volume 16_issue 5
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A European Outlook on the World of OphthalmologyTRANSCRIPT
VOLUME 16 ISSUE 5 MAY 2011
R E T I N A
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THIS MonTH...
Special Focus Retina 4 Newsmaker: Incoming EURETINA president discusses future plans for the society6 Microplasmin may help prevent retinal complications for cataract patients7 AMD clinical trials shed light on patient responder profiles 8 Daclizumab looks promising as effective long-term therapy for uveitis
Cataract 10 New ocular bandage may protect against endophthalmitis12 Expert discusses challenges and advances to come in next 10 years13 Ocular co-morbidities and cataract surgery
Refractive Laser 15 OCT imaging and the femtosecond furrow16 Surgeons find merits in both PRK or thin-flap LASIK18 Multifocal vision for presbyopes
Refractive Lens 21 Good results with novel accommodative IOL22 Prospects for treating the full range of myopia have improved24 Dual-optic Synchrony lens shows promise
Cornea 27 Ophthalmological follow-up needed to detect certain diseases 29 Study pinpoints best use of mitomycin C in surface ablation31 Amniotic membrane can enhance outcomes of ocular surface surgical procedures
Glaucoma 36 SLT and the management of glaucoma37 The importance of measuring IOP fluctuation
News 38 ESCRS supports ORBIS project to reduce childhood blindness in Ethiopia39 Free membership of ESCRS offered to young trainees40 The measurement of corneal biomechanical properties42 Ulf Stenevi is welcomed as Honoured Guest of ASCRS
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MAY 2011Volume 16 | Issue 5
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Published byThe European Society of Cataract and Refractive Surgeons
Features 44 Industry News45 Practice Development46 Eye on Travel 47 Book Review49 EU Matters50 JCRS Highlights52 Calendar
CORRECTIONIn an article on Refractive Laser published on page 5 in EuroTimes, Volume 16, Issue 3, we printed incorrect data which was attributed to Mike P Holzer MD. The data was subsequently corrected by Dr Holzer in an article which appeared on page 20 in EuroTimes Volume 16, Issue 4. Where errors occur, it is the policy of EuroTimes to correct them.
by Bill Aylward
of all the organs in the body, the eye has always been an object of wonder and fascination. Writing in The Origin of Species, Charles Darwin expressed that wonder as follows: “...all its inimitable contrivances for adjusting the
focus to different distances, for admitting different amounts of light, and for the correction of spherical and chromatic aberration...”. The essence of the eye is the retina, encapsulating the most complexity in terms of chemical and physical organisation, and there was no doubt during my own ophthalmology training that I wanted to make the retina my subspecialty. At that time, many retinal conditions were untreatable, and patients with severe macular degeneration, macula holes and vein occlusions were sent away with a clear diagnosis and prognosis, but no hope for improvement. It has therefore been very exciting indeed to witness the very significant advances in treatment which have appeared ever since then, but particularly over the last 10 years. Surgery for macula conditions is now a routine component of a retinal surgeon’s work, and patients with exudative age-related macular degeneration (ARMD) are treated both aggressively and successfully, now that treatments for that most common cause of blindness in the western world are available. Innovative and high-tech treatments which were once in the realm of science fiction are now a regular part of the scientific programme at EURETInA and other congresses.
EURETInA was founded in 2001, and its meetings have bourne witness to many of these exciting developments. There is a very short period between a new treatment being introduced, and the establishment of patient expectations of a good outcome! That means that dissemination of research findings is vitally important, and this is an area where EURETInA has played a significant role. EURETInA has recently established a partnership with Ophthalmologica, and has made it its official scientific journal. The EURETInA Section of the journal has been growing steadily, and it is expected that Ophthalmologica will become, in the very near future, the European retina journal of choice. Mere knowledge of
new treatments is not enough, as the outcome in many cases is dependent on how and when the treatment is chosen and applied. The increasing popularity of the EURETInA instructional courses is evidence of the hunger among retinal specialists to keep up to date with the nitty-gritty details of clinical management, and a real desire to improve outcomes.
The programme for EURETInA 2011 in London is designed to provide a comprehensive educational service to the community of retinal specialists. Delegates will be exposed to updates in cutting-edge retinal topics, delivered by international experts in the field. There is a long list of instructional courses, and a mix of other sessions which should cater for all tastes. We are very proud to announce the EURETInA Innovation Prize, which is a new initiative this year. The prize is an exciting initiative which will support the development of new ideas, inventions and products in the field of retina. There are three prizes ranging in value from €5,000 to €20,000, which will be awarded at our annual congress in London.
on behalf of the EURETInA Board, and the Programme Committee for EURETInA 2011, may I extend a very warm welcome to those of you who are coming to London. I would also like to thank you, and delegates to all our previous meetings. It is only due to your enthusiasm and support that EURETInA has grown to its current status as the premier retinal meeting in Europe, if not the world.
Bill Aylward is the president of EURETINA
EUROTIMES | Volume 16 | Issue 5
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EDITORIAL Volume 16 | Issue 5
Editorial
RETINA - ESSENCE OF THE EYEEURETINA meeting will provide comprehensive educational service to retina specialists
José Güell
Clive Peckar
Emanuel RosenChairman
ESCRS Publications Committee
Ioannis Pallikaris
Paul Rosen
Medical Editors
International Editorial Board
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Noel Alpins australia
Bekir Aslan turKEY
Bill Aylward uK
Peter Barry irElaND
Roberto Bellucci italY
Hiroko Bissen-Miyajima JaPaN
John Chang CHiNa
Joseph Colin FraNCE
Alaa El Danasoury sauDi araBia
Oliver Findl austria
I Howard Fine usa
Jack Holladay usa
Vikentia Katsanevaki GrEECE
Thomas Kohnen GErMaNY
Anastasios Konstas GrEECE
Dennis Lam HONG KONG
Boris Malyugin russia
Marguerite McDonald usa
Cyres Mehta iNDia
Thomas Neuhann GErMaNY
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
Q: What do you want to achieve during your term
as president of EURETInA?our aim must be to further increase the quality rather than the quantity in all areas that are important for the future of EURETInA. This concerns the discussion on clinical questions, teaching, but also research, in particular the networking with those undertaking basic research. These activities should help in bringing together Europe’s best researchers and clinicians in the fields of vitreoretinal diseases and make EURETInA attractive to them.
Q: What are the challenges facing the society in the
immediate future?EURETInA has expanded enormously over the last few years at an extent and speed that many would not have considered possible. It is important to integrate the new members on a long-term basis, linking them to EURETInA. This emphasis on the quality of EURETInA concerns the number of scientific presentations during the yearly congress, the number of training courses, the size of industrial exhibitions and other scientific activities.
Q: What are the scientific issues of particular
interest to you that you would like to see featured in future EURETInA congresses?
Retinal science has enjoyed an upswing over the last few years, not least through the increase in clinical possibilities in diagnostics and therapy, which on the other hand are based on the advances in fundamental research. our goal is to strengthen the translation of this ‘basic research’ to the clinic. In the near future, advances that are also relevant to patients are to be expected in nearly all the important fields of retinology, such as the areas of macular disease, diabetic retinopathy, ultra-microsurgery, and diagnostics with oCT. new medicines, gene therapy, stem cells and retina chips are on the doorstep and waiting for critical assessment and, if found appropriate, introduction. The EURETInA Winter Meeting should aid the integration of those undertaking fundamental research, which in some cases is not done in ophthalmological institutes, but which will be, however, of great importance for the development in the clinic.
Q: How has EURETInA grown into such a
successful organisation in a relatively short period of time?Here several factors were involved. The most important was certainly a relatively small, closely connected management team, the Board, who coordinated perfectly, and who successively further developed the society according to plan. It was possible to recruit individuals to the society all of whom had the aim of building EURETInA, putting this above their own interests. From the beginning, of major importance was also a series of presidents who each in their own way brought the society forward. There was never stagnation, always the acceptance and consequent implementation of new ideas. This was based on a professional organisational structure that paved the way for a healthy economic foundation for the subsequent upswing.
Q: How can retina specialists work with
ophthalmologists from other specialties to advance and share their knowledge?The training of ophthalmologists in Europe is relatively broad, and is not split at an
early stage into subspecialties. This has one enormous advantage in that many of our more elderly patients have problems with both the front as well as the back of the eye, for example, a cataract that needs to be operated at the same time as a disorder of the retina or vitreous body. The modern technologies, through the advances in the development of the small incision technique, make combined operational approaches possible.
For this reason, in EURETInA we have consistently carried out joint symposia with the ESCRS, and last year we even had a joint congress that was extremely successful. Some of our visitors came from the ESCRS, and some of our EURETInA members subsequently attended the ESCRS congress, to the advantage of the visitors, the societies and the industrial exhibition. We will have a joint congress with the ESCRS again in 2012, which will be held in Milan.
Q: Every president has his own personal goals and
objectives. What are yours?My main goal is to strengthen the position of EURETInA as the leading retinological institution in Europe. EURETInA should be the home of the retinologists in Europe, especially in the clinical domain, but also professionally, representing their interests, and in networking with basic research scientists. The basis for this has to be an optimisation of the organisational structures. This includes an improvement in the Internet presentation, an acceptance of EURETInA’s scientific journal, Ophthalmologica, and bringing in younger colleagues into the management structures of the society. The next task is improving the society’s links with the international retinologist. The yearly meeting of the society has the chance (supported by the special situation in the US with three retinological societies) to become one of the leading societies in this field.
Q: Is enough being done to encourage young
ophthalmologists to specialise in retinology and if not what needs to be done to bring more young doctors into the specialty?In the last few years we have observed an enormous upswing in interest in disorders of the retina and the vitreous body, especially in young ophthalmologists. This has been stimulated in particular through the new possibilities in diagnostics and treatment. Young doctors recognise that retinology is one of the most important growth markets in the whole of medicine. They draw their own conclusions from this with respect to their choice of career and their interest in our subspecialty.
Sometimes, however, they are hesitant, since they see retinology as a ‘specific skill’ and a diagnostic and surgical ‘art’ that is particularly difficult to learn. This involves, for example, the treatment of detached retinas and the ultra-microsurgery in the macular area. They see this as a contrast to operations carried out in other areas of ophthalmology, which run relatively uniformly. Through the training programmes we can strengthen the interest of the young colleagues in retinology and allay their fears, particularly in surgical questions.
Q: At the end of your term in office, what will you
hope to have achieved?At the end of my term I hope that EURETInA will be one of the leading scientific societies, that is at home in Europe and has powerful friends throughout the world. This means further growth on a healthy economic basis, a successful, well-visited congress and a generally acclaimed scientific journal. We live in an historic time of rapid emerging diagnostic and therapeutic possibilities. They are aimed at only one goal: to help sick patients.
EXCITING FUTUREIt is important to integrate new EURETINA members on a long-term basis
EUROTIMES | Volume 16 | Issue 5
Newsmaker Interview 4
11Th EURETINA CONGRESS
Gisbert Richard - [email protected]
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History of EURETINAEURETInA was founded in the year 2000 by a small group of vitreoretinal ophthalmologists after an international conference in a restaurant in Hamburg, the “Hamburger Ratskeller”. The founders were Gisbert Richard (Germany), August Deutman (The netherlands), Rosario Brancato (Italy), Borja Corcostegui (Spain), Krystyna Pecold (Poland) and Gisele Soubrane (France). It was decided to organise the first congress in Hamburg from May 25 to May 27, 2001. only 200 participants attended the first congress. But after this start a constant and exponential growth of EURETInA was recorded during the next years. There were two congresses held in Hamburg and in Barcelona, one in Milan, later one in Lisbon, Monte Carlo and Vienna. Important decisions for the development of the society was the start of the cooperation with the EURETInA office in Dublin, which has the capacity to manage a large congress and gives logistic support for the organisation of the industrial exhibition. Another important step was the establishment of Ophthalmologica as the official scientific journal of EURETInA since 2009. During the last two years the EURETInA meeting was the largest gathering of specialists in the field of vitreoretinal disorders worldwide.
For this month’s special retina themed issue, coinciding with the annual EURETINA Congress in London, EuroTimes contributing editor Roibeard O’hEineachain spoke with incoming EURETINA president Gisbert Richard MD about the organisation’s goals in the coming years.
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A BAK-free Multidose PGA
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EUROTIMES | Volume 16 | Issue 5
Microplasmin, a compound that helps dissolve proteins that bind the vitreous to the retina, may soon be available
as a non-surgical treatment for a variety of retinal disorders related to vitreous adhesions, said Marc D de Smet MDCM, PhD, FRCSC, Lausanne, Switzerland. Microplasmin may also be helpful for treating proliferative diabetic retinopathy, and managing or even preventing retinal complications for high-risk cataract patients.
“For anterior segment surgery it may be useful as a form of prophylaxis in high-risk patients, where you might consider injecting it to induce a posterior vitreous detachment (PVD) before surgery,” Dr de Smet told a symposium of the XXVIII Congress of the ESCRS.
This could lower the risk of developing cystoid macular edema (CME) or progression to proliferative diabetic retinopathy due to focal vitreous adhesions on the macula causing traction on the retina during and after surgery. Injecting microplasmin might also help prevent CME and other retinal complications after cataract surgery complications such as posterior capsule rupture, added Dr de Smet, who has participated in microplasmin pre-clinical and clinical trials.
Benefits of complete PVD Dr de Smet noted that while PVD is common in older patients, it results from a progressive process that typically takes years. It involves both synchesis, or detachment of the vitreous from the retinal surface, and syneresis, or liquefaction of the vitreous gel. When the two progress together, the vitreous separates cleanly and completely from the retina as the gel liquefies and collapses. But often the vitreous adheres firmly in the peripheral retina or around the macula producing traction on the retina as the vitreous liquefies and collapses. Vitreomacular traction syndrome and macular holes can directly result from these vitreomacular adhesions. They may also contribute to CME, and proliferative diabetic retinopathy. Firmly adherent vitreous in the periphery will contribute to the formation of tears.
A meta-analysis of published literature on the effect of PVD revealed that a complete posterior vitreous detachment
is desirable in cataract patients because it reduces the chances of post surgery CME by a factor of three compared with no PVD, Dr de Smet said.
“After complicated cataract surgery if you have a complete PVD you are less likely to develop CME.”
For patients with proliferative diabetic retinopathy, the difference is even more dramatic. A complete PVD reduces the chances of progression to about 10 per cent compared with no PVD, whereas a partial PVD increases the risk by a factor of nearly 200 compared with no PVD.
Similarly, an absent PVD is often found in eyes with wet AMD. In the presence of a PVD, oxygen levels increase at the retinal surface helping to restore function to ischemic tissues.
Benefits of pharmacological vitreolysis Dr de Smet noted that the proteins laminin and fibronectin are involved in binding the vitreous to the retinal surface.
“Weakening these adhesions can lead to a complete PVD. This is what we call pharmacological vitreolysis.”
Several compounds, including dipase, tPA/urokinase and hyulornidase have been tried, but either didn’t work or caused intolerable side effects. Plasmin showed promise. But it is a very large molecule that is difficult to synthesise in a stable form, Dr de Smet said.
However, researchers discovered that plasmin’s enzymatic activity in degrading laminin and fibronectin was produced by one small area at the tip of the molecule. This compound, called microplasmin, was successfully produced recombinantly by the manufacturer, ThromoGenics.
Injecting microplasmin in pig eyes made
the vitreous hazy, followed by complete vitreous separation, usually within an hour or two, Dr de Smet said. Post-mortem exams of human eyes revealed “a very smooth separation, much better than what you can achieve by natural separation or by surgery,” he added. This clean separation may prevent growth of epiretinal membranes, which can result from small amounts of material left behind after what appears to be a complete PVD.
In a phase II trial involving 60 patients with vitreomacular adhesions causing traction, 44 per cent receiving a 125 microgram dose achieved a complete separation by day 28, with 58 per cent doing so when a 125 microgram dose was repeated up to three times at four-week intervals.
In two recently concluded phase III trials involving 652 patients with vitreomacular adhesions, 26.5 per cent had complete resolution at 28 days following a single 125
microgram injection of microplasmin, vs 13 per cent in the placebo group. of those subjects without an epiretinal membrane, 34.5 per cent treated with microplasmin had complete resolution. of subjects with a full thickness macular hole, 40.6 per cent saw complete resolution. of all subjects, 13.4 per cent had a complete PVD.
The drug was also well tolerated. A transient increase in floaters was the most common complaint, Dr de Smet said. The incidence of retinal detachment was about the same in those injected and those who were not.
“This drug appears to have a good safety profile. It is not on the market yet, but I’m pretty sure it will get there. There are novel approaches to treat macular traction on the way. Among these microplasmin holds great promise. We can expect a significant change in our approach to macular traction in years to come.”
Marc D de Smet - [email protected]
cont
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RETINAL DISORDERSTrials successful for vitreomacular adhesions, macular hole; may also help AMDby Howard Larkin in Paris
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We can expect a significant change in our approach to macular traction in years to come
“Marc D de Smet MDCM, PhD, FRCSC
The first OCT image (top) was taken prior to surgery in a patient with a small macular hole. The second OCT shows that the hole is closed 14 days later though there is a residual serous macular detachment
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EUROTIMES | Volume 16 | Issue 5
There is growing evidence that baseline patient characteristics have a role to play in the final visual acuity outcome of patients
with neovascular age-related macular degeneration (AMD) who are being treated with anti-VEGF therapies such as ranibizumab (Lucentis, Genentech Inc.), according to a study presented at the World ophthalmology Congress.
“Treatment with ranibizumab is the current gold standard for treatment of AMD in the neovascular form and we know that customised individualised treatment regimens can give some visual acuity benefits. As more data becomes available, we are now starting to identify some predictors for the course of the disease and to establish which patients might respond best to treatment,” said Paolo Lanzetta MD, University of Udine, Italy.
Following on from the AnCHoR and MARInA clinical trials, Dr Lanzetta said that three initial injections followed by a fixed monthly regimen has been deemed optimal to maximise visual acuity outcomes for most patients. However, he noted that PRn or individualised treatments are still associated with some visual acuity gain which is inferior to the absolute gain after the loading phase.
“We can give a reduced number of injections and we have also learned that it is quite important that patients are regularly monitored with monthly visits,” he said.
