volume 16_issue 2

VOLUME 16 ISSUE 2 FEBRUARY 2011

ESCRS convenes 15th ESCRS Winter Meeting in Istanbul

PublisherCarol FitzpatrickExecutive Editor Colin KerrEditors Sean Henahan Paul McGinn

Managing Editor Caroline BrickProduction EditorAngela SweetmanSenior Designer Paddy Dunne

Assistant Designer Janice RobbCirculation ManagerAngela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

Seamus Sweeney Gearóid TuohyColour and Print Times PrintersAdvertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: [email protected]

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

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

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2009 and 31 December 2009 is 29,298.

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THIS MonTH...

Cataract 4 Surgeons discuss bilateral consecutive surgery

Refractive Lens 6 The role of phakic IoLs in correcting refractive error

Refractive Laser 8 Study favours use of mechanical microkeratome for flap creation

Cornea 10 Femtosecond laser-assisted procedures effective for keratoconus patients12 DMEK could become technique of choice for treating endothelial disease13 Advances in keratoprosthesis surgery

Glaucoma 14 Central corneal thickness important factor in glaucoma risk17 Research presented on glaucoma risk factors

Retina 18 Several advantages found with in-the-bag IoLs19 Improving visual acuity after retinal detachment surgery

Ocular 20 Incorporating new research important when training young surgeons

News 22 EURETInA launches Innovation Awards 25 ESCRS rolls-out foreign language LASIK consumer websites26 new e-learning solution for ESCRS members 28 EUREQUo could be model for registries for other specialties29 observership Programme gives young ophthalmologists more scope

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february 2011Volume 16 | Issue 2

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Published byThe European Society of Cataract and Refractive Surgeons

Features 31 EU Matters 31, 33, 36 Journal Watch 32 outlook on Industry33 Bio-ophthalmology35 Book Review 36 Industry news

37 Practice Development41 Eye on Travel42 JCRS Highlights 44 Calendar

With this month’s issue... Surgical TechniqueS: injecTing The laTeST TechnologieS

by Dr Bekir Sıtkı Aslan

As the ESCRS exists for its members, it must ensure it responds to its members’ needs.

With this in mind, the ESCRS Board and Executive Committee made their decision to offer a comprehensive

didactic programme covering visual optics, cataract as well as refractive surgery and cornea at the 15th Winter Meeting in Istanbul, Turkey.

Education is at the very centre of all of the ESCRS’s activities and the society continues to look at different approaches to help both our existing members but also members in the eastern European Countries.

This programme will run adjacent to national society meetings and will be based on the didactic courses in the Winter meeting. The aim of this programme is to broaden access to the best the ESCRS has to offer and collaborate with the support of the local societies.

For every Winter meeting, the challange for ESCRS is to become more educational and highlight the latest innovations in ophthalmology. İstanbul will be no exception.

It is a great honour for me and my colleagues in Turkey to be given the opportunity to host this great event. We also have the responsibility of matching the success of other recent Winter meetings.

It is a pleasure to organise this meeting in association with ESCRS, MEACo and the Turkish Society of ophthalmology Cataract and Refractive Surgery Division.

ESCRS has not abandoned some traditional parts of the Winter meeting programme and we will have a programme of free papers, posters and a live surgery programme highlighted by the Turkish Society of ophthalmology Cataract and Refractive Surgery Division. This will be a local initiative looking at up-to-date technology and premium lenses and different types of cataracts. An HD transmission will be the first ever live surgery broadcast in Turkey.

In İstanbul, the ESCRS will offer Cornea Day, didactic courses in cataract surgery, refractive surgery, cornea and visual optics. These courses are provided free of charge. We have invited experts from all over Europe and the Middle East to contribute to the courses and curricula.

This is an excellent opportunity for ophthalmologists in our region to attend the ESCRS Winter Meeting, an experience which can only enhance their knowledge and training, and which will ultimately benefit patients in the region.

İstanbul is a great destination, with glorious culture, outstanding architecture and a mystique heritage but a vibrant soul extending to both continents.

We hope in years to come the ESCRS Winter Meeting 2011 will be remembered as a birthplace of a new beginning, a new way of seeing things.

on behalf of ESCRS, EuroTimes, MEACo and the Turkish Society of ophthalmology Cataract and Refractive Surgery Division I am honoured to welcome all colleagues from around the world to the ESCRS Winter 2011 İstanbul Congress for successful and memorable times.

A very cordial welcome to İstanbul.

EUROTIMES | Volume 16 | Issue 2

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eDITOrIaL Volume 16 | Issue 2

editorial

Welcome to IstanbulWinter meeting will focus on delivering specific curriculum for education

José Güell

Clive Peckar

Emanuel RosenChairman

ESCRS Publications Committee

Ioannis Pallikaris

Paul Rosen

Medical Editors

International Editorial Board

EUROTIMESESC

RS ™

noel alpins australia

Bekir aslan turKEY

Bill aylward uK

Peter Barry irElaND

roberto Bellucci italY

hiroko Bissen-Miyajima JaPaN

john chang CHiNa

joseph colin FraNCE

alaa el Danasoury sauDi araBia

oliver Findl austria

i howard Fine usa

jack holladay usa

Vikentia Katsanevaki GrEECE

Thomas Kohnen GErMaNY

anastasios Konstas GrEECE

Dennis lam HONG KONG

Boris Malyugin russia

Marguerite McDonald usa

cyres Mehta iNDia

Thomas neuhann GErMaNY

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

Dr Bekir Sıtkı Aslan is head of the Eye Department,TOBB ETU [email protected]

Dr Bekir Sıtkı Aslan

Performing cataract operations on both eyes on the same day saves money, equipment and time without compromising safety,

according to advocates of Immediately Sequential Bilateral Cataract Surgery (ISBCS).

However, concerns remain that doing two operations on the same day could carry an increased possibility of bilateral blindness due to endophthalmitis, and critics question whether the strong safety data seen in some studies would be replicated if the procedure became commonplace. Proponents counter by highlighting the experience in Finland and the Canary Islands where the majority of cataract surgery is ISBCS.

A number of leading UK surgeons weighed in on the debate at the United Kingdom & Ireland Society of Cataract and Refractive Surgeons (UKISCRS) annual meeting, sparking lively exchanges and a dispute over the true extent of the risks associated with ISBCS.

Richard Packard MD, FRCS, FRCophth, who practises in Windsor and London, UK, said the procedure raises “significant animosity but there is no evidence that it compromises patient safety”. Addressing a session co-sponsored by the International Society of Bilateral Cataract Surgeons iSBCS – an advocacy group set up in 2008 – Dr Packard said patients prefer to have both eyes done on the same day.

“It requires just one hospitalisation, lower costs and less travel. It also allows more efficient use of operating theatres. of course, we wouldn’t consider these things if it compromised patient care,” he said.

Dr Packard added that patients who have same-day surgery benefit from a more rapid visual recovery and better neural adaptation, which is required by accommodative or multifocal intraocular lenses.

“By one month post-op most patients have adapted to any blurs caused by simultaneous vision,” he said.

He stressed that meticulous surgical technique is the key to success with ISBCS and he urged colleagues to treat each operation as a totally separate procedure.

“Change everything – instruments, tubing, drapes, solutions and viscoelastics. Change batches, handpieces and rescrub and gown,” he said, adding that if there are any problems with the first eye, he would advise against proceeding with the second operation.

Patients with extreme risk factors, such as very dense nuclei or loose zonules, are excluded by Dr Packard’s practice, so too are those covered by private insurers that reimburse patients less for same-day surgery.

“In general, my experience of bilateral consecutive lens surgery has been very positive with no complications to date which could be attributed in any way to bilateral surgery,” Mr Packard said.

This view was echoed by Steve Arshinoff MD FRCSC, a Canadian-based surgeon and founding president of the iSBCS, who said the society had drawn guidance that will help ensure safe bilateral surgery. The 10 principles are broadly in line with Dr Packard’s practice.

Dr Arshinoff said the procedure was gaining popularity globally and was fast becoming accepted in the profession. Some 10 per cent of ESCRS members are in favour, but some regions have been early adopters. For example, half of all cataract cases in many Finnish hospitals and 80 per cent of cases on the Canary Islands are done consecutively.

He has been advocating bilateral cataract surgery for 15 years and has performed same-day procedures on more than 3,000 patients. He asserted that the practice is safe and can even deliver improved outcomes. It appears that in the hands of the members of iSBCS, the risk of postoperative bilateral

simultaneous endophthalmitis is in the range of 1:100 million patients (article in press).

“If any unresolved complication occurs with the first eye, then the second eye should be deferred. But otherwise, the best time to operate the second eye is immediately after gaining the experience of the individual peculiarities of the first eye,” Dr Arshinoff said.

Lingering concerns However, David Smerdon who practises in Middlesbrough, UK, was not convinced. He said that while those in favour of same-day surgery mean well, the safety rates would probably be worse if performed by less skilled surgeons who were not as committed to promoting the procedure.

While he acknowledged doing two eyes in quick succession is convenient for patients and efficient for surgeons, Dr Smerdon said this practice carries an increased risk of bilateral blindness, primarily due to endophthalmitis.

“In practice, if the first eye suffers from endophthalmitis there is the possibility of both eyes being involved if you do sequential surgery whereas only one eye is involved if you delay the second operation by a week or two. This delay gives time for endophthalmitis to develop, giving you the chance to put in place measures to protect the other eye. If you do the procedures on the same day you are removing the possibility of protecting the other eye,” he said.

Dr Smerdon warned advocates of bilateral consecutive surgery against tempting surgeons with higher infection rates from embracing the procedure.

“The problem is these very good surgeons are tempting average surgeons into adopting bilateral cataract surgery,” he said.

Dr Christopher Liu, Sussex Eye Hospital, pressed for a compromise between same-day surgery evangelists and hard-line sceptics.

“You cannot say one should never do it, nor can you say it’s wise always to do it. My view is that it can sometimes be the right option but we need to look at ways to reduce the risks,” he said.

In his own practice, Dr Liu excluded high-risk eyes and takes steps to reduce bilateral infection and contamination. He noted that even though surgeons try to treat the two operations as distinct events, the procedures are not truly independent.

“You are operating on them at the same sitting. If there is an external failure – like if the air conditioning breaks down – it affects both eyes. And if a complication occurs in one eye, it’s more likely to happen to the other,” Dr Liu said.

Charles Claoué MD, FRCS, FRCophth of Queen’s Hospital London, made the point that doctors are supposed to listen to patients and showed that there is strong demand in the UK for bilateral surgery. He also noted that there are no legal barriers to the procedure.

Dr Claoué dismissed concerns over increased risk of infection saying the chances of bilateral endophthalmitis were lower than the risk of dying in a road traffic accident as a result of the extra travelling for delayed sequential surgery. This led him to wryly conclude: “not many people see well after death.” He finished with some examples of the potential financial savings achievable from adopting immediate sequential bilateral cataract surgery. “When savings can be as great as total US healthcare spending, they deserve serious consideration” said Dr Claoué.

Richard Packard – [email protected] Arshinoff – [email protected] Smerdon – [email protected] Claoué – [email protected] Liu – [email protected]

cont

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bIlateral consecutIve surgerygrowing support for same day surgery, but not all surgeons are convincedby Gary Finnegan in Brighton

4 update

caTaracT


When savings can be as great as total US healthcare spending, they deserve serious consideration

“Charles Claoué MD, FRCS, FRCOphth

It requires just one hospitalisation, lower costs and less travel. It also allows more efficient use of operating theatres

“

Richard Packard MD, FRCS, FRCOphth

Don’t miss EU Matters, see page 31

The current role of phakic IoLs (PIoLs) as a widely accepted alternative for the correction of moderate and high refractive error

can be attributed to a number of advances relating to the technology itself and surgical technique. However, developments in diagnostic imaging technology have also been important for improving preoperative identification of appropriate candidates and post-implantation safety monitoring, said Jorge L Alió MD, PhD, at the XXVIII Congress of the ESCRS.

According to Dr Alió, while there are a variety of imaging instruments that can be used for PIoL patient screening and follow-up, very high frequency ultrasound (VHF/US) represents the best modality because it alone provides precise information about the interior dimensions of the eye and the relationships between intraocular structures and the PIoL.

“Currently, we believe there is strong, consistent evidence favouring the use of VHF/US measurements over those obtained with anterior segment oCT (AS-oCT) to make critical decisions for PIoL patients, and especially in studying and measuring the sulcus anatomy and distances,” said Dr Alió, professor and chairman, Department of ophthalmology, Miguel Hernández University, Alicante, Spain.

Measurements obtained with the AS-oCT instruments available today provide an approximation to the real measurements and are perhaps only valid at the anterior chamber level. VHF/US is the only technique that has been shown to precisely measure the interior dimensions of the eye and relationships between ocular anatomy and the PIoL. Posterior chamber measurements and direct calculation of the sulcus-to-sulcus (STS) distance is possible only with VHF/US, he explained. Diagnostic imaging is essential in the preoperative evaluation to investigate the distance between the corneal endothelium and the anterior surface of the crystalline lens, the angle-to-angle (ATA) and STS distances, as well as the angle and iris anatomy. Postoperatively, it is used to investigate internal biometrical relationships of the PIoL, the implant’s centration, and the dynamic relationship between the implant and the natural crystalline lens during accommodation.

Although AS-oCT is very useful for imaging anterior chamber structures, it is not adequate for establishing the precise depth of the angle, especially in narrow and crowded conditions as represented by the situation of an eye implanted with an angle-supported PIoL. In addition, AS-oCT cannot be used to study details behind the iris so that the STS measurement can only be estimated by extrapolation.

“The extrapolation has a weak relationship with the true value of the STS distance, and so it is not a precise or reliable method for sizing posterior chamber PIoLs. In addition, since oCT is optical technology, its measurements can be affected by intraocular light reflections and differences in refractive indexes,” said Dr Alió.

In contrast, VHF/US provides high resolution images without optical bias and allows direct, precise measurement of distances and anatomical details at all locations in the anterior chamber without any need for extrapolation, he noted.

Studies published by Dr Alió and colleagues comparing AS-oCT using the Visante system (Carl Zeiss Meditec) and VHF/US with the Artemis 2 (Ultralink) highlight the performance of the two technologies and the limitations of AS-oCT. In one study including 20 normal eyes, Dr Alió and collaborators measured anterior chamber depth (ACD), central corneal thickness (CCT), ATA distance, and iridocorneal angle size (IAS) at the nasal and temporal locations using both AS-oCT and VHF/US. Each subject was imaged with both techniques, and the measurements were repeated three times.

The analyses showed both techniques provided excellent intrasession repeatability for all of the parameters, and the results obtained with the two devices for ACD, CCT, and ATA were equivalent. However, there was clinically relevant disagreement between the AS-oCT and VHF/US measured values for IAS (both temporal and nasal), indicating the two devices could not be used interchangeably for these assessments.

VHF/US is also superior to AS-oCT for postoperative evaluation of the risk for contact between the PIoL and endothelium or crystalline lens that can occur because of PIoL overvaulting or sizing error.

contact Jorge L Alio – [email protected]

PhakIc Iolsvery high frequency ultrasound considered best for screening, sizing and follow-upby Cheryl Guttman Krader in Paris

6 update

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Using a mechanical microkeratome offers surgeons a safe and efficient means of flap creation in LASIK

procedures and produces residual stromal beds of excellent smoothness and quality that compare favourably with those created by femtosecond laser, according to Maja Bohac MD.

