to welcome its delegates at the world famous Guinness Museum where a memorable Gathering is planned for all. Come and join us in Dublin!

* Abstract submission and more details at www.esaso.org.

ESASO CELEBRATESESASO’s fifth anniversary coincides with The Gathering in Dublin 2013

08_1304_05 ESASO_Anz_EUT_120x300_Mai_RZ.indd 1 19.04.13 13:33

News

EsAsO

AMD and Retina Congress to be held in Dublin in October

39

EUROTIMES | Volume 18 | Issue 6

ESCRS has helped to prevent the spread of diseases such as cholera, trachoma and conjunctivitis in the North Kivu area of the

Democratic Republic of Congo (DRC) by donating to an Oxfam project which is developing new sustainable water supplies and empowering communities to manage these resources through training schemes and public health initiatives.

The devastating impact of 20 years of conflict between armed rebels and the government in DRC is largely forgotten by the world. The brutal conflict has claimed the lives of millions and has caused countless mass movements of people within the country and across its borders. The lives of these displaced people have been impacted on an ongoing basis – children have been unable to attend school, food shortages and malnutrition are widespread and healthcare, water and sanitation facilities are widely insufficient leading to many deaths from preventable diseases.

Families living in safer areas take in large numbers of people, placing additional strain on their own resources. The coverage of clean drinking water in the DRC is estimated at 24 per cent, while sanitation is estimated at only 9 per cent. Thanks to ESCRS, Oxfam and its WASH partners can improve the health of women, men and children forced to flee their homes to live in camps, and of host communities with limited access to clean drinking water.

Sustainable water resources Oxfam Ireland’s chief executive Jim Clarken said: “The generosity of ESCRS members and the ESCRS Board has helped to deliver real

change to the communities in the Lubero and Beni territories of North Kivu. By supporting Oxfam and our partners in the Water, Sanitation and Hygiene Promotion (WASH) project, ESCRS has provided effective and sustainable water sources for communities affected by conflict”.

Increased activity of armed rebels in the Lubero territory from May-Dec 2012 led to two preventative evacuations of Oxfam staff. In spite of such on-going challenges the health and well-being of an estimated 41,547 people of displaced, returned and host communities will be improved by the completion of this project. “Oxfam will continue to commit, with the great help of our supporters, to working with local communities to ensure that their basic rights and needs are delivered,” Mr Clarken added.

Poor access to latrine and sanitation facilities coupled with a lack of information about the importance of good hygiene leads to unnecessary illnesses and deaths from diseases such as cholera and diarrhoea. The ongoing projects supported by ESCRS include the reparation and expansion of key water supply systems and the protection of 30 simple water sources alongside training to improve good hygiene practice. Investment by ESCRS has helped combat the spread of water-borne diseases along with water-washed diseases that affect the eyes, such as trachoma and conjunctivitis.

* To support the Oxfam project visit: www.escrs.org/charitable-donations

COMMUNITIESESCRS helping to improve the health of people in the Democratic Republic of Congoby Colin Kerr

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40

EUROTIMES | Volume 18 | Issue 6

“Discovery consists of seeing what everybody has seen and thinking what nobody has thought” – Albert

von Szent-Györgyi, 1893-1986; winner of the 1937 Nobel Prize in Physiology or Medicine “for his discoveries in connection with the biological combustion processes, with special reference to vitamin C and the catalysis of fumaric acid”.

The winner of the 3rd EURETINA Innovation Award sponsored by EURETINA to support and encourage innovation in the field of retinal science and medicine will be announced during the 13th EURETINA Congress in Hamburg, Germany.

The purpose of the award is to support, encourage and reward individuals who actively consider and develop novel and innovative ideas relevant to the field of retinal medicine. The award will also facilitate and support an entrepreneurial culture to deliver new market applications for the ultimate benefit of patients with retinal disorders.

Finally, the award aims to engage and encourage the networking potential of the retinal community across the EU to improve both patient care and outcomes.

The closing date for completed applications is July 8, 2013. The award, originally launched at the 11th EURETINA Congress in London in 2011, will carry

two prizes – a first award of €20,000 and a second award of €10,000.

The winner of the first prize last year was Diego Ruiz Casas of the Ramon Y Cajal University Hospital, Spain. Dr Casas and his research team won the prize for their work on the potential application of guided magnetic nanoparticles to treat rhegmatogenous retinal detachment

The second prize was awarded to Nataliya Pasyechnikova of the Filatov Institute, Odessa, Ukraine for her research into the application of high-frequency electrowelding (EWBT) in ophthalmology.

Judging panel Entry to the competition is open to all EURETINA and non-EURETINA members over the age of 18 years, other than direct employees or members of the judging panel. Currently serving Board members of EURETINA may apply, however, they may not be the lead presenter of an application and such entries will be eligible to be short-listed at the EURETINA Congress but will not be eligible to receive a prize. Entries may be submitted by individuals or by teams.

* Full information on how to enter and other aspects of the award are available on the EURETINA website at

www.euretina.org

INNOVATION AWARDClosing date for entries is July 8

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EUROTIMES | Volume 18 | Issue 6

“I had never thought about it that way,” replied Dr Remeijer when I explained to her why I considered serious corneal

pathology to be the absolute worst subset of ocular diseases, from a patient’s point of view. I was happy to be able to contribute something useful, albeit rather philosophic, to the cornea clinic that she has been running for the past 20 years.

Corneal diseases are horrible, no doubt about it. The way I see it, they cause the three primary problems encountered in ophthalmology: 1) Pain; 2) Loss of vision; and 3) Cosmetic disfigurement. Of course, specific diseases in other subspecialties encompass these three horrors as well. Severe thyroid eye disease, postsurgical endophthalmitis, and phthisis fall into this category. But they are fortunately the exceptions within their respective subspecialty fields.