The clinical trials have also shown a difference in terms of the response profile in different patients, said Dr Lanzetta.
“Most of the important trials to date have identified specific responder groups: those patients who initially gain visual acuity and maintain that gain over the follow-up period, those that initially gain visual acuity and tend to lose it over the follow-up, and also the 20 per cent to 30 per cent of patients who do not show any gain initially in the course of the treatment,” he said.
Looking at baseline patient characteristics, the AnCHoR and MARInA and SUSTAIn trials all showed that smaller baseline CnV lesion size was associated with greater visual acuity gains, both at 12 and 24 months.
Multivariate analysis of both the AnCHoR and MARInA trials also showed that lower baseline visual acuity score was associated with greater visual acuity gain
at the end of the follow-up period, said Dr Lanzetta.
other prognostic factors for patients who are more likely to lose visual acuity or will not maintain visual acuity gain during the follow-up were also identified in the AnCHoR and MARInA trials.
“These patients show some retinal pigment epithelium atrophy or pigment mottling at baseline and they are more likely to have exudation or subfoveal fibrosis. That was partially confirmed by the SUSTAIn study in which patients with subretinal or intraretinal haemorrhage at baseline had a non-favourable outcome in terms of visual acuity,” he said.
other prognostic factors identified by the ranibizumab trials include better visual acuity outcomes in patients with a younger age at baseline, as well as patients who developed some pigmented haloes surrounding the choroidal neovascularisation after treatment.
A more problematic issue, however, is identifying those patients who will maintain the visual acuity gain throughout the course of the follow-up period, as well as those who will lose visual acuity after the initial gain, said Dr Lanzetta.
Looking at the SUSTAIn and the EXCITE studies, changes in visual acuity outcomes became apparent for some patients at month four after the initial loading phase of three monthly injections of ranibizumab, he said.
“The critical window for observing patients in terms of visual acuity changes seems to be from month three to month five,” he said.
Dr Lanzetta said that it is clear that baseline patient characteristics do have a role to play in identifying which patients might respond better to ranibizumab.
“We know now that there is a kind of individualised response and these responder profiles have now been observed in most of the pivotal ranibizumab trials. These baseline characteristics seem to have an influence on the final visual acuity outcome and we can identify the three-to-five-month ‘window’ as predictive for visual acuity outcome after 12 to 24 months,” he said.
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AMD UpDATEOngoing clinical trials shed light on patient responder profilesby Dermot McGrath in Berlin
RETINAUpdate
Paulo Lanzetta - [email protected]
contact
The monoclonal antibody agent daclizumab (Zenapax, Hoffmann-La Roche), which has been widely used in transplantation surgery
to prevent organ rejection, also shows promise as a safe, well-tolerated and useful long-term therapy for uveitis, according to Robert nussenblatt MD.
Addressing delegates attending a special session on emerging treatments for uveitis at the World ophthalmology Congress, Dr nussenblatt, national Eye Institute, Bethesda, Maryland, US, said that daclizumab is effective in controlling inflammation in patients with treatment-resistant inflammatory eye disease and allows the dose of corticosteroids to be decreased or even discontinued in some cases.
“We now have almost 11 years’ experience with this drug and overall we have seen very good responses in
individuals with uveitis who received daclizumab. There have been some side effects associated with its use, but the drug seems to be well tolerated by the majority of patients over the long term. We also observed that patients responded well when we used higher doses of daclizumab in the treatment of active uveitis and it also seemed to be quite effective in the treatment of cystoid macular oedema,” said Dr nussenblatt.
Dr nussenblatt sounded a cautionary note, however, on the prospects of daclizumab becoming a widely available treatment for uveitis in the near future. “We need a lot more studies on this and unfortunately we don’t have enough patients at this point to propose a randomised trial. It is also not clear whether the manufacturer will continue to produce daclizumab in the future, not because of any perceived issues with side
effects, but I believe because they are not sure that they can sell enough of the medication to make it economically viable. There are studies continuing in multiple sclerosis and asthma, however,” he said.
Reviewing the evolution of daclizumab in treating ocular disease, Dr nussenblatt explained that the drug is a therapeutic humanised monoclonal antibody directed towards the alpha subunit of the interleukin-2 (IL-2) receptor of T cells, designed to prevent a specific chemical interaction needed for lymphocytes to develop.
In laboratory studies, nEI investigators, collaborating with researchers from the national Cancer Institute, found that daclizumab, which blocks the IL-2 receptor and thereby prevents the immune response triggered by T helper cells, showed promise in treating an experimental model of uveitis.
“The important message to emerge from a huge amount of data was that uveitis in the main is a T cell mediated disease and that this experimental model provided us with the ability to study various aspects of T cell modulation, both from an immunoregulatory as well as from the stimulatory point of view,” said Dr nussenblatt.
Further work observed that the T helper cells that attack the eye have large numbers of interleukin-2 receptors on their surface, he added.
“one of the early observations – and this is probably true now for almost every aspect of inflammatory disease in humans – is that these T cells, while being CD4 positive, also bear large numbers of interleukin-2 receptors on their surface. Interleukin-2 is involved in T cell recruitment and growth and is one of the basic players in the development of uveitis,” he said.
Much of the focus of these studies centred on the key role played by the CD25 or Tac subunit of the IL-2 receptor in T cell activation.
It was reasoned that daclizumab, which specifically binds to the CD25 subunit of the IL-2 receptor expressed on the surface of activated lymphocytes, should break the circuitry involved in T cell activation and further recruitment of pro-inflammatory cells, said Dr nussenblatt.
The initial clinical trial of the agent, published in the Proceedings of the national Academy of Science USA in 1999, found that once monthly intravenous infusions with daclizumab controlled uveitis. The drug was well tolerated in seven of 10 patients over a four-year period. Further studies also found initial evidence that a formulation of daclizumab injected under the skin conferred similar results.
A further study carried out by Steven Yeh MD et al showed that daclizumab administered in high doses successfully
reduced inflammation in active uveitis in five patients.
“This study came from observing that patients who had active disease could not be well treated with the dosage that we initially used of daclizumab, as it was clear that daclizumab was not getting to some of the sequestered sites of the immune system, particularly lymph nodes and the spleen. So we essentially treated these patients with an initial loading dose of 8 mg/kg daclizumab followed by 4 mg/kg and we found that these individuals’ disease became quiescent rather rapidly over a couple of weeks,” he said.
other studies have since shown that high-dose intravenous daclizumab reduced active inflammation in active juvenile idiopathic arthritis (JIA) – associated anterior uveitis and is also effective and well tolerated in treating cystoid macular oedema, said Dr nussenblatt.
Dr nussenblatt said that over 11 years experience with the drug indicates that it is well tolerated by most patients. However, there remains some concern about one case of renal cell carcinoma in a patient who presented with haematuria, he said.
“This patient was ultimately found to have a renal cell carcinoma, which was removed and she was taken off the daclizumab medication. After some time, she requested us to restart the treatment which we did with permission from the FDA, and the uveitis has been quiet now for something like six or seven years. So we don’t know if the carcinoma was related to the daclizumab, but it is an important concern. We have always evaluated individuals for the presence of haematuria and we have never found it again and it has not been reported by others,” he said.
Another probable side effect from daclizumab is a rash which was reported in 13 of 39 patients, said Dr nussenblatt.
“It usually is not enough to require stopping the medication in most patients, and sometimes it is transient, but we have seen enough of it to think that it is probably related to the medication or to something that is in the material that is being transferred as well,” he said.
TREATING UVEITISDaclizumab shows promise but more studies needed
EUROTIMES | Volume 16 | Issue 5
Robert Nussenblatt - [email protected]
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by Dermot McGrath in Berlin
RETINAUpdate
“We have always evaluated individuals for the presence of haematuria and we have never found it again and it has not been reported by others”Robert Nussenblatt MD
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EUROTIMES | Volume 16 | Issue 5
A hydrogel liquid ocular bandage called ocuSeal™ (Beaver Visitec International) appears to be very effective in sealing
corneal incisions after cataract surgery and may provide some protection against endophthalmitis, said Matteo Piovella MD, Centro Microchirurgia Ambulatoriale, Monza, Italy.
“ocuSeal is easy to use and provides enough of a barrier against microbial infection to allow for the incision to heal. It degrades and disappears as tissue is regenerated and is transparent and comfortable for the patient,” Dr Piovella told the 15th ESCRS Winter Meeting.
He presented the results of a study involving 123 eyes of 91 patients with a mean age of 66.5 years who received the ocuSeal liquid bandage at the conclusion of cataract surgery. The results indicated that the liquid bandage did not cause any complications or adverse reactions, he said.
The liquid ocular bandage also appeared to improve patients’ postoperative comfort. only 15 per cent of patients with the ocuSeal bandage reported a foreign body sensation in their eye on the day after surgery. That compares to 70 per cent of 63 eyes without the bandage in a subgroup of patients that received the bandage unilaterally.
Dr Piovella said that the only real difficulty with the liquid bandage occurred during the learning curve, when surgeons applied ocuSeal incorrectly in 16 eyes. The problem arose because they did not apply the preparation onto the cornea quickly enough. The liquid bandage polymerises in 15 seconds, he noted.
Surgeons still in the learning curve with ocuSeal may also have a tendency to apply too much of the substance, he said. However, eye blinking seemed to eliminate the excess within 12 hours in all cases where it occurred.
Easy to prepare for use Dr Piovella noted that ocuSeal consists of a synthetic dendritic hydrogel that is easy to apply directly onto the ocular surface as a liquid. The hydrogel’s molecular structure takes shape when the surgeon mixes two separate components, powder polyethylene glycol and liquid polyethylene amine, he explained.
Preparing the ocuSeal liquid bandage
for use involves taking the two separate containers of the two components and joining them together. After breaking the membrane between the two containers, the preparer of the hydrogel substance
must shake their contents together for five seconds. It must then be used within 10 seconds, he stressed.
When applied to the ocular surface, the ocuSeal liquid bandage cross-links within
20 seconds to form a smooth soft and transparent protective barrier film that protects corneal incisions and is non-toxic, non-irritant and non-mutagenic, Dr Piovella said. The liquid bandage becomes invisible and undetectable by slit-lap evaluation in all patients within hours. The incision site itself becomes smooth and undetectable at day one, which is not the case in eyes without ocuSeal, Dr Piovella pointed out.
As the corneal epithelium in the wound site recovers, the degradation of the hydrogel microstructure provides room for the tissue to regenerate and replace the liquid bandage material. Electron microscopy studies show that the holes in the hydrogel microstructure range from two to three microns in size 24 hours after cross-linking but by day two the holes are about 10 microns in size. The liquid bandage re-absorbs in all patients within four days.
“When the hydrogel film is spread over a patient’s wound it interacts with underlying tissues and forms a seal lasting one to two days. Since tissue healing occurs at roughly the same rate as hydrogel degradation hence the space is taken up by regenerated tissue,” Dr Piovella explained.
Dr Piovella noted that the team at the Moran Eye Institute, Salt Lake City, Utah, US, recently carried out an investigation into the wound strength of corneal incisions in cadaver eyes. It showed that the average pressure required to burst the wound was 221.84 mmHg with ocuSeal compared to only 59.64 mmHg without it (Maddula et al ASCRS 2009).
“one of ocuSeal’s advantages is that, unlike some liquid bandages it does not require activation by an argon laser to induce polymerization. In addition, unlike cyanoacrylate glue it does not require the cumbersome preparations, numerous instruments, a dry environment, a delicate application of a precise amount of adhesive,” Dr Piovella said.
ocuSeal may also provide an additional line of defence against endophthalmitis following cataract surgery. Studies have implicated unsealed clear-corneal incisions as a possible entry point for infectious bacteria, Dr Piovella said. There is also research suggesting that rapid IoP fluctuations such as might occur with eye rubbing can cause fresh cataract incisions to gape, thereby allowing conjunctival fluid and bacteria into the eye, he added.
“I cannot prove scientifically any potential for ocuSeal to decrease the endophthalmitis rate. It is difficult, perhaps impossible, to show this, because of the large case numbers required to detect any effect. But if ocuSeal does prevent these horrible infections, then I will be protecting my patients’ eyes. And, either way, it will help me serve my patients better by giving them greater comfort after surgery,” Dr Piovella concluded.
Matteo Piovella - [email protected]
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LIqUID OCULAR bANDAGE
Update
CATAraCT
New hydrogel preparation ensures corneal wound closureby Roibeard Ó hÉineacháin in Istanbul
10
No OcuSeal OcuSeal
Without OcuSeal it is possible to observe the incision limits, with OcuSeal use the corneal surface appears smooth without any sign of previous surgery
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Potential applications for BD OcuSealTM:cataract surgery, corneal abrasions A&E, refractive surgery, pterygium surgery, trabeculectomy
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EUROTIMES | Volume 16 | Issue 5
over the next decade, an explosion of new technologies will greatly expand cataract and refractive treatment options and improve
outcomes, Douglas D Koch MD told the American Academy of ophthalmology in the 2010 Charles D Kelman Lecture.
But if these advances are to be widely available to patients, ophthalmologists must address a range of technical, financial, social and workforce challenges, said the former co-editor of the Journal of Cataract and Refractive Surgery. Quoting Dr Kelman on the value of perseverance to succeed, Dr Koch urged the profession to take up the challenges for the sake of patients. He then made 10 predictions for the next 10 years.
1. First, he predicted that femtosecond lasers would become fully integrated into routine clinical practice. The technology has the potential to make perfect incisions of all types, from limbal relaxing and self-sealing corneal cuts to perfect capsulorhexis and softening of dense nuclei, Dr Koch said. “I don’t think we know what the perfect capsulorhexis is. We have just scratched the surface with this technology.”
He believes the challenge of financing this expensive technology in heavily regulated national systems can and should be overcome. A controversial issue will arise if the technology improves in safety and simplicity to the extent that non-physicians might handle everything but the intraocular portion of the procedure, presenting new workforce issues.
2. Second, he predicted that presbyopia correction would become the norm in cataract and refractive surgery. Multifocal lenses continue to improve, and the “Holy Grail” of accommodative lenses is getting closer, Dr Koch said. Corneal approaches, including presbyLASIK, small aperture lenses and intracorneal lens implants, also are entering the mainstream.
“We are going to have an amazing range of options to offer our patients, and it is going to get complicated.”
3. His third prediction was that several procedures would be used at different life stages, reinforcing the link between refractive and cataract surgery. Dr Koch envisions a typical patient who might
undergo LASIK at age 25, PRK enhancement at 34, intracorneal implants at 46 for presbyopia, an accommodating IoL at 61 and a wavefront adjustment at 70.
4. next, he stressed that ophthalmologists will need to be well versed in the optics and the techniques of multiple refractive approaches.
“We will need great hands and even better brains,” Dr Koch said.
Advanced surgical skills will be required to implant new IoLs and perform new procedures. Better tools to measure quality of vision are being developed, and surgeons must use them to understand how the optics of each approach affect quality of vision. Mastering tools for improving contrast sensitivity, such as wavefront and topo-guided corneal ablation for irregular astigmatism, will be a key.
5. Another long sought goal, accurate IoL calculation, will be achievable within 10 years, he believes. Since the 1970s, improved IoL calculation formulae have narrowed the outcome range for the majority of patients from about +/- 3.0 dioptres to about +/- 0.25 dioptres.
A formula that accounts for error due to differences in light speed through the aqueous is improving outcomes in eyes with long axial lengths, while engineering approaches show promise for predicting which patients will experience post-surgical lens movement. Accurately assessing post-refractive surgery patients remains difficult, but progress is being made. Intraoperative measurement of higher order aberrations and accommodative range will also become common.
6. Better preoperative assessment is also coming. Individual anatomy, optics and
expectations must be assessed, Dr Koch said. For example, there are 20/10 retinas and 20/25 retinas, and that affects the potential outcome. other steps, such as testing tolerance for monovision and optimising procedures to maximise lens movement in accommodating implants, will be needed to optimise outcomes. Surgeons must be prepared to walk patients through the options to determine what they want and will like.
7. Surgeons can also expect better-informed patients. However, surgeons should be ready to correct misinformation, both positive and negative, that distorts expectations.
“I had a patient with Marfan’s and a dislocated lens. I told her I would use a 'little plastic ring with a little hole in it' to support the lens. And she said to me ‘I want a double Cionni capsular tension ring.’ When we got to surgery, it turned out she was right,” Dr Koch said.
8. Financial constraints will remain a patient concern for the foreseeable future. In 2009, premium IoLs made up 13.5 per cent of the market. This would probably be much higher if patients had the financial means, Dr Koch said. on a society level, limited national health plan budgets and the need to address cataract blindness in the developing world will keep patient costs a pressing issue.
9. As a corollary, ophthalmologists will need to be more efficient both in practice and financially. In the US, the annual volume of cataract surgeries is expected to rise 34 per cent by 2020 with a decrease in surgeons. With cataract surgery alone consuming 0.8 per cent of the US Medicare budget, pressure to contain costs will only grow.
10. Finally, Dr Koch stressed that ophthalmologists will have to work harder as advocates for patients. To make advanced technology available to patients, ophthalmologists may need to work with national health plans to allow patients to pay extra for expanded services.
“We also need to enhance resident and practitioner training and rethink the way we finance medical care, and work to promote access to new technology,” Dr Koch concluded. He urged surgeons to get involved in their professional societies, and in the larger society to address the challenges of the coming years.
He closed with a quote from Dr Kelman’s book, Through My Eyes: “It becomes a matter of selecting the possible impossible dream. This is really the key to great success – evaluating your own aspirations – not setting them too low, but rather too high... just a little too high.” Dr Koch encouraged ophthalmologists, for the sake of their patients and their profession, to aim “just a little too high.”
Douglas D Koch MD - [email protected]
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CATAraCT
qUEST FOR pERFECTIONDouglas Koch’s top predictions for the next 10 yearsby Howard Larkin in Chicago
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Two new accommodating lenses: Synchrony (AMO), pictured left, and Nulens (Nulens), pictured right
Small aperture device to treat presbyopia (KAMRA, Acufocus, Inc), one of several approaches currently or soon to be available
Even with technological advances, ophthalmologists will still need to be skilled surgeons for new procedures, new devices, and management of complications and trauma (photo of iris following
pupillary cerclage for fixed dilated pupil)
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Update
CATAraCT
EUROTIMES | Volume 16 | Issue 5
Although most cataract patients with ocular co-morbidities are likely to achieve good visual outcomes following cataract
procedures, the surgery in such cases can be more difficult and patients can be at an increased risk for biometry errors and unsatisfactory visual outcomes, said Mats Lundström MD, Sweden at the 15th ESCRS Winter Meeting.
