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June 2013 l Volume 9 Number 5 l www.oteurope.com
Glaucoma surgeryOptions to help slow down progression
RETINA
Imaging and diagnostics for
retinal problems
CATARACT & REFRACTIVE
Causes and treatments for ocular
surface diseases
GLAUCOMA
Updates on IOP monitoring in
glaucoma patients
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tafluprost
The first preservative-free prostaglandin
Effective IOP-lowering (1
Low risk of hyperaemia (2
For Glaucoma
Tough on IOP.Easy on Eyes.
June 2013 l Volume 9 Number 5 l www.oteurope.com
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Tough on IOP.Easy on Eyes.
tafluprost
Ma
y 2
01
3
Abbreviated Prescribing Information TAFLOTAN® (tafluprost 0.0015% eye drops, solution, single-dose container). Presentation: Low-density polyethylene single-dose containers packed in foil pouch. Each single-dose container has a fill volume of 0.3 ml and there are 10 containers in each foil pouch. The following pack sizes are available: 30 x 0.3 ml and 90 x 0.3 ml. One ml of eye drops contains 15 micrograms of tafluprost. Indication: Reduction of elevated intraocular pressure in open angle glaucoma and ocular hypertension in patients who would benefit from preservative-free eye drops or who are insufficiently responsive or intolerant or contra-indicated to first line therapy, as monotherapy or as adjunctive therapy to beta-blockers. Dosage and Administration: The recommended dose is one drop of TAFLOTAN® in the conjunctival sac of the affected eye(s) once daily in the evening. Not recom-mended in children or adolescents (under the age of 18). In renal or hepatic impairment use with caution. Contraindications: Hypersensitivity to tafluprost or to any of the excipients. Precautions: Before treatment is initiated, patients should be informed of the possibility of eyelash growth, darkening of the eyelid skin and increased iris pigmentation. Some of these changes may be permanent, and may lead to differences in appearance between the eyes when only one eye is treated. Caution is recommended when using tafluprost in aphakic patients, pseudophakic patients with torn posterior lens capsule or anterior chamber lenses, or in patients with known risk factors for cystoid macular oedema or iritis/uveitis. There is no experience in patients with severe asthma. Such patients should therefore be treated with caution. Interactions: Specific interaction studies with other medicinal products have not been performed with tafluprost. Pregnancy: Do not use in women of childbearing age/potential unless adequate contraceptive measures are in place. Driving: Tafluprost has no influence on the ability to drive. Undesirable Effects: The most frequently reported treatment-related adverse event was ocular hyperaemia. It occurred in approximately 13% of the patients treated with preserved tafluprost and 4.1% of the patients treated with preservative-free tafluprost. Other side effects include: Common (1% to 10%): eye pruritus, eye irritation, eye pain, changes in eyelashes, dry eye, eyelash discolouration, foreign body sensation in eyes, erythema of eye lid, blurred vision, increased lacrimation, blepharal pigmentation, eye discharge, reduced visual acuity, photophobia, eyelid oedema and increased iris pigmentation and headache. Uncommon (0.1% to <1%): superficial punctate keratitis (SPK), asthenopia, conjunctival oedema, blepharitis, ocular discomfort, anterior chamber flare, conjunctival follicles, allergic conjunctivitis, anterior chamber cell, conjunctival pigmentation and abnormal sensation in eye, hypertrichosis of eyelid. Overdose: If overdose occurs, treatment should be symptomatic. Special Precautions for Storage: Store in a refrigerator (2°C - 8°C). After opening the foil pouch keep the single-dose containers in the original foil pouch, do not store above 25°C, discard an opened single-dose container with any remaining solution immediately after use. MA Holder: Santen Oy, Niittyhaankatu 20, 33720 Tampere, Finland. Date of Preparation: 11/2012.1) Taflotan lowered IOP by 6.9 - 9.7 mmHg in masked, randomized studies 1-4. 1. Uusitalo H et al. Acta Ophthalmol 2010; 88: 12-19 2. Traverso C et al. J Ocul Pharmacol Ther 2010; 26: 97-104 3. Konstas AG et al. Comparison of 24-hour efficacy with Tafluprost compared with Latanoprost in patients with primary open-single glaucoma or ocular hypertension. Abstract 5104/A2458 4. Chabi A et al. Am J Ophthalmol 2012; 153: 1187-1196 2) SPC text of Taflotan 3) Zimmerman T et al. J Ocul Pharm and Ther 2009; 25: 49-56
Taflotan has a low risk of
hyperaemia!2
4,1%2
Hyperaemia contributes to >60% of adverse event related switches with prostaglandins.3
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3www.oteurope.com
Jorge L. Alió, MD, PhD
Instituto Oftalmologico de Alicante,
Alicante, Spain
Winfried Amoaku
University Hospital, Queen’s Medical
Centre, Nottingham, UK
Gerd Auffarth, MD
University of Heidelberg, Germany
Albert Augustin, MD
Klinikum Karlsruhe, Karlsruhe, Germany
Rafael Barraquer, MD
Institut Universitari Barraquer and Centro
de Oftalmología Barraquer, Barcelona,
Spain
Christophe Baudouin, MD
Quinze-Vingts National Ophthalmology
Hospital, Paris, France
Johan Blanckaert, MD
Eye & Refractive Centre, Ieper, Belgium
Burkhard Dick, MD
Center for Vision Science, Ruhr University
Eye Hospital, Bochum, Germany
Christoph Faschinger, MD
Medical University of Graz, Clinic of
Ophthalmology, Graz, Austria
Paolo Fazio, MD
Centro Catanese di Medicina e Chirurgia
(CCHC), Catania, Italy
Alessandro Franchini, MD
University of Florence, Eye Institute -
Azienda Ospedaliera Careggi, Florence,
Italy
Frank Goes, MD
Goes Eye Centre Left Bank, Antwerp,
Belgium
Günther Grabner, MD
University Eye Clinic Salzburg, Salzburg,
Austria
Zdenek Gregor, FRCS FRCOphth
Moorfelds Eye Hospital, London, UK
Gábor Holló ,MD, PhD, DSc
Semmelweis University, Budapest,
Hungary
Vikentia Katsanevaki, MD
Vardinogiannion Eye Institute, University
of Crete, Greece
Omid Kermani, MD
Augenklinik am Neumarkt,
Augenlaserzentrum Köln, Germany
Hans-Reinhard Koch, MD
Hochkreuz Augenklinik, Bonn, Germany
Anastasios G.P. Konstas, MD, PhD
1st University Department of
Ophthalmology, AHEPA Hospital,
Thessaloniki, Greece
Pavel Kuchynka, MD
Charles University, Prague, Czech
Republic
Erik L. Mertens, MD, FEBO
Antwerp Eye Center, Antwerp. Belgium
Norbert Pfeiffer, MD
University of Mainz, Mainz, Germany
Roberto Pinelli, MD
Istituto Laser Microchirurgia Oculare,
Brescia, Italy
Matteo Piovella, MD
C.M.A. srl Centro Microchirurgia
Ambulatoriale, Monza, Italy
Imola Ratkay-Traub, MD
Danube Band Medical Centre, Hungary
Herbert A. Reitsamer, MD
Paracelsus University Salzburg, SALK
University Eye Clinic, Salzburg, Austria
Gisbert Richard, MD
University Medical Center,
Hamburg-Eppendorf, Hamburg, Germany
Theo Seiler, MD
Institut für Refraktive & Ophthalmo-
Chirurgie (IROC) and University of Zurich,
Zurich, Switzerland
Tarek Shaarawy, MD
University of Geneva, Geneva,
Switzerland
Sunil Shah, FRCOphth, FRCSEd,
FBCLA
Birmingham and Midland Eye Centre,
Midland Eye Institute, Solihull, UK
Gisèle Soubrane, MD
University Paris XII, France
David Spalton, MD
St Thomas’ Hospital & King Edward VII’s
Hospital, London, UK
Einar Stéfansson, MD, PhD
University of Iceland, National University
Hospital, Reykjavik, Iceland
John Thygesen, MD
Rigshospitalet, University of
Copenhagen, Copenhagen, Denmark
Baha Toygar, MD
Dünya Eye Hospital, Istanbul, Turkey
Petja Vassileva, MD
National Eye Institute, Sofa, Bulgaria
Jan Venter, MD
Optimax UK & Croydon Clinics, UK
Carlos Vergés, MD, PhD
C.I.M.A. Universidad Politécnica de
Cataluña, Barcelona, Spain
Paolo Vinciguerra, MD
Istituto Clinico Humanitas, Rozzano,
Milan, Italy
Thierry Zeyen, MD
University Hospital, Leuven, Leuven,
Belgium
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4Ophthalmology Times Europe June 2013
Cover Features
7 Improving the glaucoma surgical armamentarium
In this article, Professor Buys discusses a contender in the
search for an improvement on trabeculectomy, revealing her
findings from a comparative review of published data.
10 Revisiting TSCPC as an option
According to Dr Ahmed this procedure has the ability to lower
IOP and preserve vision similar to trabeculectomy and tube
shunts.
12 Reducing IOP: A comparative analysis
Dr Lindstrom describes a minimally invasive surgical procedure,
which he believes has revolutionized treatment for glaucoma
patients.
14 Microstent reduces medication use
Results of a multinational study are revealed that demonstrate
the safety and efficacy of an investigational intracanalicular
microstent.
Cataract & Refractive
16 Effects of laser refractive surgery upon tear osmolarity
In this paper, the outcomes of a recent study examining the
effects of LASIK on the ocular surface are highlighted.
20 Treating MGD and evaporative dry eye
Dr Albou-Ganem offers her thoughts on a new system and
reveals the results of her recent study.
22 NSAIDs lower inflammation, CME
Comparative study results are discussed that support the use
of once-daily treatment.
24 OVDs ideal for microincision surgery
According to Dr Deidier, moderately cohesive OVDs offer
desired performance traits.
Retina
26 Identifying patients with autoimmune retinopathy
In this article, the authors examine the best practices for
patients with autoimmune retinopathy and reveal how imaging
technologies can help.
29 Confocal infrared RM imaging of macular diseases
Dr Diniz reports on a new, commercially available scanning
laser confocal ophthalmoscope that can perform multiple
functions.
32 Atypical presentation of acute macular
neuroretinopathy
A case report is presented in which imaging, visual acuity and
literature are used to diagnose acute macular neuroretinopathy
through exclusion.
Glaucoma
36 Continuous IOP monitoring
Dr Lorenz discusses her recent study investigating the
tolerability of a device that can continuously measure IOP in
glaucomatous and healthy patients.
38 Ocular surface disease exacerbated glaucoma
The authors describe the rationale for optimizing the ocular
surface in glaucoma patients.
41 Enhanced detection of open-angle glaucoma
Professor Chauhan summarizes a recent report on an
anatomically accurate OCT-derived neuroretinal rim parameter.
Regulars
6 News
42 Products
June 2013 l Volume 9 Number 5
www.oteurope.com
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6Ophthalmology Times Europe June 2013
NEWS
NEWS IN BRIEF
Toric IOL improves QoLImplantation of a toric IOL results in
improved patient quality of life (QoL) and
better visual, refractive and aberrometric
results, states a new investigation in the
British Journal of Ophthalmology.
A team headed by Dr R. Mencucci,
Department of Specialised Surgical
Sciences-Eye Clinic, University of
Florence, Florence, Italy, assessed three
groups of subjects who underwent
unilateral cataract surgery with IOL
implantation.