The cornea clinic, however, is filled with previously untreated patients whose vision is so poor that they have trouble navigating; who suffer incessant pain, and photophobia; and whose corneas have been visibly damaged by years of inflammation and scarring. The nightmarish existence of limbal stem cell deficiency caused by Stevens-Johnson syndrome, ocular cicatricial pemphigoid, or a severe chemical burn is just too much to contemplate.

Recently, I gained insight into the discomfort experienced by patients with corneal pathology. I usually wear glasses, but I wear contact lenses when skiing. Wanting to test a new prescription before I arrived in the mountains, I once wore the contact lenses for the entire length of the drive from Rotterdam to the Alps. It’s a 900km drive. Nine hours in a car with daily disposable contact lenses with the heat blowing in your face is a perfect recipe for seriously dry eyes. With a sensory innervation 300-600 times the density of skin, corneas feel everything, and mine were very unhappy with my negligence. The next day was terrible: I couldn’t use my contact lenses, I couldn’t stand the bright sun and snow and I couldn’t even really ski.

Treating corneal disease is thus very satisfying, especially surgically. A simple phototherapeutic keratectomy can relieve a patient of his or her recurrent erosions. Awful pseudophakic bulous keratopathy

can become a thing of the past. Even deep corneal ulcers can have reasonable outcomes after penetrating keratoplasty.

The procedures are fascinating combinations of skill, technique and creativity. The first time I assisted with a DSAEK, I was afraid the donor graft would somehow end up either on the floor, due to a fault of mine, or upside down in the anterior chamber, due to its own difficult nature. Of course, it ended up precisely where it should, right-side up on the

posterior surface of the host cornea.I was more relaxed during my first

pterygium excision. This procedure, which we do with a conjunctival autograft, allows residents to feel surgically competent, from the excision through the diamond burr polishing, to the harvesting and suturing of the conjunctival graft.

This feeling contrasts sharply with the sentiments experienced on the inpatient ward. Here, everyone, from the junior residents all the way up to the senior

attendings are occasionally humbled by the aggressive and complicated pathology encountered, and further by our impotence to do much that is very useful about it. The chemical burns suffered by the manual labourers in and around the Rotterdam shipping port… Acanthamoeba ulcers… and blast injuries in children allowed to play with fireworks on New Year’s Eve. These are particularly noxious, representing an unusual combination of chemical and thermal burns covering a bluntly traumatised coup-contrecoup injury with or without globe rupture.

It’s then a relief to work in the refractive clinic for a few days, where the patients are all healthy and generally happy. They know ahead of time that they’ll suffer a bit after their PRK procedure, but a month later, that will have been forgotten along with their glasses prescription and their contact lens frustrations.

But then we return to true pathology in the ER on Tuesday mornings, when all of the patients who have been seen with acute corneal disease within the last six days return for their follow-up. Most of the patients have herpetic keratitis, treated both topically and systemically. They’re either new patients or long-term cases who are experiencing a recent recurrence. The cornea specialists are frequently consulted.

Determining the activity status of stromal keratitis, whether it is improving or not, is devilishly difficult. In fact, it takes most of us a few years to even be able to reliably identify the stromal activity at all. For a tissue to be so superficially located and easily accessible, it’s almost comical how difficult it can be to examine the cornea correctly. It is not uncommon for the patients to correctly suggest the next step of therapy before the younger residents have even made the diagnosis. “Usually we gradually reduce the acyclovir and maintain the steroids,” for example.

Fortunately, the most common corneal problems we see in the emergency room are minor pathology. The patient enters the examination room with a painful eye, an organ rendered temporarily useless by a little foreign body or an epithelial erosion. Some patients think they’re going blind. We take a look, exclude more serious disease, treat what we see and send the patients on their way with some antibiotic ointment and a profound sense of relief. “Your eyes will be fine,” we say, and they smile.

IN THE CORNEAL CLINICDespite the ongoing fear of serious pathology, often kind words and antibiotic ointment do the trickby Leigh Spielberg

41Feature

REsIDENT’s DIARY

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

Cour

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of E

oin

Cove

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avid Ardjomand, MD graduated from Medical School at the Karl-Franzens University in Graz in 1994. He was

trained at the Department of Ophthalmology, Medical University Graz and at Moorfi elds Eye Hospital, London, UK including a research fellowship in corneal transplantation immunology at Imperial College, UCL and Moorfi elds Eye Hospital, London, UK.

After a clinical fellowship in “Anterior Segment Surgery and External Disease” at Moorfi elds Eye Hospital from 2003 – 2004, he started a consultant position at the Department of Ophthalmology, Medical University Graz, Austria. He is also an Associate Professor at the same department with his main focus on cornea, cataract and refractive surgery.

Navid Ardjomand has been a member of the European Society of Cataract & Refractive Surgeons since 1999 and is author and reviewer for several peer reviewed journals including the Journal of Cataract & Refractive Surgery.As a Board Member, he would like to intensify faster communication between the members, especially those in training, and the ESCRS Board using new media.

Nominated Candidates European Society of Cataract & Refractive Surgeons

Navid Ardjomand

Austria

Thomas Kohnen

Germany

homas Kohnen is Chairman and Professor of the Department of Ophthalmology, Goethe-University

Frankfurt, Germany; a busy department helping almost 30,000 patients a year. He has worked there since 1997, fi rst as an Assistant, then, Associate Professor, before being promoted to his current role in 2012.

He studied medicine in Germany and the USA, before specialising in Ophthalmology. During his training he worked both as a resident and as a scientifi c assistant, this dual approach to the clinical and research aspect of the job is one he continues to be passionate about today. He was awarded scholarships to study in Milan, Bombay and the Cullen Eye Institute, Houston, where he later became a Visiting Professor.

He is Associate Editor of the Journal of Cataract & Refractive Surgery and sits on the Editorial Board of four other publications. He is Vice President of the German-speaking Society of Intraocular Lens Implantation, Interventional and Refractive Surgery, having been President from 2008 – 2012, as well as a Board member of the German Ophthalmological Society.