“our comparative study showed that the one Use-Plus SBK (Moria SA) is simple, easy to use, safe and effective. The flaps created by this microkeratome are highly predictable and consistent in terms of thickness, shape and size and produce high-quality stromal beds,” she told delegates attending the XXVIII Congress of the ESCRS.

The one Use-Plus SBK is a fully automated microkeratome with two independent motors, one for blade oscillation at 15,000 rpm and one for blade advancement with a faster or slower forward speed. The heads and plastic rings are single patient-use, greatly reducing sterilisation requirements and routine wear and tear.

Dr Bohac presented the results of a prospective study of 60 LASIK patients comparing flap thickness, flap and stromal bed quality, visual and refractive outcomes and patient satisfaction using either the one Use-Plus SBK mechanical microkeratome or Ziemer Femto LDV laser (Ziemer ophthalmic Systems AG).

“Both methods produced excellent results in myopic cases. The one Use-Plus SBK showed slightly better results in flap and stromal bed quality, provided easier handling and showed less patient discomfort during the surgery,” said Dr Bohac, Svjetlost Eye Clinic, Zagreb, Croatia.

The femtosecond laser, however, delivered better results in hyperopic cases due to the wider corneal bed and an ablation zone independent of K values, she added.

Looking at the results in more detail, Dr Bohac said that mean flap thickness for one Use-Plus SBK was 93 µm (±11µm) and 95 µm (±5µm) for femtosecond laser, and all flaps were aligned perfectly to the corneal bed.

All three surgeons involved in the study agreed that the quality of the flaps and stromal beds were marginally better in the traditional microkeratome group compared to those in the femtosecond laser group.

“When looking at the stromal beds of one Use-Plus at high magnification under the microscope one can see a surface of even smoothness with no interruptions caused by tissue bridges,” Dr Bohac told EuroTimes. “However, while looking at the stromal beds of the femtosecond laser, which were also of good quality and smoothness, it was possible to see a difference in areas where tissue bridges were situated,” she said.

She added that the microkeratome-created flaps were much easier to lift and manipulate compared to those created by femtosecond laser.

“Unfortunately we could not do scanning electron microscopy so we cannot give any real scientific proof except our impression and final results,” she said.

no serious intraoperative or postoperative complications were reported in either group, said Dr Bohac, although she noted that patient discomfort was greater in the femtosecond laser group.

“Much of the discomfort during LASIK surgery with the Femto LDV is related to the system’s large handpiece which is placed above the patient’s eye but is also aligned on the nose and almost half of the cheek. Since alignment of the handpiece and the actual flap creation takes about one minute, the patient experiences slight to moderate pressure on the eye and around the eye during that time. The handpiece is also placed under the excimer laser construction so some patients claim to feel somewhat claustrophobic and anxious during that time,” she said.

Another issue with the femtosecond laser is the longer ‘blackout phenomenon’ experienced by the patient, said Dr Bohac.

“The term blackout phenomenon refers to the length of time needed for flap creation after vacuum is applied on the eye to achieve proper suction. The suction for flap creation with the Femto LDV takes about 15-18 seconds depending on the parameters, but the process of aligning the laser handpiece on the patient’s eye takes about 35-40 seconds. During the entire period of about one minute, patients cannot see the lights from the excimer laser, which

makes them nervous, and then there is complete darkness as the vacuum is applied, which adds to their anxiety. The difference between mechanical microkeratome and femtosecond laser is quite significant since the whole process of aligning the one Use-Plus and flap creation takes only about 10-15 seconds,” she said.

In terms of maintaining work flow in a busy practice, Dr Bohac said that there is a clear advantage in using the mechanical microkeratome compared to the femtosecond laser.

“Looking at the whole process, including preparation of the operating room for each patient and the operation itself, we need almost half an hour for each patient when using LDV compared to about 15 minutes with the one Use-Plus. It is much more complicated to preassemble the Femto LDV for each patient than to put the new blade onto the mechanical microkeratome. We also need more time to align the laser handpiece onto the patient’s eye and more time is also lost for flap lifting. For routine surgery with one Use-Plus SBK we typically need about 8.5 to 10 minutes for both eyes, while with LDV we have not managed to perform surgery in less than 15 minutes,” she said.

While the concept of ‘all-laser LASIK’ is definitely appealing to some patients, the higher cost of femtosecond treatment must also be taken on board, noted Dr Bohac.

“We are currently performing about 20 per cent of femtosecond laser surgeries compared to 80 per cent with mechanical microkeratomes. The cost is an issue but the primary concern of most patients is to obtain a good result and a safe procedure,” she concluded.

Maja Bohac – [email protected]

cont

act

lasIk surgeryclear advantages in using the mechanical microkeratome compared to the femtosecond laserby Dermot McGrath in Paris

refracTIve Laserupdate8


Our comparative study showed that the One Use-Plus SBK (Moria SA) is simple, easy to use, safe and effective

“

Maja Bohac MD

Corneal bed in LASIK procedure with Femto LDV with rough appearance on the place of tissue bridges

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References: 1. Denis P, Gandol� S et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 12-17, 2010; Madrid, Spain. 2. Labbé A, Pauly A, Liang H. J Ocul Pharmacol Ther 2006; 22(4):267-278. 3. Liang H, Brignole-Baudouin F et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 2-17, 2010; Madrid, Spain. 4. Brignole-Baudouin F, Riancho L et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 2-17, 2010; Madrid, Spain.

IntroducingTRAVATAN® BAK*-free formulation

Demonstrates comparable IOP-lowering efcacy as original formulation TRAVATAN® 1

Contains Polyquad®, which has demonstrated a gentler effect on the ocular surface than BAK* in laboratory studies2,3

Signicantly less toxic to human conjunctival and corneal epithelial cells when compared to latanoprost solution (preserved with 0.02% BAK*) in vitro4

Date of preparation: January 2011 TBF:EUR:01/11:HC

The BAK*-free Multidose PGA

TRAVATAN 40 micrograms/ml eye drops, solution (travoprost) (Refer to full Summary of Product Characteristics (SmPC) before prescribing) Presentation: Plastic bottle containing 2.5 ml eye drop solution; 1 ml of solution contains 40 micrograms travoprost. Indication(s): Decrease of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma. Posology and method of administration: Adults, including the elderly: One drop in the affected eye(s) once daily, optimally in the evening. Children and adolescents: Not recommended. Hepatic and renal impairment:No dosage adjustment necessary. Contra-indications: Hypersensitivity to travoprost or any of the excipients. Warnings and precautions: TRAVATAN® may gradually change eye colour. This occurs slowly and may not be noticeable for months to years. Before treatment is instituted, patients must be informed of the possibility of a permanent change in eye colour. Unilateral treatment can result in permanent heterochromia. Long term effects on melanocytes and any consequences are currently unknown. After discontinuation of therapy, no further increase in brown iris pigment has been observed. Periorbital and/or eyelid skin darkening has been reported. TRAVATAN® may gradually increase the length, thickness, pigmentation, and/or number of eyelashes in the treated eye(s). Exercise caution in aphakic patients, pseudophakic patients with a torn posterior lens capsule or anterior chamber lenses, and in patients with known risk factors for cystoid macular oedema or iritis/uveitis. Skin contact with TRAVATAN® must be avoided. Patients must remove contact lenses prior to application of TRAVATAN® and wait 15 minutes after instillation before reinsertion. TRAVATAN® contains polyoxyethylene hydrogenated castor oil 40 and propylene glycol which may cause skin reactions or irritations. Interactions: none known. Pregnancy and lactation: Pregnancy: Do not use unless clearly necessary. Women of child-bearing potential: Do not use unless adequate contraceptive measures are

in place. Breast-feeding women: Not recommended. Effects on ability to drive and use machines:If blurred vision occurs, wait until vision clears before driving or using machinery. Undesirableeffects: Very common: conjunctival hyperaemia, ocular hyperaemia, iris hyperpigmentation. Common: headache, punctate keratitis, anterior chamber cell, anterior chamber �are, eye pain, photophobia, eye discharge, ocular discomfort, eye irritation, abnormal sensation in eye, foreign body sensation in eyes, visual acuity reduced, vision blurred, dry eye, eye pruritus, lacrimation increased, erythema of eyelid, eyelid oedema, eyelids pruritus, growth of eyelashes, eyelash discolouration, skin hyperpigmentation (periocular), skin discolouration, conjunctival hyperaemia. Serious: Herpes simplex, keratitis herpetic, macular degeneration, iridocyclitis, uveitis, peptic ulcer reactivated, macular oedema. Prescribers should consult the SmPC in relation to other side effects. Overdose: A topical overdose may be �ushed from the eye(s) with lukewarm water. Treatment of a suspected oral ingestion is symptomatic and supportive. Special Precautions for Storage: None. Legal Category: POM Package Quantities and Basic NHS Costs: 2.5ml £9.98 GMS Price: €17.91 MA Number(s): EU/1/01/199/001-002. Furtherinformation available from: Alcon Laboratories (UK) Limited, Pentagon Park, Boundary Way, Hemel Hempstead, Hertfordshire. HP2 7UD. Telephone: 01442 341234. Date of preparation: November 2010 (V4).

Adverse events should be reported. Reporting forms and information can be found atwww.yellowcard.gov.uk Adverse events should also be reported to Alcon Laboratories (UK) Ltd.

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*benzalkonium chloride

cOrneaupdate10


Two different techniques for anterior lamellar keratoplasty (ALK) assisted by the IntraLase femtosecond laser (Abbott Medical

optics) are safe and effective when corneal transplantation becomes indicated for management of keratoconus in paediatric eyes, reported Luca Buzzonetti MD, at the XXVIII Congress of the ESCRS.

Dr Buzzonetti presented outcomes from three eyes of three patients that underwent ALK and two eyes of two patients that underwent IntraBubble DALK. In both procedures, the 60 kHz IntraLase laser was used to prepare the graft and donor tissues. In the IntraBubble DALK procedure, which is Dr Buzzonetti’s latest variation of big bubble DALK, the femtosecond laser is also used to create an intrastromal channel that facilitates insertion of the cannula used for air injection.

Comparisons between the ALK and IntraBubble DALK groups showed no statistically significant differences in mean BSCVA (6.0 ± 1.0 vs. 6.8 ± 0.8), spherical equivalent (-1.5 ± 2.2 D vs. -2.5 ± 1.6 D), or topographic astigmatism (4.4 ± 1.0 D vs. 3.2 ± 1.0 D).

“By performing a lamellar procedure instead of penetrating keratoplasty (PKP) we can decrease the number of graft rejections in paediatric patients, and our one-year outcomes with femtosecond laser-assisted ALK and IntraBubble DALK are encouraging,” said Dr Buzzonetti, chief, Department of ophthalmology, Bambino Gesù Hospital, Rome, Italy.

“With follow-up to two years after ALK, we have seen further improvement in BSCVA, and vision outcomes after IntraBubble DALK have improved after modifying the technique of donor lamella preparation. In fact, our more recent early experience with IntraBubble DALK in a larger series of young patients suggests that it provides a better outcome than ALK,” he added.

The five patients in Dr Buzzonetti’s report had a mean age of 15 years (range, 13 to 17 years). Surgery was performed under topical anaesthesia in one patient. The normal vacuum suction ring of the IntraLase femtosecond laser was used for docking in all cases.

“However, it may be possible to use the laser without the vacuum suction ring in the smallest patients in which the bulb was fixed anyway, providing a regular and safe applanation,” Dr Buzzonetti noted.

In the ALK group the donor disc was prepared with a diameter of 8.2mm and the recipient cut was made with a diameter of 8.0mm. A 70-degree side cut was used for both the donor and recipient cuts. Planned residual stromal thickness in the recipient was 150 microns.

For the IntraBubble technique, the laser creates three cuts. First, an anterior side cut is made and a small intrastromal channel is created 50 micronsabove the thinnest point of the cornea determined by previous measurement with Scheimpflug camera imaging (Pentacam, oculus). The channel

is made at a 30 degree angle and with a 25 degree arc length.

Then, a full lamellar cut is made at 100 microns above the thinnest point, intersecting the previously created intrastromal channel. Finally, a zigzag lamellar cut is made from the depth of the full lamellar cut. next the lamella is removed and a pointed dissector is introduced into the intrastromal channel, extending the channel to a length that is adequate for inserting the 27-G flat Fogla cannula used for air injection to create the Big Bubble.

“It is easy to identify the channel after removing the lamella, but it is usually too short and has to be extended before introducing the cannula to create the big bubble. However, the channel offers a big advantage in facilitating Big Bubble DALK

as it makes insertion of the cannula easier and also safer because it is at a predefined depth close to the endothelium,” Dr Buzzonetti said.

After the Big Bubble is achieved, residual stroma is removed by scissors and the donor disc is positioned and sutured (10-0 nylon uninterrupted). Initially, the donor was prepared with a stromal interface according to Dr Buzzonetti’s original model where the thickness is calculated based on the recipient preoperative corneal thickness. Subsequently, with the goal of improving refractive and functional outcomes, he cuts the donor lamella similar to the recipient and performs endothelial stripping.

Discussing the paper, Massimo Busin MD, PhD, congratulated Dr Buzzonetti for his “interesting application” of the femtosecond laser in DALK for paediatric patients. However, considering the issue of interface quality, he questioned whether use of the femtosecond laser was compromising visual outcomes.

“Lamellar keratoplasty has an important advantage over penetrating keratoplasty in paediatric eyes where there is a high risk of graft rejection after the full-thickness procedure, and Dr Buzzonetti is to be commended for his idea of using the femtosecond laser for initial stromal removal because in theory, this approach allows the surgeon to carry on with a lamellar procedure rather than converting to penetrating keratoplasty if the big bubble is not achieved,” explained Dr Busin, professor of ophthalmology, Villa Serena Hospital, Forli, Italy.

“However, the visual outcome after DALK requires that the interface quality be compatible with good vision, and it is still to be demonstrated that the surface regularity achieved after using the femtosecond laser for tissue preparation can match that of a mechanical microkeratome,” he said.

Luca Buzzonetti – [email protected] Busin – [email protected]

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avoIdIng PkP rIsksFemtosecond laser-assisted procedures for keratoconus patientsby Cheryl Guttman Krader in Paris

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Lamellar keratoplasty has an important advantage over penetrating keratoplasty in paediatric eyes where there is a high risk of graft rejection after the full-thickness procedure

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Massimo Busin MD, PhD

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Longer-term results support the potential of Descemet's membrane endothelial keratoplasty (DMEK) for becoming the technique

of choice in the surgical treatment of endothelial disease, according to Gerrit Melles MD, PhD.

Dr Melles, director, netherlands Institute for Innovative ocular Surgery (nIIoS), Rotterdam, pioneered endothelial keratoplasty (EK) and DMEK. Speaking at the XXVIII Congress of the ESCRS, he reported that compared with penetrating keratoplasty (PKP) and other EK procedures, DMEK provides faster and better visual rehabilitation and is associated with a similar pattern of decrease in endothelial cell density (ECD). Isabel Dapena MD, nIIoS corneal fellow, presented data documenting complication risk was affected by a surgical learning curve, but also showing that after proper training and/or the learning curve, rates of complications were significantly reduced to low levels.

Investigators analysed visual acuity outcomes of 158 eyes remaining from the first 200 consecutive cases after excluding cases with failed grafts, low visual potential, or spontaneous corneal clearance despite a detached graft. BCVA was 0.5 or better in 82 per cent of 158 eyes seen at one month and in 94 per cent of 140 eyes evaluated at six months. At six months, 76 per cent of eyes achieved BCVA of 0.8 or better and 15 per cent were 1.2 or better, including one eye that achieved a BCVA of 2.0.