Overall, the toric lens resulted in a
better post-op QoL compared to the
spherical SN60AT lens.
Digital devices good for AMDDigital devices may be used as a visual
rehabilitation technique for low-vision
AMD patients, according to a paper
featured in the journal Eye.
An investigation led by Dr K. Gill,
Department of Ophthalmology,University
of Western Ontario, London, Ontario,
Canada, included 27 stable wet AMD
patients in the study.
Devices with larger display screens
and high contrast ratios are benef cial to
AMD patients who require larger texts for
reading.
Three-plane CCI effectiveThe 2.75 mm three-plane clear corneal
incision (CCI) created with a femtosecond
laser produces comparable outcomes
to single-plane angled manual incision
for anterior and posterior corneal
topography, claims a new study in the
Journal of refractive Surgery.
Dr Marco Lombardo et al., Fondazione
G.B. Bietti IRCCS, Rome, Italy, performed
inf ation testing in 14 human eye globes
to assess the topographic response to
the cornea to CCIs.
The average change of the anterior
and posterior corneal astigmatism vector
magnitude was 0.17 D or less in both
groups.
Smoking decreases choroidal thicknessCigarette smoking signif cantly decreases choroidal thickness, claims the latest results published
in the British Journal of Ophthalmology.
The investigation, led by Dr Selçuk Sızmaz, Department of Ophthalmology, Baskent
Üniversitesi Adana Arastırma ve Uygulama Merkezi, Ankara, Turkey, included 17 otherwise
healthy smokers as the study group and 17 non-smokers as the control group. All smokers
underwent OCT scanning at baseline and one and three hours after smoking one standard
cigarette.
Participants in the control group underwent OCT scanning in the morning and then two
examinations at the f rst and third hours. Choroidal thickness measurements were recorded
from all participants in both groups.
At baseline, mean choroidal thickness at the fovea was 301.1 ± 63.1 μm for smokers and
decreased to 284.2 ± 56.7 μm at one hour and 270.8 ± 80.0 μm at three hours after smoking.
This demonstrated a signif cant decrease at all f ve extrafoveal points.
The control group presented with a mean baseline choroidal thickness at the fovea of
270.6 ± 57.9 μm, which was stable at 272.5 ± 52.4 μm at one hour and 273.8 ± 57.4 μm at three
hours.
Fourier domain OCT effectively identif es reductions in choroidal thickness due to cigarette
smoking.
Sagging eye syndrome causes diplopia Widespread rectus pulley displacement and extraocular muscle (EOM) elongation causes
acquired vertical and horizontal strabismus, according to a study in the Archives of
Ophthalmology.
Dr Zia Chaudhuri et al., Jules Stein Eye Institute, University of California, Los Angeles,
California, USA, used magnetic resonance imaging to evaluate rectus EOMs, pulleys and the
lacteral rectus-superior rectus (LR-SR) band ligament on 56 orbits of 28 patients clinically
diagnosed with SES. Results were also gathered from 25 orbits of 14 control subjects.
The main outcome measures were rectus pulley locations compared with age-matched
norms and lengths of the LR-SR band ligament and rectus EOMs. This information was correlated
with facial features, binocular alignment and fundus torsion.
Blepharoptosis and superior sulcus defect was commonly exhibited in patients with SES.
Signif cant inferolateral LR pulley displacement was discovered in SES. However, the causes
extended to peripheral displacement of all other rectus pulleys and lateral displacement of the
inferior rectus pulley, with elongation of rectus EOMs.
Symmetrical LR sag was linked to divergence paralysis esotropia and asymmetrical LR sag
greater than 1 mm with cyclovertical strabismus. Small-angle esotropia or hypertropia could be
caused by common involutional changes in EOMs and orbital connective tissues.
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7www.oteurope.com
GLAUCOMA SURGERY
Landmark clinical trials have confirmed that
lowering intraocular pressure (IOP) slows
progression of glaucoma and that low target
pressures in many cases can halt progression. In
those individuals unable to achieve their target IOP
medically or unable to follow a medication regimen
(due to for example intolerance, lack of compliance or
cost), a variety of interventions are available.
Among the growing plethora of glaucoma surgical
procedures, trabeculectomy remains the most
commonly performed procedure due to its track
record of achieving low target pressures. Although
trabeculectomy has been performed for decades
the procedure has evolved over time including the
introduction of releasable sutures/suture lysis, the
use of anti-metabolites and conjunctival flap design
making the modern trabeculectomy very effective
at lowering IOP with reduced risks. Potential serious
complications exist, however, such as early and
late postoperative hypotony, reduced vision due to
accelerated cataract growth and bleb-associated
infections.
Glaucoma surgeons continue to search for an
improvement on the trabeculectomy; a procedure
that will deliver significant IOP reduction but with
fewer complications. One such contender is the
ExPRESS glaucoma shunt (Alcon Laboratories, Fort
Worth, Texas, USA — see Sidebar 1).
Similar to trabeculectomy
Originally the device was intended to be implanted
directly under the conjunctiva, however, due to high
rates of hypotony and device extrusion it is now
implanted under a scleral flap. This is essentially a
modification of a trabeculectomy, with the elimination
of manually creating an osteium and a peripheral
iridectomy.
Given the similarity to a trabeculectomy, the
procedure has a short learning curve specifically for
those familiar with trabeculectomy surgery. It was
also anticipated that the uniform internal lumen
diameter of the shunt would yield more consistent
reduction in IOP and specifically reduce rates of
early hypotony. Further proposed advantages over
conventional trabeculectomy include decreased
tissue manipulation by excluding the manual
creation of an osteium and peripheral iridectomy,
which could result in improved IOP lowering over a
trabeculectomy.
The procedure of implanting an ExPRESS shunt
under a scleral flap has been embraced by many
glaucoma surgeons with thousands of devices
implanted worldwide. Unfortunately, what is missing
in the literature are well-designed prospective
randomized controlled trials (RCTs) comparing
the device implanted under a scleral flap to a
trabeculectomy. Comparative data of this nature
would provide conclusive evidence to secure the
position of the ExPRESS shunt in the glaucoma
surgical armamentarium.
What the studies reveal
A recently published review1 comparing this device to
trabeculectomy found only two prospective RCTs in
the peer-reviewed literature and one additional RCT
with results presented at the 2012 and 2013 American
Glaucoma Society meeting. The first study, by de
Jong et al.,2 randomized 80 eyes to trabeculectomy
or ExPRESS and reported results up to 5 years.
Initially the ExPRESS group had statistically significant
lower IOP and better success than trabeculectomy,
however, after 3 years the differences were no longer
statistically significant.
Dahan et al.3 randomized fellow eyes of 15 subjects
to ExPRESS or trabeculectomy and followed these
subjects for a mean of 23.6 months. Three of the
By Prof. Yvonne M. Buys,
MD, FRCSC
Improving the glaucoma surgical armamentariumPositioning the ExPRESS shunt in the glaucoma surgeon’s practice
In short...Trabeculectomy remains the most commonly performed
procedure to surgically reduce IOP in glaucoma patients.
However, potential serious complications exist and as such
glaucoma surgeons continue to search for an improvement
on the trabeculectomy. In this article, Professor Buys
discusses a contender of this search, the ExPRESS
glaucoma shunt, revealing her findings from a comparative
review of published data.
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8Ophthalmology Times Europe June 2013
GL AUCOMA SURGERY
subjects were lost to follow-up
after 1 year. In this small series they
reported significantly better success
with the shunt but no difference in
mean IOP between groups at last
follow-up.
In both of these studies there were
no differences in any of the other
reported outcomes between the
groups including number of glaucoma
medications and complications.
None of the retrospective studies
in this series reported a difference
in IOP, success rates or number of
glaucoma medications between the
device and trabeculectomy. In terms
of complications one retrospective
study reported significantly higher
rates of early hypotony and choroidal
effusions with trabeculectomy as
compared to ExPRESS. No other
studies reported differences in
complication rates between these
procedures.
When evaluating efficacy of
various glaucoma therapies the
focus has traditionally been on IOP.
The patient, however, is typically
concerned with visual function. In all
the studies included in this review
only one evaluated visual fields and
reported no difference between
the device and trabeculectomy.
Several studies compared visual
acuity with some finding decreased
vision following surgery with either
procedure however there was no
significant difference between the
groups. The rate of visual recovery
was evaluated in 3 studies and found
to be faster following implantation of
the shunt.4–6
Overall the clinical outcome
following ExPRESS appears to be
similar to trabeculectomy with
perhaps faster visual recovery.
Non-clinical outcomes, such as
economic factors should also be
considered. It was initially suggested
that this alternative filtration surgery
was faster than trabeculectomy,
however, a study that compared
surgical time did not find a difference
between these procedures. This
same study evaluated the one year
cost difference between ExPRESS
and trabeculectomy including surgical
costs, medications and follow-up and
found that the shunt was significantly
more expensive with the difference
primarily attributed to the cost of the
implant.7
Summary
In summary various metrics are
used in the decision process
when recommending a glaucoma
procedure to an individual patient.
The current evidence regarding
the device implanted under a
scleral flap suggests equivalency
to trabeculectomy in terms of IOP,
success, number of glaucoma
medications and complications. Final
visual acuity has also been reported
to be similar, however, the rate of
visual recovery may be faster with
trabeculectomy. Unknowns include
late device specific complications
including external device exposure,
erosion into the eye, and effects on
corneal clarity. All of these outcomes
also need to be considered in the
context of the increased cost of the
device and will ultimately determine
the position of the ExPRESS in the
armamentarium of glaucoma surgical
procedures.
References
1. Y.M. Buys, Curr. Opin. Ophthalmol.,
2013;24:111–118.
2. L. de John et al., Clin. Ophthalmol.,
2011;5:527–533.
3. E. Dahan et al., Eye, 2012;26:703–710.
4. T.J. Good and M.Y. Kahook, Am. J.
Ophthalmol., 2011;151:507–513.
5. T. Sugiyama et al., Clin. Ophthalmol.,
2011;5:1063–1066.
6. L. Beltran-Agullo et al., J. Glaucoma, In
press.
7. H.Y. Patel et al., J. Glaucoma, 2012. doi:
10.1097/IJG.0b013e31827a06f4.
8. N. Geffen et al., J. Glaucoma,
2010;19:116–118.
9. L.K. Seibold et al., Br. J. Ophthalmol.,
2011;95:251–254.
Author
Professor Yvonne M. Buys, MD,
FRCSC, is Professor at the Department
of Ophthalmology and Vision Sciences,
University of Toronto, Canada. She may be
reached by E-mail: [email protected]
Prof. Buys has indicated that some
ExPRESS shunts used in a study were
provided at no charge from IMed and
Alcon Canada. Also she has received
honorarium for speaking for Alcon Canada.
Do you agree?
www.oteurope.com/discuss
Sidebar 1: Details of the
ExPRESS shunt.