A co-opted member of the ESCRS Board since 1997, he remains committed to its development and its role in supporting the adoption of best practice guidelines in surgery techniques and research.

Please note that only full members of the ESCRS are entitled to vote in the Board election.

Voting opens on 10 June and closes on 31 August.

Members will receive a ballot paper by post at the beginning of June.

ESCRS Board elections are held every two years. Board members serve for a term of four years and can be re-elected for one additional four year term. Board members must have been a full member of the ESCRS for at least the last three consecutive years and in order to stand for election candidates must be nominated by fi ve other full members of the Society.

There are fi ve positions open on the Board in this election and the names of the new Board members will be announced at the Annual General Meeting of the ESCRS which will take place during the Annual Congress in Amsterdam in October.

ESCRSBoardElection 2013

Simonetta Morselli

Italy

Massimo Busin

Italy

Pavel Stodulka

Czech Republic

Charles Claoue

UK

Paul Ursell

UK

Jérôme Vryghem

Belgium

Beatrice Cochener

France

Dan Epstein

Switzerland

graduated from the University of Verona as a General Medical Doctor in 1991 and as an Ophthalmologist in 1995. Since my

residency I have been dedicated to anterior segment surgery, specialising in cataract, refractive and cornea, at the University Hospital of Verona, Italy. In 2008 I became Chief of the Ophthalmic Department in Bassano, Italy. I have performed more than 12,000 surgical procedures, performed live surgery at many meetings, and published in international journals and books. A Board Member of the Italian Cataract Society, I am deeply involved in the organisation of national and regional meetings.

My surgical activity has always been connected with clinical research trials and especially with teaching and training young surgeons. I joined ESCRS years ago as a teacher in the Young Ophthalmologists Programme, more recently becoming a member of the Programme Committee.

If elected I would like to serve the Society and our members by increasing educational activities while maintaining the high profi le and scientifi c value of the most advanced aspects of our meetings. Science, education and clinical research are fundamentals of the ESCRS and their evolution is the very life of our Society, a Society of which we all are proud to be members.

fter training in Italy and in the USA, where I was fellow with Herbert E. Kaufman, I joined

the Faculty of the Friedrich-Wilhelm University in Bonn (Germany), where I am still apl. (ausserplanmaessiger) Professor of Ophthalmology. Since 1996 I have been the chairman of the Department of Ophthalmology at “Villa Serena-Villa Igea” hospitals in Forlì (Italy). My academic career, my research activity (106 peer reviewed articles, 32 chapters in books, 1 book) and my clinical work have focused on the anterior segment of the eye, with a particular interest in corneal transplantation.

I frequently meet with colleagues from many European and other foreign countries both at international meetings and at my institution, hosting them for observerships and/or courses. All these occasions have reinforced my belief that communication and interaction are the keys for improvement at all levels of our ethics, professional skills and legal competence.

In pursuit of contributing to the further development of ESCRS as a reference institution for European ophthalmologists, if elected, my priority would be to stand for creating concrete, “ESCRS supported” opportunities for members willing to upgrade their theoretical and practical knowledge with selected tutors.

s a head-surgeon and founder of Gemini Eye Centers in the Czech Republic, Pavel Stodulka performs a wide range

and high volume of surgeries from cataract and refractive surgery to vitreoretinal and corneal surgery. He was the fi rst surgeon in his country to perform LASIK (1994), epi-LASIK (2004) and femtosecond laser LASIK (2006). He was also the fi rst surgeon in the Czech Republic to perform MICS (2001) and femtosecond laser cataract surgery (February 2012). Today he has the world’s largest series of laser cataract surgeries performed on the Victus (B+L Technolas) laser platform (over 2,000 cases).

He was the fi rst to treat retina with Avastin in his country (2006), facing strong opposition at the time, and was one of the world pioneers in DMEK (2004). He treated several blind patients with the Boston artifi cial cornea, including a patient who had been blind for 53 years. He has operated on the President of the Czech Republic.

Pavel Stodulka holds a teaching position at Charles University in Prague. He has been educating residents and fellows for many years and has given over 500 lectures in ophthalmology, mostly in Europe and North America.

ear Colleagues and Friends, I would be grateful if you would consider voting for me. I was educated at Cambridge

University, St. Thomas’ Hospital and Moorfi elds Eye Hospital. For the past 18 years I have been Consultant at Queen’s Hospital (now the busiest multi-speciality hospital in London). I have particularly enjoyed teaching future consultants, some of whom have returned to work with me.

My family have been Franco-British for four generations; nearly 100 years. This has given me an unusually European perspective for an English ophthalmologist. I speak three European languages fl uently. I believe that in the 21st century we Europeans must work together; we have the drive and the genius to remain the world leaders that we are. I have enormous energy and would like this to be channelled to helping the ESCRS, a Society that I have supported for some 20 years. Given my long-term interest in international education, I believe that I could be well placed on the Education Committee. I have just ceased being Secretary to UKISCRS and was previously Secretary to the British Society for Refractive Surgery. I co-founded the International Society of Bilateral Cataract Surgeons and am a member of the IIIC. Thank you.

am delighted to be standing for election to the Board of your Society. I have been attending ESCRS for 20 years both as a

delegate and speaker. Over this period I have taught wetlabs, courses and presented many free papers. This has engendered a deep interest in teaching and improving standards in cataract surgery. I will represent all members of your Society whilst on the Board and will endeavor to strengthen relationships between all members. We know the future of healthcare is related to the internet and I will work to help connect the Society with members and patients online.

I have been on the Council of UKISCRS for six years and Treasurer for three. I am chairman of CESP which represents many of the UK ophthalmologists in private practice. I am also Trustee of SeeAbility, a charity which cares for people with learning diffi culties and visual impairment. I am a full time NHS consultant and lead for cataract surgery at my NHS hospital. I teach beginners and advanced trainees and lecture across European cataract surgery. I wrote my MD thesis on cataract surgery and trained at the University of Oxford. I also undertook fellowship training in Australia.

s the candidate nominated by the Belgian Society of Cataract and Refractive Surgery I want to be a worthy successor

to previous Belgian ESCRS Board members Dr Galand, Dr Budo and Professor Tassignon.