Comparison of these outcomes against other techniques highlights the visual recovery benefit of DMEK. BCVA of 0.5 or better was achieved by only 50 per cent of eyes at one year after PKP and by 60 per cent of eyes at six months after DSAEK/DSEK, Dr Melles reported.

“How well patients see after surgery is the main issue in evaluating surgical techniques, but more than one road leads to Rome. As in cataract surgery, some surgeons swear by the advantages of bimanual microincisional phacoemulsification and others prefer a single-handed approach, but what is important is whether the patient will notice a difference in vision,” said Dr Melles.

“We’ve been pleasantly surprised to see that most patients do very well early after DMEK and to my knowledge, these functional outcomes are unprecedented.”

Dr Melles commented that when DMEK was first introduced, there was concern the very thin grafts would be especially susceptible to endothelial cell (EC) loss. However, the data from follow-up early after surgery and through three years is reassuring in showing that graft insertion does not cause too much damage and the rate of EC loss decreases over time.

Specular microscopy data from 146 eyes seen preoperatively and at six months showed a 33.6 per cent reduction in ECD. Mean EC loss was 34.3 per cent at one year (58 eyes), 37.4 per cent at two years (17 eyes), and 42 per cent at three years (six eyes).

“The amount of EC loss does not seem to depend on what EK technique is used. our data from the various follow-up visits are comparable to results in published series of DMEK, DSAEK, and DSEK, as well as for PKP,” Dr Melles said.

“DMEK is now a completely no-touch technique as there is no direct handling of the tissue from preparation in the eye bank through graft implantation. The glass injector we use has a very smooth inner surface, and all of the manipulation is done by air or BSS.”

The learning curve analysis included data for the first 135 cases performed by Dr Melles and his fellows with the eyes divided into three groups of 45 eyes each. In the first group, Dr Melles performed all of the surgeries whereas a clinical fellow performed six cases (13 per cent) in the second series and 14 (31 per cent) of the last series.

Analyses of BCVA outcomes excluded 25 eyes with low visual potential, primary graft failure or graft detachment and showed no significant differences between the three study groups at six months when overall, 93 per cent of eyes achieved BCVA of 0.5 or better and 73 per cent achieved 0.8 or better.

Evaluation of ECD was based on data from 107 eyes, excluding those with graft failure, detachment or spontaneous

clearance, and also showed no significant difference between the three study groups at six months when mean ECD was 1747 cells/mm2.

The learning curve effect was evident in the safety analyses. Complete graft detachment was the main complication in the initial group of eyes where it occurred at a rate of 17.8 per cent. However, the rate decreased to 4.4 per cent in the second group of eyes and dropped to 2.2 per cent in the last cohort.

“We don’t know whether it will be possible to avoid graft detachment completely or whether there may be some factors specific to the donor tissue,” Dr Melles said.

Primary graft failure occurred in three (6.7 per cent) of the first 35 eyes, but in none of the subsequent groups. There were also progressive and dramatic decreases across the three groups in the frequencies of rebubbling procedures (11.1 per cent, 4.4 per cent, 2.2 per cent) and secondary DSEKs (22.2 per cent, 11.1 per cent, 2.2 per cent).

Dr Melles told EuroTimes that some corneal surgeons might be encouraged to change from DSEK/DSAEK to DMEK because of the visual outcomes. To facilitate its adoption, Dr Melles together with his fellows and staff at the Amnitrans Eye Bank have tried to standardise both DMEK donor preparation and surgical technique, for example the ‘Moutsouris-sign’ to determine the upright orientation of the graft, and the ‘Dirisamer-technique’ to centre and enroll the graft within the recipient anterior chamber without touching the tissue, and ‘Bubble-bumping’ to completely unfold peripheral folds.

“The procedure itself is widely accessible because it is performed with routine instruments, and we believe it is easy to learn if one follows each step of our surgical protocols. In fact, DMEK may be particularly appealing to the new generation of surgeons who tend to pick the technique up very fast, probably because it is more straightforward,” he said.

Gerrit Melles – [email protected]

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dmek data encouragIngThree-year outcomes highlight unsurpassed visual recoveryby Cheryl Guttman Krader in Paris

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Diagrammatic representation of the ‘Moutsouris-sign’ visualising the upright orientation of the Descemet graft within the recipient anterior chamber. Note that the tip of the cannula does not change in colour when the graft is positioned upside-down (upper images;

Moutsouris sign negative), but that the tip turns blue when it can ‘enter’ the folds, ie, when the graft is positioned upright (lower images; Moutsouris sign positive)

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The procedure itself is widely accessible because it is performed with routine instruments, and we believe it is easy to learn if one follows each step of our surgical protocols

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Although keratoprosthesis surgery has historically been reserved as a last resort for eyes that are absolutely not amenable to

penetrating keratoplasty (PKP) because of their end-stage condition, the time has come for a paradigm shift in the indications for implantation of an “artificial cornea”, according to Sadeer B Hannush MD.

Speaking at the 1st EuCornea Congress, Dr Hannush advocated considering one available keratoprosthesis, the Boston KPro, as an effective and valuable alternative to regrafting in eyes that would traditionally be considered good candidates for initial PKP, ie, those with underlying diagnoses of bullous keratopathy, stromal dystrophy, physical trauma, or limbal stem cell deficiency, but that have suffered one or more graft failures.

Support for this recommendation derives from evidence of the declining success of PKP with successive regrafting and recent data highlighting favourable outcomes for the Boston KPro.

Results of a landmark study published nine years ago have raised awareness that regrafting carries a poor prognosis, said Dr Hannush.

In that paper [Ophthalmology 2001;108:461-7], Bersudsky et al. reported that the chance of maintaining graft clarity after five years was only 25 per cent

for a second regraft (ie, third graft) and approached zero per cent for a third.

Meanwhile, most, if not all, serious complications associated with keratoprosthesis surgery have been conquered in the setting where the indication for implanting the Boston KPro is previous graft failure.

“Data from surgeries performed over the past eight years using a version of the Boston KPro incorporating the last major design modification show retention rates of 91.3 per cent overall and of 95.6 per cent for the subgroup of eyes where the indication was graft failure without any inflammatory condition,” Dr Hannush reported.

Advances in device design, surgical technique, and postoperative management have all contributed to the improved outcomes of Boston KPro surgery. The latter involves acceptance by corneal specialists that certain “alien” concepts must be mandatory elements of care, said Dr Hannush.

“These include long-term antibiotic coverage to prevent endophthalmitis, aggressive use of corticosteroids intraoperatively and postoperatively at the earliest sign of inflammation, continuous wear of a bandage contact lens to prevent corneal melting, and rigorous glaucoma management with routine monitoring to enable prompt intervention at the earliest sign of progression,” he explained.

More outcomes At the same EuCornea Congress session, Josef Stoiber MD, reported on the first Boston KPro surgeries performed at the University Eye Clinic, Paracelsus Private Medical University, Salzburg, Austria. The outcomes were favourable overall and lend support to the concept that the keratoprosthesis is a useful option in eyes with multiple PKP failures in addition to those not amenable to conventional corneal transplantation.

“The success of this surgery makes it very rewarding to patients and surgeons. However, patients must understand that maintaining a good outcome over the long-term depends on their compliance with postoperative care instructions, including returning for follow-up visits,” said Dr Stoiber, Privatdozent, Paracelsus Private Medical University.

The Austrian series comprises 17 patients with a duration of follow-up ranging from three to 33 months. The indications for keratoprosthesis surgery were corneal burns (nine eyes), multiple graft failures (six eyes), and total limbal deficiency associated with conjunctival carcinoma or Acanthamoeba infection (two eyes).

Visual acuity increased significantly in 14 of the 17 cases, improving from hand motion or lower up to as high as 0.8 (20/25) in one eye. Lack of functional improvement in the remaining three cases was attributable to previously undiagnosed severe retinal disease, reported Dr Stoiber.

Ten eyes presented with pre-existing glaucoma and worsening glaucoma in three patients required management with shunt surgery. Two eyes with severe ocular surface disease developed a corneal melt requiring explantation of the keratoprosthesis.

A novel concept Although safety outcomes with keratoprosthesis surgery have improved, because the procedure involves entry into the anterior chamber, risks such as epithelial downgrowth and fistulation leading to endophthalmitis or expulsion remain.

About 10 years ago when he was a research fellow at the Bascom Palmer Eye Institute, University of Miami, Florida, Dr Stoiber and colleagues began work to develop a supradescemetic (lamellar) synthetic cornea based on the theory that it could avoid some of the risks of a penetrating keratoprosthesis. Initial studies conducted in animal models to optimise the design, material, and

implantation technique resulted in an investigational prototype (Keralia, Corneal Laboratories) constructed of a Hema-MMA copolymer with a 7.0mm diameter, including a 350-micron thick 4.5mm optical zone and 100-micron thick surrounding periphery containing 24 holes, allowing for tissue ingrowth to confer device stability.

In an animal model where the implantation was performed in vascularised corneas with experimentally induced corneal burns and limbus resection, the device showed good biocompatibility, stability, and transparency after one year of follow-up. However, results in a Phase I European multicentre study have been disappointing with the development of corneal melting, stromal opacification, and implant extrusion.

Among seven cases, the lamellar keratoprosthesis remains in place in only one eye. The latter patient was using topical medications for glaucoma management and developed intense opacification of the keratoprosthesis. However, the device was not explanted because the eye had low potential visual acuity secondary to retinal disease.

“This experience reinforces that success in preclinical studies does not imply success in humans. It has also taught us that dry eye is an absolute contraindication for this type of keratoprosthesis while patients requiring intensive treatment with eye drops containing preservatives should be avoided,” said Dr Stoiber.

“While a lamellar keratoprosthesis has important potential advantages, we still have a long way to go before it is a useful clinical option. Currently, the Keralia project is on hold as modifications in the implant design, material, and surgical technique are being considered.”

Sadeer B Hannush – [email protected] Stoiber – [email protected]

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artIFIcIal corneasImproved outcomes support expanded use of one device, but remaining risks motivate further innovationby Cheryl Guttman Krader in Venice

Keratoprosthesis

33 months post-op Boston KPro VA

Pre-op Boston KPro VA hand motion

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Adjusting Goldmann applanation tonometry (GAT) values based on central corneal thickness (CCT) will only add to the inaccuracy

of the measurement, according to James D Brandt MD, University of California, Davis, Sacramento, California, US.

“We have good data from oHTS that adjusting Goldmann applanation tonometry values in this way does not eliminate central corneal thickness from the oHTS predictive model. Engineering models suggest that central corneal thickness is only a mild contributor to GAT error, and signal-to-noise error makes the attempt to adjust the noisy measurements unreliable. And finally there is good and improving epidemiological evidence that central corneal thickness is a risk factor independent of IoP,” Dr Brandt said at the 9th European Glaucoma Society Congress. He noted that when he and the other oHTS investigators were designing the study’s protocol, he pushed for inclusion of patients’ corneal thickness data. There was at that time a growing recognition of corneal thickness as a confounder of GAT measurements, particularly in ocular hypertensives. In theory, thinner corneas could lead to an underestimation of IoP and therefore also of glaucoma risk, he said

“What I predicted in 1994 was that central corneal thickness would play a role in the risk model and that adjusting IoP measurements by central corneal thickness measurements would represent a more accurate risk model, and that perhaps even back-calculating the IoP adjustments from the risk model might result in a better IoP adjustment formula. The last two predictions turned out not to be the case,” he added.

Dr Brandt noted that central corneal thickness turned out to be the most powerful component of oHTS investigators’ predictive model for conversion to glaucoma based on the study’s results. They found that the contribution of CCT to the risk for glaucoma far exceeded what would have been expected from the underestimation of IoP resulting from a thinner, more yielding cornea.

“We have looked at this very powerful relationship between central corneal thickness and glaucoma risk and despite calculating and re-adjusting the IoPs for CCT, CCT remains a very powerful component of the risk model. Correcting GAT for CCT does not eliminate CCT from

the oHTS multivariate model,” he said.In a study where Dr Brandt and his

associates applied four of the published algorithms for correcting IoP based on CCT to the oHTS dataset, they found that CCT had the same predictive value for glaucoma whether or not they included the adjusted IoP (Brandt et al, ARVO 2010).

“We found that the calculation of individual risk for the development of PoAG is simpler and equally accurate using IoP and CCT as measured, rather than applying an algorithm to ‘correct’ IoP for CCT. This analysis suggests that CCT’s influence as a glaucoma risk factor derives from more than just GAT artefact,” he said.

Epidemiological studies showing CCT to be a more powerful predictor of glaucoma than IoP include the Los Angeles Latino Eye Study (LALES) and the Barbados Eye Survey, Dr Brandt added. In addition, research in corneal biomechanics conducted by Cynthia Roberts PhD show that variations in corneal thickness will account for only around 3.0 mmHg measurement error (Liu et al, JCRS 2005; 31: 146-155). Dr Roberts’ engineering model of the cornea suggests that the effect of the cornea’s material properties on GAT measurements are much greater than the effect of CCT, and could account for as much as 15 mmHg of variation.

“If you’re presented with a patient with a central corneal thickness of 620 microns, you don’t know whether that patient has a thick soft cornea or a thick stiff cornea. Thus you can be correcting in the wrong way if you attempt to apply a fixed algorithm to correct GAT measurements for central corneal thickness,” Dr Brandt noted.

other confounders of GAT measurements include diurnal IoP fluctuation and calibration errors, he noted. Even in the rigorous setting of an IoP-focused clinical trial, the agreement between observers varies by 2.5 mmHg. Furthermore, a recent survey in the UK found that almost 50 per cent of Goldmann applanation tonometers were out of calibration by over 2.5 mmHg after a few months of use.

Current theories as to how thinner corneas could contribute to glaucoma pathogenesis have yet to be submitted to rigorous scientific investigation, Dr Brandt said.

contactJames D Brandt – [email protected]

IoP correctIoncontribution of central cornea thickness to glaucoma risk not limited to effect on gat measurementsby Roibeard O’hEineachain in Madrid

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GLaucOmaupdate

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EuroTimes February 2011He trained you to be the best ophthalmologist you can be

And he chose you to perform his cataract surgery

That’s success story 50 million and one

CONFIDENCE

EURETINAINNOVATION AWARDSThe European Society of Retina Specialists is delighted to announce the 2011 EURETINA Innovation Awards, a new initiative sponsored by EURETINA to support and encourage innovation in the field of retinal medicine.

The purpose of the Awards is:

nTo support, encourage and reward individuals, who actively consider and develop novel and innovative ideas relevant to the field of retinal medicine;

nTo facilitate and support an entrepreneurial culture to deliver new market applications for the ultimate benefit of patients with retinal disorders;

nTo engage and encourage the networking potential of the retinal community across the EU to improve both patient care and outcomes.

All eligible entries will be evaluated by a Judging Panel comprising of:

A 1st Prize of €20,000, a 2nd Prize of €10,000 and a 3rd Prize of €5,000 will be awarded at the 11th EURETINA Congress, which takes place at the QEII Centre in London from 26-29 May 2011.