The ExPRESS shunt received
FDA approval in 2002. It basically
consists of a stainless steel tube
less than 3 mm in length. There
have been several design changes
with the P-50 model being the
most recent version. In addition
to the tube design there is a distal
footplate to prevent migration
of the tube into the anterior
chamber as well as a groove
in the footplate to promote
posterior drainage of aqueous and
a proximal spur to prevent device
extrusion. Together the footplate
and spur anchor the device to
the sclera. Tests have shown
that although the device does
have ferromagnetic properties
it is likely safe with MRI of up to
3 Telsa.8,9
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>>> Sophisticated algorithm minimizing induction of undesired aberrations
>>> Designed for the full refractive treatment range:
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>>> Suitable for subsequent enhancements
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ES254209_OTE0613_009_FP.pgs 05.23.2013 02:25 ADV blackyellowmagentacyan
10Ophthalmology Times Europe June 2013
GLAUCOMA SURGERY
A variety of procedures are available for the
treatment of open-angle glaucoma, catering
to different degrees of severity. Microinvasive
glaucoma surgery is a relatively new category
aimed at mild-to-moderate glaucoma, and includes
the trabecular micro-bypass (iStent, Glaukos,
Laguna Hills, California, USA) and Trabectome
(NeoMedix, Tustin, California, USA). These
procedures use a clear-corneal microincision,
spare the conjunctiva and present only a minimal
disruption of the normal anatomy and physiology of
the eye. Their modest efficacy is combined with an
extremely high safety profile.
Blebless ab externo glaucoma surgeries, which
include canaloplasty and deep sclerectomy,
are successful at lowering high IOP while still
maintaining a good safety profile. Filtering
surgeries, such as trabeculectomy, ExPRESS shunt
(Alcon Laboratories, Fort Worth, Texas, USA), and
tubes, are the go-to options when a patient requires
an IOP lower than 10 to 12 mmHg.
Transscleral cyclophotocoagulation (TSCPC)
has typically been reserved for patients with
little hope of maintaining their vision. The
American Academy of Ophthalmology Ophthalmic
Technology Assessment Committee stated,
“Cyclophotocoagulation is indicated for patients
with refractory glaucoma who have failed
trabeculectomy or tube shunt procedures, patients
with minimal useful vision and elevated IOP,
patients who have no visual potential and need pain
relief, and patients with complicated glaucoma and
conjunctival scarring from previous surgery.”1
A few changes in technique combined
with a re-evaluation of the data merit a new
attitude toward this treatment option, however.
Cyclodestruction and later cryotherapy were
techniques associated with serious complications
including: substantial post-treatment visual loss,
sympathetic ophthalmia, and phthisis. Cryotherapy
has largely been replaced by TSCPC, which has a
vastly improved safety profile.
New techniques, such as the slow coagulation
method by Doug Gaasterland, are making TSCPC
safer. This approach uses a lower amount of energy
over a longer duration of time, leaving the eyes
quieter, and it reduces some of the complications,
such as inflammation, uveitis and cystoid macular
oedema.
On the cusp of development is a MicroPulse CPC
procedure, which is believed will further enhance
safety and allow more comfort in using the procedure
earlier in the treatment paradigm. In addition, the
use of steroids and non-steroidal anti-inflammatory
drugs perioperatively has helped mitigate some of the
complications.
A glaucoma device (G-Probe, Iridex, Mountain View,
California, USA) is designed to direct infrared energy
toward the ciliary body and I tend to err on the side of
posterior placement as well. In highly myopic eyes, I
often use transillumination to identify the exact location
of the ciliary body. This technique is effective anytime
extra confidence is needed with where to direct the
laser and more precise targeting of the ciliary processes
can reduce pain and inflammation after the procedure.
TSCPC in eyes with good visual acuity
Analysing the data on TSCPC will show that it
has historically been used in very sick eyes with
By Dr Ike K. Ahmed
Revisiting TSCPC as an optionProcedure has ability to lower IOP, preserve vision similar to trabeculectomy and tube
shunts
In short...Transscleral cyclophotocoagulation is not the same as
cryotherapy of the past; it has the ability to lower IOP and
preserve vision similar to trabeculectomy and tube shunts,
while avoiding a complicated filtering surgery.
“Instead of searching for one
ideal glaucoma procedure,
ophthalmologists should be
identifying the best option for
each patient.”
ES253704_OTE0613_010.pgs 05.22.2013 22:10 ADV blackyellowmagentacyan
11www.oteurope.com/glaucoma
GL AUCOMA SURGERY
minimal visual acuity, contributing
to the idea that loss of visual acuity
is linked to TSCPC. However, more
recent studies of eyes with better
visual potential have shown that this
may not be fully accurate. Rotchford
and colleagues studied TSCPC in 49
eyes with a median pre-treatment
visual acuity of 20/60, and after
5 years of follow-up, the median
visual acuity remained 20/60.2
A loss of two or more lines was
recorded in 30.6% of eyes, a number
similar to other procedures.
The three-year follow-up for the
Tube Versus Trabeculectomy Study
showed an average decrease in
IOP of 48% for both randomized
groups, with surgical complications
related to re-operation or visual
acuity loss of greater than 2 Snellen
lines in 22% of the tube group and
27% of the trabeculectomy group.3
This is similar to the results of 74
eyes that underwent TSCPC and
were followed for 12 months.4 The
mean reduction in IOP was 43% and
mean visual acuity was preserved
in subgroups with good vision,
whereas 13% of patients lost vision
due to a progressive cataract or
glaucoma.
In another study comparing
TSCPC with a glaucoma valve
(Ahmed Glaucoma Valve, New
World Medical, Rancho Cucamonga,
California, USA), there was a 57%
decrease in IOP in the TSCPC group
and a 47% decrease in IOP in the
Ahmed group.5 Both groups had an
incidence of decreased vision of
about 25%, and predominantly in
patients with neovascular glaucoma
who are difficult to treat.
In my practice, I use TSCPC in
patients whose disease is often
advanced in nature, who may have
had previous glaucoma surgery
and who need IOP lowered to the
low teens or less. I expect that
patients will be taking one to two
medications after the procedure.
Patients for whom
trabeculectomy or tube shunts
would pre sent a significant risk are
often excellent TSCPC candidates.
This includes patients with a
previous failed subconjunctival
procedure or who have had a
previous incisional surgery, whether
or not they have good vision.
An example of a TSCPC patient in
my clinic is a 60-year-old male who
has high myopia, has split fixation
and vision around 20/25 with a small
tunnel of vision of 3° to 4°. His IOP
is low 20s mmHg with maximum
medical therapy, which is too high
for the optic nerve. This patient is
at very high risk for immediate snuff
out with a filtering procedure. In this
patient I would perform TSCPC with
a titrated, gentle approach, starting
modestly and then re-treating
again if necessary after a couple of
months.
I start treatment at 1250 mW
of power for 4000 ms and apply
between 12 and 16 spots along the
limbus, with the G-probe. The goal
is to lower IOP to 13–14 mmHg and
it is common that the patient would
remain taking medication. It may be
necessary to re-treat this patient,
but the goal is to maintain central
vision.
Re-treatment with TSCPC is not
the same as re-treatment with
trabeculectomy or tube shunts. If
after two treatments the patient
needs additional IOP lowering, I
would increase the energy until I
hear audible pops that indicate the
explosion of the ciliary processes.
I avoid this endpoint because it
results in greater inflammation and
risk of cystoid macular oedema.
Individualized treatment
A variety of treatment options are
available today and it is necessary
to analyse which procedure is
optimal for each individual patient.
Trabeculectomy and tube shunts
definitely still have a place in my
practice, but there is a segment
of the population that does not
do well with these procedures.
Patients with failed filtering
surgeries, fixation defects, risk of
suprachoroidal haemorrhage, or
high risk in general will often lose
vision following trabeculectomy
or tube shunts. Losing vision after
undergoing such a procedure is
devastating.
TSCPC is not the same as
cryotherapy of the past; it has the
ability to lower IOP and preserve
vision similar to trabeculectomy
and tube shunts, while avoiding
a complicated filtering surgery.
Instead of searching for one
ideal glaucoma procedure,
ophthalmologists should be
identifying the best option for each
patient.
References
1. S.A. Pastor et al., Ophthalmology,
2001;108:2130–2138.
2. A. P. Rotchford et al., Br. J.
Ophthalmol., 2010;94:1180–1183.
3. N. Goldenberg-Cohen et al.,
Ophthalmic Surg. Lasers Imaging,
2005;36:272–279.
4. E. Ansari and J. Gandhewar, Eye,
2007;21:936–940.
5. N. Yildirim et al., J. Glaucoma,
2009;18:192–196.
Author
Dr Ike K. Ahmed is in practice
in Credit Valley Eye Care and
assistant professor at the
University of Toronto, Canada.
He is also fellowship director,
Glaucoma and Anterior
Segment Fellowship; University of Toronto
Research Fellowship Director; University
of Toronto, Department of Ophthalmology
and Vision Sciences Chief; and co-medical
director of TLC Laser Eye Center,
Mississauga, Ontario, Canada.
Dr Ahmed receives consultant/consulting
fees, speakers honoraria, or research
grant/support from numerous companies.
Would you consider
revisiting TSCPC?
www.oteurope.com/discuss
ES253710_OTE0613_011.pgs 05.22.2013 22:11 ADV blackyellowmagentacyan
12Ophthalmology Times Europe June 2013
GLAUCOMA SURGERY
The high comorbidity of cataracts and glaucoma
or ocular hypertension (OHT) has made it
expedient for ophthalmologists to determine how to
best treat this growing population. There have been
several different surgical therapies available, but
until now we have lacked a low-risk option to help
patients maintain controlled intraocular pressure
(IOP) and reduce their medication burden.
Phacoemulsification alone has been proven to
lower IOP a clinically significant amount over a
sustained period of time.1 Cataract surgery also has
the added benefit of being considered an extremely
safe and effective procedure with limited risks and
high quality of life value. With my patients presenting
with coexisting pathologies, I am often able to lower
their IOPs sufficiently with cataract surgery alone
that a combined procedure is not necessary.
When low pressures are needed to prevent
visual field loss in patients with moderate to severe
glaucoma, trabeculectomy or tube shunts are
optimum options. However, they have far more risks
associated with them than with cataract surgery
alone and studies have also shown that combining
these procedures with cataract surgery has a high
rate of failure.2
Glaucoma bleb surgeries, like trabeculectomies,
can be unpredictable and fraught with
complications. The success of a trabeculectomy
in lowering IOP hinges upon the size, shape and
contour of the sclerostomy and conjuctival bleb.
The bleb can fail if too much scarring occurs as
the operative site heals. Needling of the bleb can
reopen the outflow channel if scarring blocks it,
but if this is unsuccessful, IOP returns to high levels
and the treatment fails. An extended period of time
until IOP and vision stabilize and acceleration of
cataract formation are common symptoms following
trabeculectomy. A study of 1240 eyes found
46% of patients experienced early complications
and 42% had latent complications following a
trabeculectomy.2 The fickle nature of bleb surgeries
prompted the transition to treating patients with
cataract and glaucoma disease with cataract
surgery alone.
Cataract surgery alone
Transitioning from combined procedures to cataract
surgery alone resulted from findings that showed
significant reductions in IOP and medication burden
were achievable with cataract surgery alone. In a
retrospective review of 588 eyes that underwent
phacoemulsification and IOL implantation,
glaucomatous eyes with preoperative IOPs between
23 to 31 mmHg had a mean 4.8 mmHg reduction
in pressure sustained for 10 years.1 While this is
good news, additional lowering of IOP could mean a
patient is relieved of some medication burden. When
planning the treatment of patients with coexistent
pathologies, it is expedient to weigh the risk factors
and complication rates against the potential overall
reduction in pressure and determine what will be
maximally beneficial to the patient in the long run.