I have written many peer and non-peer reviewed articles, organised several scientifi c sessions and live surgeries (ESCRS Brussels 2000, MICS-Masters) and have regularly been invited to demonstrate my surgical technique during live surgeries abroad (Berlin, Moscow, Alicante, etc.).

I have organised an instructional course on the prevention and management of complications in LASIK at ESCRS congresses since 2001. Since 2010 I have been the organizer of an annual worldwide expert meeting on the surgical management of keratoconus.

My recent focus of interest about which I have given several presentations at ESCRS congresses is micro-incision cataract surgery, trifocal IOLs and topography-guided laser treatments.

Should I be elected as a Board Member of the ESCRS I would above all like to work on the scientifi c programme for the next congresses. I believe there is a need for more didactic sessions on hot topics where experts formulate clear and useful messages. I would like as well to work on ways to bring the ESCRS closer to its members.

our years ago I was elected to the Board and promised to serve our Society and actively participate in its education and

innovation commitments. I have been involved in the work of the Programme and Cornea committees. I am a member of the EuroTimes and Journal of Cataract & Refractive Surgery editorial boards.

I am past president of the French Society of Ophthalmology, current president of the French Academy of Ophthalmology, and president elect of the French Cataract and Refractive Surgery Society.

I have been head of the Ophthalmology department at Brest University since 2008. I have published 30 articles on refractive surgery, ocular imaging and ocular surface. I chair the French ocular surface disorders post graduate educational programme and co-organise the certifi cation in refractive and cataract surgery.

In a partnership between our university eye clinic and the research Inserm unit on medical imaging (LaTIM laboratory), I worked on ocular 3D ultrasound for eye rebuilding and on imaging recognition for telediagnosis. In addition, over the past fi ve years we have conducted 18 clinical trials.

It would be an honour to continue to serve our strong and growing European Society, a Society that requires independence of mind, innovation, education and dedication.

an Epstein has been active within the ESCRS for the past 15 years. He has been a member of the Programme

Committee among others, an initiator and faculty member of the Refractive Surgery Didactic Course, lecturer at the Young Ophthalmologists Programme, faculty at various ESCRS instructional courses, senior wetlab instructor, and the Programme Committee member responsible for the organisation of the main ESCRS symposia. He is currently contributing to the creation of ESCRS’s iLearn platform, which provides free interactive teaching for members.

He has been consultant ophthalmologist for refractive surgery at the Department of Ophthalmology, University Hospital, Zurich for 15 years, having previously held an appointment at Uppsala University Hospital in Sweden. Earlier he had received a PhD from the Karolinska Institute after completing his residency at the Karolinska University Hospital in Stockholm. In addition to collaboration with several universities and clinics in Europe and running a private practice, he is also active in research/publications, and has recently completed a 15-year appointment as an editor of the Journal of Refractive Surgery.

If elected to the Board, he hopes to build on his teaching and organisational experience to expand the ESCRS’s role in providing superior educational programmes for Europe and beyond.

EUROTIMES | Volume 18 | Issue 6

New products highlighted at ASCRSBausch + Lomb highlighted the recently approved PROLENSA (bromfenac ophthalmic solution) 0.07 per cent prescription eye drop at the ASCRS congress in San Francisco. PROLENSA is a new once-daily nonsteroidal anti-

inflammatory drug (NSAID) for the treatment of postoperative inflammation and reduction of ocular pain in patients who have undergone cataract surgery.

The company also highlighted LOTEMAX (loteprednol etabonate ophthalmic gel) 0.5 per cent gel drop formulation, a new topical corticosteroid formulation in its line of loteprednol etabonate C-20 ester corticosteroid-based ophthalmic products. Introduced in January, LOTEMAX Gel is indicated for the treatment of postoperative inflammation and pain following ocular surgery. n www.bausch.com

Cataract Suite Carl Zeiss Meditec introduced the ZEISS Cataract Suite featuring the new CALLISTO eye OR management system, which recently received US FDA 510k clearance, at the 2013 American Society of Cataract and Refractive Surgery (ASCRS) Congress in San Francisco. The company also announced the US release of the FORUM Viewer App which provides doctors with mobile access to the broad range of ZEISS and third-party diagnostic images and reports. n www.meditec.zeiss.com

New fundingNovaliq GmbH, a drug delivery company with a focus on the efficacious topical application of poorly soluble drugs, has announced the successful completion of a fifth round of financing of €13.9m ($18.1m).

“Since 2007, the company has raised €27.1m ($35.2m),” said a company spokesman. “Financing was again secured exclusively from the investment company of SAP, co-founder Dietmar Hopp’s Dievini Hopp Bio Tech Holding GmbH & Co. KG. With the new funds, the company intends to advance its lead projects into the medical device field to approval, progress its pharmaceutical project CyclASol into clinical development, and extend its technology platform,” he said.n www.novaliq.de

New partnershipLeica Microsystems and Bausch + Lomb have announced that Bausch + Lomb will distribute Leica ophthalmic surgical microscopes and accessories in select markets across Europe, the US, India and Latin America from April this year.

“The partnership combines the strength of Leica Microsystems’ innovative ophthalmic microscopes with Bausch + Lomb’s global commercial infrastructure, while expanding Bausch + Lomb’s offerings for ophthalmic surgeons. Bausch + Lomb’s current portfolio of products for cataract, refractive and retinal surgery includes intraocular lenses, equipment, instruments, procedure packs and other supplies,” said a Leica spokeswoman.n www.leica-microsystems.comn www.bausch.com

New AMD studyOraya Therapeutics, Inc has announced that results of its INTREPID study evaluating the safety and efficacy of Oraya Therap Stereotactic Radiotherapy for the treatment of Wet Age-Related Macular Degeneration (AMD) have now been published online in the leading peer-reviewed journal Ophthalmology.