The competition is open and entries will be accepted until 5pm on Monday, March 14th, 2011. You can enter by applying online at www.euretina.org/Innovation

Further information is available on the website or you can contact:Dara Conlon, EURETINA Project Manager at 00-353-1-2100092; email [email protected]

See interview with Prof. Einar Stefansson (Judging Panel Chairperson) on page 22

Prof. Einar Stefansson PhD, Landspitali University Hospital, Iceland,Chairperson of the EURETINA Research Committee (Judging Panel Chairperson)

Prof. Dr. Sebastian Wolf, University of Bern, Switzerland,General Secretary of EURETINA

Mr Douglas Anderson OBE FRSE FRSA, Founder and VP of Global Advocacy, Optos Plc,Founder and Chairman of Crombie Anderson Associates

Prof. Pete Coffey BSc, DPhil, Head of Ocular Biology & Therapeutics, University College London

Mr Richard Condon, Director of Marketing (Ophthalmology), Bayer UK/Ireland.

Dr Gearoid Tuohy PhD, Ocular Genetics Unit, Smurfit Institute of Genetics, Trinity College Dublin and Founder of Genable Technologies Limited

LONDON 201126–29 May 2011

11TH EURETINA CONGRESS

INNOVATION AWARDS


Research has identified several risk factors for the onset and progression of different types of glaucoma, and although

those observations may apply to large populations in a general way, weighing the odds in individual patients requires a careful parsing of the data, said Gus Gazzard MA MD FRCophth, Moorfields Eye Hospital, London, UK.

“Risk factors are clues to the likelihood of a given individual having a given disease. They are derived from clinic-based, population-based, or, in some cases, controlled studies. They can give us a glimpse of the causative factors and hints into their pathogenesis. But most commonly they provide too complex a picture to easily unravel the contributions of those individual factors in an individual patient,” Dr Gazzard said at the 9th European Glaucoma Society Congress.

He noted that risk factor profiling for glaucoma will become an increasingly important factor in managing medical resources as the population ages and the prevalence of glaucoma increases. Assessing a patient’s risk factors could enhance the specificity of diagnostic procedures and allow

attention to be focused on patients who require treatment.

“We need to risk-stratify that ever-growing tidal wave of patients coming through our doors from the ageing population so that we can calibrate our follow-up appoints for those at risk and fine-tune our thresholds for preventative treatment and intervention,” Dr Gazzard said.

The different types of glaucoma share many of the same risk factors but the factors interact in different ways in different disease types and in different populations, Dr Gazzard said. The risk for all of the primary open angle and angle closure variants are all influenced by IoP, age, race, ocular anatomy, and possibly the environment in which a patient lives, he noted. “The complexity comes from the assessment of multiple risk factors because there are multiple interactions and most importantly differences in the interactions between the risk factors in the different diseases,” he added.

Dr Gazzard noted that a published review of data from population-based studies showed that there are differences in the way age influences the risk of primary open-angle (PoAG) glaucoma and the way it influences

that of angle-closure glaucoma (ACG). It also showed that age affects the prevalence of the diseases in different ways in different populations (Quigley et al, Br J Ophthalmol 2006; 90:262-267).

For example, the study showed that the prevalence of PoAG increased only modestly between the ages of 40 years to 80 years in European and Japanese populations, from around zero to 0.5 per cent.

However, in China the prevalence of ACG seemed to increase very sharply after the age of 60 years, rising from around one per cent to around five per cent at 80 years of age. In the Indian population the prevalence rose more gradually from around 0.3 per cent to around 1.5 per cent between the ages of 40 and 80 years.

The same study showed that the prevalence of PoAG began to rise steeply after the age of 65 years among African and Latin American populations, reaching around 20 per cent by age 85. Among the Chinese population there was a similarly steep rise in the prevalence of PoAG, but starting later, at around the age of 75 years, rising from five per cent to around 15 per cent at age 85. In contrast the prevalence of PoAG among the populations of Europe, Japan and India increased with age in a more gradual linear fashion reaching only five per cent at 87.5 years of age.

“We know there is more angle-closure glaucoma in the Chinese population and more primary open-angle glaucoma in the African populations. Race clearly affects disease prevalence but also profoundly modifies the impact of age,” Dr Gazzard said.

Age can also interact with other risk factors such as myopia. The Blue Mountain

Eye Study showed that the incidence of PoAG increases much more rapidly among myopes than among non-myopes during the eighth and ninth decade of life rising from around five per cent to around 20 per cent. By comparison among non-myopes, the incidence of glaucoma rose around 2.5 per cent at 70 years of age to around seven per cent at age 70 and reached around 10 per cent during the ninth decade of life.

“Long axial lengths show a markedly increased risk with primary open-angle glaucoma. That teases out some of the interactions between myopia and refractive error and intraocular pressure. It seems that in some individuals high refractive error is as great a risk factor for primary open-angle glaucoma as high IoP,” Dr Gazzard added.

The biometric factors that influence the risk of ACG are primarily those which affect the shape of the angle, such as shallow anterior chamber and steep keratometry readings, Dr Gazzard said.

He noted that there is conflicting evidence with regard to the influence of gender on PoAG, with some studies showing men as being at greater risk, others showing women to be at greater risk. However, research does show a strong association between female gender and ACG, he noted.

“What we have is a complex web of interaction between these many different risk factors. Determining how these individual risk factors modify each other in the different glaucoma types is going to be important if we are to make sense of this massive deluge of data from individual studies,” Dr Gazzard concluded.

Gus Gazzard – [email protected]

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rIsk Factorsassessing interaction between risk factors important when gauging the likelihood of glaucomaby Roibeard O’hEineachain in Madrid

17

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Intraocular devices for treating end-stage macular degeneration that can be implanted in the capsular bag using conventional cataract surgery technique

are becoming a reality. The new lenses offer several advantages over implanted Galilean telescopes, which eliminate peripheral vision and obstruct the view of the retina.

The Lipshitz Macular Implant (optoLight Vision Technology) preserves peripheral vision, which allows it to be implanted bilaterally. The LMI device also allows imaging of the fundus after surgery, making it possible to continue injections and laser procedures on the retina and posterior capsule after implantation, which is not possible with implanted telescopes, Isaac Lipshitz MD told the ASCRS annual meeting.

In place of lenses lined up on the visual axis used in implantable telescopes, the LMI device uses mirror telescope technology to capture, magnify and direct incoming images to areas of the retina undamaged by macular degeneration. To prevent the central image, which is magnified 2.5 times, from appearing darker than the unmagnified peripheral image, the device splits about 80 per cent of incoming light to the central image and about 20 per cent to the periphery, Dr Lipshitz said.

Constructed of polymethyl methacrylate, the LMI’s optic measures 5.5mm to 6.0mm with 13mm loop haptics, and is 2.1mm thick. This allows it to be implanted in the capsular bag after phacoemulsification through a 6.0mm to 6.5mm incision with normal post-op cataract recovery, Dr Lipshitz said. In two series of patients the device improved best corrected distance vision by 3.6 and 1.0 lines, and near vision by 4.9 and 4.0 lines, though it is not clear why one series achieved lower distance improvement, he said. Side effects included mild uveitis and mild glare, with one case of severe anterior uveitis that resolved with conservative treatment. The LMI device was granted CE approval in May 2009, but is not FDA approved.

By comparison, the Implantable Miniaturized Telescope (VisionCare Technologies, Saratoga, California, US), which is also designed by Dr Lipshitz and won FDA approval in July, is implanted unilaterally. It eliminates peripheral vision, so patients must use the fellow eye to see for ambulation. Utilising inline lenses in a Galilean telescope arrangement, the IMT device is 3.6mm in diameter and 4.4mm

thick, and the optic protrudes though the pupil. Large-scale studies have found the IMT device improved best corrected visual acuity by 3.6 lines for the 3X magnification version and 2.8 lines for the 2.2X version.

The P-Flex (Rayner Intraocular Lenses Ltd, East Sussex, UK) prismatic IoL takes a different approach. The prototype PMMA lens is based on a standard Rayner platform design with Fresnel prisms on its posterior surface. These prisms redirect incoming light away from the degenerated central macula to healthy peripheral retina. The goal is to eliminate the central scotoma, making it possible for patients to better use low-vision aids, Charles Claoué MD, FRCS, FRCophth, London, UK, told EuroTimes.

In 2008, a prototype was implanted in two eyes in two patients by Dr Claoué and Frik Potgeiter MD, FRCS, in Pretoria, South Africa. Visual acuity in these patients did not improve. “We never expected it to be better than 20/200 because the peripheral retina is less sensitive,” Dr Claoué said. However, the lens succeeded in displacing the blotch in the middle of the visual field without inducing double vision, which is a theoretical issue with prismatic lenses.

“We would regard as a success a patient who could not read being able to read with aids after the surgery. We think the annoyance of the central scotoma is a major problem with using low-vision aids, but we will need to do much larger studies to document the efficacy of this approach.”

Based on the experience with the first two implants, the lens optics was refined. “The optics were not as perfect as we wanted and it required some further work. We wanted a prismatic effect, but when you both focus light and deviate it, its behaviour becomes very complicated,” Dr Claoué said.

The revised lens has now entered phase 2 trials with as many as 16 lenses to be implanted, Dr Claoué added. “The latest patients are extremely satisfied with the improvement in their vision.” A larger trial is planned for the UK, possibly beginning late this year, said Rayner CEo Donnie Munro.

Advances in lenses for treating AMD could restore functional vision for millions of end-stage AMD patients now classified as legally blind, Dr Claoué said.

contactCharles Claoué – [email protected]

In-the-bag Iolsmirror telescope device improves visionby Howard Larkin in Boston

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reTInaupdate


Epiretinal membrane development remains a known complication of retinal detachment (RD) repair, but surgical removal of the membranes

remains a viable means of improving visual acuity for these patients, according to a study presented at the 10th EURETInA Congress.

“In our series, 8.9 per cent of patients who underwent primary pseudophakic rhegmatogenous retinal detachment (RRD) repair with pars plana vitrectomy (PPV) alone developed a postoperative macular pucker. overall it was clear that the patients benefited from membrane peeling surgery although the visual acuity outcome was probably limited by the previous retinal detachment,” said Anna Boixadera MD, Vall d’Hebron University Hospital, Barcelona, Spain.

Dr Boixadera noted that epiretinal membrane formation is one of the most common causes of visual reduction after successful RD surgery.

“The ERM incidence after scleral buckling surgery is between three per cent and 8.5 per cent and after PPV between eight per cent and 12 per cent,” she said.

Dr Boixadera’s prospective consecutive study included 312 pseudophakic RRD patients with a mean age of 66 years who underwent pars plana vitrectomy (PPV) alone. Exclusion criteria included traumatic RRD, concomitant scleral buckle, RRD duration of greater than two months, vitreoretinal proliferation of grade B or more, other visually significant ocular conditions and silicone oil tamponade.

The surgical technique included 20- or 23-gauge PPV, ERM peeling and brilliant blue-assisted internal limiting membrane dissection. Intravitreal triamcinolone was not used at the end of surgery, and the mean follow-up after ERM surgery was 8.2 months.

Dr Boixadera reported that 28 per cent of the RRDs (eight) were operated before one week and 71 per cent (20) eight or more days after the visual loss onset. The retinal detachment type was macula off in 89 per cent (25) of patients. The ERM incidence was 8.9 per cent (28/312), with a mean time of 6.2 months from ERM diagnosis after RRD repair.

of the 28 ERM patients, 22 were operated and six were not. one patient, a 90-year-old, refused surgery and the remaining five patients were defined as grade 1 ERM without metamorphopsia or significant

visual acuity loss. Complications for the ERM patients included one intraoperative retinal break and six cases of postoperative cystoid macular oedema (CME). There were no recurrent RRDs in this series.

Dr Boixadera noted that worse final visual acuity correlated with older age, lower pre-ERM visual acuity and ERM surgery less than three months after RRD surgery. no correlation was found between final visual acuity and the number of retinal breaks and the size of retinal breaks.

The average improvement in vision after repeated surgery was 1.3 Snellen chart lines and 95 per cent of patients had a final visual acuity equal to or greater than their best visual acuity after RD repair. The visual acuity gain was superior in the patients that underwent ERM surgery compared to the non-operated group and there was a direct correlation between the visual acuity before and after ERM surgery. The patients that were not operated showed stable visual acuity.

Putting the results into context, Dr Boixadera said that the visual acuity prognosis after ERM removal is probably conditioned by the previous RRD and is worse than after idiopathic ERM surgery.

“The recurrence of ERM could not be analysed in this study due to the short follow-up period. It is clear, however, that the final visual acuity is better in the group of operated ERMs. In the non-treated group, the visual acuity remained stable probably because the ERMs were asymptomatic and with good visual acuity,” she concluded.

contactAnna Boixadera – [email protected]

rd surgeryImproving visual acuity after rd surgeryby Dermot McGrath in Paris

19

dr boixadera noted that epiretinal membrane formation is one of the most common causes of visual reduction after successful rd surgery


Hospitals committed to training young surgeons should embrace the best technology available as well as incorporating new

research on how trainees learn, according to Larry Benjamin FRCS(Ed) FRCophth, a consultant at Stoke Mandeville Hospital, Aylesbury, UK.

Delivering a lecture on training methods in honour of neil Dallas, the first president of the United Kingdom & Ireland Society of Cataract and Refractive Surgeons (UKISCRS), Dr Benjamin told the society’s annual meeting that major leaps had been made in training facilities over the past two decades but there is no substitute for investing hours in practice. He also stressed the need to “train the trainers” given that not all surgeons are natural teachers and many have only a limited understanding of how people learn.

“We all think we’re good trainers, but some are not. What’s changed is that we now

understand that not everyone is a natural teacher and we can do something about it,” Dr Benjamin said.

He recommended that consultants undergo a specially-designed course which will help them understand why some newly-qualified surgeons are slower to learn than others.

Trainees should get surgery time every week, he stressed, although measures can be put in place to ensure that this does not affect patient care or upset theatre schedules. He also suggested having a code for intervening if complications arise.

“There are little tricks that help new surgeons get theatre time, such as limiting the time they have to complete a procedure. Give them 30 or 40 minutes – whatever you’re comfortable with – and take over at the end of that time. What happens then is that all the nurses know, and you know, that this is going to get finished and the trainee will still get experience. Every week they should get two 40-minute slots to operate,” he explained.

The risks associated with inexperienced surgeons operating on patients can be minimised if patients are selected carefully. Risk factors for a range of procedures have been calculated and a risk value can be put on having a trainee perform the surgery. In effect, this can mean lower complication rates if age and patient history are factored into an equation to help determine when an experienced surgeon is most necessary.

new training techniques can also help curb the risk to patients by getting new surgeons’ skills up to speed more quickly than was possible in the past. Developing cognitive skills has become a key component of modern training. Surgeons practising a new skill are often so focused on the forceps that they are oblivious to all around them. once they become more comfortable with the technique it demands less focus and they are better able to incorporate other information.

“Cognitive skills training has been shown to reduce operative complications by around 50 per cent. You are taught something new, you think about it, you talk about it in your own words, you notice how this fits into other things you know. You can really separate good learners from average ones based on how well they integrate new information and how it might affect their practice. Listening, understanding, and then applying what has been learned – that’s the application of cognitive skills,” Mr Benjamin said.

He showed a video giving an example of how newly-minted surgeons can be so intent on focusing on tip of the forceps that everything else is a blur, leading to errors.

“You can’t hear what people are saying, you’re not aware of what the instruments are doing. But as trainees get more experienced their cognitive skills increase, they see more around them. It’s a bit like driving: when you’re learning you grip the steering wheel, your teeth are clenched, you stare straight ahead and you lean with the car as you turn the corner. More experienced drivers are comfortable steering with one hand or listening to music.”

new surgical simulators have changed the face of training and allow trainees to practise on very detailed and realistic models. Long-standing models such as pig eyes and low-tech practices like lasers pieces of paper have been supplemented with detailed skills boards.