There is a 90% satisfaction rate in quality of life
issues with cataract surgery with a complication
rate of less than 5% and very few potential sight
threatening risks. In some patients, the greater risk
associated with a combined procedure is necessary
to take, because a greater pressure reduction is
By Dr Richard Lindstrom
Reducing IOP: A comparative analysisAn exciting new option in combination with cataract surgery
In short...The high comorbidity of cataracts and glaucoma or
OHT has meant it is advisable for ophthalmologists to
determine how best to treat this growing population.
Although there are a few options available, there has
not been, until now, a low risk option to lower IOP and
reduce the number of medications a patient requires.
Dr Lindstrom describes a minimally invasive surgical
procedure, which he believes has revolutionized treatment
for glaucoma patients.
“The optimal procedure for the
physician and the patient is a
minimally invasive glaucoma
surgery…”
ES253702_OTE0613_012.pgs 05.22.2013 22:10 ADV blackyellowmagentacyan
13www.oteurope.com
GL AUCOMA SURGERY
needed, but many patients do not
need a drastic reduction in pressure
and can benefit from cataract
surgery alone.
Minimally invasive: The optimal
procedure
The optimal procedure for the
physician and the patient is a
minimally invasive glaucoma surgery
that can lower pressure greater
than cataract surgery alone, with
no or extremely low additional risk.
Recent advancements in glaucoma
procedures have changed the tide in
IOP management.
The Glaukos iStent (Glaukos,
Laguna Hills, California, USA), along
with other ab interno devices like
the Transcend CyPass (Transcend
Medical, Menlo Park, California,
USA) and AqueSys Zen (AqueSys,
Allison Viego, California, USA), have
changed the invasive nature of
glaucoma procedures. The iStent
stands out because it is the first
ab interno method that bypasses
trabecular resistance with the
placement of a micro-bypass stent
in Schlemm’s Canal. Additionally,
the stent is only 1 mm long. It is
inserted through the same corneal
incision used to remove the cataract
on a preloaded handle device with a
release button for easy insertion. In
US FDA clinical trials, a single stent
was implanted but in Canada and
Europe it has been found that with
the implantation of 2 or 3 stents
there is an even greater reduction
of IOP.
In the US pivotal trial, the mean
reduction of IOP after Phaco/IOL
with iStent insertion was 8.4 mmHg
in patients with a mean baseline
IOP of 24.4 mmHg.3 Fea found
that a single stent lowers the IOP
an additional 3 mm over cataract
surgery alone.4 Clinically, it has been
shown that every millimetre drop in
IOP reduces the risk of progressive
glaucoma damage by 10%.5 With the
iStent, one is able to reduce the risk
of progressive glaucoma damage
nearly 30% more than with cataract
surgery alone, without significant
additional risk.4
The Fea study also showed that
in addition to the reduction of IOP,
the medication burden was also
significantly reduced or eliminated
postoperatively. 67% of patients
who received iStent remained
medication free after 15 months
while maintaining IOPs of less than
21 mmHg at one-year post-op.4
In my own practice I went
from doing a lot of phaco
trabeculectomies to phaco alone
because while I could get a 13 mm
drop in pressure, there were a lot
of potential risks and complications
that had life-long implications for
the patient. I changed my method of
treatment to phaco alone and waited
to see patient progression and if
later it became necessary, I would
perform a trabeculectomy or a tube
shunt as a last resort procedure
due to the high complication rate.
The Glaukos iStent revolutionizes
the treatment of glaucoma because
the surgeon is able to lower IOP,
decrease the risk of glaucoma
progression, and reduce or eliminate
the need for medications with
little additional risk of surgical
complications. The iStent creates a
platform in which we can view the
treatment methodologies of patients
with cataract and glaucoma in a new
and innovative way.
References
1. B.J. Poley et al., J. Cataract Refract.
Surg., 2008;34:735–742.
2. B. Edmunds et al., Eye,
2002;16:297–303.
3. B. Shingleton, M. Tetz and N. Krober,
J. Cataract Refract. Surg.,
2008;34:433–440.
4. A.M. Fea, J. Cataract Refract. Surg.,
2010;36:407–412.
5. M.C. Leske et al., Curr. Opin.
Opthalmol., 2004;15(2):102–106.
Author
Dr Richard Lindstrom is
founder and attending surgeon
of Minnesota Eye Consultants
and Adjunct Clinical Professor
Emeritus at the University of
Minnesota of Ophthalmology,
Department of Ophthalmology, Minnesota,
USA. He is also the associate director
for the Minnesota Lions Eye Bank, board
member of the Minnesota Medical
Foundation, and a visiting professor
at UC Irvine: Gavin Herbert Eye. He is
a board-certified ophthalmologist and
internationally recognized leader in
corneal, cataract, refractive and laser
surgery.
Dr Lindstrom serves on the Board of
Directors of AcuFocus, TLC Vision, TearLab,
Refractec, Wavetec, Encore, RevitalVision
the Minnesota Medical Foundation, the
Eye Bank Association of Minnesota and
Inner City Tennis.
Do you use
a combined
approach? www.oteurope.com/discuss
“The Glaukos iStent revolutionizes the treatment
of glaucoma because the surgeon is able to
lower IOP, decrease the risk of glaucoma
progression, and reduce or eliminate the need for
medications with little additional risk of surgical
complications.”
ES253706_OTE0613_013.pgs 05.22.2013 22:10 ADV blackyellowmagentacyan
14Ophthalmology Times Europe June 2013
GLAUCOMA SURGERY
Results from a multinational study demonstrate
the efficacy and safety of an investigational
intracanalicular microstent (Hydrus I, Ivantis, Irvine,
California, USA) implanted with an ab interno surgical
approach for reducing IOP in eyes with mild-to-moderate
primary open-angle glaucoma (POAG), announced Dr
Thomas W. Samuelson, at the annual meeting of the
American Academy of Ophthalmology (AAO).
The open study enrolled 69 patients at 7 centres.
Forty eyes underwent microinvasive glaucoma
surgery (MIGS) alone and 29 had combination
phacoemulsification. After one year of follow-up in both
subgroups, both mean IOP and mean medication use
were significantly reduced from baseline. No serious
complications occurred and there were no cases of
device migration or perforation.
“MIGS is an evolving therapeutic option conceived
to treat glaucoma surgically more safely than
trabeculectomy while still maintaining traditional
options,” claimed Dr Samuelson, founding partner,
Minnesota Eye Consultants, Minneapolis, Minnesota,
USA, and medical monitor for the multinational study.
“However, the MIGS procedures are often performed
in conjunction with cataract extraction, which makes
it difficult to know what is the pressure effect from the
MIGS procedure itself.
“Data from this investigation show benefit with and
without cataract surgery and IOP control appears to
be stable in patients who have been followed to 18
months,” he noted. “We look forward to further data
from this study and others under way, including the
US PMA trial of the intracanalicular microstent and
two trials outside the US comparing it with other MIGS
devices.”
The intracanalicular microstent is a nickel-titanium
(nitinol) device measuring 8 mm in length that is placed
ab interno into Schlemm’s canal through a clear corneal
incision (Figure 1). It features a small inlet that resides
within the anterior chamber and provides a path through
the trabecular meshwork. An open-window design
prevents obstruction of collector channels in Schlemm’s
canal.
“Not only does the stent occupy nearly 8 mm of
Schlemm’s canal, providing access for aqueous to
multiple collector channels, but it also dilates the
canal,” Dr Samuelson said. “Laboratory studies
have shown that this true stenting further improves
aqueous outflow.”
Study details
The multinational study included patients with POAG
or pseudoexfoliation glaucoma who had a visual
field mean deviation no worse than –12 dB, IOP of
By Cheryl Guttman
Krader
Reviewed by
Dr Thomas W. Samuelson
Microstent reduces medication useIntracanalicular device providing durable IOP reduction as standalone
procedure
In short...In a multinational study of eyes with mild-to-moderate
glaucoma, ab interno implantation of an intracanalicular
microstent (Hydrus I, Ivantis) resulted in significant
reductions in IOP and medication use whether performed
alone or combined with phacoemulsification.
Figure 1: The intracanalicular microstent is a nickel-titanium (nitinol) device measuring 8 mm in length that is placed ab interno into Schlemm’s canal through a clear corneal incision. It features a small inlet that resides within the anterior chamber and provides a path through the trabecular meshwork. (Photo courtesy of Ivantis.)
ES253739_OTE0613_014.pgs 05.22.2013 22:15 ADV blackyellowmagentacyan
15www.oteurope.com
GL AUCOMA SURGERY
26 mmHg or less on medications and
IOP 21 to 32 mmHg if washed out on
medication.
“In this early trial of the stent,
the safety of glaucoma medication
washout was left to the investigator’s
discretion as was the decision to add
back medications,” Dr Samuelson
explained.
At baseline in the subgroup
of patients who had microstent
surgery only, average mean
deviation was –4.82 dB, mean
IOP was 21.6 mmHg and mean
medication use was 1.7.
Thirty-seven of the 40 patients
were seen at 12 months. Mean IOP
was reduced to 17.9 mmHg while
patients were taking an average of
0.2 medications. The results were
similar at 18 months at which time
32 patients were evaluated.
In the combined
phacoemulsification group, all
29 patients were evaluated at
12 months. Mean IOP was reduced
by 34% from 25.5 mmHg at baseline
to 16.9 mmHg; mean medication use
decreased from 2.2 at baseline to 0.1.
Safety review
The safety review identified a
single patient who lost two lines
of best-corrected visual acuity.
However, that was due to a retinal
vein occlusion that was judged not
to be device-related, Dr Samuelson
revealed.
“The patient never had high IOP,
and with this procedure, IOP cannot
get below episcleral venous pressure
so hypotony was not a factor in this
particular patient, or in the study in
general,” he concluded.
Transient hyphaema was the
most common adverse event (15%)
followed by peripheral anterior
synechia (9.5%).
Special contributor
Dr Thomas W. Samuelson
is a founding partner of
Minnesota Eye Consultants,
Minneapolis, Minnesota, USA.
He may be reached by E-mail:
Dr Samuelson is an advisor and
investigator to Ivantis and several other
companies developing MIGS procedures.
What do you think
the future holds for
MIGS? www.oteurope.com/discuss
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ES253738_OTE0613_015.pgs 05.22.2013 22:15 ADV blackyellowmagentacyan
16Ophthalmology Times Europe June 2013
CATARACT & REFRACTIVE
In short...Post-refractive dry eye is the most common postoperative
complaint by patients and can be extremely debilitating
but it has also been linked with a higher risk of post-LASIK
regression, according to the authors. In this paper, they
highlight the outcomes of their recent study examining the
effects of LASIK on the ocular surface.
Dr Ian Dooley and his colleagues at the Mater
Private Hospital in Dublin, Republic of Ireland,
have recently published a study in the Journal of
Cataract and Refractive Surgery examining the effects
of laser refractive surgery upon tear osmolarity.1
As you may be aware post-refractive surgery dry
eye is the most common postoperative complaint
by patients and can be extremely debilitating but it
has also been linked with a higher risk of post-LASIK
regression (laser in situ keratomileusis).2
Osmolarity is a marker for dry eye, which is central
to the current definition by the dry eye workshop
(DEWS):
“Dry eye is a multifactorial disease of the tears
and ocular surface that results in symptoms
of discomfort, visual disturbance, and tear
film instability with potential damage to the
ocular surface. It is accompanied by increased
osmolarity of the tear film and inflammation of
the ocular surface.”3
As the aqueous portion of tear is reduced, the
relative levels of dissolved materials increase, leading
to hyperosmolarity. This can induce apoptosis and
lead to further inflammation and result in permanent
damage to the ocular surface and degradation of
visual quality.4 Tear osmolarity has become increasing
recognized as a diagnostic and prognostic ‘bed side’
test.