“The study met primary endpoints, showing that a single dose of Oraya Therapy significantly reduces the need for anti-VEGF injections for patients with Wet AMD, with a favourable safety profile one year after administration,” said a company spokeswoman.n www.orayainc.com

Chronic diabetic macular edema treatmentAlimera Sciences, Inc, a biopharmaceutical company that specialises in the research, development and commercialisation of prescription ophthalmic pharmaceuticals, has announced that ILUVIEN, the first sustained release pharmaceutical product for the treatment of chronic diabetic

macular edema (DME), is now available in the UK.

In addition, said a company spokeswoman, Alimera has recently submitted a simple Patient Access Scheme (PAS) to the United Kingdom's National Institute for Health and Care Excellence (NICE) for consideration of the guidance under rapid review. n www.alimerasciences.com

44 Feature

INDUsTRY NEwsRecent developments in the vision care industry

Microkeratome set-up for LASIK Gebauer Medizintechnik GmbH recently launched a new packaging which enables surgeons to prepare the Gebauer SLc microkeratome for LASIK surgery in a very short time. A company spokeswoman said the new packaging also safeguards an error-free set-up process with minimal actions and handling.

“The intelligent packaging incorporates a precision Single-Use Head complete with pre-mounted blade allowing a range of flap thicknesses,” she said. “It can be combined with a range of reusable suction rings to customise the microkeratome head for each individual patient’s eye requirements.”n www.gebauermedical.com

Authorisation for combined system Geuder AG has announced that since April 2013 the Megatron S4 for anterior and posterior segment surgeries has been authorised for the market in Brazil.

“With the combined Megatron S4, modern biaxial and coaxial phaco microsurgeries as well as high-speed vitrectomies with a big range of magnetic and pneumatic vitreous cutters can be performed. Another highlight of the system is its flexible configuration to the individual needs of the surgeon,” said a company spokeswoman.n www.geuder.com

Patients quickly forget most of their doctors' instructions and much of what they do remember is incorrect, according

to neuropsychology researcher Roy Kessels PhD.

Dr Kessels' research interest is human memory, specifically focusing on neuropsychological impairments of memory in clinical groups. He recently surveyed a wide variety of studies, dating from 1975 to 2002, on patient compliance with

physicians's instructions, problems with memory function and ways to improve recall. "Several studies have been done and I think it is safe to say that approximately two-thirds of the information doctors give to patients is forgotten immediately. In addition, almost half the information patients do seem to remember is actually recalled incorrectly," he told EuroTimes.

n From EuroTimes, Volume 8, Issue 7, July 2003, p19

from the ArchivePatients forget about two-thirds of doctors' treatment instructions, says neuropsychologist

45

EUROTIMES | Volume 18 | Issue 6

ExploreNEWFRONTIERS

40 grants of €1000 to young ophthalmologists

who want to travel abroad to improve their skills

The ESCRS is awarding

Visit www.escrs.orgto apply

Ocular surgery is usually a relatively straightforward process, and a competent surgeon can become proficient in many of the commonly performed procedures within 100 or so cases. Managing complications is another matter, however. A complicated case is infinitely more difficult to solve than a routine one, in part because of its relative rarity, and, in part because of its unexpected nature.

Dr Amar Agarwal and Dr Soosan Jacob set out to change this, to bridge the difficulty gap between standard and complicated cases. The result is their newest book, Complications in Ocular Surgery: A Guide to Managing the Most Common Challenges. The book’s 30 chapters were written by a field of experienced surgeons invited to share their expertise on the trickiest situations in the operating theatre.

The book is organised into seven sections. The subtitle of each section is, “Avoidance and Management,” reminding the reader that the avoidance of complications is as crucial as managing them once they have occurred.

The first section, “Preliminary Preparations,” covers the proper sterilisation techniques to avoid complications and the complications of anaesthesia in ocular surgery. A particularly interesting tip is to place agar plates in the operating theatre for evaluation of the air contamination. Anaesthetic complications are discussed.

In the next five sections of the book, the authors cover five subspecialties in sequential order.

Section 2, “Complications in Oculoplastics,” is divided into three chapters on eyelid surgery, orbital surgery and lacrimal surgery, respectively. “The eyelids and the eyes are the focus of the face; but eyelid surgery, unlike many intraocular procedures, has every postoperative sign on display for all to see.” Thus, suggest the authors, preoperative counselling is hugely helpful to warn patients of what is (ab)normal after a particular procedure. The eyelid chapter is divided into “Minor Complications” and “Serious Complications,” while the orbital chapter covers the various orbitotomy approaches.

“Elective surgery and the patients who choose to have surgery demand perfect results,” the authors observe in the third section, “Complications in Refractive Surgery.” Such a comment is particularly relevant in terms of avoiding, misunderstanding and immense frustration. The section begins with a chapter on “Topography and Imaging to Avoid Disaster,” and moves on to cover the actual complications of refractive surgery, including PTK, intrastromal segment implantation and collagen cross-linking, each discussed in separate chapters.

The book’s fourth section, “Complications in Cornea, Conjunctiva and Glaucoma” is broad, but primarily focuses on ocular surface and suture-related complications as well as graft failure and endophthalmitis. This section’s strength is the many representative and informative photographs.

The most extensive section of the book is the fifth section, “Complications in Cataract Surgery.” This is also the section that will garner interest for the largest segment of the readership. Of particular interest are two chapters on complications possible at each step of a standard cataract procedure. A third chapter, “Challenging Cataract Cases,” includes instructions on how to deal with such complications as subluxated cataracts, lens coloboma and floppy iris syndrome. The remaining chapters of the section highlight the pitfalls in very specific situations, perfect for reading up the night before a difficult case like aniridia.

The book concludes with a seventh section, “Miscellaneous,” which deals with procedures not easily classified within a particular subspecialty.