“I wish our trainees would spend more time in the skills labs. These types of facilities have been around a long time but most hospitals don’t have them. It’s a shame that some young surgeons think going into theatre with their boss is sufficient practice,” he said.

Another feature of modern training that has improved skill levels and surgical outcomes is biofeedback. Mr Benjamin admits he was sceptical of biofeedback at first but has since been converted.

“I laughed at this when it first came out. We were approached by a group of people who had read a study showing musicians’ performances increased dramatically after biofeedback. So we tried this with our juniors and found that it worked,” he said.

The 20 young surgeons participating in the study were trained to move a line on a computer screen – a standard technique in biofeedback training. The subjects were assigned randomly to this protocol for eight half-hour sessions of biofeedback, followed by some surgical tasks. Their performances were scored by consultants who were unaware of which surgeons had undergone biofeedback training.

“They had improvements in overall technique, were better at suturing, the overall time was reduced and, their anxiety levels were reduced,” Mr Benjamin said.

The combination of better organised training schemes, better trained trainers and new technology will make it easier for new surgeons to hone their skills. In the end though, he said practice makes perfect.

“The future of training is necessarily structured and innovative. I think every training unit should have a wet lab and a simulator – but you’ve got to use them. They say it takes 10,000 hours to become an expert. At three hours a day, that is 10 years. There is no question that increased time spent practising will speed up surgical prowess.”

Larry Benjamin – [email protected]

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traInIng young surgeonsunits must have wet lab and simulators and trainers need supportby Gary Finnegan in Brighton

20

OcuLarupdate

Don’t miss e-learning, see page 26

“We all think we’re good trainers, but some are not. What’s changed is that we now understand that not everyone is a natural teacher and we can do something about it”

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The European Society of Retina Specialists (EURETInA) has launched the 2011 EURETInA Innovation Awards, a new

initiative sponsored by EURETInA to support and encourage innovation in the field of retinal medicine.

The purpose of the awards is:nTo support, encourage and reward

individuals, who actively consider and develop novel and innovative ideas relevant to the field of retinal medicine;

nTo facilitate and support an entrepreneurial culture to deliver new market applications for the ultimate benefit of patients with retinal disorders;

nTo engage and encourage the networking potential of the retinal community across the EU to improve both patient care and outcomes.

All eligible entries will be evaluated by a Judging Panel, comprising of:nProf Einar Stefansson PhD, Landspitali

University Hospital, Iceland; chairperson of the EURETInA Research Committee (panel chairperson);

nProf Dr Sebastian Wolf, University of Bern, Switzerland; general secretary of EURETInA;

nMr Douglas Anderson oBE, FRSE, FRSA, founder and VP of Global Advocacy, optos Plc; founder and chairman of Crombie Anderson Associates;

nProf Pete Coffey BSc, DPhil, University College London, UK;

nMr Richard Condon, director of marketing (ophthalmology), Bayer UK/Ireland;

nDr Gearoid Tuohy Phd, ocular Genetics Unit, Smurfit Institute of Genetics, Trinity College Dublin and Founder of Genable Technologies Limited.

A First Prize of €20,000, a Second Prize of €10,000 and a Third Prize of €5,000 will be awarded at the 11th EURETInA Congress, which takes place at the QEII Conference Centre in London from 26-29 May 2011.

Prof Stefansson, announcing the launch of the awards, said: “I am very honoured to be invited to be the chairperson of the EURETInA Innovation Awards. Research in retinal medicine has never been more active. Recent developments spanning bioimaging, instrumentation, surgery, diagnostics, genetics and therapeutics, all arising from rapid advances in knowledge and the dissemination of knowledge, have created a fertile environment for innovation. From such innovation our field is poised to create new products, processes, tools and methods through which improved and advanced care can be delivered more efficiently and with greater impact,” he said.

Prof Stefansson said that EURETInA is conscious of the opportunities and challenges arising from such advances and is ideally placed to support and contribute to the ideas that will seed the practice of tomorrow’s retinal medical care.

“The challenge with this initiative is for you to look forward and think big! We would like to see ideas on how the way we do things today can be improved tomorrow; we would like to see where your curiosity and ingenuity can take you and how it can be applied; we would like to see and support the best and brightest innovations with the capacity to change how we support and treat patients with retinal diseases,” he said.

contactEinar Stefansson – [email protected]

neW aWardssupporting and encouraging innovation in the field of retinal medicine

22 news

eureTIna

We would like to see ideas on how the way we do things today can be improved tomorrow

“Prof Einar Stefansson PhD

Don’t miss EUREQUO update, see page 28

See ad on page 16 for more information

EuropEan SociEty of cataract & rEfractivE SurgEonS

SYMPOSIA TOPICSnCataract and Endothelium (Joint Symposium with EuCornea)

nFemtosecond Cataract Surgery

nRefractive Adjustments after Ocular Surgery

nDecision-making in Presbyopia

nAnterior Segment Reconstruction

Abstract Submission Deadline: 15 March 2011


Following the successful launch of “LASIK Safe in Our Hands” (www.LASIKSafeinOurHands.com), a consumer-oriented website

dedicated to highlighting the facts about LASIK surgery, ESCRS has launched a number of dedicated foreign language sites to promote awareness of the procedure. Patients who log on to the main website can now access translations of the content in English, French, Spanish, German and Italian.

The LASIK website, launched at the XXVIII Congress of the ESCRS in Paris, France, last year, was the centrepiece of a new campaign to address, through education, lingering concerns about the procedure held by many who have not had LASIK.

The website answers frequently asked questions such as who can have LASIK, selecting a surgeon and what happens after LASIK.

Survey European patients who have experienced the benefits of LASIK surgery are nearly unanimous in their enthusiasm for the procedure. A staggering 98 per cent confirmed they would recommend it to someone else, according to an international survey conducted by the well-known Opinion Health poll.

Even so, four out of five respondents who had not had LASIK still had concerns – even though 69 per cent agreed that eye surgery is a safe and well-established procedure. Of those expressing reservations, the greatest number, 30 per cent, said they needed more information. Another 24 per cent didn’t think they could afford it. Potential side effects were a major worry for 17 per cent while 11 per cent said they would not consider the procedure.

“LASIK can be a life-changing procedure, but these survey results show that people do not understand just how safe and effective modern LASIK is in the hands of a well-qualified and experienced laser surgeon. We hope that our new campaign will help bridge the information gap so that more people might benefit from good vision without glasses or contact lenses,” said ESCRS president José Güell MD.

Symposium Among the other activities organised last year to promote LASIK awareness was a special congress in Crete, Greece, organised by the ‘father’ of modern LASIK, Greek ophthalmologist Ioannis Pallikaris MD, PhD.

A special symposium was also held during the ESCRS Congress in Paris to mark the 20th Anniversary of the LASIK procedure. The session co-chaired by Beatrice Cochener MD, France and Vikentia Katsanevaki MD, Greece, provided an in-depth review of the procedure’s evolution as well as an update on the latest developments and speculative glimpses into the future of the technique.

“The presenters at this symposium are truly the experts in the topics they will discuss. They include the pioneers that have been involved in the long story of LASIK, from the early development of the laser as a way of delivering energy to the corneal tissues, to the most recent advances in customised treatment,” said Prof Cochener.

Prof Cochener told EuroTimes that the symposium marked an important milestone not only for LASIK but for refractive surgery in general, which came of age with the advent of the LASIK technique. Although the amount of correction achievable with the procedure turned out to be less than originally expected and although there have been unforeseen complications in some cases, improvements in laser technology and a better understanding of the technique’s limitations have done much to restore any lost confidence in the procedure’s safety and efficacy, she said.

“The LASIK of yesterday is not the LASIK of today," said Prof Cochener. “We no longer need to be afraid of secondary ectasia. We expect that thanks to the precision of femtosecond laser (performing thin flap, adjusted edges design) but also to a better selection of patients with risk factors for this complication, the incidence of secondary ectasia could considerably decrease. Moreover, we now have the capability to tailor the treatment for each patient,” she said.

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LASIK webSIteSeSCRS launches foreign language LASIK consumer websites

News

LASIK


A new e-learning solution for ESCRS members will be officially launched at the 2011 ESCRS Winter Meeting in

Istanbul.The ESCRS iLearn: Interactive

Education initiative, which has been several years in the planning and execution, is designed to further serve the interests of the ESCRS’s growing global community of cataract and refractive surgeons and general ophthalmologists.

The online learning programme, which will be launched initially as a pilot programme, will allow users to access learning material in a flexible manner to suit their own schedule and pace of learning.

Welcoming the initiative, Paul Rosen FRCS, FRCOphth, past-president of the ESCRS and current chair of the Education Committee, said that the e-learning programme goes right to the heart of the core mission of the ESCRS.

“I think this is a very important development and underscores the ESCRS’s commitment to continually enhance the range of services we offer to our members. With ophthalmic technology evolving so quickly, everyone recognises the importance of keeping our surgical skills and knowledge up to date for the benefit of our patients. The e-learning solution will allow ophthalmologists to access educational opportunities over the Internet and provide a valuable forum for our members to exchange views and tap into the expertise of their colleagues and fellow society members around the world,” he said.

Developed and implemented by a team of instructional designers who joined the ESCRS for the express purpose of developing the organisation’s own online educational programme, the solution will allow members to access a wealth of educational opportunities over the Internet.

The goal is to allow users to take highly engaging and interactive units in order to learn about the theories, techniques and practical aspects of cataract and refractive surgery.

“The idea is to provide an online space where ESCRS members can learn, share and develop their knowledge of cataract

and refractive surgery from fundamental concepts to advanced skills using assessed, accredited and self reflective activities and resources,” explained Dr Rosen.

The system provides a range of assessment opportunities, which allows learners to monitor their own understanding and progress. The e-learning tool will also provide forums and other collaborative features to allow users of all levels to talk to each other and learn from the experience of others.

At launch, the popular Refractive Surgery Didactic Course and Cataract Surgery Didactic Courses will be available. As the site develops, users will have the option of choosing from a diverse range of courses and materials with varying levels of complexity, thereby ensuring that less experienced ophthalmologists as well as more seasoned practitioners can derive maximum benefit from their learning experience.

Learners will have the choice of longer didactic courses or shorter and single-topic courses covering surgical techniques, technologies and practices. Social media will also be integrated into the e-learning solution to allow surgeons to communicate, collaborate and share their knowledge and experiences.

The ESCRS iLearn: Interactive Education initiative will be online in March.

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OnLIne eduCAtIOneSCRS rolls out e-learning initiative

News

e-LeArnIng

Paul Rosen - [email protected]

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ASOA Specialty ForumsMarch 26−29www.ASOAForums.org

Technicians & Nurses ProgramMarch 26−28www.ASCRS.org

Early-bird DeadlineJanuary 28, 2011


If the European Registry of Quality Outcomes for Cataract & Refractive Surgery (EUREQUO) succeeds, it could become a model for other specialties

seeking to share information and develop evidence-based standards across borders, predicts Georgios Margetidis, of the European Union’s Executive Agency for Health and Consumers (EAHC), responsible for implementing the EU Health Programme.

“Maybe eye care can be used as a pilot to encourage cross-border care,” suggests Mr Margetidis, who is scientific project officer at EAHC, covering a portfolio of 30 projects dealing with performance and

quality indicators in several areas of health and healthcare. But he sees monitoring the volume and outcomes of surgery and other health services as essential to ensure quality, which in turn is a prerequisite for cross-border care delivery.

The proposal for an EU directive on patients’ rights to cross-border care was drafted by the European Commission in July 2008 and approved by the European Council in September 2010. It is now in final stages before adoption, pending a vote by the European Parliament.

EUREQUO is a first step towards developing the exchange of information

and experience on good practice, which was established as a policy objective by the European Commission, Mr Margetidis notes. “Though this objective existed, no other specialty submitted a proposal. The European Society of Cardiology had an idea to build a system, but they didn’t.” Focusing the first registry on eye surgery may be easier because there is little chance of mortality, he says.

After a peer review process, EUREQUO received a grant through the EU Public Health Programme of about €900,000 for three years. Mr Margetidis and the EAHC are monitoring the project. In a few months, preliminary analysis of the results will begin.

EUREQUO’s success will be assessed in part by how effective it is in integrating multiple national registries, and also by how potentially useful the data it generates will be for improving patient safety and outcomes, Mr Margetidis says. If the project is deemed useful for supporting the Health Programme objective of generating and disseminating health information and knowledge, further expansion may be funded. The agency’s goal is to test concepts and develop action plans

that EU member states can adopt to achieve their national policy objectives, he adds.

Significant obstacles exist to implementing standardised outcomes reporting across the continent, Mr Margetidis says. One is that the organisation of health systems varies from country to country. In Spain, for example, healthcare is the responsibility of the regions rather than that of a unified national system. Mr Margetidis hopes that relying on national societies that represent surgeons across countries will help. “There are differences between states and this project will show what can be done and what cannot, and how far the different EU member states can take it.”

Most important is how EUREQUO affects quality. Once enough surgeons are participating, it will take time to judge the impact of making the data available. “The fact that ESCRS has committed to backing the project for three more years will give us a chance to use it and to have an effect,” Mr Margetidis says. “This programme will provide us with the initial information to see if we can push the approach forward at the policy level.”

Georgios Margetidis - georgios.margetidis @ec.europa.eu

cont

act

European Societyof Ophthalmology

Key Note Lecturers

LeAdIng the wAyeuReQuO could become model for registries for other specialtiesby Howard Larkin

28 News

eUreQUO


Paddy Dunne, senior designer, EuroTimes, has won the Designer of the Year (Business Magazines) award 2010.

The judges of the award presented by Magazines Ireland said they saw evidence of major design innovation and excellence with a refreshing new look for the magazine following its redesign last year.

Magazines Ireland represents 42 Irish publishers who together produce over 200 magazines, both consumer and business-to-business titles.

“I believe the rebranded issue of EuroTimes vastly improves on the previous template,” said Paddy in his submission for the award.

“Reader feedback on our new look has been very positive. With every issue since June 2010, we strive to make further improvements giving our readers a much more satisfying reading experience. This rebrand has given our product a massive reinvigoration and it is for these reasons that I believe EuroTimes was eligible for Best Designer in B2B."

After accepting his award Paddy also paid tribute to EuroTimes assistant designer Janice Robb who played a major part in the 2010 redesign.

Dr Emanuel Rosen, chairman of the ESCRS Publications Committee, EuroTimes, congratulated

Paddy on his achievement and said that winning the award was a major recognition for the magazine.

“This was very much a team effort and I would also like to thank the editorial and marketing team at EuroTimes, the medical editors and the International Editorial Board,” he said.

This is the second award that EuroTimes has received from Magazines Ireland in the last four years. In 2007, the magazine won the Business to Business Specialist Magazine of the Year award.

contact

29

euROtImeS deSIgn AwARd

News

YOUng OphthALmOLOgIStS

Paddy Dunne (centre) receives his award from Roy Thewlis of Typeform (left). Also pictured is Bryan Dobson who presented the awards..

Last year (2010), in a major new initiative, the ESCRS decided to set up an Observership Programme for young ophthalmologists.

The Observership Programme is designed for young ophthalmologists who are starting their surgical training or already in surgical training and is under the direction of Oliver Findl MD, MBA, chairman of the ESCRS Young Ophthalmologists’ Forum.