It should be stressed that tear osmolarity is a highly
volatile parameter, which rises acutely if the patient
is staring for even a small period, as with visual acuity
testing, also recent topical drops (within 2 hours) will
also alter osmolarity readings. Thus, the sequencing
of the examination is important, where possible
tear osmolarity should be the first examination
performed.4
Post-LASIK dry eye
Post-LASIK dry eye affects up to half of patients at
1 week, 40% at 1 month, and 20–40% at 6 months.
While typically transient, a significant cohort of
patients experience severe symptoms. Surface
refractive laser, including LASEK (laser assisted
subepithelial keratectomy) and PRK (photorefractive
keratectomy), is associated with transient
postoperative dry eye symptoms. Patients with
extreme dry eye such with Sjogren’s syndrome should
not be considered for corneal procedures.4
Post-LASIK dry eye describes a spectrum of
diseases encompassing transient or persistent
postoperative neurotrophic disease, tear instability,
By Dr Ian John Dooley,
MSc, MRCOPHTH, and
Professor Michael
O’Keefe, MD, FRCOPHTH
Effects of laser refractive surgery upon tear osmolarity LASIK may pose a greater risk of post-op dry eye
Figure 1: Line series, showing mean Schirmer values (mm/5 min) at baseline, 3, 6 and 12 months post surgery in LASIK (bold line) versus LASEK patients (dashed line). Error bars depict ± 1 standard error of the mean (SEM).
ES253753_OTE0613_016.pgs 05.22.2013 22:26 ADV blackyellowmagentacyan
The power of oneTwo types of incisions – one module
The Ziemer FEMTO LDV Z Models are FDA cleared and CE marked and available for immediate delivery. For some countries, availability may be restricted due to local
regulatory requirements. Cataract procedures are not approved in the United States and in some other countries. Please contact Ziemer for details.
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• Topographically matched
• Added precision and reproducibility
• Intrastromal incisions possibleExclusively available for the
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ES254208_OTE0613_017_FP.pgs 05.23.2013 02:25 ADV blackyellowmagentacyan
18Ophthalmology Times Europe June 2013
CATAR ACT & REFR ACTIVE
true aqueous tear deficiency, corneal
and conjunctival epitheliopathy,
and neuropathic pain states.
Neural changes in the cornea and
neuropathic causes of ocular surface
discomfort may play a separate or
synergistic role in the development of
symptoms in some patients.
The post-LASIK neurotrophic effect
and damage to goblet cells, are
related to the corneal flap sectioning
and suction effect, respectively.
These effects may not be seen in
surface refractive laser patients,
so theoretically LASIK would have
a more profound effect on the
precorneal tear film and induce more
dry eye disease. This neurtophic
cornea is sometimes referred to
as LASIK-induced neurotrophic
epitheliopathy (LINE).4
Several factors are associated
with the development of post-
LASIK dry eye. Higher refractive
correction, deeper ablation depth,
narrow flap hinge and female gender
have been repeatedly reported to
be associated with an increased
incidence of post-LASIK dry eye. Flap
thickness has both been reported
to be directly related to dry eye post
LASIK and be unrelated.4 The dry
eye effects of LASIK seem to have
been comprehensively reported,
however there was a paucity of data
comparing LASIK and LASEK dry eye
rates and especially in relation to tear
osmolarity changes.
LASIK vs LASEK
Dooley et al. compared the one-year
postoperative changes in dry eye
metrics between thin flap LASIK
(120 microns, n = 50) and LASEK eyes
(n = 35).1
Pre- and postoperative levels of
tear osmolarity, Schirmer testing,
ocular surface disease index (OSDI),
modified dry eye workshop severity
score and rate of topical lubricant
use were compared between the two
groups.
Preoperatively the LASEK patients
had more dry eye features than the
LASIK group. This is explained in part
because, patients with moderate dry
eye were only offered LASEK, thus
preoperatively the LASEK group had
lower mean Schirmer test values
(Figure 1) and higher mean OSDI
(Figure 2). Interestingly they actually
had similar mean tear osmolarity
(Figure 3).1
The postoperative OSDI was
significantly higher in LASIK patients
than LASEK patients at 3 months,
suggesting that LASIK patients were
experiencing a greater increase in
level of dry eye symptoms compared
to LASEK patients.
At three and six months post-op
the LASIK group had more dry eye
features, with lower mean Schirmer
test values, higher mean OSDI and
higher mean tear osmolarity.1 By
12 months the gap was much less.
Thus the LASEK patients improved
postoperatively, despite having
worse parameters preoperatively,
while the LASIK patients transiently
deteriorated but recovered by 12
months. It would seem that LASEK
is a better procedure for patients
with dry eye features and the dry eye
effect of both procedures are usually
temporary.1,4
Conclusions
All laser refractive procedures are
associated with risk of dry eye.
LASIK may be associated with a
higher risk, due to the associated
neurotrophia, which is supported by
the data presented in the study by
Dooley et al.1 It is usually transient
but may prove problematic in some
patients. Preoperative discussion
regarding dry eye is essential and
early postoperative treatment is
advisable. Tear osmolarity helps the
clinician to provide the best care to
their patients.
Figure 2: Line series, showing mean ocular surface disease index (OSDI) values (%) at baseline, 3, 6 and 12 months post surgery in LASIK (bold line) versus LASEK patients (dashed line).
Figure 3: Line series, showing mean tear osmolarity values (mOsm/L) at baseline, 3, 6 and 12 months post surgery in LASIK (bold line) versus LASEK patients (dashed line). Error bars depict ± 1 standard error of the mean (SEM).
ES253752_OTE0613_018.pgs 05.22.2013 22:26 ADV blackyellowmagentacyan
www.oteurope.com/cat_ref
References
1. I. Dooley, F. D’Arcy and M. O’Keefe,
J. Cataract Refract. Surg.,
2012;38(6):1058–1064.
2. J.M. Albietz, L.M. Lenton and S.G.
McLennan, J. Cataract Refract. Surg.,
2004;30(3):675–684.
3. The epidemiology of dry eye disease:
report of the Epidemiology Subcommittee
of the International Dry Eye WorkShop
(2007), Ocul. Surf., 2007;5(2):93–107.
4. I. Dooley, Dry eyes in patients undergoing
refractive surgery. In: M. O’Keefe,
ed. Current understanding and new
techniques in refractive surgery: Nova;
2013.
Authors
Dr Ian John Dooley, MSc MRCOPHTH, is
a Specialist Registrar in Ophthalmology in
the Irish Ophthalmology Higher Surgical
Training Scheme, currently working the Mater
Misericordiae University Hospital, Dublin,
Republic of Ireland. He may be reached by
E-mail: [email protected]
Professor Michael O’Keefe, MD,
FRCOPHTH, is Professor of Ophthalmology
at the University College, Dublin, and the
Director of Refractive Surgery at Mater
Private Hospital, Dublin, Republic of Ireland.
He may be reached by E-mail: mokeefe@
materprivate.ie
The authors have no financial interests in the
subject matter of this piece.
What are your
experiences?
www.oteurope.com/discuss
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ES253751_OTE0613_019.pgs 05.22.2013 22:26 ADV blackyellowmagentacyan
20Ophthalmology Times Europe June 2013
CATARACT & REFRACTIVE
In short...Evaporative dry eye is caused by the loss of tear fluid
through evaporation. The functionality of the meibomian
glands is important in evaporative dry eye and in a
recent study, a new system was evaluated that has
been designed to treat patients with meibomian gland
dysfunction and evaporative dry eye. In this article, Dr
Albou‑Ganem discusses this study and her thoughts on
the benefits this system offers.
Evaporative dry eye is caused by the loss of tear fluid
through evaporation. It is known that this evaporation
occurs as a result of insufficient oil in the hybrid layer
coating the surface of the cornea. The meibomian
glands, located in the eyelids, contribute to the oils in
this hybrid layer and any obstructions or lack of function
of these glands will affect the composition of the tear
film and hence the rate of evaporation. Therefore, their
functionality plays an important role in evaporative dry
eye.
In a recent study,1 Dr Cati Albou‑Ganem (Centre
National d’Ophthalmologie des Quinze‑Vingts, Paris,
France) and Dr R. Amar evaluated a new system
(LipiFlow, TearScience, Morrisville, North Carolina, USA)
to treat patients with meibomian gland dysfunction
(MGD) and evaporative dry eye. “I was very interested by
the performance of the diagnostic platform and thought
that our dry eye patients desperately needed a solution
for their problem,” she said.
Evaluating a new system
To evaluate this new system, 16 eyes of 12 patients
were studied. These patients had been diagnosed with
MGD based on the results of a symptom questionnaire,
quantification of the lipid layer thickness and
standardized meibomian gland expression.
“We selected patients using the SPEED (Standard
Patient Evaluation of Eye Dryness) questionnaire,”
explained Dr Albou‑Ganem. “This questionnaire allows
the patient to describe their symptoms easily.” All
patients studied were suffering from dry eye without any
surgical impact and any patient that had a score higher
than 6 (out of 28) from the questionnaire were selected
to have the lipid layer of their eyes analysed.
“First, the LipiView (TearScience) exam allowed us to
measure the lipid layer thickness,” continued Dr Albou‑
Ganem. It has been demonstrated that a thin lipid layer
(below 70 nm) is correlated to the symptoms of dry eye,
she noted.
“When the lipid layer was below 70 we analysed
the functionality of the meibomian glands using the
Meibomian Gland Evaluator (MGE),” she said. “The MGE
allows us to apply a constant force to the lid, mimicking
the force of a deliberate blink. Therefore, we can observe
the secretions expressed at each blink. For the first time,
we were able to reproducibly look at secretions.”
If the number of meibomian glands capable of
secreting clear and liquid lipids was below 5 (out of 15
that were observed), Dr Albou‑Ganem and Dr Amar
confirmed diagnosis that the patient was experiencing
evaporative dry eye as a result of MGD. A direct
correlation between the number of functioning glands
and the symptoms of dry eye has also been previously
demonstrated.2,3
LipiFlow treatment
Once the patient had been confirmed as having
evaporative dry eye as a result of MGD, the team used
the LipiFlow treatment, which has been designed
to unblock the meibomian glands and restore their
function. “This system applies a constant heat to the
posterior face of the lids during 12 minutes and a series
of pulsations on the outer face of the lids in order to
massage them,” added Dr Albou‑Ganem.
“By applying the right temperature and a moderate
pressure, it is not painful for the patients and very
efficient,” she continued. “Post‑treatment we could
observe a significant improvement in the gland function.”
Application of a constant temperature is also
important, she explained as a temperature of 42.5 ºC is
necessary to liquefy the secretions that block the glands.
“It is important to note that this temperature is not only
applied to the lid margin but to the whole surface of the
posterior lids, unblocking the glands in their depth,” Dr
Albou‑Ganem asserted.
By Felicity Thomas
Reviewed by
Dr Cati Albou-Ganem
Treating MGD and evaporative dry eyeEvaluation of a new system
ES253800_OTE0613_020.pgs 05.22.2013 22:36 ADV blackmagentacyan
www.oteurope.com/cat_ref
Decrease in symptoms
It was found that through the use of this system all patients
experienced a decrease in symptoms at 12–18 months
post‑treatment. “Symptoms decreased at 1 month for most of the
patients,” revealed Dr Albou‑Ganem. “What was very astonishing,
was that we observed symptomatic control at 12–18 months.”