He reported findings from the Swedish cataract register, which included the clinical data from 98 per cent of patients undergoing cataract surgery in Sweden from March 2008 to March 2010. He also presented findings from a survey of 2,138 patients treated at 35 clinics who completed the Catquest-9SF questionnaire.
The study showed that the proportion of cataract patients with ocular co-morbidity was 36.1 per cent, which was very similar to the 34.1 per cent incidence in the EUREQUo registry of the same years, and the 36.7 per cent incidence in the European Cataract outcome study. The breakdown of ocular co-morbidities was also similar, with 8.2 per cent having glaucoma, 18.8 per cent having AMD, and 3.5 per cent having diabetic retinopathy.
The cataract procedures of patients with glaucoma were significantly more likely to be difficult than those without ocular co-morbidities. That is, 18.2 per cent of their operations required additional manoeuvres, such as capsule staining, mechanical stretching of the pupil, compared to only 8.2 per cent of procedures in patients without ocular co-morbidity (p<0.001).
Glaucoma patients also had significantly worse outcomes in terms of visual acuity and refractive predictability. He pointed out that 17.4 per cent had a visual acuity less than 0.5, compared to only eight per cent of patients without ocular co-morbidity (p<0.001). In addition, 10.7 per cent of glaucoma patients had a postoperative refractive error greater than 1.0 D, compared to 6.8 per cent in cataract patients without additional ocular disease (p<0.001).
Among patients with AMD, the surgery was generally no more difficult than in patients without ocular morbidities. However, 25.2 per cent had a visual acuity worse than 0.5 D and patients with AMD were also significantly more likely to report
having more disabilities after surgery than they had before than were those without ocular co-morbidity.
“The reasons commonly found for poor self-reported outcomes in best cases include the presence of few disabilities before surgery, poor vision in the operated eye after surgery and anisometropia greater than 2.5 D,” Dr Lundström said.
Cataract surgery in patients with diabetic retinopathy is related to poor visual outcome and biometry prediction error, he continued. nearly a third of patients with diabetic retinopathy had a visual acuity less than 0.5 and 13.5 per cent had absolute postoperative refractive error that was more than 1.0 D higher than target refraction.
Patients with various other ocular co-morbidities also had poorer visual outcomes as a group. That is 22 per cent had visual acuities lower than 0.5 and 12 per cent had absolute postoperative refractive errors that were over 1.0 D higher than intended.
“Cataract surgery is related to surgical problems in glaucoma patients, to poor visual outcome and biometry prediction error in patients with diabetic retinopathy, and to poorer self-reported outcome in patients with AMD. However, for the majority of patients with ocular co-morbidity cataract surgery means improved vision, refraction on target and good self-reported outcome,” Dr Lundström added.
Mats Lundström - Mats.Lundströ[email protected]
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CO-MORbIDITIESpatients with cataracts often have other ocular conditions affecting outcomes by Roibeard O’hEineachain in Istanbul
For the majority of patients with ocular co-morbidity cataract surgery means improved vision, refraction on target and good self-reported outcome
“
Mats Lundström MD
Programme Chairpersons: Keith Barton, UK
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EUROTIMES | Volume 16 | Issue 5
Anterior segment oCT imaging (RTVue, optoVue) post-LASIK revealed the presence of a stromal tissue gap between the distal
flap edge and peripheral untouched cornea in eyes whose flap was fashioned with a 60 kHz femtosecond laser (IntraLase, AMo), reported James Lewis MD, at the XXVIII Congress of the ESCRS in Paris, France.
This newly described phenomenon was seen immediately after surgery and the first day post-op. This femtosecond furrow was more subtle one week after surgery. no such findings were observed in eyes whose flap was created with a mechanical microkeratome (one Use Plus SBK, Moria), said Dr Lewis, director of cornea and refractive surgery, Salus University, Elkins Park, PA, US. “The discovery of an early post-op stromal furrow nullifies any benefit of the 150 degree inverted-bevel side cut. The concept of tongue-in-groove tissue alignment can have no merit if there is no stromal apposition. The espoused theory of improved flap adhesion, enhanced biomechanical stability, and reduced risk of epithelial ingrowth are now highly suspect,” he said.
The oCT images were captured in a two-surgeon, two-centre study involving two groups of 30 eyes each. Flaps were created using the femtosecond laser (90-degree side cut) or a mechanical microkeratome. Images were interpreted by a third, masked observer. Immediately after surgery, a furrow was observed in all femtosecond laser eyes. Its width was irregular from the surface to the bottom of the furrow, measuring at least 10 microns in all eyes, averaging 42 microns, and extending up to 62 microns in some cases, Dr Lewis reported.
With a mechanically constructed flap, a 5 to 10 micron gap separated the flap epithelium from the epithelium of the peripheral untouched cornea. In all of these cases the stromal edges were in perfect apposition for 360 degrees.
At one week, the oCT images suggested that the femtosecond furrow was filled with an epithelial plug, Dr Lewis said.
He theorised that the femtosecond laser may ablate and thereby remove stromal tissue. Another possibility, he said, is heat damage and resultant collagen foreshortening. Dr Lewis also suspected that the epithelial plug may erode as can happen in old RK incisions. He is currently
using thermal imaging to detect excess heat generated during the femtosecond side cut. He is also studying flap apposition in eyes with a 150-degree inverted bevel. Further study is needed to explore whether the femtosecond furrow represents a peculiarity of an individual surgeon's technique, Dr Lewis said.
Although it appears that the gap becomes filled with epithelium, Dr Lewis said there is no evidence of an increased incidence of epithelial ingrowth after primary LASIK procedures performed with the 60k Hz femtosecond laser. Currently, epithelial ingrowth is a complication of late flap lifts regardless of the flap creation modality. As many surgeons are now choosing advanced surface ablation for LASIK enhancements, the issue becomes moot.
The increased biomechanical stability some attribute to femtosecond flaps is based on a false premise since no “tongue in groove” stromal contact is actually achieved. If, in the future, a femtosecond flap could be created without the furrow, the rabbit studies suggesting increased strength are still not applicable. These studies are based on full thickness bevelled penetrating keratoplasty incisions with an over-sized donor-recipient tissue diameter and over 10 times the amount of stroma to stroma contact as is in LASIK.
Dr Lewis calculated that a 150 degree bevelled incision offers only a 20 per cent increase in tissue apposition surface area as compared to a typical femtosecond vertical incision. Furthermore, mechanical microkeratomes often achieve an even greater stroma to stroma contact although the edge is not inverted.
other proposed evidence of enhanced adhesion is based on a peculiar hooking of the flap with a measure of the force needed to gradually peel the flap from the underlying cornea. Flaps are not exposed to such an unusual force vector in non-experimental conditions making these comparisons irrelevant. Real proof would require data showing higher rates of trauma-induced flap loss or dislocation in mechanical flaps. Dr Lewis has shown repeatable 99 micron flap thicknesses with a mechanical microkeratome in a controlled study of over 500 eyes.
James Lewis - [email protected]
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OCT IMAGINGpotential clinical implications of femtosecond laser flap furrows unknownby Cheryl Guttman Krader in Paris
Update
REFraCTIVE LASER
EUROTIMES | Volume 16 | Issue 5
To reduce the risk of post-procedure ectasia, many refractive surgeons favour surface ablation over LASIK for patients with central corneas
less than 500 microns thick. But with the advent of sub-100 micron planar flaps cut by femtosecond lasers, thin-flap LASIK may be just as safe and more comfortable for patients.
PRK pioneer Marguerite McDonald MD, of new York University US, and Jan Venter MD, medical director for optical Express, London, UK, debated the merits of the two approaches at the International Society of Refractive Surgery of the American Academy of ophthalmology (ISRS/AAo) 2010 meeting.
The topic remains controversial because the true incidence of post-LASIK and post-PRK ectasia is unknown, Dr McDonald noted. Reasons for this include lack of a standard definition of ectasia, lack of mandatory reporting, and lack of long-term follow-up of laser vision correction patients by refractive surgeons.
Detecting post-PRK ectasia is particularly challenging because it typically presents three to five years after surgery, compared with six to 18 months for post-LASIK ectasia. As a result, effects such as increased myopia in
post-PRK patients may be misdiagnosed, often as cataractous nuclear sclerotic changes. She recommends looking at topography difference maps to make the diagnosis because the steepening pattern can be hard to detect on straight topography images.
“We do know which procedure poses the greater ectasia risk,” Dr McDonald said, arguing that the bulk of evidence in the medical literature and clinical experience supports PRK as the safer alternative.
According to a 2007 review by J Bradley Randleman MD of Emory University, Atlanta, US, there were 23 times more reports of post-LASIK ectasia in English language journals. Dr Randleman also has reported that 36 times more cases of post-LASIK ectasia have been treated at Emory, a tertiary referral centre, Dr McDonald noted. Even accounting for the relative differences in case volumes (in the US, there is seven times as much LASIK performed as surface ablation), there is still a two times greater chance of being sued in the US after LASIK compared to surface ablation (data from the last 20 years of the ophthalmic Mutual Insurance Company, a malpractice insurance company associated with the AAo). In addition, the primary cause for a
suit after LASIK is ectasia; not so for PRK.The higher incidence of post-LASIK
ectasia is especially remarkable in that most surface procedures are done on thin corneas, Dr McDonald emphasised. Surveys of US refractive surgeons by Market Scope have consistently found that thin corneas are by far the most common reason they recommend surface ablation, which currently holds about a 13 per cent share of the market, over LASIK.
“From this we can infer that there is less risk of ectasia when performing PRK on a thin cornea versus the risk with LASIK. What we should not infer is that it is always safe to do PRK on thin corneas instead of LASIK, and instead of abstaining from surgery,” Dr McDonald said.
She noted that corneal thickness is involved in two of the top four risk factors identified by Dr Randleman and colleagues for both post-PRK and post-LASIK ectasia.
Dr McDonald recommended only operating if corneal topography is normal, and holding thin-cornea ablation to a refraction of -8.0 dioptres or less.
“If you have a thin pre-op central corneal thickness, go back and look at the topography. If you wouldn’t do LASIK on the patient, you shouldn’t do PRK.” Dr Venter sees the literature differently. He said that several studies have found LASIK to be equal or superior to PRK in efficacy and safety in the short and long term. While studies such as Dr Randleman’s comparing ectatic and non-ectatic post-LASIK eyes have identified thin corneas as a risk factor, several other studies of eyes with corneas thinner than 500 microns have found no increased incidence of ectasia post-LASIK, he added.
Dr Venter’s experience also supports the
notion that thin-flap LASIK is safe for thin corneas. out of 81,715 consecutive LASIK cases performed from April 2008 through March 2009 at optical Express centres, 2,181 eyes had central corneas less than 500 microns. These thin cornea eyes had normal topography and were treated with flap thickness of 100 microns or less. Among the 79,534 eyes with corneas 500 microns or more, some flaps were cut with femtosecond lasers and others mechanical microkeratomes. Distribution of preoperative sphere and patient demographics were similar between the two groups.
In follow-up ranging from 18 to 30 months, outcomes were also similar. There were no cases of ectasia in the thin cornea group, and two cases in the much larger thick cornea group, an outcome that was not statistically significant. no significant differences were found in best correct vision at three months, or in complication rates for glare, light sensitivity, decentred ablations, dry eye or mild DLK.
A second study comparing 2,000 eyes with flaps of 90 microns, with 2,000 eyes with flaps of 100 microns or more found no significant differences in visual outcomes or complications, demonstrating the safety of thin flap procedures, Dr Venter said.
Dr Venter believes the thin planar flap made possible by the femtosecond laser may reduce the risk of post-LASIK ectasia in thin corneas. He cites research showing that femtosecond laser flaps are more stable compared with microkeratome flaps, and by John Marshall PhD showing that the structural strength of corneas treated with thin-flap LASIK is equivalent to corneas treated with surface ablation.
Marguerite McDonald - [email protected] Venter - [email protected]
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THIN CORNEASpRK or thin-flap LASIK? Experts find merit in both approachesby Howard Larkin in Chicago
16 Update
REFraCTIVE LASER
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EUROTIMES | Volume 16 | Issue 5
An improved laser thermal keratoplasty technique known as optimal keratoplasty (opti-K, nTK Enterprises) has shown
promising initial results in delivering excellent near and distance vision for emmetropic and hyperopic presbyopes, according to Michael Berry PhD.
“opti-K has been used to improve uncorrected near visual acuity in emmetropic presbyopes while retaining or even improving uncorrected distance visual acuity – a truly optimal result that is linked to corneal multifocality produced by optimal keratoplasty. It is also effective for hyperopic presbyopes,” Dr Berry told delegates attending the Aegean Cornea meeting.
Dr Berry said that the safety and effectiveness of opti-K have been evaluated in a clinical study carried out by Dr Jonathan Rodgers in nassau, Bahamas, and are also currently being evaluated in an ongoing trial in the US.
“With this technique, we have a totally safe, completely non-invasive procedure which I think Hippocrates the father of medicine would have appreciated in terms of the 'do no harm' maxim. It is simple, rapid and comfortable for the patient. The downside is that the effect is only temporary, but so too are patients’ prescriptions for eyeglasses in this age group which change with progressive loss of accommodation and progressive hyperopic shift,” he said.
While the technique has clear similarities with laser thermal keratoplasty and conductive keratoplasty, Dr Berry said that the key difference is that opti-K is not limited to a one-off procedure.
“As far as we can tell, the technique is repeatable indefinitely. We have done so little to the cornea that we can come back time and again and just repeat what we have done initially. So we really hope that many physicians will prescribe this for their patients to give them rejuvenated vision. I think there is certainly a market for a totally non-invasive procedure as many patients simply do not want to have their eyes touched or otherwise probed or invaded,” he said.
Dr Berry explained that opti-K offers surgeons an improved method of laser thermal keratoplasty that is performed using a continuous wave laser for anterior stromal heating together with a sapphire applanation window for epithelial protection.
outlining the surgical steps, Dr Berry said that after administration of topical anaesthetic, the sapphire applanation window/suction ring (SAWSR) is positioned over the eye. The crosshair reticule on the sapphire applanation window is used for centration on the pupil centre and suction is then applied with a pneumatic syringe in order to applanate the cornea. A handpiece is docked onto the SAWSR using pre-aligned permanent magnets. The handpiece contains 16 optical fibres that are pre-aligned in a
pattern of two concentric rings with eight fibres per ring. The cornea is then irradiated by laser light over a 2.5 second period, with each spot irradiated for 150 milliseconds. During each irradiation, the corneal epithelium is kept cool and undamaged while the anterior corneal stroma is heated to produce extracellular matrix change.
“The result is a familiar treatment pattern to LTK and CK practitioners, with one important difference: all of the opacifications are purely intrastromal and the epithelium is not damaged,” said Dr Berry. This is achieved by balancing the heating of the laser with conductive cooling by the sapphire window in order to move the maximum of the temperature distribution away from the epithelium and relocate it to the anterior stroma, added Dr Berry.
To date over 200 patients have been treated at nassau, divided evenly between hyperopic presbyopes and emmetropic presbyopes. Presenting the data of the emmetropic presbyopes with a preoperative spherical equivalent between -0.25 D to +0.75 D, Dr Berry said that 63 eyes received primary treatments, 41 went on to receive secondary treatments, and of those patients seven received tertiary treatments. The mean add for each patient was about 2.0 D.
“nowadays we are using staged secondary treatments for everyone and we have developed a protocol where patients are very comfortable by trying to give them three-
quarters of the treatment in the primary procedure and then a month or so later, topping them off and adjusting for patient to patient variability with the same secondary treatment,” he said.
While initial treatments comprised a monovision protocol, this was soon discarded when it became evident that the non-dominant eye being treated for near vision was not losing any distance visual acuity.
“This was a pleasant surprise so we rapidly switched to a multifocal vision protocol in which both eyes were treated for best near vision. The patient usually sees well both at distance and near immediately post treatment,” he said.
Corneal multifocality is provided by the Eight-Fold Way in which opti-K produces alternating steepened and flattened sectors of topographical change. The multifocal pattern extends from the cornea centre to the periphery so that multifocality is achieved for all pupil sizes.
Another advantage of the procedure is the fact that the patients encounter no visual recovery or neuroadaptation problems.
“This technique is immediately neuroadapted by all our patients and we have no adaption lag and no problems with night vision or other visual symptoms. With respect to safety, there have been zero safety issues, with no adverse events or loss of two or more lines of best-corrected visual acuity. nor have there been any problems of induced astigmatism, which was something that plagued LTK and CK in the past,” he said.
In terms of the regression of near vision over time, Dr Berry said that most patients achieved J1 in the immediate postoperative period, followed by a quick decline between one week and one month postoperatively, usually stabilising at J2 thereafter.
“There are only four patients at 24 months postoperatively, but even those are above J3 which is thought to represent functional near visual acuity. Looking at the early hyperopic presbyopes who were treated with opti-K, complete regression seems to take place within five years. However, we believe overall ocular surface health is part of the equation here and we see a correlation between initial poor ocular surface health and eventual outcomes, so we can probably improve on this in the future,” he said.
An update: with nine patients at 24 months post-secondary Tx, mean B-UDVA is retained or slightly improved (since some patients had pre-Tx values less than 20/20) while mean B-UnVA has remained stable at ca. J2. (See Figures 1 and 2.)
The nassau Clinical Study was a Bahamian-American collaboration. K Jonathan Rodgers, FRCS (C), DABo performed opti-K Txs at the Vision Rejuvenation Center (see www.vrcbahamas.com) in collaboration with Harry G Glen MD and Michael Berry PhD.
SECTION hEADSection sub head
Update
REFraCTIVE LASER
Michael Berry - [email protected]
cont
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MULTIFOCAL VISIONNon-invasive technique delivers multifocal vision for presbyopesby Dermot McGrath in Crete
18
Figure 1 Figure 2
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EUROTIMES | Volume 16 | Issue 5
Initial results with a novel accommodative IoL (WIoL-CF, A.M.I. Care) indicate that the lens delivers very good uncorrected vision
at all distances and sustained a consistent level of pseudo-accommodation over time, according to Ioannis Pallikaris MD, PhD and Dimitra Portaliou MD.