“When we set the programme up we decided to look at short observerships for a few days or a week at most in different European centres,” he said. “We also asked participating centres to draw up a short curriculum and to give our observers the opportunities to see patients in a clinical setting.”

Prof Findl said that while the young ophthalmologists taking part in the programme will not be able to carry out surgery, they will get the opportunity to see senior ophthalmologists working. “It will also be interesting for them to see first hand the logistics of how an ophthalmological department is run,” he said.

As part of the new programme, a special website has been set up to allow young ophthalmologists who are ESCRS members to register for the programme. The website also includes a list of participating sites. Young ophthalmologists who are not ESCRS members can join the society free of charge and this allows them access to the website. The ESCRS is also giving some financial

support to young ophthalmologists to help them cover some of their travel and accommodation costs. The participating centres are listed on the Young Ophthalmologists website at: http://escrs.org/youngophthalmologist/default.asp.

Travel abroad Prof Findl said that many young ophthalmologists will go on for further education and training outside of their own countries. “The ESCRS Observership Programme will give them a chance early in their education to see how ophthalmology is practised in different settings,” he said. “I think this is one of the big strengths of the ESCRS, the European Union and Europe. We have different cultures and different health systems and we should try to broaden our horizons and learn from seeing other systems, other surgeons and other techniques.”

Prof Findl said that the new programme was one of the most exciting initiatives to be launched by the ESCRS in recent years. “Sometimes it may be difficult for trainees to take time off, even for a few days, but I think this will be very worth while as training and education is very important, particularly for young ophthalmologists,” he said.

Oliver Findl - [email protected]

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EuroTimes February 2011


Ophthalmologists may soon see more extensive claims in drug advertisements depending on the outcome of a case now before

Europe’s highest court.The case, which arose over claims by

a pharmaceutical company about its diabetes drug, has reached the European Court of Justice in Strasbourg. At issue is whether pharmaceutical manufacturers can include information about a drug in an advertisement in a medical journal if that information has not already been included in the drug’s official Summary of Product Characteristics.

Under the EU Directive on the Community Code Relating to Medicinal Products for Human Use, the summary of product characteristics of a drug must be included in all applications for marketing authorisation. The directive, which was adopted in 2001, also specifies the type of information that must be included in the summary, including its therapeutic indications, method of administration, special warnings and precautions.

Article 87 of the same Medicinal Products Directive mandates that “all parts of the advertising of a medicinal product must comply with the particulars listed in the summary of product characteristics.” The law also stipulates that “advertising of a medicinal product: shall encourage the rational use of the medicinal product, by presenting it objectively and without exaggerating its properties,” and “shall not be misleading.”

The Estonian case arose after an ad for the diabetes drug, Levemir®, appeared in the April 2008 issue of the Estonian medical journal, Lege Artis.

In June of 2008, Ravimiamet, the Estonian medicines agency, prohibited the further publication of the advertisement unless its manufacturer, Novo Nordisk, removed three claims that were not included in the product summary.

In its objection, Ravimiamet alleged that the advertisement failed to comply with the terms of article 87 of the Medicinal Products Directive.

Novo Nordisk appealed the decision to an administrative court in the city of Tartu. After that court upheld the Ravimiamet decision in November of 2008, the company again appealed – to the Court of Appeal in Tartu.

In its defense, Novo Nordisk has argued that the interpretation of Article 87 by Ravimiamet — and ban of its Levemir advertisement — violated its right to Freedom of commercial speech and was disproportionate.

When the case came before a court in Estonia, that court stayed the appeal and referred the matter to the EU Court of Justice to clarify how EU law should be interpreted in the appeal. In its referral, the Estonia Court of Appeal posed two specific questions to the EU Court of Justice:

Must Article 87(2) of the Medicinal Products Directive be interpreted as extending also to quotations taken from medical journals or other scientific works which are included in advertisements for medicinal products directed to persons qualified to prescribe medicines?

Must Article 87(2) of the Medicinal Products Directive be interpreted as prohibiting the publication in advertisements for medicinal products of claims which conflict with the summary of product characteristics, but not requiring that all the claims in advertisements for medicinal products must be included in the summary of product characteristics or be derivable from information in the summary?

Following its usual procedure, the Court of Appeal – after receiving written submissions but before hearing oral argument from the parties – sought an opinion about the case from its advocate general. Under court procedure, the Court of Justice can use the reasoning in the opinion of the advocate general to make its own decision after hearing oral argument. Although the judges who will ultimately hear the case are not bound by the opinion of the advocate general they will certainly give the opinion extensive consideration. In general, the Court of Justice follows the opinion of the advocate general in making its own binding ruling.

In his opinion, the advocate general, Niilo Jääskinen answered decisively “yes” to the first question posed by the Estonian court. According to the advocate general, Article 87 of the Medicinal Products Directive did regulate all aspects of drug advertising in medical journals, including any citations from other medical journals or clinical studies, regardless of whether they

were included in the summary of product characteristics.

In answering the second question posed by the Estonian court, however, the advocate general has opened the possibility that drug companies can include information strictly outside of the summary of product characteristics in certain circumstances.

Firstly, the advocate general rejected the Novo Nordisk argument that the ban of its ad violated its freedom of speech or that the ban was disproportionate.

“In my view, public health must prevail in the interpretation of the provisions in question,” Jääskinen wrote. “Therefore, it does not seem justified to adopt an

alternative approach that would result in maximising the freedom of expression of pharmaceutical laboratories and commercial communications while minimising the scope of restrictions on advertising as a principle of interpreting Directive 2001/83.”

In rejecting Novo Nordisk’s argument, the advocate general said that the directive prohibited a pharmaceutical company from including any information in an advertisement if that information did not – but should have – already appeared in the product summary. Such information should rightfully be approved by the appropriate medicines agency for inclusion in the summary before it is disseminated through advertising.

Despite such an interpretation, Jääskinen said that EU law did appear to allow pharmaceutical companies to include in drug advertisements information outside of the scope of the summary but which might otherwise help doctors make appropriate decisions when prescribing the drug to their patients.

For example, a drug company could legally include in their advertisement the level of patient satisfaction with a drug or the degree of compliance by patients. Such information, however, would only be allowed in an advertisement if it did not conflict with the information already contained in the product summary and if it was not misleading.

A decision from the Court of Justice in the matter is expected before the end of the year.

For more information about the case, Novo Nordisk AS –v- Ravimiamet (Case C-249/09), visit the European Court of Justice website at www.curia.eu.

eU mAtterSFeature

puShIng Out Ad bOundARIeSOphthalmic drug advertising may soon include more extensive claimsby Paul McGinn

31

Journal WatchEye test for scrapieAn accidental discovery in an abattoir could form the basis for a quick non-invasive test for scrapie in sheep, mad cow disease in cattle, and Creutzfeldt-Jakob disease in humans. While working on a fluorescence spectroscopy device to test livestock carcasses for faeces and possible E. coli contamination, researchers made a surprising observation. They noticed that when they pointed the device at the carcass, the spinal cord would fluoresce brightly. They then collected 140 eyeballs from 73 sheep. Thirty-five of those sheep were infected with scrapie; 38 were not. The researchers took fluorescence readings from various parts of the eyes of all the sheep. Only scrapie-positive retinas fluoresced. They attribute the glow from scrapie-positive retinas to the elevated levels of lipofuscin. The team is now working on a diagnostic test that initially could be used to test commercial livestock.

n R Adhikary et al., Analytical Chemistry, Fluorescence Spectroscopy of the Retina for Diagnosis of Transmissible Spongiform Encephalopathies, 2010, 82 (10), pp 4097–4101.

For example, a drug company could legally include in their advertisement the level of patient satisfaction with a drug or the degree of compliance by patients

Feature

OUtLOOK On IndUStrY


The global cataract market is roughly 10 times the size of the refractive surgery market, and most adults over the age of 40

have presbyopia to some degree. Technolas Perfect Vision (TPV), based in Munich, Germany, is offering a host of new laser products to meet the refractive needs of this growing older population.

“With LASIK, the target was age 20 to 40 years. We are extending the range,” says the chief executive officer of TPV, Kristian Hohla PhD.

Laser procedures for presbyopia – including INTRACOR for mild hyperopes and SUPRACOR, a new excimer procedure for myopes, hyperopes and emmetropes – extend the target range to 40- to 60-year-olds. INTRACOR combined with monofocal or toric intraocular lenses extends the target past 60 years. And CUSTOMLENS, TPV’s new OCT-guided femtosecond laser-assisted cataract surgery platform, extends the precision of laser surgery to all cataract patients.

Unveiled at the XXVIII ESCRS Congress in Paris, France, CUSTOMLENS and SUPRACOR will be commercially available in Europe around mid-2011, Dr Hohla pledges. In keeping with TPV’s practice of keeping existing customers on the leading edge, both will be available as upgrades or exchanges for many existing TPV excimer and femtosecond laser systems.

With LASIK vulnerable to economic downturns, Dr Hohla believes that tapping the older refractive market will grow and stabilise TPV’s market. Many surgeons feel the same way about their own businesses. In a survey TPV conducted of surgeons in Europe, the Middle East and Africa in 2010, 93 per cent responded that presbyopia correction was important or very important to the future of their practice. More than half said they already offered or planned to add INTRACOR or a similar presbyopia-correcting procedure within the next year.

“By offering technology for early presbyopes and cataract patients, we are not cannibalising the existing laser refractive market; we are adding to it,” notes Rupert Veith, TPV’s chief commercial officer and head of business coordination. “Our excimer and femtosecond lasers are truly complementary across the entire spectrum of refractive procedures and needs.”

Femto-cataract surgery Perhaps the most far-reaching breakthrough is the addition of CUSTOMLENS procedures to TPV’s proven femtosecond laser platform, Dr Hohla says. By adding intraoperative OCT guidance, the system can now perform capsulorhexis, and lens fragmentation as well as self-sealing phaco incisions and relaxing incisions to correct astigmatism. “We were able to do this quickly because we already had a lot of experience with femtosecond lasers,” he says.

The precision of femtosecond laser technology cannot be matched by manual cataract surgery, Mr Veith notes. Very hard nuclei can be cracked to a precise depth, reducing the chance of capsular rupture compared with chopping or phaco alone. Capsulorhexes can be perfectly centred on the visual axis, and perfectly sized to cut down on the risk of posterior capsular

opacification. “When the blood pressure goes up for the surgeon, it is during the rhexis,” Mr Veith says. “With this technology the surgeon can concentrate on the entire procedure rather than focusing on the most technically difficult parts.”

Dr Hohla sees femtosecond-assisted cataract surgery entering the market as a premium procedure. But over time he believes its potentially greater safety and repeatability, and its reduced learning curve, will make it standard within a few years. He also points out that the same TPV femtosecond laser also can be used for cutting LASIK flaps, performing lamellar and penetrating keratoplasty, and INTRACOR presbyopia treatments.

Dr Hohla believes that combining INTRACOR with monofocal and toric lenses may prove a more satisfactory way to correct presbyopia for cataract patients

than existing multifocal or accommodating lenses. In Spain, Carlos Gutiérrez Amorós MD has had good success by calculating final IOL power based on pre-INTRACOR biometry, and then treating patients with INTRACOR before cataract surgery. The approximately 0.5 D of myopic shift is compensated for by adjusting the power of the spherical or toric lens implant. Patients who have undergone this procedure end up with about a +2.0 add in the centre of the cornea. Combined with the increase in depth of field due to the negative asphericity induced by the concentric intrastromal rings INTRACOR cuts, these patients typically end up with 20/25 and J2 after surgery. While this is less near add than some multifocal lenses, there are no intermediate vision drop offs, and dysphotopsias associated with INTRACOR disappear as the stroma remodels, usually within three months. The optics of the combination may also be less sensitive to PCO than a multifocal lens.

Treating early presbyopes TPV’s experience with INTRACOR also has helped the firm develop SUPRACOR, a new, aberration optimised presbyopic algorithm for excimer lasers. Unlike most presbyopic laser profiles, SUPRACOR has no abrupt transition zone between near and far vision zones within the pupil zone. This reduces higher order aberrations and also enhances intermediate range vision, Mr Veith notes.

Mr Veith believes that previous LASIK patients will be good candidates for SUPRACOR. He anticipates the procedure will receive the CE mark in the first half of 2011, and will be available as a software upgrade for users of the Technolas Excimer Workstation 217P.

“In the two years since the formation of Technolas Perfect Vision, we have remained focused on bringing value to our users,” Dr Hohla says. “With the addition of the CUSTOMLENS module to our femtosecond laser, surgeons will be able to perform cataract, intrastromal, refractive, and therapeutic procedures using the same femtosecond laser. No other company can offer this level of versatility with one system. With the advent of SUPRACOR, we are truly positioning ourselves as the presbyopia company.”

Lindsay Brooks - [email protected]

cont

act

OLdeR eyeSFemtosecond cataract surgery, new excimer presbyopia procedure from technolas perfect vision will expand refractive marketby Howard Larkin

32

TECHNOLAS Femtosecond Workstation with the CUSTOMLENS module

TECHNOLAS femto-capsulotomy TECHNOLAS femto-lens-fragmentation in-process

With LASIK, the target was age 20 to 40 years. We are extending the range

“Kristian Hohla PhD

Researchers in the US have reported on the use of a novel peptide to reduce the level of photoreceptor cell death associated with retinal

detachment. The mode of cell death in retinal detachment is similar to many other types of retinal degeneration in which cells die by a process known as “apoptosis.” As such, the findings have the potential to extend photoreceptor cell survival not only in cases of retinal detachment but additionally in cases involving photoreceptor cell loss, including age-related macular degeneration and retinitis pigmentosa.

The biological process of “apoptosis” has been shown in recent years to be highly relevant to a range of ocular disorders including macular degeneration, diabetic retinopathy, glaucoma and retinitis pigmentosa. Apoptosis is a genetically controlled mechanism of cell death in which the cell activates a specific set of instructions that lead to the deconstruction of the cell from within. Such cell death contrasts markedly with the more familiar mechanism known as “necrosis.” Necrosis occurs when a cell is injured mechanically or receives some shock whereby it is unable to continue carrying out the activities of life.

Though the end result of both apoptosis

and necrosis are the same, that is, the death of the cell, the mechanisms leading to such death are crucially different. Necrosis is characterised by swelling, rupture, leakage and inflammation, while apoptosis is characterised by shrinkage, condensation and the engulfment of cellular remnants by healthy neighbours. Cells dying by apoptosis replace swelling with shrinkage and rupture with an elegant packaging of cellular contents into a convenient size for disposal. There is no leakage of cellular material and no inflammation in cells undergoing apoptosis. The remaining fragments of an apoptosed cell are neatly and quietly disposed of by either neighbouring healthy cells or by the body’s household staff – the macrophages.

The actual protein tools of the apoptotic programme are a family of cysteine proteases called the “caspases.” Extensive research has uncovered this relatively new family of proteins as the mediators of the cell death programme. This family of proteins represents the executioners responsible for the internal deconstruction of the cell whereby they act as a selective set of molecular scissors capable of cutting a variety of structural and physiological proteins within the cell. Apoptosis can

kick start through two broad mechanisms: extrinsic, in which a protein’s extracellular domain on the cell surface is triggered to activate an internal caspase (caspase 8); or intrinsic, in which cytochrome c from the mitochondrion triggers caspases 3 and 9.