This book is a good choice for senior residents, surgical fellows, young general ophthalmologists and surgeons who must develop their skills independently, outside of dedicated surgical training centres.

Review

BOOk REVIEw

Anticipating complications

If you 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

PUBLICATIONCompLiCationS in oCuLar Surgery

EDITORS IN CHIEFamar agarwal and Soosan Jacob

puBLiSHeD By SLaCk

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47

EUROTIMES | Volume 18 | Issue 6

JCRS Symposium

Sunday, October 6, 201314:00–16:00

Will Femtosecond Laser–Assisted Cataract Surgery Represent a Real Paradigm Shift in Future Cataract Surgery?H. Burkhard Dick, MD, PhD, David F. Chang, MD

Is Excimer Laser Treatment of Suspected Keratoconic Eyes Justifi ed?Noel Alpins, MD, FACS, David R. Hardten, MD

What Is the Best Solution for Presbyopic Cataract or RLE Eyes?Hiroko Bissen-Miyajima, MD, Graham Barrett, MD

Chairs: Emanuel S. Rosen, MD, FRCSEd Th omas Kohnen, MD, PhD, FEBO

During the XXXI Congress of the ESCRS, Amsterdam, the Netherlands

Questions for theCataract–RefractiveSurgeon in 2013

New femtosecond interfaceJCRS editor Thomas Kohnen discussed the state of femtosecond laser interfaces in a lead editorial. Femtosecond lasers first gained popularity for their ability to create reproducible and uniform flaps for refractive surgery. More recently they are gaining supporters as an aid to cataract surgery. However, the best method of docking the laser to the eye is not yet established. Some systems utilise a flat transparent window pressed against the cornea using a suction ring applied just outside the limbus. Other femtosecond flap laser systems use a curved interface in which the interface has some amount of curvature to better fit the natural corneal curvature. This limits and reduces globe deformation and associated IOP rise during suction seen with the flat interface. A contact lens with a curved surface that approximates the natural radius of curvature of the anterior cornea reduces globe deformation and associated IOP elevation compared with a flat contact lens.

One promising alternative approach could be a liquid immersion interface. A layer of transparent fluid between the cornea and an optical window provides a clear path for the laser beam and allows imaging of high optical quality. Mechanical attachment in this case is achieved with a suction ring outside the limbus. Anatomic variation is minimal in this region of contact, thus minimising globe deformation and patient-to-patient variation using one standard attachment. Because the cornea itself is in contact with liquid rather than a rigid surface, it is not forced to conform to a different shape. Therefore, the liquid interface does not induce corneal folds.

JH Talamo and colleagues compared a curved contact lens interface with a liquid optical immersion interface for the creation of femtosecond laser capsulotomies. They found that curved contact interfaces created corneal folds in 70 per cent of cases that can lead to incomplete capsulotomy during laser cataract surgery. No corneal folds or incomplete capsulotomies occurred in eyes treated via the liquid interface. Those eyes also had improved globe stability, reduced subconjunctival haemorrhage and less IOP elevation.

n T Kohnen, JCRS, “Interface for femtosecond laser–assisted lens surgery”, Volume 39, Issue 4, 491-492.

n JH Talamo et al., JCRS, “Optical patient interface in femtosecond laser–assisted cataract surgery: Contact corneal applanation versus liquid immersion”, Volume 39, Issue 4, 501-510.

Multifocal add-on IOLsThe implantation of additional IOLs (add-on IOLs) in the pseudophakic eye extends the variety of options and allows fine-tuning of residual refractive errors. Studies evaluating the potential of multifocal add-on IOLs are now under way. In one such study German researchers compared the visual outcomes of additional multifocal intraocular lenses (IOLs) for sulcus fixation with those of standard multifocal IOLs in the capsular bag. Patients in the prospective controlled clinical trial had phacoemulsification and implantation of a monofocal IOL in the capsular bag and an additional aberration-free diffractive IOL in the ciliary sulcus. The study found no statistically significant differences in uncorrected and distance-corrected distance, intermediate, or near visual acuities between the add-on IOL group and a control group. At three months the median uncorrected distance visual acuity was 0.00 logMAR in both groups, and the median uncorrected near visual acuity was 0.10 logMAR in both groups. Contrast sensitivity testing yielded significantly better results in the multifocal add-on IOL group, especially at spatial frequencies over 1.5 cycles per degree. Defocus curves were similar in the two groups. Neuroadaptation may improve visual performance over time. A long-term evaluation of visual performance of the IOLs tested is under way.

n J Schrecker et al., JCRS, “Additional multifocal sulcus-based intraocular lens: Alternative to multifocal intraocular lens in the capsular bag”, Volume 39, Issue 4, 548-555.

Review

Thomas Kohnenassociate editor of jcrs

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

Don’t Miss Eye on Travel, see page 50

JCRs HIGHLIGHTsJournal of Cataract and Refractive Surgery

Meeting SpotlightView exclusive videos of clinical presentations from the 2013 ASCRS Symposium in San Francisco.

American Society of Cataract and Refractive Surgery

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SYMPOSIUM & CONGRESS

2014 APRIL 25–29B O S T O N

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Additional Programming

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EUROTIMES | Volume 18 | Issue 6

The 17th century is alive and well in Amsterdam as the city, the venue for the XXXI ESCRS Congress from 5-9 October, celebrates the

400-year anniversary of its famous Canal District, now an UNESCO Heritage Site.

The city's fathers embarked on the construction of the “Grachtengordel,” a girdle of four canals with intersecting waterways, in the city's Golden Age. They designated three of the canals – the Herengracht, Keizersgracht and Prinsengracht – for residential development. The fourth, the Singel, was designated for defence and water management. Although Amsterdam, like every modern city, now has its shopping malls, ring roads and a shabby Central Station area, the Grachtengordel, still encloses neighbourhoods of durable charm. Here the 17th century has been intruded upon only lightly by the 21st.