“The WIoL-CF can be considered a promising alternative solution for patients that lead an active life and require good vision for near, intermediate and far. In our patient series, all patients obtained some level of accommodation that remained stable throughout the follow-up period. no complications occurred intraoperatively or postoperatively, although naturally we need a larger series of patients and longer follow-up to confirm these encouraging results,” Dr Portaliou told delegates attending the Aegean Cornea X meeting.
Dr Portaliou, Institute of Vision and optics, University of Crete School of Medicine, Heraklion, Crete, said that analysis of the results indicate that there may be a rehabilitation component to the procedure, although this needed to be verified by larger studies with longer follow-up. The results also seemed to correlate with other individual factors such as higher order aberrations, manifest refractive error, eye dominance and pre-existing residual accommodative capacity.
Invented by the late Prof otto Wichterle, a Czech chemist who is also credited as the inventor of the soft contact lens, the WIoL-CF is based on the biomimetic principle, said Dr Portaliou.
“This essentially means that both the hydrogel material used and the lens geometry (Figure 1) simulate some of the key properties of the crystalline lens itself. From this perspective, the WIoL-CF can be actually considered more as a natural product and not a typical engineered one,” she said.
The lens characteristics were selected to ensure adequate contact with the biggest part of the posterior capsule but without alteration of the capsule shape, said Dr Portaliou. The material used for the construction of the WIoL-CF has a high water content, a negative surface charge and a low refractive index. These parameters ensure maximum biocompatibility, resistance to calcification and elimination of cell attachment or spreading deemed to be the
main causes of lens and posterior capsule opacification.
“The large continuous aspheric optics of the WIoL-CF assures lens centricity and reduces reflections and haloes that can cause night vision problems. The lens design is intended to provide up to 2.0 D of pseudo-accommodation capability, facilitating near vision,” she said.
The WIoL-CF can be inserted through a 2.8mm incision. once the lens is inserted it unfolds inside the capsule and gradually hydrates using the fluid present in the eye. Complete hydration is achieved within the first 48 hours and full equilibrium with the ocular fluids is achieved in this time frame, said Dr Portaliou.
Dr Portaliou noted that the large optics
of the WIoL-CF ensure good optical performance even in large-diameter pupils in scotopic conditions. The large optical zone also means that the IoL can be used for younger patients, and that it will perform better in mesopic conditions, and will not impede vitreoretinal surgery.
The pseudo-accommodative effect of the WIoL-CF appears to result from several different mechanisms, said Dr Portaliou. The first is the anterior-posterior movement of the implant due to tightening and relaxation of the ciliary muscle, with the movement of the lens causing an increase or decrease in the distance between the lens plane and the retina. Another possibility is that the far focus is due to a combination of lens polyfocality, anterior-posterior movement and shape relaxation. iTrace technology helps us visualise the lens movement during accommodative effort (Figure 2) says Dr Portaliou.
Dr Portaliou said that so far 30 eyes of 15 routine cataract patients with a mean age of 67 have been implanted with the WIoL-CF. All implantations were performed at the University of Crete by Prof Pallikaris who is the main investigator of this clinical study being held at the Institute of Vision and optics.
Exclusion criteria for the WIoL-CF includes astigmatism higher than 1.25 D, pre-existing ocular history, corneal endothelial disease, abnormal cornea, macular degeneration, retinal degeneration, glaucoma and previous refractive surgery, said Dr Portaliou.
The lens should not be implanted in patients with retinal pathologies, ambylopia, clinically severe corneal dystrophy, very shallow anterior chamber depth, recurrent inflammation of the anterior or posterior chamber, aniridia, optic nerve atrophy or trauma.
Turning to the results, Dr Portaliou said that the mean uncorrected distance visual acuity improved from 0.45 D to 0.66 D postoperatively. The mean corrected distance visual acuity improved from 0.57 D preoperatively to 0.75 D at the last follow-up. no eyes lost any lines of corrected distance visual acuity and 71 per cent of eyes gained lines of corrected distance visual acuity. Approximately 65 per cent of patients achieved J1 near vision without any spectacle aid.
Putting the results into context, Dr Portaliou said that the WIoL-CF seems to represent a promising solution for patients who lead an active life and require good near, intermediate and far vision. However, the nature of the lens means that postoperative patient training is critical in order to achieve the maximum degree of pseudo-accommodation and provide high-quality near vision without the use of glasses.
Update
REFraCTIVE LENS
Ioannis G Pallikaris - [email protected] M Portaliou - [email protected]
cont
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IOL SHOWS pROMISENew lens simulates crystalline lensby Dermot McGrath in Crete
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Figure 1: WIOL-CF geometry
Figure 2: Pseudo-accommodation assessed with the iTrace
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EUROTIMES | Volume 16 | Issue 5
Innovations in laser technology and intraocular lens design have improved prospects for treating the full range of myopia, according to
Karl Stonecipher MD, Greensboro, Raleigh, north Carolina, US.
“We tend to treat a higher level of myopia with the 400 Hz Allegretto laser than typically we do with the 200 Hz Visx laser, but refractive lens surgery is becoming an increasingly popular option, including refractive lensectomy which we’re starting to see even in the high myopes,” he said at the XXVIII Congress of the ESCRS.
Dr Stonecipher presented a review of a consecutive series of 238 eyes of 119 patients who underwent treatment of -6.0 D to nearly -20.0D of myopia and as much as -3.0 D cylinder with LASIK, using either a 200 Hz Visx laser (AMo) or a 400 Hz Wavelight Allegretto laser (Alcon), or implantation of a Staar ICL™ phakic IoL.
At the six-month visit, 92.3 per cent (60/65) of eyes treated with the 400 Hz laser achieved 20/20 or better uncorrected vision, compared to only 77 per cent (109/141) of eyes treated with the 200 Hz system. “With the 200 Hz platform, I started to find less predictability when I tried a nomogram above -7.0 D. one of the reasons for this is that a 400 Hz laser ablation takes only half the time of a 200 Hz laser,” Dr Stonecipher said.
A contralateral eye study supported his findings with regard to the efficacy of the two systems. It showed that all eyes treated with the 400 Hz Wavelight system had uncorrected visual acuity of 20/20 or better, compared to 86 per cent of eyes treated with the 200 Hz Visx platform.
Dr Stonecipher noted that the eye trackers of the two systems have differences that could also influence a surgeon’s choice of which to use.
The intraocular approach Meanwhile, among 21 patients implanted with the Staar ICL, the uncorrected visual acuity at the three-month mark was equal to or better than the preoperative best-corrected visual acuity in 90 per cent of cases. The mean postoperative UCVA was 1.04, compared to a mean preoperative BCVA of 0.7 and a mean preoperative UCVA of 0.27.
Their preoperative spherical equivalent ranged from -8.25 D to -19.75 D with a mean value of -12.07 D. That compared to a mean postoperative spherical equivalent of +0.06 D.
“We have used the ICL for treating up to -19.0 D and have gotten excellent results and are very happy with that platform. In 90 per cent of patients uncorrected visual acuity was equal to their preoperative best-corrected visual acuity. Moreover, uncorrected visual acuity was better than preoperative BCVA in 33 per cent,” he said.
The ICL may also provide higher myopes with a better quality of vision, Dr Stonecipher said. He noted that in a study carried out by the US military, patients with the ICL appeared to have better low contrast uncorrected visual acuity than those who had undergone wavefront optimised LASIK. That is probably because of the microstriae that are often present after the laser procedure, he said.
However, the difference between the low contrast acuities of the two groups in that study was small, roughly the equivalent of two to three letters on a logMAR chart.
“That might make a difference if you were landing F-14 on an aircraft carrier at night, but for the general population the difference in contrast acuity wouldn’t be a big issue regarding the two populations.”
He noted that ICL implantation is making inroads into the refractive surgery practice in the US military, and currently accounts for around 12 per cent of cases.
He added that refractive lensectomy is a safe option for even higher myopes. In his series of patients with 15 years of follow-up, the rate of retinal detachment was lower than that of the general patient population. A study by Thomas neuhann MD and his associates involving 5,000 patients supports those findings, Dr Stonecipher noted.
His approach has been to refer patients to his retinal colleagues for pre-treatment to prevent the complication, he said.
Karl G Stonecipher - [email protected]
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EUROTIMES | Volume 16 | Issue 5
A dual-optic accommodating intraocular lens design may be more effective than current single-optic alternatives, and its
mechanism of action appears stable over the long term. Studies presented at the XXVIII Congress of the ESCRS once again showed that the Synchrony dual-optic IoL (Abbott Medical optics) typically provides accommodative range beyond what is achieved by single-optic designs or that can be explained by pseudo-accommodation.
In addition, evidence showed that true physiological accommodation persists for at least three years in many patients implanted with the dual-optic Synchrony lens. observation of accommodative tonus in Synchrony-implanted eyes bolsters earlier ultrasound and aberrometry findings confirming movement of the optics during accommodation.
Advantages of dual lens The Synchrony dual-optic lens consists of a 5.5mm, 32.0 D anterior lens attached by a spring-like mechanism to a posterior 6.0mm lens of a correct power for the patients’ needs. The anterior optic moves forward axially with accommodative effort, resulting in up to 3 D of accommodation without splitting light. By comparison, the Crystalens HD (Bausch + Lomb, Rochester, new York, US) is a hinged single-optic lens designed to move the entire lens forward to produce accommodation. It also incorporates a central area that amounts to a 1.5 D add, noted George H H Beiko BM BCh, FRCSC, St Catherine’s, Canada.
In theory, the dual-optic design holds a couple of significant advantages over the single-optic, Dr Beiko said. The separate anterior lens produces a greater degree of accommodation for a given amount of axial movement; about 2.5 D per 1.0mm. Also, the amount of accommodative power for the dual-optic lens is independent of its total power, whereas the stronger a single-optic lens, the more accommodation it produces as it moves.
In practice, the dual-optic lens may also have an advantage. It has repeatedly been shown to move in response to accommodative effort, with accommodation correlating. In other words, true accommodation. on the other hand, several investigators have been
unable to confirm movement of single-optic designs.
However, up to 1.5 D to 2.0 D of accommodative power can be derived from pseudo-accommodation, Dr Beiko pointed out. Pinhole effect, residual myopia, with-the-rule astigmatism, and corneal multifocality due to higher order aberrations such as spherical aberration all contribute to pseudoaccommodation without lens movement.
These pseudo-accommodative factors appear to be responsible for much of the single-optic design’s performance, Dr Beiko said. In a prospective randomised study reported at the ESCRS meeting, he found no significant difference in distance, intermediate and near vision, or in contrast sensitivity, for the Crystalens HD or Tetraflex (Lenstec, St Petersburg, Florida, US) single-optic accommodating IoL compared with a standard non-accommodating lens and mini-monovision (-0.25 D dominant, -0.75 D non-dominant).
“The 1.5 D advantage you get with Crystalens because of the button certainly was compensated for by the mini-monovision in the other two groups, and quality of vision was the same.”
In another study comparing the performance of the Synchrony with the Crystalens HD, Dr Beiko controlled for pseudo-accommodation by carefully matching 10 patients from the Crystalens arm of the single-optic study with 11 patients implanted with the Synchrony. The groups were similar in mesopic and photopic pupil sizes, and IoL
power, though the Synchrony group was about 10 years older on average. At six months, distance and intermediate vision differences were not statistically significant between the two groups, but the Synchrony group achieved 20/20 near vision compared with 20/40 for the Crystalens HD (p = 0.002).
“We were able to show the Synchrony lens gives 20/20 at all distances, and this despite a 10-year greater age for the study group.”
Latent accommodation observed observation of accommodative tonus, or latent accommodation, in patients three years after bilateral implantation of the Synchrony lens provides further evidence that the dual-optic approach provides true accommodation, said Victor Bohorquez MD, Bogota, Colombia, who disclosed he is an AMo consultant. He noted that in the absence of stimulation, a healthy 20-year-old eye exhibits about -1.5 D+/- 0.75 D hyperopic shift from its normal objective refraction to complete relaxation, or loss of normal accommodative tonus, of the ciliary muscles. If the Synchrony lens accommodates by a similar mechanism, latent accommodation should be observable.
To measure accommodative tonus, Dr Bohorquez used an iTrace aberrometer to measure objective far refraction and cycloplegic refraction over a 3mm pupillary area in each of 28 eyes. Baseline far refraction was measured with the patient fixating on an internal target at optical infinity. Cycloplegic refraction was
measured 30 minutes after introduction of one per cent cyclopentolate. Accommodative tonus equalled the cycloplegic minus the far measurement. To measure range of accommodation, each patient’s distance and distance-corrected near visual acuity was recorded using an ETDRS chart.
Dr Bohorquez found not only that the majority of patients demonstrated more than 0.25 D of accommodative tonus, but that more latent accommodation corresponded with better near visual acuity. of the 16 eyes, or 57 per cent, showing 0.25 D to 1.25 D accommodative tonus, near visual acuity averaged -0.02 logMAR. The 12 eyes with less than 0.25 D averaged 0.13 logMAR, a difference of about 1.5 lines that is statistically significant.
These results confirm Dr Bohorquez’s one-year ultrasound and two-year iTrace observations confirming lens movement as the mechanism of action. He also reported at the 2010 AAo meeting that these patients retain accommodation after four years. Along with a low rate of PCo formation, and five-year studies of early dual-optic prototypes, they also suggest that fibrosis does not interfere with lens movement over medium-to-long time frames. This may be due in part to the fact that the dual-optic lens fills the entire capsule, leaving little room for cellular infiltration. Dr Bohorquez recommends meticulous polishing of capsules at surgery and complete removal of viscoelastics in the capsule and between the dual lenses to prevent opacification and ensure unimpeded movement of the lenses.
George Beiko - [email protected] Bohorquez - [email protected]
cont
acts
DUAL-OpTIC IOL
Update
REFraCTIVE LENS
patients exhibit latent accommodation at three yearsby Howard Larkin in Paris
24
We were able to show the Synchrony lens gives 20/20 at all distances, and this despite a 10-year greater age for the study group
“
George H H Beiko BM BCh FRCSC
Synchrony is a dual-optic accommodating IOL that features two optics connected by haptics that have spring-like action
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PRAGUE 201216TH ESCRS WINTER MEETING
3-5 February 2012Hilton Hotel, Prague, Czech Republic
EuropEan SociEty of cataract & rEfractivE SurgEonS
EUROTIMES | Volume 16 | Issue 5
A retrospective study of 100 patients who received allogeneic hematopoietic stem cell transplants (HSCT) at Sheba
Medical Center, Tel Aviv University found that about half had dry eye signs and 37 per cent suffered from potentially sight-threatening ocular graft-versus-host disease (GVHD). But while some patients showed signs of severe dry eye syndrome including reduced visual acuity, many were either asymptomatic or had no previous ocular examination, said study co-author Irina S Barequet MD, who presented the research at the American Academy of Ophthalmology.
“There were many patients who had problems that were not detected until we examined them. In some cases, patients knew they had dry eye problems, but dismissed them as chemotherapy side effects. They were surprised to find they had GVHD in the eye,” Dr Barequet said.
Usually presenting within three months of the receipt of donor bone marrow stem cells, GVHD involves transplanted cells mounting an immune response against host target organs, including the skin, liver, mucous membranes and eyes. Ocular GVHD may occur alone or along with GVHD affecting other organ systems.
In the study, 100 consecutive allogeneic HSCT patients treated at the Sheba Medical Center programme in the past three years were given a full ophthalmological examination and filled out the 12-question Ocular Surface Disease Index (OSDI) questionnaire. The HSCT procedures were performed for a variety of indications, with acute myeloid leukaemia, myelodysplastic syndrome, acute lymphoblastic leukaemia and chronic myelogenous leukaemia making up 78 per cent of the total. The exams conducted an average of 18.6 months after transplant, and the patients averaged 48.5 years old with 46 per cent female. Siblings made up 54 per cent of the donors.
Overall, dry eye symptoms were much worse in patients who had ocular GVHD, but were also significant in many other patients. Schirmer test results were
less than 5.0mm in 49 per cent of all patients, and in 30 per cent of those not diagnosed with ocular GVHD. Log MAR visual acuity was 0.2 in ocular GVHD patients compared with 0.04 in those without; Schirmer tests averaged 3.8mm vs 9.0mm; mean tear film break-up time was 4.8 seconds vs 6.8; corneal staining scores were 5.29 vs 1.54; and OSDI scores averaged 20.5 vs 8.7. All of these findings were highly statistically significant.
In addition to the 37 per cent diagnosed with present or past ocular GVHD, 60 per cent had present or past GVHD involving another organ system. No association was found between ocular GVHD and non-ocular GVHD, and no association was found between the indication for HSCT and the occurrence of ocular GVHD.
Noting that some patients with undiagnosed ocular GVHD experienced corneal damage, Dr Barequet stressed the need for ophthalmological follow-up for all HSCT patients. She is working to incorporate it into the HSCT protocol at the Sheba Medical Center.
“There is a need for much more awareness among bone marrow transplant people of the ocular risk,” she said.
contactIrina S Barequet MD – [email protected]
Severe dry eyeFollow-up recommended to detect ocular graft-versus-host diseaseby Howard Larkin in Chicago
27
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EUROTIMES | Volume 16 | Issue 5
Despite concerns about the long-term effects of its use on the cornea, mitomycin C (MMC) remains a highly useful adjunct
to surface ablation that is most effectively deployed as primary prophylaxis for the development of haze, said Roger F Steinert MD, professor and chair of ophthalmology and director of the Gavin Herbert Eye Institute, University of California, Irvine.
“When I initiated this study I expected to find many more complications in the literature than I did find. I have always been very conservative using MMC because of concerns about toxicity, and we all know that just because it is not in the literature does not mean that it does not happen. However, I have been surprised to find how well tolerated this very toxic substance is in the eye. The keratocytes do seem to come back and repopulate over time and there is no real evidence of serious adverse events when MMC has been correctly used,” Dr Steinert told the XXVIII Congress of the ESCRS.