Retinal detachment has been shown to activate an extrinsic pathway known as the “Fas/Fas ligand” pathway and it is this pathway that has become the target of a research team led by Dr Cagri Besirli and Prof David Zacks at the Kellogg Eye Centre of the University of Michigan.

The research team used a 12 amino acid length peptide (Met-12) derived from the N terminal sequence motif portion of the extracellular alpha chain of “Met’, an oncogene that encodes the tyrosine kinase receptor for hepatocyte growth receptor. So what has an oncogene got to do with retinal degeneration? Cancer and cellular degeneration appear to be opposite sides of the same coin. In many respects, cancer may be viewed not only as an uncontrolled proliferation of cells but also as a failure of the cell to activate the apoptotic pathway. Equally, degenerative diseases such as retinal degeneration may be viewed as a failure to control apoptosis, resulting in too much cell death.

Understanding how cancer cells interfere with desirable cell death may be harnessed to halt degeneration when too many cells are dying. Previous studies had shown that Met could act as an inhibitor of the apoptotic activating Fas/FasL pathway, one of the two major cell death pathways involved in photoreceptor apoptosis. Experiments using a transformed photoreceptor cell line (661W cells) and an animal model of retinal detachment were used to assess the inhibition of cell death following administration of Met-12.

The results demonstrated that a sub-retinal injection of 50ug of Met-12 reduced caspase 8, 9 and 3 – the executioners of apoptosis – by as much as 50 per cent. The caspases act as “molecular scissors” in the choreographed deconstruction of the cell that represents a key characteristic of apoptotic (versus necrotic) cell death. In addition, injecting Met-12 into the sub-retinal space resulted in 77 per cent less cell death when compared to controls. Finally, retinas injected with Met-12 showed a 37 per cent increase in the outer nuclear layer (ONL) cell count and had a 27 per cent increase in ONL thickness measurements.

While the initial results proved encouraging for the potential therapeutic application of Met-12, it was clear that a certain number of cells continued to perish in serious retinal detachments. The researchers postulated that dosage and bio-availability of Met-12 may require adjustment to ensure sufficient peptide reaches the targets. Reassuringly, testing of Met-12 under tissue culture conditions achieved high levels of cell protection and therefore it may certainly be useful to focus future research on delivery or formulation techniques in an effort to increase in vivo effects. Most importantly, the researchers comment that “the usefulness of photoreceptor-protective therapy would be to help prevent further photoreceptor loss until the retina can be surgically re-attached and normal retina-RPE homeostasis can be restored”. Combined with other anti-apoptotic approaches and pro-survival strategies the development of Met-12 may buy critical time in terms of slowing photoreceptor cell loss.

The research results represent an extension of previous studies by these researchers, in which large and small molecules and inhibitory RNA structures have been used to preserve photoreceptor cell populations. The most recent work with the small peptide, Met-12, may allow for a scalable and clinically attractive opportunity to transfer such observations to patients suffering a retinal detachment or several other insults known to cause photoreceptor cell loss.

Feature

bIO-OphthALmOLOgY


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extendIng CeLL LIFeInhibiting photoreceptor cell death with small peptide may point way for treating retinal degenerative diseasesby Gearóid Tuohy PhD

Journal WatchEye on the ballA vision training method known as the ‘quiet eye technique’ could help improve your performance on the putting green. University of Exeter School of Sport and Health Sciences uses video and eye tracker technologies to assess the putting techniques of professional and amateur golfers. Research has shown that the best putters all follow a similar pattern of visual control, before and during a shot. When lining up a putt, experts alternate quick fixations between the ball and the hole. Then before and during the stroke they hold a steady fixation on the back of the ball, for around two to three seconds. After contact with the ball the eyes remain steady for a further half a second. The researchers dubbed the technique the Quiet Eye. To assess the benefits of the Quiet Eye technique the Exeter team measured the putting performance of a group of golfers (with an average handicap of 2.5) before and after they’d been taught the Quiet Eye technique. After the training, they sunk six per cent more of their putts and reduced their average number of putts by two per round. The same group of golfers were then put in a high-pressure environment, competing for a cash prize in a putting competition against a second group of golfers who had not been taught the Quiet Eye technique. Those using the Quiet Eye came out on top, sinking 17 per cent more putts than their competitors. The researchers believe the technique is effective because it allows the golfer to take in only the necessary visual information required to make the shot. Focusing anywhere else can interrupt the organisation of millions of neurons in the brain that convert the visual information into movements of the putter. Learning to control your vision in this way can improve your accuracy, allow you to maintain focus under pressure and ultimately make more putts, they report.n S Vine et al., Journal of Applied Sports Psychology, in press.

2nd EuCornea Congress

Vienna, Austria16–17 September 2011

www.eucornea.org

Vienna

Immediately preceding the XXIX Congress of the ESCRS


Documenting dissectionEvery medical speciality is stereotyped by those outside the specialty in the wider profession. The image of surgeons is of brisk, no-nonsense technocrats who tend to prefer action to words. All stereotypes are false as absolute descriptions of reality, but generally are based on something true and valid about the subject. Certainly surgery, by its very nature, encourages decisiveness and concision. Every incision can cause a complication, and therefore an unnecessary incision leads to an unnecessary complication.

Traditionally, surgery and medicine have been the final subjects taught in medical school, and have had an associated prestige within undergraduate medical education. In recent years, the argument has been made that as the bulk of medical graduates will end up working in the community, that surely community-based specialties should have more of a role in medical teaching. While there is much good sense to this, perhaps something would be lost if surgery lost some of its status and indeed mystique in medical teaching. Surgery is medical practice in its raw, most pure state, one in which the ambiguities and imprecision of other specialties, and the various philosophical debates about the nature of health and illness, seem to fade away before the simple equation of surgeon, patient and knife.

A two-decade bestseller, Mark R Levine’s Manual of Oculoplastic Surgery is widely respected, as evinced by the range of contributors who have written in this volume. Levine’s list of appointments alone – Emeritus Clinical Professor of Ophthalmology at Case Western Reserve University School of Medicine, staff physician at the Cleveland Clinic, former chief of ophthalmology at Mount Sinai Medical Center, former head of the Oculoplastic Section of the University Hospitals of Cleveland – is enough to make one wonder how some people find time to do their multiple posts when most of us find one post enough.

The book is intended to provide a concise guide for basic oculoplastic procedures for ophthalmologists familiar with the anatomy and the principles of the surgery. It is therefore assumed that the reader is familiar with the diagnosis, indications for medical and surgical treatment, and medical interventions.

So this is a surgical text and right from the

first chapter on applied surgical anatomy of the ocular adnexa we are in the brisk, no-nonsense world of surgery. “The order of presentation of this chapter follows the progression of a typical oculoplastic surgical procedure,” this chapter begins, and you can’t get more direct than that. Of course, the view of surgery described in the second paragraph above is a romantic one, one which elides the messy complexity of all medical practice and indeed all human life.

The book covers a wide range of clinical presentations, including trauma, cosmetic surgery, congenital and acquired ptosis, eyelid malposition, facial nerve dysfunction and orbital surgery. Like so many classic surgical texts, the book is illustrated by clear and precise line drawings. There is room for some kind of thesis – if one hasn’t been done already – on the artistic language of surgical texts. Some specialties, such as plastic surgery, are themselves art forms, in which aesthetic effect is as important as any other outcome. The relationship between anatomy and art, between the urge to document the human form and to dissect it, is one that historically has been strong. Abstract and then conceptual art, in which accuracy of physical relation is less and less important and indeed is often suspect. There are over 500 of these illustrations inside which are an integral part of the text. It is easy to see why Levine’s Manual has become a classic.

28 Examinations in 56 Seconds*

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In just 2 seconds the Pentacam provides accurate diagnostic data for both, the anterior and posteri-or surface of the cornea. This supports you in the detection of early Keratoconus, to obtain more accurate K readings and to be more confident while interpreting the Pentacam results. Through the rotating scan, more measurement points are provided in the center of the cornea. The second pupil camera detects eye movements during the exam. Plus, it provides the EKR (equiv-alent keratometer readings) which supports in the IOL power calculation for patients who have un-derwent refractive surgery in the past.

Pentacam – the gold standard in anterior segment tomography.

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ESCRS, Level 1OCULUSbooth #126

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35

bOOK revIeWFeature

BOOks editOR:Seamus Sweeney

PuBLicatiOn:Manual of oculoplaStic Surgery, fourth editionBY: Mark r levine, Slack incorporated

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

Feature

IndUStrY neWSRecent developments in the vision care industry


Ce markAvedro has announced that its KXL™ System for performing accelerated corneal cross‐linking (KXL) has received the European Union’s CE Mark.

The CE Mark certifies that the KXL System has met the EU’s health and safety standards and opens the door to immediate commercialisation across the European Union and in other countries recognising the CE Mark.

“Lasik Xtra™ is one of Avedro’s new procedures made possible by its KXL System. Lasik Xtra helps patients avoid the risk of post‐Lasik ectasia, which has become a troublesome and unpredictable problem,” said David Muller PhD, president and CEO of Avedro.www.avedro.com

eC-3 intraocular lensUS IOL manufacturer, Aaren Scientific,

has announced FDA approval for its EC-3 intraocular lens implant for the treatment of cataracts in the US.

“The proprietary hydrophobic lens material of the EC-3 is designed for optimum clarity with no reported glistenings by patients at the one-year postoperative follow-up visit,” said Aaren president Rick Aguilera.www.aareninc.com

36

new epi-K ringsMORIA has completed its range of reusable metallic rings for Epi-KTM epikeratome, with 0, +1 and +2 sizes.“They allow refractive surgeons to create smaller epithelial resections, which heal faster and yet are still sufficient for the 6.0mm optical zone treatments usually performed on myopic eyes,” said a company spokesman.www.moria-surgical.com

Journal WatchNeuroadaptation enhances touchPeople who are born blind are believed to compensate with more acute awareness among the other senses. A study by neuroscientists confirms this and quantifies the difference in sense of touch among the blind and non-blind. A Canadian team tested the tactile skills of 89 people with sight and 57 people with various levels of vision loss. The volunteers were asked to discern the movements of a small probe that was tapped against the tips of their index fingers. Both groups performed the same on simple tasks, such as distinguishing small taps versus stronger taps. When a small tap was followed almost instantly by a larger and longer-lasting vibration, the vibration interfered with most participants’ ability to detect the tap — a phenomenon called masking. However, the 22 people who had been blind since birth performed better than both people with vision and people who had become blind later in life. Those same individuals also read Braille fastest. The researchers believe these findings reveal that one way the brain adapts to the absence of vision is to accelerate the sense of touch. They note that the ability to quickly process non-visual information probably enhances the quality of life of blind individuals who rely more on the non-visual senses.

n D Goldreich et al., Journal of Neuroscience, Oct. 27 2010.

Alcon and novartis agree to merger termsAlcon has approved a merger agreement with Novartis AG, whereby Novartis will pay a total merger consideration valued at $168 per share for the Alcon shares it does not currently own. Under the terms of the deal, the merger consideration will be comprised of a combination of Novartis shares and, if necessary, a cash contingent value amount to result in a total value of $168 per share.

“This merger will create a stronger eye care business with broader commercial reach and enhanced capabilities to develop more new and innovative eye care products that address unmet clinical needs in eye care,” said Kevin Buehler, Alcon’s president and chief executive officer.

“The combination of Alcon’s deep understanding of the eye care specialty and the broad expertise and scale of Novartis will allow us to address virtually all key areas of eye care with quality products and will position the Alcon business for faster growth.”

Upon completion of the merger, Alcon will become the second largest division within Novartis. CIBA VISION and select Novartis ophthalmic medicines will be integrated into Alcon, forming an organisation with more than $8.7bn in sales covering over 70 per cent of the eye care segment. www.alcon.com

hydrodissection cannula Sterimedix has announced the introduction of a new hydrodissection cannula for cataract surgery.

Designed in conjunction with Dr Richard Mackool, the new cannula is angled and flattened to allow easy access under the anterior capsule. “Available in 23g Cannula the New Mackool Cannula is available sterile, packed in boxes of 10 units, and designed for single use,” said a company spokesman.www.sterimedix.com

Carl Zeiss meditec exceeds expectationsCarl Zeiss Meditec has reported that it has closed its financial year (ending 30 September 2009) on a high with record results.

The company generated consolidated revenue of €677m in financial year 2009/2010, compared to €640m the previous year.

This represents an increase of 5.7 per cent. Microsurgery SBU grew by seven per cent. The Surgical Ophthalmology SBU, driven by sales of intraocular lenses, grew by eight per cent.

“In addition to a clear strategy, this success is above all attributable to the untiring efforts of our committed employees. With a clear focus on the customer, it is they who are responsible for promoting the future of medical technology,” said Ludwin Monz, president and CEO of Carl Zeiss Meditec AG.For further information visit www.meditec.zeiss.de

Ludwin Monz MD

Kevin Buehler

Sterimedix new hydrodissection cannula for cataract surgery

MORIA Epi-K rings

Feature

pRACtICe deveLOpment


The ophthalmologists who attended the first two annual ESCRS/EuroTimes Practice Development Master Classes are a diverse group.

They range from just out of residency to clinical leaders and administrators of diversified ophthalmology groups of 30 surgeons and more. They are cataract surgeons and refractive surgeons, in private practice and public clinics, some with huge investments in equipment and staff and some looking to start their first practice or set up a part-time private practice after public clinic hours.

But they all share a common desire to transform their practices, says course director and associate professor at London Business School Keith Willey. Almost all want to grow their practices – and are willing to take risks to do it. Whether they see themselves as such or not, this trait makes these surgeons entrepreneurs, he adds. Success as an entrepreneur requires an understanding of the nature of entrepreneurship, which Prof Willey characterises as “the relentless pursuit of opportunity without regard to tangible resources currently controlled.” In other words, entrepreneurs imagine and pursue an enterprise beyond what they can support with their current skills, organisation and finances.

Any attempt at new business or new

venture creation by an individual, a team or an established business is an exercise in entrepreneurship, Prof Willey notes. These include self-employment, a new business organisation or the expansion of an existing business.

To gain control of the tangible resources required to realise an imagined enterprise requires continuous development of intangible resources needed to pursue opportunity, Prof Willey says. These intangible resources include developing the capacity to convince others to support you.

This could be as simple as reassuring your wife that you won’t lose the house if you quit your day job for private practice. Typically, it also requires enlisting the services of other surgeons as partners or associates, hiring and training staff, securing financing, and maintaining control over the business as it grows and requires professional management. Always, it requires a focus on identifying and meeting the needs of patients and other customers, including patients’ family members and referring practices.

The more that all these stakeholders are in agreement with the goals of the enterprise – and confident they can be achieved without sacrificing core values – the greater the chances for success. Creating a clear vision for your practice is a key step to clarifying, building, and maintaining

support for your practice development goals.

Core values, envisioned future In developing your professional vision, it is important to understand the difference between what should never change and what should be open for change, Prof Willey says. In his ESCRS/EuroTimes Master Classes, Prof Willey uses a case study of Ophthalmic Consultants of Boston. The practice, led by Brad Shingleton MD, illustrates how an enterprise can be highly successful as both a profitable business and a world-class professional practice by embracing core values of integrity, compassion, teamwork, effort, and training – and a commitment to excellence.

Over the years, Dr Shingleton has successfully grown the practice, which incorporates 32 surgeons across a range of ophthalmic subspecialties, while increasing his own surgical case load. He has done so in part by creating a practice team that handles every aspect of patient care before and after surgery. Practice systems are constantly improved, measured, and changed to improve outcomes and efficiency. As a result, in 2009, he was able to handle up to 50 operations per day without in any way compromising quality.