Where to begin? A short walk from the railway station brings you to the Grachtenhuis museum, the “gateway” to the canals, at 386 Herengracht. Scale models of the city and the canal houses plus multimedia presentations tell the story of the expansion of the inner canal system in Amsterdam. The building is not only a beautiful example of a canal house, but offers an overview of life in the city from the 17th to the 21st century. Open Tuesday to Sunday from 10:00 to 17:00. www.hetgrachtenhuis.nl.

You could also begin with a walk along the canals, admiring the facades of the elegant red brick houses, as they themselves seem to admire their own reflection in the water. Take photographs from the bridges. Let time go by while you enjoy a coffee in a corner side cafe. And then if you start to wonder

about the people who built these houses and what lies behind these lovingly preserved exteriors, enter one of them to imagine for yourself what life was like; there are several possibilities. One is the Van Loon mansion at Keizergracht 672. Built in 1691, its first resident was a pupil of Rembrandt. Wider than most of the canal side houses, this building was purchased by Hendrik Van Loon as a wedding present for his son in 1884. The house is still in the possession of the Van Loon family, who open their home and collections to the public six days a week. The house is unique in that the garden and the coach house with its classic facade are also preserved. Open 11:00 to 17:00 except on Tuesdays. www.museumvanloon.nl.

The Willet-Holthuysen canal house at 605 Herengracht affords another quiet glimpse into the past. Built in 1687 and left to the city in 1894, its rooms are a time capsule of well-to-do life in Amsterdam in times gone by. Visit the kitchens, the garden, and the reception rooms. Open daily, Monday to Friday 10:00 to 17:00, weekends 11:00 to 17:00. www.willetholthuysen.org.

A bonus to visitors to the Museum of Bags and Purses, 573 Herengracht, is a look inside an elegant old building. In 2006, the house was given to the woman whose astonishing collection it now houses by an anonymous and very generous benefactor. There are painted ceilings, an elaborate reception room, and an exceptionally pleasant cafe overlooking the garden. Incidentally, you don’t have to be particularly interested in bags and purses to enjoy a visit to the museum exhibitions. Through the story of these accessories the curators have illustrated history itself, from the days when bags and purses were unisex to the present. Open daily 10:00 to 17:00. www.tassenmuseum.nl.

Houseboats line the canals in the Grachtengordel; they are now some of the most prized residences in the city. There are over 2,500 of them, each with its own address, postal delivery and access to the city services. The Hendrika Marja, built in 1913, was a freighter until it was converted into a houseboat in the 1960s. It's now a museum where you can see what the

living conditions were on board when the skipper lived there with his family. There's a museum shop selling among other things, books on houseboats. Prinsengracht 296K. Open daily 11:00 to 17:00. www.houseboatmuseum.nl.

Nearby on Prinsengracht 263-267, is the “Anne Frank House.” Over one million people a year make their way to the house to see for themselves the hidden annex in which this young Jewish girl, her parents and sister along with four other people, evaded the Nazis for two years. Betrayed in 1945, they were transported to extermination camps where all but the father died. Anne Frank's diary, found in the abandoned secret rooms, has been translated into over 30 languages. The first digital edition of the book, containing previously unseen material including video footage, was launched earlier this year as an app for iPad and Nook. An exhibition centre, shop and cafe have been added to the side of the house to accommodate the seemingly endless queue of visitors. Consider booking a time slot online; you print out your ticket in advance and enter with minimal delay through a separate doorway. The visit may break your heart but you won't forget it. www.annefrank.org.

Cross the Prinsengracht with the Anne Frank House at your back, and you are heading into the Jordaan section, one of the prettiest areas of Amsterdam, full of boutiques, antique shops and restaurants. Just opposite the Anne Frank House is the highly recommended Cafe de Prins, Prinsengracht 124. Although it has retained its “brown café” character, this is a stylish place to enjoy anything from a simple snack to a fine dinner. The kitchen is open from 10:00 until 20:00 daily. www.cafedeprins.nl.

17th CENTURY LIVESAmsterdam’s Canal District celebrates city’s Golden Ageby Maryalicia Post

50 Feature

EYE ON TRAVEL

EUROTIMESESC

RS ™

РОССИЙСКИЙ ВЫПУСК

RUSSIAN LANGUAGE EDITION NOW ONLINE

Visit: www.eurotimesrussian.org

A canal house kitchen An Amsterdam bridge Canal view

51

EUROTIMES | Volume 18 | Issue 6

– William Butler Yeats

EDUCATION

FILLINGLIGHTING

F I R E

IS NOT THE

OF A

OF A PAIL, BUT THE

http://elearning.escrs.orgGain access to all of this and more online at

Learn and explore key aspects of modern anterior segment surgery

Prepared by ESCRS in partnership with Society opinion-leaders

Earn CME points

36 hours of interactive, assessed and accredited eLearning

Refractive Surgery Didactic Course

Cataract Surgery Didactic Course

Workshop on Visual Optics

Cornea Didactic Course

Basic Phaco Instructional Course

Surface Ablation Techniques Instructional Course

Endophthalmitis Instructional Course

PDT anti-VEGF combo shows promise in macular telangiectasiaA combination of reduced-fluence photody-namic therapy combined with ranibizumab can improve vision in patients with nonpro-liferative macular telangiectasia type 2. The study involved five eyes of four patients all of whom underwent reduced-fluence PDT and intravitreal ranibizumab within 24 h. At three months' follow-up, three out of five eyes had gains in BCVA ranging from one to six lines and median logMAR visual acuity improved to 0.4 from a baseline value of 1.0. The two eyes that did not improve remained stable. By 12 months the median logMAR visual acuity was 0.7. Two eyes were continuing to show an improvement compared to baseline, two eyes lost some vision and one eye remained unchanged.

nZehetner et al. Ophthalmologica, “Reduced-Fluence Photodynamic Therapy Combined with Ranibizumab for Nonproliferative Macular Telangiectasia Type 2”, 2013 June; DOI:10.1159/000350033.