These results are inline with the multicentric randomized
study that had been conducted in the US to gain FDA approval
for the treatment and Dr Albou‑Ganem noted that further results
from a study by Dr Greiner (published at the AAO last year) has
also demonstrated similar outcomes after 3 years.4 “This is very
encouraging and creates a lot of hope for the patients and the
ophthalmologists using this technology,” she said.
A great improvement
“This new system is a great improvement in the way we can treat
MGD patients,” stressed Dr Albou‑Ganem. “For the first time, we
can propose something to them that will free them from their daily
warm compress therapy and symptoms.”
The system also provides an effective and, importantly, a quick
treatment for patients. “When you see a patient who has been
suffering from dry eye for several months and who tells you after
1 month ‘I don’t feel my eyes anymore’, as an ophthalmologist, you
feel very grateful,” she said.
“The TearScience system is revolutionizing our approach of dry
eye because it creates satisfaction for patients and practitioners,”
Dr Albou‑Ganem concluded. “We now know that 86% of dry eye
patients are suffering from MGD related dry eye. I am very confident
that this system will become the standard of care for evaporative
dry eye in the near future.”
References
1. C. Albou‑Ganem and R. Amar, A novel system for the treatment of
meibomian gland dysfunction and evaporative dry eye with a 12 to 18
month follow-up, Poster presentation, ESCRS 2012, Milan, Italy.
2. D.R. Korb and C.A. Blackie, Cornea, 2008;27(10):1142–1147.
3. C.A. Blackie and D.R. Korb, Cornea, 2009;28(3):293–297.
4. J.V. Greiner, DO, PhD, Long-Term (3 Year) Effects of A Single LipiFlow
Thermal Pulsation System Treatment on Meibomian Gland Function
and Dry Eye Symptoms, Poster presentation, ASCRS 2012, Chicago,
Illinois, USA.
Special contributor
Dr Cati Albou-Ganem is a cataract and refractive surgeon practising in
the Centre National d’Ophthalmologie des Quinze‑Vingts, and in private
practice, in Paris, France. She is one of the founders of the first private
refractive surgery clinic in France and is the president of the French Society
of Cataract and Refractive Surgery (SAFIR). She is also a board member of
the French Society of Ophthalmology (SFO). She may be reached by E‑mail:
Dr Albou‑Ganem has indicated no financial disclosures.
ES253799_OTE0613_021.pgs 05.22.2013 22:36 ADV blackyellowmagentacyan
22Ophthalmology Times Europe June 2013
CATARACT & REFRACTIVE
In short...Two studies were conducted to compare outcomes of
patients undergoing cataract surgery using two different
nonsteroidal anti-inflammatory drugs for controlling pain
and postoperative inflammation. The results support the
efficacy of both products, but suggest some potential
benefits for once-daily bromfenac 0.09% (Bromday, Bausch
+ Lomb, Rochester, New York, USA).
Both bromfenac 0.09% once daily (Bromday,
Bausch + Lomb, Rochester, New York, USA) and
nepafenac 0.1% (Nevanac, Alcon Laboratories, Fort
Worth, Texas, USA) appear to be safe and effective
in preventing anterior segment inflammation and
clinical cystoid macular edema (CME) after cataract
surgery, even in high-risk patients. However, results
from retrospective and prospective comparative
studies suggest there may be an advantage for
using bromfenac, noted Dr Melissa Morrison
Toyos, private practice, Discover Vision Centre,
Independence, Missouri, USA.
“Both nepafenac and bromfenac are
newer-generation nonsteroidal anti-inflammatory
drugs (NSAIDs) with molecular structural
modifications that confer enhanced potency
relative to older-generation NSAIDs,” explained
Dr Toyos. “Bromfenac offers the convenience of
once-daily dosing, but both products are known
to be efficacious and well-tolerated based on
placebo-controlled pivotal trials. However, to my
knowledge, these two products had never been
compared in a head-to-head trial.
“I was struck to find that the results of a small
pilot prospective study suggested advantages
of bromfenac and a benefit of bromfenac was
also observed in a subsequently conducted
retrospective analysis comparing these NSAIDs in a
much larger patient cohort,” she claimed.
Prospective study
The prospective study1 randomly assigned 20
patients under going unilateral cataract surgery
to treatment with nepafenac three times daily or
bromfenac once daily. Both NSAIDs were started
3 days before cataract surgery and continued
for 21 days after the procedure. Patients with
diabetes were eligible for the study unless they had
pre-existing macular or retinal oedema or two or
more microaneurysms within the fundus. Primary
endpoints assessed included ETDRS best-corrected
visual acuity (BCVA), summed ocular inflammation
score and OCT-measured macular volume and
retinal thickness. Evaluations were conducted at
one day and one, three and six weeks after surgery.
The two treatment groups were well-matched
at baseline and there were no statistically
significant differences between them for any
endpoints at any follow-up visits. However,
findings from intragroup analyses of changes from
baseline showed some evidence of better clinical
outcomes in the bromfenac group compared with
the nepafenac-treated patients in terms of less
retinal thickening, more stable macular volumes
in the immediate postoperative period, and a
trend toward greater improvements in BCVA from
baseline, Dr Toyos stressed.
Retrospective study
The retrospective study included data for 600
patients who were treated postoperatively with
bromfenac once daily and 591 patients treated
postoperatively with nepafenac. Reported
frequency of dosing with nepafenac varied from
By Cheryl Guttman
Krader
Reviewed by Dr Melissa
Morrison Toyos
NSAIDs lower inflammation, CMEComparative study results support use of once-daily treatment, but
both satisfactory
“…findings from intragroup
analyses of changes from baseline
showed some evidence of
better clinical outcomes in the
bromfenac group…”
ES253831_OTE0613_022.pgs 05.22.2013 22:40 ADV blackmagentacyan
www.oteurope.com/cat_ref
one to four times daily, but nearly all
patients (93.5%) used nepafenac three
times daily. The two groups had similar
proportions of patients with diabetic
retinopathy (10%) and proliferative
diabetic retinopathy (5%), but the rate
of pre-existing epiretinal membranes
was about two-fold higher in the
bromfenac group compared with the
nepafenac group (15% versus 7%).
Clinical CME occurred in just one
patient in the bromfenac group (0.15%)
and in five patients using nepafenac
(0.8%). The bromfenac-treated patient
who developed clinical CME had a
pre-existing epiretinal membrane.
Among the five nepafenac-treated
patients who developed clinical CME,
one had mild diabetic retinopathy
and one had proliferative diabetic
retinopathy, but three had no
risk factors. All five patients used
nepafenac three times daily.
Reference
1. M. Cable, Clin. Ophthalmol.,
2012;6:997–1004.
Special contributor
Dr Melissa Morrison Toyos is in
private practice, Discover Vision Centre,
Independence, Missouri, USA. She may be
reached by E-mail: mcable@discovervision.
com
Dr Toyos is a speaker and consultant for Alcon
Laboratories and ISTA Pharmaceuticals and
received research funding from Bausch + Lomb
and ISTA.
Would you use
bromfenac?
www.oteurope.com/discuss
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ES253832_OTE0613_023.pgs 05.22.2013 22:41 ADV blackyellowmagentacyan
24Ophthalmology Times Europe June 2013
CATARACT & REFRACTIVE
A retrospective analysis of cataract surgery
procedures performed with three different
moderately cohesive ophthalmic viscosurgical
devices (OVDs) show that these products are
well-suited to use in microincision procedures,
according to Dr Danielle Deidier, St Vincent Clinic,
Toulon, France.
She presented findings from a study evaluating
the OVD behaviour and endothelial cell loss
in groups of 20 eyes each operated on using
PhysioVisc Integral (PhysIOL, Liège, Belgium),
Amvisc Plus (Bausch + Lomb Surgical, Greater
London, UK) or Z-Hyalin Plus (Carl Zeiss Meditec,
Jena, Germany). All surgeries were performed using
the same phacoemulsification platform (Stellaris,
Bausch + Lomb) and a bimanual microincision
technique involving two 1.2 mm incisions and with
enlargement of one incision to 1.7 mm for IOL
implantation.
Observations
Surgeon observations showed the anterior
chamber remained deep and stable and the OVDs
allowed perfect control and visualization during
capsulorhexis, hydrodissection and IOL injection.
There were no cases of capsular rupture, complete
OVD removal was achieved at the end of the
procedure and endothelial cell count (ECC) loss was
similarly low across all three groups, revealed Dr
Deidier.
“When surgeons perform cataract surgery
through self-sealing incisions, the OVD is expected
to maintain the anterior chamber depth so as
to facilitate the capsulorhexis,” she explained.
“However, while the OVD needs to provide space
and tissue protection, if it is not spontaneously
expelled during surgical manoeuvers, particularly
during hydrodissection, there is a risk of
overpressurisation that can lead to capsule rupture.
“The study results show that each of these OVDs
offers behaviour that is in line with [the] surgeon’s
expectations and that the OVDs provided good
protection for the corneal endothelium,” Dr Deidier
added.
By Cheryl Guttman
Krader
Reviewed by
Dr Danielle Deidier
OVDs ideal for microincision surgeryModerately cohesive ophthalmic viscosurgical devices offer desired performance traits
Special contributor
Dr Danielle Deidier is ophthalmologist at St
Vincent Clinic, Toulon, France. She may be
contacted by E-mail: [email protected]
Dr Deidier has no financial interests in the
subject matter.
Do you use OVDs in
microincision surgery?
www.oteurope.com/discuss
As moderately cohesive OVDs, all three products
evaluated in the study have high viscosity, strong
elasticity and strong pseudoplasticity that allow
easy injection through a 27-gauge cannula and
removal at the end of the procedure, even with
1.2 mm microincision instruments, noted Dr Deidier.
The three study groups were similar with respect
to mean patient age (72 to 76 years), cataract grade
(about LOCS III) and preoperative ECC measured by
specular microscopy (about 2400 cells/mm2). Based
on measurements performed at a month after
surgery, mean ECC loss was 1% in eyes operated on
with PhysioVisc Integral, 1.09% in the Amvisc Plus
group and 1.01% for the Z-Hyalin Plus procedures.
In short...The intraoperative behaviour and endothelial protection
performance of three moderately cohesive ophthalmic
viscosurgical devices were compared in a retrospective
study with favourable results for all products.
ES253839_OTE0613_024.pgs 05.22.2013 22:45 ADV blackyellowmagentacyan
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ES254235_OTE0613_025_FP.pgs 05.23.2013 02:27 ADV blackyellowmagentacyan
26Ophthalmology Times Europe June 2013
RETINA
The term autoimmune retinopathy refers to a
group of rare acquired retinal degeneration
syndromes characterized by acute or subacute
vision loss in combination with an abnormal (often
unrecordable) electroretinogram (ERG) and anti‑retinal
serum antibodies.1 The diagnosis encompasses
the paraneoplastic presentations known as Cancer
Associated retinopathy (CAR) and Melanoma Associated
Retinopathy (MAR) as well as non‑paraneoplastic
retinopathies.
CAR was first reported in association with small cell
lung cancer, but can occur with other malignancies
including prostate, breast, and colon cancer.2 Prompt
diagnosis is important due to the possibility of an
underlying malignancy in patients with CAR or MAR, and
the correct diagnosis can lead to initiation of potentially
life saving systemic treatment.