To create a practice vision, Prof Willey advocates the use of Jim Collins’ frameworks to develop a core ideology and envision a practice future. Author of Good to Great (HarperCollins 2001), a study of how companies improved their performance, Collins published his ideas on how core values can help businesses adapt to changing conditions in a 1996 article, Building Your Company’s Vision, in the Harvard Business Review with Jerry I Porras.

These start by challenging you to Identify your core values and Formulate a core

purpose. These are intended to be enduring aspects of your business and with this in mind should be considered deeply and honed to the basic minimum description of why you are building your practice.

The next step is the one which Prof Willey says surgeons find most difficult – envisioning their future. Collins identifies two components – an audacious goal and a vivid description of your envisioned future. The goals really have to be tangible and compelling – preferably expressed with numbers, dates and specific objectives. Rather than simply extrapolating experience to date there needs to be some ‘stretch’ which requires all involved to develop new capabilities and reach for new achievements. The description helps to bring to life what the future might be like if the practice realises its ambitions. Ask yourself:

Where do you see yourself in 10 or even 25 years?

If a journalist were to write about your success, what topics would the article cover?

What limits have you set for yourself as a professional? What would it look like if you exceeded those limits?

With these tools, you can share your vision with others. The first time a surgeon works through these steps is often the first time he or she has actually attempted to articulate why developing their practice is important. It can herald the move from a career oriented strictly towards patient care and professional development and expand it to include all the other aspects a practice needs to be successful, especially the creation and growth of a team. “Transformation requires a leader, and a leader requires a vision to guide the plan and enroll colleagues,” Prof Willey says.

keith Willey - [email protected]

cont

acts

buILdIng A vISIOnIdentifying core values and principles, and a clear practice goal, helps others follow your leadby Howard Larkin

37

European Registry of Quality Outcomes for Cataract & Refractive Surgery

EUREQUO

What is EUREQUO?

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

Join the network

EUREQUO gives a unique opportunity to monitor and compare results

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

Collecting data will support you to make an audit report

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

See www.eurequo.org for more information

Improve treatment and standards of care for cataract and refractive surgery

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

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

The project aims to:

with the kind contribution of

123

Mark your calendars now!

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

Among the topics to be covered in these AMA PRA Category 1 CreditsTM designated sessions are:

These non-CME, ASCRS-authorized educational programs will provide timely and important information on:

EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products,procedures, and applications of existing products. Includedamong the topics discussed in these sessions are:

www.EyeWorld.orgPlease check often for updates.

LONDON 2011

26–29 May 2011

Queen eliZaBeth ii conference centrelondon, uk

www.euretina.org

11TH EURETINA CONGRESS


Feature

eYe On tRAveL

Even if you’ve never been in London before, Big Ben, the Houses of Parliament and Westminster Abbey will look

familiar to you. This iconic cluster of spires and towers spells “London” to people the world over. It is a UNESCO World Heritage site and London’s number one tourist attraction.

Ancient as it appears, however, the splendid Gothic Revival building in which the Houses of Parliament hold their sessions is surprisingly new; it replaced the Palace of Westminster destroyed by fire in 1834. Big Ben, the 13-ton bell in the clock tower, first rang out its variation on a theme from Handel’s Messiah in 1859.

Westminster Abbey, on the other hand, is authentically, awesomely, old. British Monarchs have been crowned here since 1066. It’s impossible not to be impressed by the soaring vaulted ceiling, the stained glass, the monuments and memorials, which range from effigies of Elizabeth I and her half-sister, Mary Queen of Scots to statues of 10 contemporary martyrs, including Martin Luther King Jr.

Find your way through the cloisters to the Abbey Museum. This modest room houses the oldest known panel painting in England. A 13th century retable, it was taken down from the High Altar in the 16th century and by the 18th it was being used as the lid of a chest. It was sent for restoration in 1998 and returned to the Abbey in 2005. And if you’ll settle for paste gems instead of the real thing you can save yourself a trip to the Tower of London to see the Crown jewels. Replicas of the Coronation Regalia, used for rehearsals of the ceremony, are displayed here. (The museum is “usually” open

every day but only from 10.30 to 16.00 on Sundays.)

The Abbey’s College Garden is another hidden treasure. This leafy space is open throughout the year but is especially beautiful in the spring when its apple and cherry trees are in bloom. In the summer, lunchtime band concerts are sometimes held. (Garden is open Tuesday,

Wednesday and Thursday; in winter from 10.00 to 16.00, in summer from 10.00 to 18.00.)

The Queen Elizabeth II Conference Centre across Broad Sanctuary from the Abbey was finished in 1986; it included a bug-proof room on the fourth floor for Prime Minister Thatcher’s top-level meetings.

LOndOn'S hIStORy IS ALIveyou don’t have to wander far from big ben to find yourself awed, charmed or intriguedby Maryalicia Post

41

For sidelights on London, stroll down Parliament Street...From Broad Sanctuary and Parliament Street to Trafalgar Square is less than a mile – but it’s a mile packed with insights into London history.

nThe Supreme Court of the United Kingdom occupies the restored art deco building at the corner. Visitors are welcome to drop in on court hearings and watch bewigged barristers at work. The atrium coffee shop is open to the public.

nThe Churchill Museum and Cabinet War Rooms are tunnelled under Government Buildings (detour down King Charles Street). This is the secret bunker from which Winston Churchill directed World War II. The warren of 27 rooms includes all the necessary offices, plus Mrs Churchill’s bedroom with chintz covered arm chair. (Open daily, last admission 17.00.)

nDowning Street leads off Parliament Street but iron gates block access. Join the sightseers on the left for the best view of the Prime Minister’s home at Number 10.

nWhere Parliament Street becomes Whitehall, mounted cavalrymen stand guard under twin arches. Since 1750, this has been the Household Cavalry’s headquarters; here it prepares for ceremonial work such as the changing of the guard at Buckingham Palace. Walk under the arch to the Household Cavalry Museum. Inside, through a glass partition, you can glimpse the day’s work being carried out in the stables. (Open daily until 17.00.)

nDirectly across Parliament Street, visit the Banqueting House designed by Indigo Jones for King James in1622; its crowning glory is an astonishing ceiling by Rubens. The Banqueting House was designed as the setting for royal masqued balls, but is best remembered as the site of King Charles’s execution in 1649. (Open 10.00 to 17.00. Closed Sunday and for private functions.)

nIn Trafalgar Square – the geographical centre of London – a statue of Lord Nelson surveys the traffic from his plinth. Behind him, the huge National Gallery houses one of Europe’s major collection’s of European paintings. (Open until 18.00 but on Friday until 21.00.)

nAround the corner from the gallery is the porticoed entrance to St Martin-in-the-Fields. Don’t fail to experience the sublime interior of this 18th century church. Recently revamped, it features an intriguing East Window, designed by an Iranian-born artist. The church holds free concerts, usually at 13.00 and 19.45. The popular “Cafe in the Crypt” is downstairs.

...and visit Big Ben, Parliament and Westminster AbbeyOnly UK residents may climb the clock tower’s 335 stairs to see Big Ben, but all are welcome to visit the Houses of Parliament (for details, see www.parliament.uk.)

To tour Westminster Abbey, simply pick up an audio guide, free with your ticket. If you prefer to wander on you own, your queries will be answered by one of the colourfully gowned Abbey staff members. (The Abbey is closed to tourists Saturday afternoon and Sunday; otherwise, last entrance at 15.30 or 18.00 on Wednesday.) Experience the Abbey as a living church by attending evensong, sung by the Westminster Abbey Choir. (Evensong sung at 15.00 Saturday and Sunday, and at 17.00 on Monday, Tuesday, and Thursday. On Wednesday, the service is spoken.)

Trafalgar Square

Big Ben


Standardising refractive surgery results in 2011As refractive surgery has become more complex, so too has reporting the results of various procedures. Presbyopia correcting procedures in particular have introduced a need for new reporting terms. Recognising a growing need for clarity in clinical reporting, the editors of the JCRS, along with colleagues at the Journal of Refractive Surgery collaborated in the development of standardised formats for reporting results of refractive surgical procedures. Authors are now being asked to report refractive surgery data in a set of six standard graphs. These graphs are intended to display core data for quick but meaningful comparative analysis of outcomes of essentially all refractive surgical procedures. A recent revision is the inclusion of a histogram bar graph that displays the magnitude of refractive astigmatism before and after refractive surgery, replacing the defocus equivalent graph. The new guidelines also introduce a standard set of visual acuity terms and abbreviations. ‘Best’ and ‘spectacle’ are now gone, for example, since it was felt that these terms were implied when reporting corrected visual acuity. The new abbreviations also account for the increase in studies reporting outcomes of presbyopic patients in which intermediate and near vision are often reported in addition to distance vision. The new abbreviations provide a consistent structure for corrected and uncorrected vision at each distance. Authors are also being reminded to use the geometric mean when averaging visual acuity data and not an arithmetic mean. Modern visual acuity charts are designed so the letter sizes on each line follow a geometric progression (ie, change in a uniform step on a logarithmic scale). Therefore, data should be converted into logMAR values. To aid authors, an Excel spreadsheet that can be downloaded and used to produce the six graphs is available at http://www.londonvisionclinic.com/refractivesurgeryoutcomes.n WJ Dupps et al., JCRS, “Standardized

graphs and terms for refractive surgery results”, Volume 37, Issue 1, Pages 1-3 (January 2011).

Improving phakic IOL sizingAccurate determination of lateral anterior segment dimensions is key to the safety of phakic IOLs. High-frequency ultrasound biomicroscopy (UBM) can improve the accuracy of phakic intraocular lens sizing by increasing the incidence of acceptable

postoperative vault, a US study suggests. The prospective multicentre clinical study evaluated eyes having phakic IOL (Visian Implantable Collamer Lens, Staar) implantation. Researchers performed a retrospective data analysis using UBM measurements (VuMax-II) of preoperative sulcus-to-sulcus distance and postoperative vault. They used regression data and clinical input from investigators to develop a phakic IOL sizing nomogram. The nomogram used only sulcus-to-sulcus and phakic IOL power as variables to determine length. One eye was excluded from the analysis because the wrong length lens was placed. The mean postoperative vault in the remaining 72 cases was 340 μm ± 174 (SD) (range 90 to 952 μm). There were no cases of inadequate or excessive vault with the newly developed UBM nomogram. Sizing methods using white-to-white measurements would have resulted in different-sized phakic IOLs in 36 per cent to 69 per cent of cases compared with the sulcus-to-sulcus method. The researchers note that a standardised method of collecting and evaluating images should be used to ensure repeatability and reproducibility. This study was performed using a high-frequency UBM system with a 35 MHz sector scanning probe. The system’s software has a preset configuration for accurate sulcus analysis and a deconvolution algorithm (e-gain) to maximise visualisation of the posterior capsule, the most important landmark when measuring the STS diameter. Because of the complexity of the technique and the configuration of the software, we recommend that the nomogram developed with this UBM system be scientifically validated before it is used with other types of ultrasound equipment.n PJ Dougherty et al., JCRS, “Improving

accuracy of phakic intraocular lens sizing using high-frequency ultrasound biomicroscopy”, Volume 37, Issue 1, Pages 13-18 (January 2011).

42 Review

JCrS hIghLIghtSJournal of Cataract and Refractive Surgery

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

thomas kohnenassOciate editOR OF JcRs

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

to find out more about the new ESCRS Observership Programme.

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

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

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

Young Ophthalmologists’Resource Centre

Recommend the AcrySof® IQ Toric IOL for your astigmatic cataract patients.

CONFIDENCE

Recognize both. Recommend AcrySof® IQ Toric IOL.

©2010 Alcon, Inc. 12/10 TOR10286JAD-EU For International (non-USA) Use Only.


Advertising Directory: Alcon Laboratories: Pages: IFC, 9, 15, 23, 30, 43, OBC; ASCRS / Eyeworld Pages: 27, 38-39; Bausch + Lomb Page: 11; Benz Research and Development Page: 5; Croma-Pharma Page: 26; D.O.R.C International BV Page: 25; Haag-Streit International Page: 22; Katena Products Inc Page: 18; Medicel AG Page: 17; Medicontur International SA Page: 21; NIDEK Page: 19; Oculus Optikgeraete GmbH Page: 35; Oertli Instruments AG Page: 7; Rayner Intraocular Lenses Ltd Page: IBC; Rumex International Co Page: 29; SOE Page: 28; Surgistar Page: 6; UK Specialist Hospitals Ltd. Page: 20; VSY Biotechnology Page: 3

May

February

September

2011

2011

2011

26-29london, UK

11th EURETINA Congresswww.euretina.org

22-25oRlAndo, Fl, USA

American Academy of Ophthalmology Annual Meetingwww.aao.org

17-21XXIX Congress of the ESCRS www.escrs.org

Reference44

CALendAr Of eventSDates for your Diary

June

March

March

OctoberSeptember

2011

2011

2011

20112011

3

6-10

3-6

20-24

13-1616-17

GenevA, SwitzeRlAnd

MAR del PlAtA,

ARGentinA

viennA, AUStRiA

PRESBYMANIA 2011www.presbymania.com

19th Argentinian Ophthalmology Congresswww.oftalmologia2011.com.ar

The Royal College of Ophthalmologists Annual Congress 2011www.rcophth.ac.uk/annualcongress

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

2011 Congress of the APAOwww.apaosydney2011.com/

2011 APACRS-KSCRS Annual Meetingwww.apacrs.org

2nd EuCornea Congresswww.eucornea.org

BARcelonA, SPAin

Sydney, AUStRAliA

SeoUl, KoReA

April2011

11-12

25-30

24-26

AlicAnte, SPAin

SAn dieGo, cA, USA

BiRMinGhAM

UK

May2011

1-5ARVO 2011 - Annual Meetingwww.arvo.org

FloRidA, USA

19-22 iStAnBUl, tURKey

VIII Congress of SEEOSAnd IX Congress of BSOSwww.seeos-bsos2011.org

July2011

1-3Leuven Retina Meetingwww.leuvenretinameeting.eu

leUven, BelGiUM

ARI Monographic 2011 – “Presbyopia… its treatment”www.alicanterefractiva.com

ASCRS/ASOA Symposium and Congresswww.ascrs.org

9-11

4-7

MilAn,itAly

GenevA,SwitzeRlAnd

Retina in Progress present and future 2011www.retina3000.it

Joint Congress of SOE/AAO www.soe2011.org

June2011

29-2 PARiS, FRAnce

World Glaucoma Congress 2011www.worldglaucoma.org

May2011

19-2224th Intl. Congress of German Ophthalmic Surgeonswww.mcn-nuernberg.de

nURnBeRG, GeRMAny

3-5

5-8

veRonA, itAly

PoRto AleGRe, BRAzil

Present & Future Challenges in severe Retinal Diseases www.retinaldiseases2011.com

XXXVI Ophthalmology Brazilian Congresswww.cbo2011.com.br/

24-27

23-24

AthenS, GReece

BoRdeAUx, FRAnce

18-20

8-9

iStAnBUl, tURKey

GothenBURG, Sweden

15th ESCRS Winter Meetingwww.escrs.org

1st World Congress on Surgical Trainingwww.surgicon.org

25th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery www.hsioirs.org

Eurokeratoconus IIwww.jbhsante.fr

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is a registered trademark of Alcon, Inc. ©2010 Alcon, Inc. INF546EU


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