Keratoconus patients prone to retinal pathologyPart of the vision loss that occurs in keratoco-nus patients may result from retinal pathol-ogy, according to a study which compared electroretinography and OCT findings in 32 keratoconus patients and 30 controls. All underwent thorough ophthalmic examina-tions. The study's authors found that although there was no significant difference between the groups in terms of central foveal thickness as measured by OCT and p 1 latency as meas-ured by in multifocal electroretinography (mf-ERG). However, mf-ERG showed that retinal response density (RRD) differed significantly between keratoconus patients and controls and BCVA was positively associated with RRD in keratoconus patients.

nM Moschos et al. Ophthalmologica, “Assessment of the Macula in Keratoconus: An Optical Coherence Tomography and Multifocal Electroretinography Study”, 2013 June; DOI:10.1159/000350801.

Intravitreal bevacizumab has variable efficacy in radiation-induced CMEIntravitreal bevacizumab may bring about anatomical and visual improvements in patients who develop cystoid macular oedema (CME) following external beam

radiotherapy for nasopharyngeal carcinoma although its efficacy appears to be variable, according to a new study involving seven eyes of five patients. All received a series of monthly intravitreal injections of beva-cizumab (1.25 mg/0.05 ml). After a follow-up ranging from six months to two years, three eyes (71 per cent) had improvements in both central subfield thickness and BCVA, two eyes worsened in terms of both parameters and two eyes had no change in BCVA despite an improvement in central subfield thickness.

nV Subrayan Ophthalmologica “Intravitreal Bevacizumab for Radiation-Induced Cystoid Macular Oedema in Patients with Nasopharyngeal Carcinoma: A Clinical Series”. 2013 June; DOI: 10.1159/000348630.

NSAID better than steroids for preventing cystoid macular oedemaThe NSAID bromfenac sodium 0.1 per cent appears to be more effective than the steroids fluorometholone 0.1 per cent and dexamethasone 0.1 per cent in the control of postoperative inflammation and preven-tion of cystoid macular oedema (CME) after phacoemulsification, according to the results of a comparative trial. In the ran-domised study, bromfenac sodium cleared the ocular inflammation more rapidly than fluorometholone and dexamethasone and in the second month the foveal thickness was thinner and the incidence of CME was lower in those receiving the NSAID.

nQ.Wang et al. Ophthalmologica, “Bromfenac Sodium 0.1%, Fluorometholone 0.1% and Dexamethasone 0.1% for Control of Ocular Inflammation and Prevention of Cystoid Macular Edema after Phacoemulsification” DOI:10.1159/000346847.

Review

OPHTHALMOLOGICA

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

Reference

CALENDAR Of EVENTsDates for your Diary

Advertising Directory: Abbott Medical Optics: Page: IBC; Alsanza Medizintechnik und Pharma GmbH: Page: 19; A.R.C Laser: Page: 52; ASCRS/Eyeworld: Pages: 46, 48, 49; Carl Zeiss Meditec: Page: 37; Croma-Pharma GmbH: Page: 31; D.O.R.C. International BV: Page: 26; ESASO: Page: 38; HSIOIRS: Page: 36; Keeler: Page: 39; Medicel Ag: Page: 9; Medicontur Interantional SA: Page: 3; Nidek: Page: 7; Oculus Optikgerate GmbH: Page: 40; Oertli Instruments AG: Page: IFC; Rayner Intraocular Lenses Ltd: Page: 11; Technolas Perfect Vision: Page: OBC; Ziemer Ophthalmic Systems: Page: 17

2013 2014

52

JUNE

European Society of Ophthalmology (SOE) 20138-11 JuneCopenhagen, Denmarkwww.soe2013.org

10th Congress SEEOS and 3rd Congress of Macedonian Ophthalmologists20-23 JuneOhrid, Macedoniawww.zom.mk

International Meeting on Anterior Segment Surgery22-23 JuneVerona, Italywww.femtocongress.com

JULY

Indian Intraocular Implant & Refractive Surgery Convention6-7 JulyChennai, Indiawww.iirsi.com

26th APACRS Annual Meeting11-14 JulySingaporewww.apacrs.org

5th World Glaucoma Congress17-20 JulyVancouver, Canadawww.worldglaucoma.org

SEPTEMBER

XXXVII UKISCRS Annual Meeting5-6 SeptemberManchester, UKwww.ukiscrs.org.uk

14th International Paediatric Ophthalmology Meeting12-13 SeptemberDublin, IrelandEmail: hmurphy@materprivate.ie

13th EURETINA Congress26-29 SeptemberHamburg, Germanywww.euretina.org

OCTOBER

ESCRS Glaucoma Day4 OctoberAmsterdam, Th e Netherlandswww.escrs.org

4th EuCornea Congress4-5 OctoberAmsterdam, Th e Netherlandswww.eucornea.org

XXXI Congress of the ESCRS5-9 OctoberAmsterdam, Th e Netherlandswww.escrs.org

EPOS/WSPOS Paediatric Sub Speciality Day9 OctoberAmsterdam, Th e Netherlandswww.wspos.org

OCTOBER

NEW ENTRY43rd ECLSO Congress25-26 OctoberMunich, Germanywww.eclso.eu

NOVEMBER

AAO Annual Meeting16-19 NovemberNew Orleans, USAwww.aao.org

93rd SOI National Congress27-30 NovemberRome, Italywww.congressisoi.com

2014 JANUARY

NEW ENTRY5th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery8-10 JanuaryVienna, Austriawww.ophthalmictrainings.com

FEBRUARY

18th ESCRS Winter Meeting14-16 FebruaryLjubljana, Sloveniawww.escrs.org

APRIL

NEW ENTRYASCRS•ASOA Symposium and Congress25-29 AprilBoston, USAwww.ascrs.org

MAY

NEW ENTRYSOI International Congress21-24 MayMilan, Italywww.congressisoi.com

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