Reviewing the mechanism of action of MMC, Dr Steinert explained that it is an alkylating agent that cross-links DNA adenine and guanine and blocks DNA synthesis. It also inhibits cell mitosis, and arrests the cell cycle, although other cytotoxic effects of its use are still poorly understood. There is strong evidence that a single exposure does not permanently inhibit fibroblasts, he said.
Looking at the corneal response to surface ablation, Dr Steinert said that after initial keratocyte apoptosis, the surrounding keratocytes repopulate the stroma. The problem of haze occurs when epithelium-derived cytokines stimulate keratocytes to differentiate into myofibroblasts that scatter light directly and lay down disorganised collagen, especially type III. The result is a fibrotic, hypercellular scar.
Dr Steinert said that the effect of MMC on this process is twofold: first, there is a higher initial keratocyte apoptosis which takes place in a matter of hours, but it also causes a delay in keratocyte repopulation that endures for weeks or even months after exposure.
“The anti mitotic effect of MMC means lower keratocyte and myofibroblast density and less deposit of new collagen and extracellular matrix that goes on for months and results in less haze on the average and increased corneal transparency,” he said.
To illustrate the effect of MMC on the
corneal surface, Dr Steinert cited studies conducted by Farid et al looking at in-vivo confocal microscopy and corneal metrics after -9.0 D surface ablation in rabbits and 10 seconds of MMC exposure. Rabbits treated with MMC showed much less disorganisation and new collagen deposition compared to the control group. The scores for epithelial thickness, stromal thickness and haze were also worse for rabbits not treated with MMC.
Dr Steinert said that in primary surface ablation most surgeons are using MMC for moderate to high myopia in the range of -4.0 D to -7.0 D on average. As a result of the inhibition of healing with MMC, there is a tendency for overcorrection in sphere but not in cylinder, he said, noting that an adjustment in about 10 per cent of cases is most common.
In terms of dosage, concentration seems to be more important than exposure time in terms of inhibiting cell re-growth and haze. Studies have shown that the greater the concentration, the bigger the increase in apoptosis and less haze has been found with 0.02 per cent solution than 0.002 per cent.
“The most common application is 0.02 per cent (0.2 mg/ml) for 12 seconds to one minute. It is critical to double-check the dosage, because some people have unwittingly prescribed 0.2 per cent and gotten 10 times the concentration than expected. In hyperopic surface ablation there is generally a belief that there is perhaps more haze, and more regression, in the hyperopic pattern, so some surgeons who do surface treatment for hyperopia will use MMC for low corrections,” he said. The most commonly applied duration time from 12 seconds to one minute is probably correct, he added. “This time seems logical because we know that in a de-epithelialised cornea that the collagen acts like a sponge. We do not want it on the endothelium and we want the concentration on the front of the cornea, so the short duration makes much more sense,” he said.
Turning to possible adverse effects of MMC in refractive surgery, Dr Steinert said that vulnerability is probably greater in the epithelium, limbal stem cells and keratocytes more than the endothelium.
He noted that the literature does not indicate any significant epithelial toxicity associated with MMC.
contactRoger F Steinert MD – [email protected]
SUrFACe ABLATIONStudy sheds light on optimal use of mitomycin C in surface ablationby Dermot McGrath in Paris
29
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EUROTIMES | Volume 16 | Issue 5
The use of amniotic membrane can enhance the outcomes of pterygium, conjunctivochalasis and other ocular surface surgical procedures,
according to Christos Kalogeropoulos MD.“Amniotic membrane transplantation
has many advantages. It enhances the re-epithelialisation of the ocular surface, thanks to its anti-inflammatory, anti-scarring and anti-neovascular properties. It increases the apoptotic death rate of inflammatory cells, acts as a tectum of the underlying tissues and facilitates the migration and differentiation of epithelial cells. Furthermore, amniotic membrane rejection is extremely rare,” Dr Kalogeropoulos told delegates attending the Aegean Cornea X meeting.
Prior to amniotic membrane transplantation, chronic ocular surface disorders were often deemed untreatable.
Dr Kalogeropoulos’ study set out to evaluate the contribution of amniotic membrane transplantation in terms of the anatomic integrity and function of the eye in pathological conditions of the ocular surface.
The procedure was performed on 66 eyes of 63 patients ranging from 35 to 82 years for the treatment of ocular surface disorders, including corneal ulcers/perforation, persistent defects of the corneal epithelium, bullous keratopathy, chemical burns, conjunctivochalasis, pterygium surgery, and ocular surface tumours.
In the first 35 eyes a “homemade” amniotic graft was used, following which custom-made delivery systems for the amniotic membrane such as Ambiodry, Amniograft “F” version and ProKera were used.
The results showed a success rate of 97 per cent, said Dr Kalogeropoulos, who said that the procedure is a very effective and safe technique for treating debilitating ocular surface disorders.
In a separate presentation, Marie-Jose Tassignon MD, PhD, FEBO described how a team at Antwerp University Hospital has developed a standardised, xenogenic-free protocol for the manufacture of limbal epithelial stem cell grafts and a "no touch" surgical technique for its standardised transplantation.
Discussing the aetiology of limbal stem cell deficiency (LSCD), Prof Tassignon said that conditions with abnormalities of ocular surface repair include pterygium, limbal tumours, aniridia, severe scarring
following burns, cicatricial pemphigoid and Stevens-Johnson Syndrome, contact lens induced keratopathy, ultraviolet and ionising radiation, multiple surgeries, anti-metabolites and extensive microbial infections.
In terms of diagnosis, Prof Tassignon said that clinical signs to look for included epithelial haze, persistent epithelial defects, superficial subepithelial vascularisation, epithelial and stromal inflammation, late fluorescein staining, and loss of limbal palisades of Vogt. The clinical diagnosis also involves impression cytology of the corneal cells, with CK19-positive cells considered an expression of limbal cell deficiency.
Prof Tassignon explained that the limbo-amnion composite graft is generated by cultivating limbal epithelial stem cells onto a standardised amniotic membrane stretched within an interlockable amnion ring. The cells are cultured in CnT-20 medium with the addition of one per cent human AB serum for a period of two weeks, which is usually adequate time for sufficient outgrowth of the cells to permit transplantation.
To place the amniotic membrane graft, the surgeon first performs a 360-degree conjunctival periotomy and carefully prepares the recipient bed, removing all proliferative tissue. Fibrin glue is applied to the surgically prepared recipient’s cornea and in one fluid motion the composite graft within the amnion ring construct is transferred from culture and positioned onto the graft bed.
The required size is cut out at the level of the limbus by means of a trephine or microsurgical scissors. A protective layer of Healon and a second amniotic membrane patch is then positioned in order to protect the primary graft. To finish the procedure, the second membrane is tucked under the conjunctiva, sutured at four cardinal points and then covered with a bandage contact lens.
Prof Tassignon said that specialist computer software has enabled the research team to confirm the reduction in corneal vascularisation after the amniotic membrane transplantation. “We can see over time if the eye remains quiet with no recurrence of vascularisation we may then consider the eye ready for penetrating keratoplasty,” she said.
contactsChristos Kalogeropoulos MD – [email protected] Tassignon – [email protected]
eye SUrFACeAmniotic membrane transplantation has many advantagesby Dermot McGrath in Crete
31
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Eurotimes SDI Because 3er e 120x3 3 01.04.2011 09:35:23
CORNEAUpdate
17-21 SEPTEMBER
REED MESSEVIENNAAUSTRIA
BINKHORST MEDAL LECTURE
CLINICAL RESEARCH SYMPOSIA
OTHER HIGHLIGHTS
M.J. TassignonAntwerp University Hospital, Belgium
‘To bag or not to bag’
Sunday 18 SeptemberDuring the Opening Ceremony, 10.30 – 11.00
Saturday 17 September
08.30 – 10.30
ADVANCED OPTICS OF THE EYE, GULLSTRAND ANNIVERSARY
Chairpersons: T. Olsen DENMARK M.J. Tassignon BELGIUM
11.00 – 13.00
ESCRS/EUCORNEA SYMPOSIUMBIOTREATMENT OF THE CORNEA
Chairpersons: J. Alio SPAIN F. Malecaze FRANCE (EuCornea)
13.30 – 15.30
NEW CORNEAL SURGICAL TREATMENTS Chairpersons: D. Gatinel FRANCE
J. Murta PORTUGAL
15.30 – 17.30
CAPSULAR BAG TRANSPARENCY
Chairpersons: P. Sourdille FRANCE D. Spalton UK
JOURNAL OF CATARACT & REFRACTIVE SURGERY SYMPOSIUM
Controversies in Cataract and Refractive Surgery 2011Sunday 18 September
14.00 – 16.00
Chairpersons: T. Kohnen GERMANY E. Rosen UK
REFRACTIVE SURGERY DIDACTIC COURSE
Saturday 17 September
08.30 – 17.00
SURGICAL VIDEO SYMPOSIA
Monday 19 & Tuesday 20 September
14.00 – 16.00
VIDEO SYMPOSIUM ON CHALLENGING CASES
Saturday 17 September
16.15 – 17.45
Chairperson: R. Osher USA
WORKSHOP ON VISUAL OPTICS
Sunday 18 September
08.15 – 17.40
Chairpersons: I. Pallikaris GREECE M.J. Tassignon BELGIUM
YOUNG OPHTHALMOLOGISTS PROGRAMME
Saturday 17 September
09.00 - 16.00
Chairpersons: O. Findl AUSTRIA C. Zetterstrom SWEDEN
n Congress Registration
n Scientifi c Programme
n Courses and Wetlabs
n Hotel Bookings
Available at www.escrs.org:
MAIN SYMPOSIA
Saturday 17 September
14.00 – 16.00
ESCRS/EUCORNEA SYMPOSIUMCATARACT AND THE ENDOTHELIUM
Chairpersons: H. Dua UK (EuCornea) J. Guell SPAIN
14.00 S. Patel USA The endothelium: physiology, preoperative
evaluation and post-surgical evolution
14.15 Discussion
14.18 F. Kruse GERMANY Surgical approaches and the timing of cataract
extraction in the presence of endothelial disease
14.33 Discussion
14.36 R. Bellucci ITALY Endothelial protection during cataract extraction
in normal and grafted eyes
14.51 Discussion
14.54 S. Hannush USA The triple procedure: classical vs modern approach
15.09 Discussion
15.12 S. Kinoshita JAPAN Future non-surgical techniques for endothelial
enhancement: mitotic stimulations and gene therapy
15.27 Discussion
15.30 F. Larkin UK Posterior lamellar keratoplasty in pseudophakic
and aphakic bullous keratopathy
15.45 Discussion
16.00 End of session
Sunday 18 September
11.00 – 13.00
FEMTOSECOND CATARACT SURGERY
Chairpersons: G. Grabner AUSTRIA R. Nuijts THE NETHERLANDS
11.00 H. Lubatschowski GERMANY Technological requirements of femtosecond lasers
in cataract surgery
11.15 Discussion
11.22 Z. Nagy HUNGARY My experience with femtosecond laser cataract
surgery with the LenSx laser
11.37 W. Culbertson USA My experience with femtosecond laser cataract
surgery with the OptiMedica laser
11.52 Discussion
11.59 R. Krueger USA My experience with femtosecond laser cataract
surgery with the LensAR laser
12.14 G. Auffarth GERMANY My experience with femtosecond laser cataract
surgery with the Femtech laser
12.29 Discussion
12.36 P. Rosen UK Femtosecond laser cataract surgery: will it become
a cost-effective technology in the European health care environment?
12.51 Discussion
13.00 End of session
Monday 19 September
11.00 – 13.00
REFRACTIVE ADJUSTMENTS AFTER OCULAR SURGERY
Chairpersons: B. Cochener FRANCE M.J. Tassignon BELGIUM
11.00 S. Morselli ITALY Refractive surprises after monofocal cataract surgery
11.15 M. Knorz GERMANY Enhancement after LASIK: custom or standard; on
or under the flap
11.30 Discussion
11.37 P. Rozot FRANCE Management of unsatisfied patients with
multifocal IOLs
11.52 Discussion
11.59 R. Nuijts THE NETHERLANDS Optimizing vision after penetrating or lamellar
corneal surgery
12.14 M. Amon AUSTRIA How effective are the add-on IOLs?
12.29 Discussion
12.36 B. Dick GEMANY Is there a place for light adjustable IOLs?
12.51 Discussion
13.00 End of session
Tuesday 20 September
11.00 – 13.00
DECISION-MAKING IN PRESBYOPIA
Chairpersons: P. Rosen UK O. Findl AUSTRIA
11.00 H. Burd UK Why we become prebyopic: finite element analysis
modelling - the engineer’s approach
11.15 G. Barrett AUSTRALIA Monovision: does it still have a place?
11.30 Discussion
11.34 S. Pieh AUSTRIA Multifocal IOLs: optics, options and outcomes
11.49 D. Spalton UK Accommodating IOLs: do they work?
12.04 Discussion
12.08 G. Grabner AUSTRIA The corneal approach: presbylasik and inlays; are
they realistic options?
12.23 M. Fromm GERMANY The femtosecond approach: procedures on the
cornea and crystalline lens
12.38 Discussion
12.42 O. Nishi JAPAN Lens refilling: the holy grail
12.57 Discussion
13.00 End of session
Wednesday 21 September
11.00 – 13.00
APHAKIA AND ANTERIOR SEGMENT RECONSTRUCTION
Chairpersons: P. Barry IRELAND S. Binder AUSTRIA
11.00 O. Findl AUSTRIA Failed IOL implantation: implications and
prevention
11.15 G. Jakobsson SWEDEN Late dislocation of IOLs: what is causing this
new epidemic and how do we re-locate or replace these lenses?
11.30 Discussion
11.37 R. Steinert USA Reconstruction of other anatomy: iris, cornea,
and vitreous
11.52 Discussion
11.59 J. Güell SPAIN Secondary IOL implantation: iris claw is best?
12.14 G. Scharioth GERMANY Secondary IOL implantation: scleral fixation
is best?
12.29 Discussion
12.36 H.R. Koch GERMANY Aphakia and Aniridia: how is it best managed?
12.51 Discussion
13.00 End of session
The 2nd EuCornea Congress will take place from 16–17 September at the Reed Messe in conjunction with the ESCRS Congress.
A joint Symposium will take place on Saturday.
For full details of the EuCornea programme please go to www.eucornea.org
instructional coursesand wetlabs
INSTRUCTIONAL COURSES ARE NOW FREE OF CHARGE
For full details go to www.escrs.org
vien
naLUNCHTIME SYMPOSIA
SATURDAY 17 SEPTEMBER13.00 – 14.00
LEADING THE WAY FOR VISION REJUVENATIONRoom: Strauss 1Moderator: M. Tetz GERMANY
Sponsored by:
13.00 – 14.00
ZIEMER SATELLITE MEETINGRoom: Lehar 4
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13.00 – 14.00
LUMENIS SATELLITE SYMPOSIUM LASERS IN OPHTHALMOLOGYRoom: Strauss
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TECHNOLAS SATELLITE MEETINGRoom: Strauss 3
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13.00 – 14.00
HAAG STREIT SATELLITE MEETINGRoom: Schubert 1w
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CATARACT SURGERY WHERE EVERY COMPONENT DELIVERSRoom: Stolz 2Moderator: A. Brezin FRANCE, O. Findl AUSTRIA
Sponsored by:
SUNDAY 18 SEPTEMBER13.00 – 14.00
INNOVATIONS IMPACTING OUTCOMESRoom: Strauss 1
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13.00 – 14.00
BAUSCH+LOMB PHARMA SATELLITE MEETINGRoom: Strauss 3
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LEADING TECHNOLOGY IN REFRACTIVE SURGERYRoom: Stolz 2
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13.00 – 14.00
NIDEK SATELLITE MEETINGRoom: Stolz 3
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DORC SATELLITE MEETINGRoom: Schubert 1 & 2
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MGD: THE MOST COMMON OCULAR SURFACE DISEASE AND ITS SURGICAL IMPLICATIONSRoom: Lehar 1
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RAYNER IOLS: PAEDIATRIC PIONEERS FOR 60 YEARSRoom: Lehar 3
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HIGH DEFINITION LASER VISION CORRECTION WAVEFRONT AND BEYONDRoom: Lehar 4Moderator: K. Greenberg USA
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XXIX Congress of the ESCRS17-21 September 2011
viennaSATELLITE EDUCATION PROGRAMME
REGISTER ONLINEwww.escrs.org/satellites
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NEW INNOVATIONS IN GLAUCOMA SURGERY: IMPROVING PREDICTABILITY IN FILTRATION SURGERYRoom: Strauss 1
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INNOVATIONS IN PATIENT CENTRIC PROCEDURESRoom: Strauss 2Moderator: B. Malyugin RUSSIA
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STARR SURGICAL LUNCH SYMPOSIUMRoom: Lehar 4
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LIVE SURGERY: PRESENTING ADVANCING TECHNOLOGIES FOR ADVANCING TECHNIQUESRoom: Hall A1
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EUROTIMES™
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GlAuCOmAUpdate
EUROTIMES | Volume 16 | Issue 5
As a life-long progressive condition, primary open-angle glaucoma (POAG) presents significant management challenges. Not the
least of these are the high cost of some of the most effective medications, along with patient self-treatment issues ranging from forgetting doses, to running out of eye drops, to an inability to even get the drops into the eye.
All of this makes laser trabeculoplasty – particularly selective laser trabeculoplasty (SLT) – attractive as an initial glaucoma treatment. If it works, it is safe and relieves the patient of financial burden and the risk of non-compliance. Could SLT even be superior to topical medications for initial management of POAG?
According to Jorge A Alvarado MD of the University of California-San Francisco, US, SLT is not just an acceptable initial therapy, it is the better choice. Dr Alvarado and L Jay Katz MD, Wills Eye Institute, Thomas Jefferson University, Philadelphia, US, were asked to present opposing positions on whether glaucoma medication or SLT be the initial treatment for open angle glaucoma
as part of a Great Debates symposium at the American Academy of Ophthalmology annual meeting in 2010.
Dr Alvarado told the symposium that: “SLT is already known as an effective primary glaucoma treatment and this fact is recognised in articles published worldwide.” He pointed to initial research by Shlomo Melamed MD in Israel as well as studies in Britain and the US showing that SLT is equivalent in efficacy to prostaglandin analogues, typically the most effective topical medication.