The classic anti‑retinal antibody associated with CAR
is directed against the 23 kDa protein, and detection of
this antibody in the serum of a patient with acute vision
loss should prompt a thorough systemic evaluation
for an occult malignancy. However, in most case
series the majority of patients with an autoimmune
retinopathy will not have anti‑recoverin antibodies or
an underlying malignancy so the extent of the workup
is controversial.
Easily overlooked
Autoimmune retinopathies are easily overlooked
and can be difficult to diagnose. Patients classically
present with acute to sub‑acute vision loss, nyctalopia,
scotomas and photopsias. However, visual complaints
can be vague and nonspecific. The physical exam is
often unremarkable with the most common findings
being optic nerve pallor and vascular attenuation.
So how does the clinician decide when to pursue a
patient’s non‑specific visual complaints with expensive
and sometimes difficult to obtain tests like ERG and
serum antibody analysis?
The first step is to expand the history. Some patients
will have a recent diagnosis of cancer, or a history of
prior malignancy. In patients with a non‑paraneoplastic
retinopathy, a personal or family history of
autoimmunity can often be elicited.
Then a review of systems should be obtained
to identify any pertinent positives that suggest an
underlying malignancy such as unexplained weight
loss or dyspnea. In addition, visual field testing is
important for establishing an objective measure of
vision loss. Concentric constriction is a classic finding,
but the presence of any scotomata should heighten
clinical suspicion.
Importance of imaging
Imaging technologies such as fundus
autofluorescence (AF) and spectral domain optical
coherence tomography (SD‑OCT) are quickly
becoming the most frequently ordered studies in
ophthalmology, and they can provide important
diagnostic information in conditions where the
conventional exam is unremarkable. Using these
imaging modalities, our group described fundus
abnormalities in a group of seven patients with an
autoimmune retinopathy.3
Using SD‑OCT we found loss of outer retinal layers
including the outer nuclear layer (ONL), the inner
segment and outer segment junction (IS/OS) and
external limiting membrane (ELM). The loss of these
outer retinal structures was found within the macula,
but spared the fovea. In one patient with CAR followed
over eight months, these retinal changes progressed
centripetally with a corresponding loss of vision by
Goldman visual field testing. Lima et al. reported
similar findings in a series of four patients with an
autoimmune retinopathy.4 They also demonstrated a
functional consequence associated with these imaging
changes by microperimetry.
By Dr Kathryn L. Pepple,
PhD, and Dr Prithvi
Mruthyunjaya
Identifying patients with autoimmune retinopathyImaging with autofluorescence and SD‑OCT can help
In short...Autoimmune retinopathies are easily overlooked and
can be difficult to diagnose. Moreover, visual complaints
can be vague and non‑specific. In this article, the
authors examine the best practices for these patients
and reveal how imaging technologies, such as fundus
autofluorescence and SD‑OCT, are offering clinicians a new
tool to help identify patients requiring expeditious follow
up testing and further systemic evaluation.
ES253843_OTE0613_026.pgs 05.22.2013 22:53 ADV blackyellowmagenta
www.oteurope.com/retina
RETINA
Another similar finding in both
studies was the presence of abnormal
fundus autofluorescence that
corresponded with the boundaries
of the structural changes noted on
SD‑OCT. In the areas of outer retinal
loss, abnormal hyper‑autofluorescence
was seen acutely, but over
time evolved to mottled
hypo‑autofluorescence. Typically, the
area of hyper‑autofluorescence formed
a ring around the central area of
preserved retinal architecture, but this
was not a uniform finding.
Case examples
The following case example highlights
how these imaging modalities can
be used to suggest the diagnosis
of an autoimmune retinopathy. A
46 year‑old woman presented for
glasses due to ‘poor vision’. Her
central vision was 6/6 in both eyes,
but her visual fields were severely
constricted in both eyes (see Figure 1).
Her fundus exam was unremarkable
without peripheral pigmentary
changes, but OCT revealed the loss of
outer retinal layers sparing the fovea
and peri‑fovea, with corresponding
hyper‑autofluorescence.
She was sent immediately for
further testing, and was found to have
an unrecordable ERG and anti‑retinal
antibodies in her serum. A systemic
evaluation was also initiated in
coordination with her PCP, but no
malignancy or other autoimmune
condition has been detected.
Despite the utility SD‑OCT and
AF demonstrated in diagnosing
this patient, not all patients with
an autoimmune retinopathy will
have abnormalities that can be
identified with imaging. A patient
with melanoma from our case
series highlights this point. This
patient had constricted visual fields,
an unrecordable ERG, and serum
autoantibodies targeting bipolar
cells and the outer plexiform layer
by immunohistochemistry to human
retinal sections.
This combination of history, exam
and lab findings is strongly consistent
with the diagnosis of MAR, and yet his
SD‑OCT and AF imaging studies were
completely normal.
Thus, the take home message is
that these imaging modalities can be
helpful in suggesting the diagnosis
of an autoimmune retinopathy, but
the absence of imaging findings
should not be a reason to exclude
an autoimmune retinopathy from
your differential in the proper clinical
context.
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ES253844_OTE0613_027.pgs 05.22.2013 22:53 ADV blackyellowmagentacyan
28Ophthalmology Times Europe June 2013
RET INA
No definitive test
Currently, there is no definitive test
that can distinguish autoimmune
retinopathy from other retinal
degenerative diagnoses such as
acute zonal occult outer retinopathy
(AZOOR), retinitis pigmentosa, cone
dystrophy, Vitamin A deficiency
and toxic retinopathy (chloroquine,
hydroxychloroquine). For each
suspected case of an autoimmune
retinopathy, the clinician will
continue to need to use all the
clinical and laboratory data available
to them to make the correct
diagnosis.
However, with the increasing use
of fundus autofluorescence and
SD‑OCT imaging, the clinician has
an new tool to help them quickly
identify patients that require
expeditious follow up testing and
further systemic evaluation.
References
1. J.R. Heckenlively and H.A. Ferreyra,
Semin. Immunopathol.,
2008;30(2):127–134.
2. Y. Shildkrot, L. Sobrin and E.S.
Gragoudas, Semin. Ophthalmol.,
2011;26(4–5):321–328.
3. K.L. Pepple et al., Br. J. Ophthalmol.,
2013;97(2):139–144.
4. L.H. Lima et al., Retina,
2012;32(7):1385–1394.
Authors
Dr Kathryn L. Pepple, MD, PhD, is a medical
retina fellow at the Duke University Eye
Center, Durham, North Carolina, USA.
Dr Prithvi Mruthyunjaya, MD, is an
associate professor of ophthalmology at the
Duke University Eye Center in the division of
Ocular Oncology and Vitreoretinal Surgery,
Durham, North Carolina, USA. He may be
reached by E‑mail: [email protected]
Neither author has any financial interests.
Figure 1: Autofuorescence and SD‑OCT imaging identify fundus abnormalities in a patient with an autoimmune retinopathy.
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ES253851_OTE0613_028.pgs 05.22.2013 22:53 ADV blackyellowmagentacyan
29www.oteurope.com/retina
RETINA
The F10 (Nidek, Gamagori, Japan) is a new,
commercially available scanning laser confocal
ophthalmoscope (SLO) that can perform multiple
functions including fluorescein angiography,
indocyanine green angiography, fundus
autofluorescence, and infrared retromode (RM)
imaging.
The RM imaging enables investigators to observe
the details of deep retinal structures, noninvasively
and clearly, by illuminating the fundus with an
infrared laser and collecting the scattered light
reflected from the retina and choroid through a
semicircular and pericentral aperture by a new
confocal technique. This allows for a clearer pseudo
three-dimensional image, which is a new method of
detecting abnormalities in the macula.1
Some advantages of using the F10 SLO to
examine the macula are: non-invasive procedure,
short testing time and the entire extent of the
macula can be obtained in one image under non-
mydriatic conditions.
Optical coherence tomography (OCT) is a valuable
way to provide morphologic features and diagnose
macular diseases, but sometimes it can be difficult
to detect the entire extent of the lesion.
This report aims to show some macular diseases
features in which this imaging method could be
helpful.
Drusen
RM imaging has been reported to detect
more drusen then conventional color fundus
photography.2 The drusen borders, by this imaging
method are well highlighted, making them easier to
manually segment and grade.
A recent study evaluated the detection of drusen
using the different infrared confocal apertures of
the Nidek F10.3 The standard confocal infrared
imaging system uses a central aperture (CA), while
the RM images are obtained using lateral (right or
left) aperture positions.
The measurements of drusen number and
area obtained by RM were compared with
those obtained using standard colour fundus
photography. Drusen number grades were found
to be significantly higher using the right (AR) and
left (AL) lateral apertures in which the laterally
scattered light is captured.
The mean drusen number detection with the AR
retromode was almost two times greater than for
the colour photographs. Small drusen, as well as
drusen more distant from the fovea, were more
easily visualized with the AR and AL retromodes.
The AR retromode would probably be preferred
and recommended in further comparative studies;
while drusen appear in an elevated convex shape
in the AR, in the AL the conformation seems to be
inverted.
Another study reports that RM imaging might
be superior even to OCT in detection of very small
drusen.4 These findings suggest that RM imaging
may be more sensitive for detection of drusen,
particularly early in the disease course and/or
when the drusen are small or subtle. Larger and
longitudinal studies will be critical for validating
these approaches.
Pigment epithelial detachment
The F10 confocal optical arrangement allows
investigators to observe the details of the retinal
pigment epithelium (RPE), such as drusen and
pigment epithelial detachments (PED). PEDs and
RPE protrusions are identified as well- to ill-defined,
flat to lowly convex, slightly irregular, translucent
to opaque prominences with a dark shadow.5 In
OCT they may appear as a regular, dome-shaped
elevation of the band of the RPE.
SLO in the RM imaging modality and OCT have a
mild intermethod agreement (k = 0.51) in detecting
By Dr Bruno Diniz
Confocal infrared RM imaging of macular diseasesAbility to observe details of deep retinal structures noninvasively and clearly
In short...Dr Diniz reports on a new, commercially available scanning
laser confocal ophthalmoscope that can perform multiple
functions, discussing specific macular disease features
that could benefit from the technology.
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30Ophthalmology Times Europe June 2013
RET INA
PEDs in patients with retinal
changes secondary to exudative
age related macular degeneration
(AMD).6 Another imaging study
detected polypoidal vessels and
network vessels of polypoidal
choroidal vasculopathy (PCV) as
vascular indentations of the RPE
on RM.7 In that study, the vessels
were identified by RM in 70% of all
patients with the disease.
Subretinal fluid
Subretinal fluid (SRF) is identified
in RM as a well-defined, lowly to
moderately convex, circular to
ovoid, translucent prominence
with a dark shadow.5 Intermethod
agreement with OCT was poor
for the RM modality (k = 0.29)
in patients with retinal changes
secondary to AMD.6 The multiple
features in AMD eyes (SRF,
PED, cysts) may be related to a
difficult interpretation of the RM
image and the low agreement
found. In patients with SRF and
diabetic macular edema (DME) this
agreement was almost perfect
(k = 0.83).8
Cystoid macular oedema
In the RM, scattered light that
passed the aperture and deviated
laterally, give a shadow to the
silhouetted cystoid spaces, and
enable visualization of the cystoid
macular oedema (CME).9 It can show
each cystoid space located in any
layer of the retina, and can allow
to detect the extent of the CME in
PCV, AMD and DME.
The agreement between RM and
OCT in evaluating cystoid pattern
was excellent (k = 0.80) in patients
with DME and almost perfect
(k = 0.88) in patients with retinal
changes secondary to AMD.6,8
The combined use of non-invasive
imaging techniques could improve
the diagnostic interpretation of
different aspects of CME.