SLT generally lowers intraocular pressure by about 30 per cent. About 20 per cent of patients don’t respond, similar to what is seen with prostaglandins. This may be because the mechanism of action of prostaglandins and SLT are thought to be similar.
“If you treated the patient with the laser and then give that person a prostaglandin analogue to see if there is a residual effect, you will find most often that there is only a minor residual effect. This is particularly the case, as pointed out in his publications, when the number of laser shots delivered is
doubled (ie ~ 200 shots) and the powered delivered/shots is decreased (ie 0.7 mJ/shots).”
Dr Alvarado also believes the safety of SLT has been demonstrated. There are only transient flare cell and minor discomfort issues. There are no allergies or chemical effects, as there can be with medications, he notes. “There is unanimous consensus that in fact it might be superior. Also it is cheaper, far cheaper than medical therapy, and that is an important consideration given the economic situation today,” he noted.
Many studies have found SLT to be significantly less expensive over time. These include a Canadian study putting the three-year savings at about €416 (Lee R et al Can J Ophthalmol. 2006), a US study finding a five-year saving of about €1,250 (Cantor LB et al Curr Med Res Opin, 2008) and an Australian study that found a €2.50 savings for every €1.00 spent on SLT (Taylor HR Ophthalmol. 2009).
“SLT is efficacious, predictable and effective, and compliance is removed as an issue for patient management. We recommend laser trabeculoplasty, ALT and SLT, as primary procedures,” Dr Alvarado said.
Flexibility and evidence Not so fast, Dr Katz said. While laser trabeculoplasty is appropriate in some cases, it suffers from several limitations, and its long-term efficacy is unproven. “There is very little data regarding visual preservation after laser trabeculoplasty,” he said.
By contrast, several large, long-term studies have demonstrated the efficacy of medications in reducing progression, Dr Katz pointed out. These include the Ocular Hypertension Treatment Study of more than 1,600 patients, in which the medication arm reduced progression by 50 per cent compared with the control arm after five years. Similarly, the Collaborative Initial Glaucoma Treatment Study found similar rates of progression at five years among patients managed with medications and those who received trabeculectomy.
Studies also suggest that the IOP-lowering effects of laser trabeculoplasty are limited compared with multi-drug therapy, and wane over time, Dr Katz said. He pointed to the Glaucoma Laser Trial follow-up, which found that 44 per cent of patients had successful control of IOP at two years with laser treatment only, a figure that fell to just 20 per cent at seven years.
“With lasers you often have a modest effect and you have to add medications anyway. And you often have to wait six weeks after the treatment to assess the response.”
This is problematic because many patients see SLT as a “cure,” and are lost to follow-up, Dr Katz said. With drugs, patients are reminded every day of their condition and are actively involved with their treatment. Medications also allow greater flexibility in customising treatments, he added.
Potential laser complications are also not trivial, Dr Katz noted. Complications include IOP spikes, uveitis, hyphaema, corneal oedema and abrasions, angle scarring and a dramatic hyperopic shift that is usually transient. Also, damage to the trabecular meshwork and related structures may limit options for future penetrating surgery, including trabeculectomy and canaloplasty.
“Medication as initial therapy is time-honoured through evidence-based trials and offers multiple choices to individualise treatment. Laser is limited by modest effect and lack of long-term trials, and there are certainly risks to the procedure,” Dr Katz concluded.
Dr Alvarado countered that Dr Katz himself led a prospective trial, the SLT/MED multicentre study, examining SLT as a viable primary therapy. But Dr Katz responded the decision to use medicines or SLT should be made on a case-by-case basis in consultation with the patient, and believes medication offers the most flexibility over the short and long term.
“There are cases where laser trabeculoplasty is going to be a viable alternative, whether it is for safety concerns, compliance issues, cost or simply patient preference. But today it remains a secondary procedure, with medication the primary therapy for the majority of patients with open angle glaucoma,” Dr Katz said.
Jorge Alvarado – [email protected] Jay Katz – [email protected]
cont
acts
SLT FOr POAG?Laser gains as initial therapy, but drugs offer flexibilityby Howard Larkin in Chicago
36
See www.escrs.org for details
The John Henahan Prize 2011
My Best Teacher
The prize is named in honour of John Henahan the founding editor of EuroTimes, who edited the magazine from 1996 to 2001.
a €1,000 travel bursary to the XXIX Congress of the ESCRS in Vienna and a special trophy
Young ophthalmologists, aged 40 or under, are invited to write about their memories of their Best Teacher in medical school or residency.
EUROTIMES | Volume 16 | Issue 5
All current strategies for treating glaucoma centre on the control of IOP, yet single IOP measurements carried out during
office hours will not accurately reflect the true amount of hypertension in a patient's eye and may therefore be inadequate as a basis for treatment decisions, according to Robert N Weinreb MD, who delivered a keynote lecture at the 9th European Glaucoma Society Congress.
“If you are measuring IOP in your office at least two-thirds of the time you will not be measuring the peak IOP. In fact, with one single measurement of IOP during your office hours – which is what most of us do in clinical practice – you are going to be missing the peak IOP more than 60 per cent of the time,” said Dr Weinreb, distinguished professor and Morris Gleich Chair at the Hamilton Glaucoma Center, the University of California, San Diego, La Jolla, California, US.
He noted that sleep laboratory studies conducted with John Liu PhD, at his centre and involving a total of over 1500 patients have demonstrated that IOP has a circadian rhythm and generally reaches its peak values during the evening and occurs outside of office hours in two-thirds of cases.
Earlier research has shown that aqueous humour formation and flow has a circadian habit, reaching its highest values in the six hours before noon and its lowest values
between 10 o’clock in the evening, six o’clock in the morning. Ocular Perfusion pressure, which is blood pressure minus IOP, peaks during the day and has its lowest values at night for most patients. Clinical implications of IOP fluctuation The circadian rhythm of the flow of aqueous humour can have important clinical implications, Dr Weinreb said. For example, beta-blockers, such as timolol, and alpha agonists such as brimonidine do not appear to have any hypotensive effect during the evening hours even when used as adjunctive therapy, as studies at his and other centres have confirmed. Meanwhile prostaglandin analogues (PGAs) and carbonic anhydrase inhibitors work equally well in the day and evening, he noted.
Prostaglandin analogues increase aqueous outflow, largely through the uveoscleral outflow space. On the other hand, beta-blockers and carbonic anhydrase inhibitors work by inhibiting aqueous production. The alpha agonists appear to initially affect aqueous humour production and then increase outflow, perhaps through the uveoscleral pathway, he said.
“As each of these classes of drugs have different mechanisms of action, it is not surprising that they have distinct and unique 24-hour pressure effects,” he added.
New 24-hour tonometry technology The 24-hour sleep lab assessment of all glaucoma and ocular hypertension patients would be impractical if not impossible. However, there are several new technologies now available or under development that will allow much more convenient ways of tracking the 24-hour IOP of individual patients, Dr Weinreb said. They include self-tonometers, a contact lens-based tonometer, and implantable tonometers.
Self-tonometry is the easiest approach. However the devices are expensive and require some skill on the part of the patient to obtain accurate measurements. They also require the patient to wake up during the night and measure IOP. Moreover, patients will be sitting up rather than lying down when they measure their IOP at night, which would in itself reduce their IOP during the measurement.
The new contact lens-based device (Triggerfish®, Sensimed) is designed to provide a one-day assessment of IOP. The contact lens component of the system contains a strain-gauge to monitor changes in IOP based on changes occurring at the corneoscleral junction. The lens contains a telemetric chip and a microloop antenna.
The system’s external components consist of a flexible adhesive Antenna worn around the eye and connected to a portable data recorder. Once they complete their 8- or 24-hour monitoring session, patients return the recorder to their physician who transfers the IOP readings to a computer.
“The temporary measurement of this contact lens-based approach is not invasive. However it doesn’t measure absolute IOP. It is a strain gauge and just measures differences in IOP at the current time and these are technical issues that need to be resolved,” Dr Weinreb said. With this technology, Kahweh Mansouri MD has confirmed the increased IOP that occurs during the night-time period.
Also under development is a new implantable device developed by a German company called IOP Gmbh that offers the prospect of lifelong IOP monitoring. The device has a pressure sensor, a temperature sensor and data transmitter and can be placed through a cataract style incision or external to the sclera. The device has proved very accurate in animal testing. In work from Klaus Dohlman MD and Samir Melki MD, human patients with K-Pro artificial corneas have also undergone successful implantation of the device.
Dr Weinreb noted that factors other than IOP are also likely to be important in assessing a patient’s risk of developing glaucoma or glaucoma progression. He cited recent research showing that low cerebral spinal fluid (CSF) pressure and high intralaminar pressure difference, which is the difference between CSF pressure and IOP, are also risk factors for glaucoma, including normal tension glaucoma (Ren et al, Ophthalmology 2010;117:259-266).
“We may need more than IOP measurements to understand IOP. We might need to understand not only IOP but CSF pressure and intracranial pressure,” he added.
Robert N Weinreb – [email protected]
cont
act
24-hOUr IOPMeasurement may lead to better treatment of glaucomaby Roibeard O’hEineachain in Madrid
37
GlAuCOmAUpdate
“It is a strain gauge and just measures differences in IOP at the current time and these are technical issues that need to be resolved”
Robert N Weinreb MD
EUROTIMESESC
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Visit: www.eurotimesturkey.org
EUROTIMES | Volume 16 | Issue 5
As a result of a new initiative launched by the ESCRS, urgent funding is being raised to reduce childhood blindness in the
Gondar area in North West Ethiopia.Ethiopia has one of the highest blindness
prevalence rates in the world, around twice that of other developing countries, with 1.2 million blind people out of a population of 82 million. Over 80 per cent of the
population lives in rural areas and there are currently only 35 ophthalmologists working outside of Addis Ababa to care for approximately 70 million people. This works out at around one ophthalmologist for every two million people in rural areas.
ORBIS in Gondar Gondar is located 725km north west of Addis Ababa in Amhara regional state. Like the rest of
Ethiopia, the main causes of blindness in Amhara are cataract, trachoma and refractive error. There are an estimated 6,300 blind children in Amhara, and another 31,500 children with low vision.
The government-funded Gondar University Hospital is located 725km north of Addis Ababa, in the town of Gondar, servicing an estimated population of around 14 million in the region and 3-4 million in the project area. ORBIS partnered with Gondar University from December 2004 until December 2010 to implement an innovative and cost-effective approach to increasing levels of eye care in rural areas.
The project was designed to train mid-level health professionals, such as nurses or optometrists, to effectively treat cataract blindness in the rural setting, to screen and prescribe eye glasses and to prevent blindness caused by the late effects of trachoma. The deployment of newly-trained eye care workers to the rural areas has significantly improved access to and use of services.
Gondar 2011-2014 The ORBIS partnership with Gondar University Referral Hospital concluded at the end of 2010. However, following on from the strong success of this project, ORBIS has committed to work with Gondar University Hospital to establish a Child Eye Health Tertiary Facility (CEHTF) for North West Ethiopia.
“The goal of this project is to support the development of a paediatric eye care service at Gondar Referral Hospital. This will provide children with access to high-quality eye care, which in turn will contribute to a decrease in childhood blindness and low vision in North West Ethiopia,” Allan Thompson of ORBIS told EuroTimes.
“It is very important to stress the fact that we are identifying and recruiting training doctors from the region to work on the project,” said Mr Thompson. “Training is a key component of the ORBIS programme and we want to establish projects that are sustainable by ensuring that local doctors receive the best possible instruction. As part of our training programme, we are also sending these doctors on fellowships to
centres of excellence in Europe and other international centres.”
Over the next four years, with the support of the ESCRS, the ORBIS Gondar Project aims to establish a fully equipped CEHTF with a trained paediatric eye care team at Gondar University Referral Hospital to ensure delivery of high-quality eye care. It is hoped this will strengthen the referral network and follow-up system within North West Ethiopia to ensure that children have access to eye care, and will ultimately increase awareness amongst adults, parents, guardians and the wider community, of the importance of seeking prompt medical advice for children’s eye conditions to ensure early detection and treatment.
New Eye Centre “I am delighted that the ESCRS has decided to support this very important project,” said José Güell MD, president of ESCRS,” and I would urge members and delegates attending our XXIX Congress to pledge a donation to help ORBIS implement this project.”
The inauguration of the new Eye Care centre in Gondar took place in March and in the coming months EuroTimes will be providing regular updates on the project.
“We are delighted that the new Eye Care centre is now open,” said Mr Thompson, “which is based in a brand new hospital and is a fantastic improvement on the old hospital. One of the most important issues we have now is ensuring the new ophthalmology unit is child friendly as the hospital environment can be very frightening for children. Finally, on behalf of ORBIS, I would like to thank ESCRS for its support of this project and we look forward to working with the society in the coming years.”
Allan Thompson – [email protected]é güell – [email protected]
cont
acts
ChILdhOOd BLINdNeSSeSCrS supports OrBIS project in ethiopia
38 News
ORbis
Inside the newly equipped Gondar Eye Centre
Makeshift examination rooms at the old eye clinic before the opening of the new centre
* To support the ORBIS project in Gondar delegates attending the XXIX ESCRS Congress in Vienna, Austria can make a donation at the end of the registration process. For further information visit: www.escrs.org.
Training is a key component of the ORBIS programme and we want to establish projects that are sustainable by ensuring that local doctors receive the best possible instruction
“
Allan Thompson
© ORBIS
© ORBIS
EUROTIMES | Volume 16 | Issue 5
Last year, the ESCRS established the ESCRS Young Ophthalmologists’ Forum to address the needs of residents and young surgeons.
We set up the forum in the belief that the expertise we have at the ESCRS with our educational programme is something we want to share with more of our younger members.
I am delighted to announce that almost a year after the establishment of the forum that the ESCRS has now decided to offer free membership of the society to trainees under the age of 35.
Wide range This will entitle the trainees to a wide range of services including reduced registration fees at ESCRS meetings, free access to our online service, ESCRS On Demand, and free online access to the Journal of Cataract and Refractive Surgery.
In establishing the Young Ophthalmologists' Forum, our aim was to create and support a community of young doctors who need support in the formative years of their careers.
To spread the message of the forum we now have our own website, our own page on Facebook and a bi-monthly column in this magazine which gives young ophthalmologists a chance to share their experiences.
Podcasts Another valuable resource is the Eye Chat podcast feature on the EuroTimes website at www.eurotimes.org where leading ophthalmologists discuss some of the hot topics in their specialities.
These podcasts, which have featured many of our most valued colleagues including David Spalton, Philippe Sourdille and Bill Aylward are also directed at young ophthalmologists.
A frequent question I like to ask my colleagues is: “What advice would you give to young ophthalmologists based on your personal and clinical experiences?”
Their answers in our podcast interviews have been both illuminating and refreshing and I would urge young ophthalmologists to go online to listen to the podcasts.
Future work A lot of activities are planned for the future and we will be building on the research carried out from the focus groups at the 14th ESCRS Winter Meeting in Budapest.
This research showed that younger doctors recognise the important role played by the ESCRS in education and training, but more needs to be done to support these doctors in training and in the early years of their practice.
We also have an exciting list of activities planned for the XXIX ESCRS Congress in Vienna, Austria including the Young Ophthalmologists' Programme which will be held on Saturday 18 September from 09.00 to 16.00.
I urge young ophthalmologists to visit our website at: http://www.escrs.org/youngophthalmologists for details of our special Observership Programme.
The Observership Programme is for young ophthalmologists who are starting their surgical training or already in surgical training. We are looking at short observerships for a few days or a week at most in different European centres. We will ask participating centres to draw up a short curriculum and to give our observers the opportunities to see patients in a clinical setting.
Finally, I would ask all young ophthalmologists to become a part of our community by joining the society. As chairman of the Young Ophthalmologists' Forum, I believe that young doctors have a major role to play in the development of the society, so come join us in this great adventure!
n Oliver Findl is chairman of the ESCRS Young Ophthalmologists’ Forum
contactoliver Findl – [email protected]
MeMBerShIPeSCrS offers free membership of the society to trainees under age 35by Oliver Findl
39News
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...our aim was to create and support a community of young doctors who need support in the formative years of their careers.
“
Oliver Findl MD, MBA
News
REsEARCH
EUROTIMES | Volume 16 | Issue 5
Corneal biomechanical properties characterise the response of corneal tissue to an applied force. Tissue that is “soft” stretches to a greater degree than tissue that is “stiff” under the same
force. Until recent years, the only techniques available to characterise corneal biomechanical properties required invasive methodology which precluded measurement in living eyes. However, the development of new in vivo technologies leads to the beginning of a new era in determining how biomechanical properties can assist the clinician in screening patients for subclinical corneal conditions that make them “at risk” for refractive surgery, monitoring development and progression in glaucoma, as well as planning and evaluating outcomes of biomechanical treatments such as corneal collagen crosslinking.
Ocular Response Analyzer (ORA) The first device on the market to provide an in vivo measurement of corneal biomechanical response to an air puff is the Ocular Response Analyzer (ORA), introduced at the ESCRS in 2005. This device not only provides a more accurate estimation of intraocular pressure (IOP) than Goldmann Applanation Tonometry (GAT), but also provides an assessment of corneal hysteresis (CH), a viscoelastic property which has been shown to correlate with glaucomatous damage, as well as produce different mean values between various disease
states. CH is the difference between an inward and outward applanation pressure, and does NOT provide information on the elastic properties – how stiff or soft the cornea is – but rather the rate-dependent viscoelastic response. CH alone has not proven useful as a screening device due to overlap between populations. However, with the addition of specific signal analysis strategies, useful supplementary information is provided about the biomechanical state of the cornea. ORA signal analysis has been shown to differentiate a normal post-LASIK cornea from the fellow eye with iatrogenic ectasia, as well as produce an abnormal biomechanical profile in the presence of seemingly normal topography in the fellow eye of a keratoconic patient with asymmetric expression of disease. At the time of the printing of this article, this is the only commercially available device that assesses corneal biomechanical parameters. n www.reichert.com
CorVis ST The CorVis ST is a new device introduced at the American Academy of Ophthalmology in 2010, which is near, but not yet commercially available. This device uses a high-speed camera at a rate of 4,300 frames per second to capture a series of horizontal Scheimpflug images during corneal deformation with an air puff. The depth of deformation is influenced by the IOP, corneal biomechanical properties, corneal thickness, and to a lesser extent, corneal
curvature. Figure 1 shows overlapped images at the same time point during the air puff, of a normal thin cornea and a keratoconic cornea. The keratoconic cornea is in red and the normal thin cornea is in blue. The ORA corneal compensated IOPcc is similar between the two corneas, as well as the central corneal thickness. Therefore, the difference in deformation depth is primarily due to corneal biomechanical properties, with the softer keratoconic cornea showing much greater deformation depth than the normal thin cornea. This example highlights the importance of biomechanical properties in accurate estimation of IOP, possibly to a greater extent than corneal thickness. n www.oculus.de
Dynamic Corneal Imaging (DCI) Dynamic Corneal Imaging (DCI) was developed by Gunther Grabner MD, in Salzburg, Austria, and uses a physical probe to indent the central cornea in combination with Placido topographic imaging. A series of Placido images are acquired as the probe is advanced in a step-wise fashion. Figure 2 shows a series of three images from a normal cornea, a keratoconic cornea, and a post-LASIK cornea for comparison. The “difference flexing curve” is defined as the overall change in surface curvature as a function of indentation due to applied force, and is calculated from the pre-indentation and post-indentation curvature data. Greater difference flexing curves have been demonstrated with lower IOP and thinner corneas, which is consistent with greater deformation. In addition, greater difference flexing curves have been shown in keratoconic vs normal corneas, which is consistent with greater deformation and a softer cornea in keratoconus. n [email protected]
Dynamic Rasterstereographic Corneal Topography (d.RCT) The d.RCT involves surface topographic corneal imaging during an air puff. The off-axis geometry of the system includes a calibrated grid arm and an imaging arm. In the presence of fluorescein, the image of the deformed grid pattern is captured by the camera, as seen in Figure 3. The surface elevation can then be reconstructed with knowledge of the system geometry. This allows evaluation of the spatial distribution of biomechanical properties, which may be especially important in keratoconus where asymmetry of biomechanical properties has been shown to be a component in finite element modeling of the disease. n www.visionoptimization.com
Optical Coherence Tomography (OCT) Elastography An OCT Elastography prototype has been developed through a collaboration between William J Dupps MD, PhD of the Cleveland Clinic Cole Eye Institute and Andrew Rollins PhD of Case Western Reserve University, US, that uses high-speed OCT to characterise three-dimensional dynamic corneal behaviour. A transparent force-sensing lens delivers a menu of perturbations while allowing simultaneous high-speed imaging of the corneal response with swept-source OCT, and frame-by-frame analyses of speckle displacement and the force provides measures of local viscoelastic properties such as elastic modulus, shear modulus, and hysteresis. The OCT elastography device is designed to provide three-dimensional corneal shape information and a depth-resolved analysis of corneal biomechanical properties in the same sitting. Figure 4 shows the axial stretch ratio of an 8mm keratoconic corneal button, mounted in a modified artificial anterior chamber, under a change in pressure of 10 mmHg. The cone demonstrates the highest concentration of strain and the lowest resistance to deformation. Researchers are working
A New erAIn the latest article from the eSCrS research Committee, we look at the measurement of corneal biomechanical propertiesby Cynthia J Roberts PhD, The Ohio State Universityand François Malecaze, Hôpital Purpan
40
Figure 1: Overlapped images of normal thin cornea (blue) and kearatoconic cornea (red) at the same time point in the course of the CorVis ST air puff. Both corneas have similar IOPcc, as well as similar corneal thicknesses. The greater deformation depth of
the keratoconic cornea is due to the weaker biomechanical properties. (Data provided by Renato Ambrosio, Rio de Janeiro, Brazil.)
Figure 3: In vivo image of an undeformed human cornea (left) and deforming under an air puff (right)
Figure 4: Axial stretch ratio of an 8mm keratoconic corneal button, mounted in a modified artificial anterior chamber, under a change in pressure of 10 mmHg. The tissue
above the label A on the OCT elastography image was identified as the cone by the Keratron Scout. The cone demonstrates the highest concentration of strain and the lowest
resistance to deformation
Figure 2: Dynamic Corneal Imaging (DCI) of a normal cornea (upper), and a keratoconic cornea (lower), with three serial images including pre-deformation (left), 100
microns of deformation (middle) and 300 microns of deformation (right)
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EUROTIMES | Volume 16 | Issue 5
to combine these measurements with whole-eye finite element modelling to develop a system capable of advanced biomechanical diagnostics and patient-specific simulation-based surgery. n [email protected]
Corneal Transient Elastography (CTE) Corneal Transient Elastography, or CTE, is adapted from a technology in current use for breast tissue imaging using a modified ultrasonic transducer developed by Supersonic Imaging (Aix-en-Provence, France), and is under development for ophthalmic use by D Touboul MD (Bordeaux) and the Langevin’s Institute team (Paris). The aim of this technique is to allow in vivo corneal Young’s elastic modulus (YM) mapping based on true physical parameters. An echographic transducer was designed to analyse the shear wave speed into the tissue, which is mathematically correlated with YM. The echographic probe was specifically designed to couple a homogenous transverse compression wave into the tissue (supersonic mode), during about 50 µs. In a second step, the probe switches into an ultrafast echographic acquisition mode (20000 frames/sec) that allows determination of the speed of the shear wave cluster that spreads into the tissue laterally, from which the YM elasticity mapping is generated in a few ms. The experimental trials in animals demonstrated the correlation between IOP and corneal stiffness, as well as quantified the changes after corneal collagen cross-linking (CXL). (See Figure 5.) The first human clinical study is already planned this year, and will start at the National Referral Center for Keratoconus (CRNK), Bordeaux University, France. This work is supported by the French Research National Agency (ANR). n [email protected]
Quantitative Ultrasound Spectroscopy (QUSi) The Quantitative Ultrasound Spectroscopy (QUSi) method, developed by Jun Liu PhD and her research team at The Ohio State University, measures corneal elastic properties based on quantitative analysis of the raw radio frequency data. Corneal acoustic and elastic properties have been shown to correlate, and the technique has been shown to measure increased stiffness after corneal collagen crosslinking in vitro. Figure 6 shows an example of spectral waveform. Clinical evaluation of normal and keratoconic subjects is under way. QUSi is an immersion technique, similar to clinical A-scan in terms of measurement procedure and subject experience. It differs from clinical ultrasound in that it derives more information from the acoustic signals based on the analysis of the wave propagation in the cornea. This method is currently being developed to map corneal elastic properties through-thickness and across different regions. n [email protected]
Dr Roberts is a consultant to Oculus Optikgeräte GmbH and is the owner of Vision Optimization, LLC and the d.RCT technology. She has a small interest in the Quantitative Ultrasound Spectroscopy (QUSi) method.
41
Figure 5: In vivo CXL was performed in porcine eyes, comparing mean shear wave speed with opposite NON-CXL eye, showing a 50 per cent rising of the mean shear wave speed (localised central stiffening)
Figure 6: Example spectral waveforms from two porcine corneas with different peak height and location indicating different corneal stiffness and thickness. (Adapted from Invest Ophthalmol Vis Sci.2009;50:5148–5154.)
RESEARCHCo
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mEETiNG REPORT
EUROTIMES | Volume 16 | Issue 5
Incoming ASCRS president Edward J Holland MD welcomed Ulf Stenevi MD as an Honoured Guest to the 2011 ASCRS annual meeting. Prof Stenevi,
chair of the Department of Ophthalmology at the University of Gothenburg, Sweden, and past chair of the Department of Ophthalmology at the University of Lund, Sweden, received his award at the opening session of the ASCRS congress in the San Diego Convention Centre on Saturday March 26.
“Prof Stenevi is one of the world’s leaders in stem cell research and corneal repair. He is an internationally known teacher and writer and has served as president and secretary of the ESCRS. We are proud to honour him today,” Dr Holland told the ASCRS congress.
In his address, Prof Stenevi stressed the value of the relationship between the ESCRS and ASCRS in advancing eye care. “I have for many years advocated international collaboration and discussion of ideas. This is truly an international meeting on the podium and in the audience, and this collaboration is continuing.”
ESCRS president Jose Guell MD credited Prof Stenevi, who was president of the ESCRS from 2002-2003, for his ongoing efforts to spread knowledge worldwide.
“He has been part of that group that creates this relationship across both sides of the ocean, not only at the journal level but also the society level. This relationship makes everybody grow faster and better. He is an extremely important person for the ESCRS,” said Dr Guell.
The ASCRS also welcomed Gavin S Herbert, chairman Emeritus of Allergan as an Honoured Guest. Mr Herbert, who helped found the company in 1950, had served as its chairman from 1977 to 1995 and its chief executive officer from 1961 to 1991.
ASCrS AwArdFormer eSCrS president is ASCrS honoured Guestby Howard Larkin in San Diego
42
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Edward J Holland (left), incoming ASCRS president, presents Ulf Stenevi MD with his Honoured Guest Award at the ASCRS congress
“Prof Stenevi is one of the world’s leaders in stem cell research and corneal repair”Edward J Holland MD
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EUROTIMES | Volume 16 | Issue 5
Integrated solutionCarl Zeiss Meditec says it is now successfully launching the next-generation, modular phaco and vitrectomy system on the market, therefore expanding its line of solutions for eye surgery in regard both to the fields of application they offer and to their regional distribution.
“From the applications viewpoint, VISALIS 500 expands the company’s product offering with an integrated workstation for cataract treatment,” said a company spokeswoman. “Thanks to its modularity, VISALIS 500 can also be utilised for retinal surgery and therefore offers most of the system functions needed in the ophthalmic OR.The system’s modular structure enables the addition of the vitrectomy function at a later date.
“This is made possible by equipping the phacoemulsification system with dual pump technology.With the appropriate accessories and fluidics, VISALIS® 500 also permits MICS procedures and is therefore an important part of the ZEISS MICS platform.The ultra-light handpieces – currently unique on the market – allow outstanding ease of use for the doctor and comfortable work in the OR,” she saidn www.meditec.zeiss.com
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Feature
iNdusTRY NEwsRecent developments in the vision care industry
Micro-Implantation Cataract SuiteAbbott has introduced a Micro-Implantation Cataract Suite which the company says is designed to help improve cataract procedure outcomes and safety.
“The Micro-Implantation Cataract Suite, featured at the American Society of Cataract and Refractive Surgery Symposium and Congress in San Diego, enables the surgeon to perform an entire micro-surgical procedure, which can reduce surgically induced astigmatism, provide a safer intra-operative environment, and promote faster healing and visual recovery,” said an Abbott spokeswoman.n www.abbott.com.
One platform laserBausch + Lomb (B + L) and Technolas Perfect Vision GmbH (TPV) have announced an agreement in principle to globally distribute what they say is the first femtosecond laser capable of performing both cataract and refractive procedures on one platform.
Under the arrangement, TPV will develop and manufacture its femtosecond cataract and refractive laser system from its facilities in Munich, Germany, and service the product through its current worldwide service organisation. Bausch + Lomb Surgical will leverage its cataract expertise and commercial capabilities to globally distribute TPV’s femtosecond laser, said a B+L spokeswoman.n www.bausch.com.
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PRACTiCE dEVElOPmENT
EUROTIMES | Volume 16 | Issue 5
With eight ophthalmologists, an anaesthesiologist, and 15 residents, Eye Clinic Svjetlost is one of the largest and most
comprehensive private practices in Croatia. Last year, the clinic's ophthalmologists conducted more than 4,500 surgical procedures in the clinic’s 2,000-square-metre facility in Zagreb. Of those procedures, about 20 per cent were performed without charge for low-income patients. Among them were laser refractive, lenticular refractive, cataract, corneal transplant, vitrectomy, squint and oculoplastic surgeries, as well as a variety of minor surgical procedures.
And despite the economic downturn, the clinic generated more than €4.5m in revenue and more than €500,000 in profit – all of it on the free market and without state insurance contracts.
Both financial strength and clinical excellence have been essential for the clinic’s growth from a 70-square-metre office providing general ophthalmology services, says Nikica Gabric MD, PhD, who founded Eye Clinic Svjetlost in 1997 along with his teacher and mentor Kresimir Cupak MD, PhD.
“The idea of being a great surgeon but at the same time a successful businessman is something that has been leading me through my entire professional life,” Dr Gabric says. “I can say that I have been successful in those two different roles. I make money by being a surgeon, but it is necessary to know how and when to invest this money to create new opportunities in your medical career. Technology is developing really fast and if you want to stay among the top surgeons, you have to keep pace with all the novelties in ophthalmology.”
Building skills – and sharing Dr Gabric also works with six other clinics in the region as co-owner or consultant. Beyond teaching and operating a successful practice, his goal is to build a firm foundation for local private clinics to succeed as global chains enter the growing markets in Croatia, Serbia, Kosovo, Montenegro, Bosnia and Herzegovina. He believes such success depends on ophthalmologists cultivating business skills – and the earlier the better.
“I have in my clinic 15 residents of ophthalmology and I am trying to engraft this idea in their lives as well,” Dr Gabric
explains. “I am aware that in the future it will be even harder to compete and that learning to be a ‘small manager’ is something that will put them ahead of others.”
While he has no formal business education, Dr Gabric has drawn on his early experience as a student leader in medical school to build a business philosophy that he believes helps him achieve extraordinary results. He calls this approach an “economy of collectiveness”. All employees are encouraged to present new ideas and participate in new projects. All are regularly informed of the clinic’s income, expenses, and profit. Physicians joining the practice may choose to pursue either partnership or remain workers. As workers, they will have better salaries, better work conditions, and better possibilities of promotion than doctors in state hospitals or many other private clinics. As partners, they can
advance faster and achieve higher positions in decision making, development of new projects and profit sharing – but they must demonstrate leadership skills and personal commitment to the organisation to do so.
As Dr Gabric sees it, partnership is the highest form of cooperation. Achieving it requires not only material contributions to the partnership, but also loyalty. Loyalty consists of respect towards partners and consciousness of their importance, tolerance of the differences among individuals, and gratitude for all the things that partners do for each other. Loyalty is a non-material quality that depends on personal character – many partnerships break up precisely because partners don’t accept this intangible, Dr Gabric says.
For young doctors to become partners, they must show loyalty through their work and actions. They must also contribute by
showing responsibility for their own work and the work of others. They must be both excellent surgeons and show a capability in leading others.
Sharing is another concept Dr Gabric embraces. He believes that colleagues achieve more by sharing with others than simply adding to their own interests. Providing services to those who can’t afford them and participating in foundations supporting eye banks and scholarships help build trust within the partnership and with the larger community.
The value of training Dr Gabric facilitates collegial development by meeting once or twice weekly with clinic doctors to give advice and feedback on their progress. He encourages them to strengthen their personalities, improve themselves as humans, gain self-esteem and self-confidence, get rid of bad habits and become more tolerant towards other people. At Christmas, he asks clinic doctors to write out their wishes for improving their skills in the coming year, to lay out how they intend to contribute to the enterprise. These ideas help guide future development, he adds.
Clinic Svjetlost is willing to consider for employment anyone who will volunteer for three months. During this trial period, the candidate’s focus, dedication, and passion are measured from one to 10. Young people have an advantage because Dr Gabric believes it is easier to inculcate the values he believes are essential to a long term partnership in young physicians than in those with already-formed practice habits and personalities.
Dr Gabric believes that all ophthalmologists should take advantage of opportunities to learn business skills from such practice development programmes as those sponsored by the ESCRS. “It is important to start teaching young ophthalmologists to develop their business skills along with medical ones. They should be aware of the entire business process, including marketing, communication, and deciding upon improvements,” he says. “I think these kinds of workshops are more than welcome, especially in former east European countries because they have great development possibilities.”
PArTNerShIP IS KeyShared goals, values and loyalty among colleagues helps clinic thriveby Howard Larkin
45
It is important to start teaching young ophthalmologists to develop their business skills along with medical ones
“
Nikica Gabric MD, PhD
Operating room in Eye Clinic Svjetlost
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Vienna could have been planned with the tourist in mind.
The inner city's treasures – from St Stephen’s Cathedral to the dazzling Hofburg Palace – are
linked by eminently walkable streets. Museums, art galleries, and theatres are only minutes apart.
Even relatively distant attractions like Schloss Schönbrunn are easily reached by an efficient underground system. And wherever you go, you are never too far from one of Vienna's legendary cafés.
Like the dollop of whipped cream on your Sacher Torte, Vienna’s over-the-top architecture, its sheer exuberant style, makes even a short stay richly satisfying.
Here are six places to see on a first visit to Vienna – or to visit again if you know Vienna well:
1. St Stephen’s Cathedral, affectionately called “Steffi,” is at the heart of the city, literally and figuratively. The Viennese even admire the postmodernist glass facade of the Haas-Haus opposite because its windows reflect their beloved Gothic church. To tour St Stephen’s, its towers and the catacombs, purchase an “all-inclusive” ticket. Simply looking around the nave on your own is free.
2. Among the seven or eight museums in the Hofburg Palace, one of the most visited is the recently expanded “Sisi” museum, a collection of objects belonging to the beautiful and doomed “Sisi,” – the Empress Elizabeth. The exhibition of items, many of a very personal nature, was enhanced in 2006 with the addition of 240 pieces from a private collection. Admittance to the Silver Collection and the Imperial Apartments is included on the “Sisi” ticket. For details, visit: www.hofburg-wien.at. The Hofburg is also the home of the famous Spanish Riding School; its performances are booked out well in advance, but as some spectators leave, others are admitted. To be sure of a place, book online as far ahead as possible. For details, visit: www.srs.at. The Vienna Boys Choir sings in the medieval chapel of the palace on Sundays, a tradition that has endured for 500 years. The choir travels in July and August, but in 2011, it resumes in the Hofmusikkapelle on September 18. Standing room is free; queuing for admission to the Sunday 9am Mass begins at 8am.
3. Vienna's new “Museumsquartier” is one of the 10 largest cultural centres in the world. In a mix of buildings ranging from Baroque to Contemporary, there's a Museum of Modern Art, a Museum of Contemporary Art, plus centres devoted to dance, photography, architecture and more. The sleek Leopold Museum, established in 2001 is the star attraction. It boasts the definitive Shiele collection as well as many works by Klimt. Original Art Nouveau and Wiener Werkstaate furniture form an interesting mini-collection... A panoramic window on the fourth floor frames Vienna's rooftops like a work of art. The Leopold is open from 10:00 to 18:00, and until 21:00 on Thursday. Outstanding cafe/bistro. Closed Tuesdays. For details, visit: www.leopoldmuseum.org.
4. In the mid-19th century, the Ringstrasse, a broad road encircling Vienna's old city, replaced the city’s former city walls and moats. By the direct edict of Emperor Franz Joseph I in 1857 ("It is my will....") the new Ringstrasse was lined with opulent town houses called Palais. Though all were built between 1860 and 1890, the architectural styles are a scrapbook in stone, a medley called "Ringstraßenstil." Readers of Edmund de Waal's award-winning memoir, The Hare with the Amber Eyes will take a long look at the facade of the Palais Ephrussi where so much of the story took place. It stands on Dr Karl-Lueger-Ring opposite the University. Today, the building is the headquarters of “Casino Austria.”
5. The Schönbrunn rivals Versailles for magnificence; in its Baroque Hall of Mirrors, the five-year old Mozart played for the Imperial family. This summer home of the Hapsburgs boasts 1,441 rooms. By comparison, Versailles has about 2000. Don’t worry about the number: on the “Grand Tour” you will only see 40 rooms; on the “Imperial Tour” you will see only 22. Buy a ticket online and skip the long queues at one of the most visited sites in Europe. For details, visit: www.schoenbrunn.at. The Palace gardens are enlivened by a zoo featuring giant pandas, a palm house, a carriage collection, and a viewing pavilion, the “Gloriette.” There are relaxing cafes throughout the grounds, but for a proper meal in a delightful setting book a table at the Cafe Restaurant Residenz in a wing of the Palace. On Saturday and Sunday afternoon, enjoy free piano music with your coffee and cake.For details, visit: www.cafe-residenz.at.
6. The Judenplatz Memorial, by British architect Rebecca Whiteread, commemorates the 65,000 Viennese victims of the Holocaust. A squat steel and concrete structure, it is designed to look as if it were constructed of thousands of books placed backwards on shelves, their contents forever unknowable. The names of the camps in which the victims perished are inscribed around its base. The memorial, the initiative of Simon Wiesenthal, was unveiled in 2000.
EUROTIMES | Volume 16 | Issue 5
ChArM TO SPAreThere’s plenty to enjoy in stylish viennaby Maryalicia Post
46 Feature
EYE ON TRAVEl
Treasure TroveVienna’s famous auction house, the Palais Dorotheum, at Dorotheergasse 17, is also Vienna’s largest antique shop. The building houses several floors of treasures; most will be auctioned, but you might find a ready-to-go souvenir in the “Glashof” or in the Art and Design Gallery. There, porcelain, glass and collectables are for sale at fixed prices. A delightful, old-fashioned cafe is on the second floor. The Dorotheum is open Monday to Friday from 9:00-18:00 and Saturday from 9:00-17:00.
* The XXIX ESCRS Congress and 2nd EuCornea Congress take place in Vienna from 16-21 September 2011.
Hofburg Palace
The eastern wing of Schloss Schönbrunn as seen from inside the Prinzenpark
EUROTIMES | Volume 16 | Issue 5
Immediate answersUrgent questions find generous responseHow nice it is to realise that the authors and editors of textbooks are human beings, and not unapproachable entities from Mount Olympus!
The biography of Thomas John on the back of this manual certainly gives a sense of a well-rounded human being. “TJ,” as friends know him, describes his clinical and academic work as “one subject in his ‘report card of life.’”
By his own account, Dr John has taken quite a variety of subjects in his personal school of life. In addition to his extremely extensive range of clinical and academic activity – which while only constituting one subject on the report card gets a fair degree of attention – Dr John reminds us that he organised the first ARVO rock concert in Fort Lauderdale, is devoted to his family and children and that “above all in his report card of life, Jesus Christ is foremost, to whom he owes everything.”
Dr John ends his preface by wishing everyone global peace and happiness. This somewhat unconventional approach to medical biography is a winning one, for we are all much more than the mere sum of our work parts.
Dr John’s evident enthusiasm for this particular subject is evident in the book, in which he has assembled contributions from a team of experts from both the US and India.
As Dr Lindstrom writes in the foreword, a concise easily accessible resource is invaluable when facing an ocular emergency, or a complication postoperatively. There are two main poles of medical book publishing – reference texts for the library and portable texts for the emergency. With the rise of the Internet, perhaps it will be the reference text which suffers most, for there will always be situations when the easiest thing is to look things up in an easily accessible book. In those urgent cases, such a book beats waiting for a PDA to upload, only to find that the software is corrupted or the wireless broadband is down.
This book is extremely practical, with the text predominantly in bullet points. There is a good amount of clear space on each page and the typeface is pleasingly large and visible. There are plenty of diagrams and photos and tables. The first chapter is an overview of symptoms, signs and tests, and
this is a valuable refresher for the experienced ophthalmologist, and a good guide for those non-ophthalmic physicians who may be required to respond to potential ocular emergencies.
The second chapter by Dr John himself is on the cornea, and takes us through the full range of corneal presentations and conditions. Charles S Bouchard and Amy Lin of Loyola University Medical Centre contribute the chapter on eyelids and conjunctiva, which is also extremely comprehensive. The same thoroughness and practicality is evident in the remaining chapters on: refractive surgery, glaucoma, lens issues, scleral issues, retina/vitreous/choroid issues, uveitis, ophthalmic disease, neuro-ophthalmology, paediatric ophthalmology, ocular emergencies and ocular therapeutic agents. The whole thrust of the text is a concentration on practical matters and clarity.
Certainly, it should be accessible for doctors in a wide range of specialties, and will be of use not just for emergency physicians and ophthalmologists but also for those physicians with responsibilities for a long-stay unit of any kind. Overall, this book has much to recommend it as it meets the purpose for which it was designed.
47
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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
Eu mAttERsFeature
EUROTIMES | Volume 16 | Issue 5
The EU's highest court has effectively blocked pharmaceutical and medical device companies from using a new patent system that could have reduced the cost and delay in introducing and
protecting their products.The impediment arose after the EU Court of Justice ruled
that a proposed European Patent Court to adjudicate patent disputes was contrary to existing European Union law.
The decision followed the review of a draft international agreement, which was concluded between the 27 EU and 11 non-EU countries that are parties to the European Patent Convention. Under the new agreement, all disputes arising from any patent granted by the convention would be decided by a new Patent Court.
The Patent Court was part of a wider and more integrated system for patents to be issued by the European Patents Office. Although a European patent now exists in theory, that patent is essentially a bundle of national patents, each governed by the domestic law of the country. By contrast, the future European Patent would be unitary and autonomous and have equal effect throughout the 38 European countries that belong to the Patent Convention.
The key to the new European patent agreement was the so-called “European and Community Patent Court.” The Patent Court would include a court of first instance to hear evidence and decide claims arising from patent disputes, and an appellate court to hear appeals from the court of first instance.
Against that background, the European Council – which is made of government representatives from each of the EU’s 27 member countries – requested the Court of Justice
to provide an opinion about the compatibility of the proposed Patent Court with existing European Union law.
Under EU law, the council, an individual EU country, the European Parliament, or the European Commission can request the Court of Justice to provide an opinion about the compatibility of an envisaged agreement with the EU Treaties, which form the EU’s “Constitution.”
In its opinion, the Court of Justice commented that the proposed Patent Court would hold distinct legal personality under international law and operate outside the institutional and judicial framework of the European Union.
The Court of Justice added that the proposed Patent Court would have exclusive jurisdiction to hear lawsuits involving infringement of patents, revocation of patents, and compensation for abuse or misuse of patents. To that extent, the courts of individual EU countries and the Court of Justice would be excluded from interfering with the decisions of the Patent Court.
Against that background, the Court of Justice noted while EU law did not prevent the European Union from entering international agreements that may affect the court’s own powers, such agreements could only be entered if there were strict conditions to limit the effect of the agreement on the rights of EU countries and their citizens and the ability of the Court of Justice and national courts throughout the EU to uphold the legal order already established under EU law.
On that basis, the Court of Justice ruled that the creation of the patent court would deprive national courts and the
Court of Justice itself from cooperating in a manner to ensure that EU law is correctly and uniformly interpreted throughout the European Union.
For example, the Court of Justice noted that under EU law an EU country is obliged to compensate individuals for any damage caused by a breach of European Union law, irrespective of which authority of that country, including a court, caused the breach. Likewise, where an infringement of European Union law is committed by a national court, a case may be brought before the court to obtain a declaration that the Member State concerned has failed to fulfill its obligations.
By contrast, the Court of Justice stated that if a decision of the Patent Court were in breach of European Union law, the EU could not take any steps to overturn such a decision or to enforce EU law against a country that failed to discharge its legal responsibilities under the Patent Convention.
“Consequently, the envisaged agreement, by conferring on an international court which is outside the institutional and judicial framework of the European Union an exclusive jurisdiction to hear a significant number of actions brought by individuals in the field of the Community patent and to interpret and apply European Union law in that field, would deprive courts of Member States of their powers in relation to the interpretation and application of European Union law and the court of its powers to reply, by preliminary ruling, to questions referred by those courts and, consequently, would alter the essential character of the powers which the Treaties confer on the institutions of the European Union and on the Member States and which are indispensable to the preservation of the very nature of European Union law,” the Court of Justice concluded.
On that basis, the Court of Justice decided that the agreement creating a European and Community Patent Court “is not compatible” with the provisions of European Union law and thus would be illegal.
In light of the court’s opinion, the Patent Court will not be able to go ahead until either:
The 38 member countries of the European Patent Convention agree to limit the jurisdiction of the proposed Patent Court;
The EU amends the EU Treaty – the European Union’s “Constitution” – to specifically allow the establishment of the Patent Court as proposed.
Given the importance of patents to the future of the EU and the rest of Europe as a centre for research and development – and the strategic difficulty posed by any amendment to the EU Treaty – the 27 EU countries and 11 non-EU countries of the Patent Convention are expected to revisit the terms of the proposed Patent Court and devise a different court structure that comes within existing EU law and the Court of Justice opinion.
PATeNT SySTeMeU rules against patenting system for ophthalmic drugs and devicesby Paul McGinn
49
“Although a european patent now exists in theory, that patent is essentially a bundle of national patents, each governed by the domestic law of the country”
VISIT ouR NeW LooK WeBSITe FoR INDIAN DoCToRS
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RS ™
India
www.eurotimesindia.org
EUROTIMES | Volume 16 | Issue 5
Quality of vision, quality of lifeWhen it comes to post-op evaluation after cataract surgery, visual acuity testing does not tell the whole story. Patients may report dissatisfaction despite a 20/20 visual acuity reading. Questions remain about quality of vision and daily functioning. J Alio and colleagues utilised the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) to tease out quality of life issues in a comparison trial of three lenses: a monofocal IOL, the Acri.Smart 48S (Carl Zeiss Meditec); an apodised multifocal IOL, the AcrySof ReSTOR SN6AD3 (Alcon Laboratories); and a full diffractive multifocal IOL Acri.LISA 366D (Carl Zeiss Meditec).
The study of 106 eyes of 53 patients showed no statistically significant differences in manifest sphere or cylinder between the three IOL groups. There were also no statistically significant differences in postoperative distance visual acuities. Patients receiving either of the multifocal IOLs had significantly less difficulty than monofocal recipients in reading the newspaper and bills, and in performing hobbies that required near vision. However, patients who received the Acri.LISA 366D multifocal had significantly less difficulty driving at night than those who received the AcrySof ReSTOR. Patients receiving the monofocal IOLs had significantly better postoperative photopic contrast sensitivity than monofocal recipients.n Jorge L. Alió et al, JCRS, “Quality of life
evaluation after implantation of 2 multifocal intraocular lens models and a monofocal model”, Vol. 37, Issue 4, 638-648.
Endothelial survival after DSAEK and AC IOLIs endothelial cell survival worse in patients undergoing DSAEK in the presence of an anterior chamber IOL? Two-year follow-up of a series of cases suggests the answer is no. The study of 20 eyes, all with a well-centred AC IOL with an AC IOL-to-endothelial depth greater than 3.0mm, showed a mean postoperative donor endothelial cell loss of 24 per cent at one year and 28 per cent at two years. There was no significant difference in cell loss in this series compared with ECD loss in DSAEK surgeries performed in the presence of a posterior chamber IOL. However, the presence of an AC IOL is almost always associated with a history of vitrectomy and loss of an intact lens–iris diaphragm, which may make the retention of an air bubble after surgery difficult. This may theoretically increase the likelihood of dislocation and possible
IOL touch with loss of endothelial cells. Therefore, the surgical decision of retaining or exchanging the IOL when performing endothelial keratoplasty in the presence of an AC IOL should be individualised to each case, the researchers emphasise.n S Esquenazi et al, JCRS, “Endothelial
survival after Descemet-stripping automated endothelial keratoplasty in eyes with retained anterior chamber intraocular lenses: Two-year follow-up”, Vol. 37, Issue 4, 714-719.
Latest on lens refillingLens-refilling procedures with flexible polymer have the potential to provide accommodative vision. However, success with this approach has so far been elusive. One of the many problems has been the variability in lens dimensions. High-precision control when injecting a flexible polymer also poses significant challenges.Only the optimum amount of polymer will allow adequate lens refilling and yield the necessary changes in lens curvature for accommodation. Magnetic resonance imaging studies on animal eyes suggest a way forward in the quantitative evaluation of the lens shape. O Stachs and colleagues conducted high resolution MRI studies in rabbit eyes for up to three years after lens refilling procedures. This allowed them to visualise the entire geometry of the crystalline and refilled lenses in vivo. The capsule and the polymer remained in close contact with no visible interface in refilled eyes. The dimensions of the refilled lens were significantly smaller than those of the crystalline lens of the contralateral eye. This points to the need to optimise the amount of polymer injected during lens refilling to achieve a predictable refractive outcome after lens refilling surgery, the investigators note. nO Stachs et al., JCRS, “In vivo 7.1 T magnetic
resonance imaging to assess the lens geometry in rabbit eyes 3 years after lens-refilling surgery”, Vol. 37, Issue 4, 749-757.
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Reference: 1. Chen Y-A, Hirnschall N and Findl O. Corneal wetting with a viscous eye lubricant to maintain optical clarity during cataract surgery. Submitted to J Cataract Refract Surg under review.
CORNEA PROTECT® is a registered trademark of Croma-Pharma GmbH. BSS PLUS® is a registered trademark of Alcon Laboratories, Inc.
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JCRs HiGHliGHTsJournal of Cataract and Refractive Surgery
Review50
FURTHER STUDYBecome a member of ESCRS to receive a copy of EuroTimes and JCRS journal
Thomas KohnenaSSOCIaTE EDITOR OF jCRS
EuroTimes M
ay 2011
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Advertising Directory: Abbott Medical Optics Page: IFC; Alcon Laboratories: Pages: 5, 11, 25, 30, 43, 51, OBC, ASCRS / Eyeworld Pages: 20, 48; Bausch + Lomb Page: 17; Benz Research and Development Page: 19; Carl Zeiss Meditec AG Page: 42; Croma-Pharma Pages: 15, 50; D.O.R.C International BV Pages: 13, 44; Geuder AG Page: 22; Haag-Streit International Page: 39; Katena Products Inc Page: 41; Khairabad Eye Hospital Page: 8; Medicel AG Page: 16; Medicontur International SA Page: 9; NIDEK Page: 7; Oculus Optikgeraete GmbH Pages: 27, 29, 31; Oertli Instruments AG Page: 23; ORBIS Page: 47; Rayner Intraocular Lenses Ltd Page: IBC; VSY Biotechnology Page: 3
July2011
17-21XXIX Congress of the ESCRS www.escrs.org
Reference52
CAlENdAR Of EVENTsDates for your Diary
June
September
2011
2011
9-11
16-17
Milan,italy
vienna, austria
Retina in Progress present and future 2011www.retina3000.it
2nd EuCornea Congresswww.eucornea.org
May2011
February 2012
3-516th ESCRS Winter Meetingwww.escrs.org
prague,czech republic
1-3 21-23
29-2
leuven, belgiuM
DeaD sea, israel
paris, France
Leuven Retina Meetingwww.leuvenretinameeting.eu
Fifth International Symposium on Refractive Surgery, Cataract and Corneawww.dead-sea2011.co.il/
World Glaucoma Congress 2011www.worldglaucoma.org
June2011
3 geneva, switzerlanD
PRESBYMANIA 2011www.presbymania.com
4-7geneva,switzerlanD
Joint Congress of SOE/AAO www.soe2011.org
July2011
8-10 crete, greece
12th Aegean Retina Meetingwww.aegeanretina.gr
September2011
1-5 FlOriDa, usaARVO 2011 - Annual Meetingwww.arvo.org
19-22 istanbul, turKey
18-21 rOMe, italy9th SOI International Congresswww.soiweb.com
May2011
19-22 nurnberg, gerMany24th Intl. Congress of German Ophthalmic Surgeonswww.mcn-nuernberg.de
26-29 lOnDOn, uK
24-26 birMinghaM, uKThe Royal College of Ophthalmologists Annual Congress 2011www.rcophth.ac.uk/annualcongress
11th EURETINA Congresswww.euretina.org
VIII Congress of SEEOSAnd IX Congress of BSOSwww.seeos-bsos2011.org
5-8 pOrtO alegre, brazilXXXVI Ophthalmology Brazilian Congresswww.cbo2011.com.br/
23-24 bOrDeaux, France
8-9 gOthenburg, sweDen1st World Congress on Surgical Trainingwww.surgicon.org
Eurokeratoconus IIwww.jbhsante.fr
1-4
6-7
23-2622-25
13-16
vienna,austria
Dublin,irelanD
Milan,italy
OrlanDO,Fl, usa
seOul,KOrea
International Symposium on Ocular Pharmacology and Therapeuticswww.isopt.net
13th International Paediatric Ophthalmology Meeting Dublin
91st SOI National Congresswww.soiweb.com
American Academy of Ophthalmology Annual Meetingwww.aao.org
2011 APACRS-KSCRS Annual Meetingwww.apacrs.org
DecemberOctober
October
November20112011
2011
2011
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ay 2011
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