Retinoschisis
OCT and RM examinations show a
perfect agreement in myopic eyes
that have macular retinoschisis.
Retromode imaging by F10 showed
a characteristic fingerprint pattern
at the corresponding area of the
macular retinoschisis.1 This pattern
Figure 2: (a) RM imaging reveals a large PED that appears as a well defned, convex, and translucent prominence with a dark shadow; (b) OCT image of the same patient.
(a) (b)
Figure 3: Patient with central serous chorioretinopathy, acute phase. (a) Subretinal fuid appears as a well-defned, convex, circular and translucent prominence with a dark shadow in RM images; (b) fuid accumulation anterior to the RPE appreciated on OCT.
(a) (b)
Figure 1: Drusen detection by each F10 image modality: (a) Digital colour photograph; (b) central aperture infrared (CA); (c) infrared RM with aperture on the right side (AR); (d) aperture on the left side (AL).
(a)
(c)
(b)
(d)
ES253857_OTE0613_030.pgs 05.22.2013 22:56 ADV blackyellowmagentacyan
31www.oteurope.com/retina
RETINA
consists of radiating retinal striae
centered on the fovea and many
light dots and lines that run in
parallel to the striae or form a
whorled pattern surrounding the
radiating striae.
Sites of laser application
It has been reported that retromode
with infrared light can delineate
sites of laser application, even when
using subthreshold micropulse.10
No obvious laser scars affecting
the treated area was noticed in any
of the patients on color images,
but the RM images obtained
immediately after subthreshold
laser photocoagulation showed
dark spots at the sites where the
laser had been applied. Those dark
spots detected by RM are believed
to be related to swelling of the
pigment epithelium after laser
application. This method may be
useful to confirm the invisible spots
created by subthreshold micropulse
photocoagulation.
Macular hole
Changes around macular holes
were recorded by SLO and it was
observed retinal wrinkling and
radiating striae around the holes.
Those radiating retinal folds
disappeared after successful
vitreous surgery. The retinal folds
may indicate the presence of
traction on the macula and hence
may be good a marker for macular
repair after vitreous surgery.11
Conclusion
We propose RM imaging as another
noninvasive diagnostic tool for
use in detecting macular diseases.
RM may be capable of providing
comprehensive topographic
information related to the deep
retina and RPE alterations.
However, the investigation and
interpretation of RM imaging is in
its earliest stages.
References
1. Y. Tanaka et al., Am. J. Ophthalmol.,
2010;149:635–40.
2. J.H. Acton et al., Acta Ophthalmol.,
2011;89:404–11.
3. B. Diniz et al., Br. J. Ophthalmol.,
2013;97:285–90.
4. M. Takeda et al., Nihon Ganka Gakkai
Zasshi, 2012;116:635-42.
5. Y.U. Shin and B.R. Lee, Am. J.
Ophthalmol., 2012;154:155–63.
6. E. Pilotto et al., Graefes Arch. Clin.
Exp. Ophthalmol., 2013;251:27–34.
7. M. Takeda and Y. Sato, Nihon Ganka
Gakkai Zasshi, 2012;116:946-54.
8. S. Vujosevi et al., Acta Ophthalmol.,
2012;90:e374–80.
9. M. Yamamoto et al., Int. Ophthalmol.,
2009;29:503-6.
10. K. Ohkoshi et al., Am. J. Ophthalmol.,
2010;150:856–62.
11. A. Yoshida et al., Graefes Arch. Clin.
Exp. Ophthalmol., 1998;236:445–450.
Author
Dr Bruno Diniz is postdoctoral associate
at the Ophthalmology Department,
Universidade Federal de São Paulo, São
Paulo, Brazil. He may be reached by E-mail:
Dr Diniz has no conflicts of interest to
disclosure.
Have you used RM
imaging in this
way? www.oteurope.com/discuss
Figure 5: (a) Circular depression corresponding to macular hole and perilesional elevated edges; (b) full thickness, stage IV macular hole.
(a) (b)
Figure 4: (a) RM shows a large central cyst with smaller adjacent cysts; (b) OCT scan of the same patient.
(a)
(b)
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32Ophthalmology Times Europe June 2013
RETINA
“When you have eliminated the impossible,
whatever remains, however improbable, must
be the truth.”
S. Holmes
A 31 year old caucasian female was referred to
us with the sudden appearance of superior
paracentral scotoma over the course of a 24 hour
period. The patient’s clinical history didn’t reveal
any systemic disease or drug consumption with the
exception of the birth control pill. The patient herself
also described previous flu symptoms, which had
since resolved.
The clinical examination
BCVA: 10/10 (0.0 LogMar) with sf –1.00 = cyl –3.50 (90)
Anterior segment: Dioptres transparent, photomotor
reflex normal, anterior chamber empty and its depth
normal
Ocular pressure: 11 mmHg
Fundus oculi: Presence of a rounded shape white
lesion, inferior to the fovea, across the papillo-
macular bundle vessels (Figure 1). Remaining
sectors of the retina were unharmed. Vitreous body
transparent.
No sure diagnosis
We immediately performed an OCT (TOPCON OCT
3D-1000), finding a focal zone of thickening of
neurosensorial retina corresponding to the lesion
observed with biomicroscopy and involving the
inner plexiform layer, the inner nuclear layer, the
IS/OS junction and the inner limiting membrane,
By Dr Fabrizio G. Puce,
Dr P. Lvezzari and
Dr Fabrizio Neri
Atypical presentation of acute macular neuroretinopathyA case report
In short...The authors describe a case report in which they use
imaging, visual acuity and literature references to
diagnose, through exclusion, a case of atypical acute
macular neuroretinitis.
Figure 1: Colour retinography performed at the time of the f rst visit.
Figure 2: OCT of the lesion.
Figure 3: OCT of the foveal region.
ES254396_OTE0613_032.pgs 05.23.2013 13:47 ADV blackyellowmagentacyan
33www.oteurope.com/retina
RETINA
without involving the RPE-Bruch
membrane-choroid complex
(Figure 2). Additionally, the foveal
region appeared unharmed (Figure 3).
Initially, suspecting a vasculitis or a
self-immune or an infectious retinitis,
we decided to perform a fluorescein
angiography. The following day we
programmed infectious disease and
rheumatologic consulting consisting
of the following laboratory exams:
• CBC, coagulation, hepatic and
kidney function, urinalysis,
anti-streptolysin title, angiotensin
converting enzyme, CRP.
• Generic inflammation indexes:
c-reactive protein, alpha-1-acid
glicoprotein, erythrocyte
sedimentation speed.
• Reumathic diseases exams:
reumathoid factor, antinucleus
antibodies, anti-DNA native
antibodies (ANA), extractable
nucleus antigens antibodies
(ENA), anti neutrophils cytoplasm
antibodies (ANCA), anti
mytocondria antibodies (AMA), anti
smooth muscle antibodies (ASMA),
sieric crioglobulines antibodies,
complement fractions C3 and C4
antibodies, immunoglobulins and
lysozyme serum dosage, (LZM).
• Infectious diseases exams:
anticorpal immunity determination
for Herpes viruses (simplex, zoster,
Epstein-Barr, citomegalovirus), HIV,
Hepatitis B and C, Toxoplasmosis
and tests for tuberculosis and
syphilis.
• Chest and sacroiliac joint X-ray.
• Gallium scintigraphy.
Fluorescein retinal angiography
showed a normal filling of
chorioretinal circulation without
leakage or ‘window-effect’ or ‘shield
effect’ areas (Figure 4).
Visual field analysis, performed by
computerized Humphrey HFA-II-I, with
‘full threshold 30-2’ strategy, didn’t
show any negative scotoma (Figure 5).
Infectious disease and
reumathological consulting didn’t
reveal any pathological conditions
or diseases to explain the clinical
findings and the symptoms described
by the patient.
As we couldn’t make a sure
diagnosis, the patient was closely
monitored without any therapy to
evaluate the evolution of the clinical
picture that remained unchanged for
about 2 weeks. Then the patient went
abroad owing to work commitments
and came back for a visit after a
further 2 weeks.
At the new visit, which was about
1 month after the first observation,
the patient described subjective
visual improvement with a reduction
of the scotoma. Visual acuity was
unchanged and the retinal lesion,
previously observed at the fundus
oculi examination, had disappeared
(Figure 6). The OCT images, however,
demonstrated an important reduction
of the retinal thickening and only a
slight hyper-reflective band persist on
the inner plexiform and nuclear layers
(Figure 7).
Suspected idiopathic posterior uveitis
As the blood exams and the expert
advice were negative, using only the
ophthalmoscopic pattern, gender and
age of the patient, we suspected a
form of idiopathic posterior uveitis.
We particularly focused our diagnosis
on three forms of this disease —
multiple evanescent dot syndrome,
acute pigmentosus retinal epithelitis
and acute macular neuroretinopathy.
These three diseases have many
common features, such as retinal
involvement without involving the
anterior segment or the vitreous
body, retinal ophthalmoscopy and
visual field pattern.
Acute macular neuroretinopathy,
however, may present with either
multiple or single retinal lesions. In a
great number of cases monolateral
lesions occur within the neurosensorial
Figure 4: Fluorescein retinal angiography: normal fnding.
Figure 5: Visual feld analysis, ‘full threshold 30-2’ strategy.
Figure 6: Colour retinography after 1 month.
Figure 7: Corresponding OCT scan.
ES254397_OTE0613_033.pgs 05.23.2013 13:47 ADV blackyellowmagentacyan
34Ophthalmology Times Europe June 2013
RET INA
retina, visual impairment is lower
and the visual field analysis shows a
paracentral scotoma corresponding
to the retinal lesion and the retinal
fluorescein angiography is normal.1
Typically lesions in acute macular
neuroretinopathy are round or oval
shaped, brown or dark red and, when
multiple, they surround the macula
in a flower petal pattern (Figures 8
and 9).
Many other atypical forms of
this disease are described in the
literature.2,3 The first description
of this disease dates back to 1975
from Bos and Deutman4 and so far
only 60 cases have been reported in
the UK.5 Usually the patient, more
often a woman, around 30 years
old, will describe sudden onset of a
paracentral scotoma, which is often
monolateral. Sometimes the scotoma
can be preceded by previous flu
syndrome or hypotensive episodes.
No risk factors have been detected
but many authors suspect excessive
caffeine consumption, birth control
pill, epinephrine or hormone therapy
as potential factors. Yannuzzi has
found a correlation with certain
drugs.6 Aetiology is still unknown but
some authors speculate a vascular
based mechanism.
In many cases after 7–8 days from
the onset of the first scotoma, the
patient will describe the appearance
of a second scotoma, always
paracentral. Usually with time, the
scotoma tends to diminish gradually
but never completely disappears.7
However, it must be noted that
electrophysiological tests (electro-
retinogram and electro-oculogram) are
not helpful because they measure the
whole physiological response and are
not sensible for pathological process
involving the macula.8
Atypical acute macular neuroretinopathy
In our case the observed lesion did
not have the classical features of
acute macular neuroretinopathy but
of ‘the multiple evanescent white
dot syndrome’ for which we did a
differential diagnosis.9
Gass and Hamed, in this regard,
reported an association between
these two aforementioned diseases,
suggesting that these two rare
syndromes could be related by
pathogenesis and aetiology. The
lightest forms, where the macular
lesions are lower, can be confused
with retinal pigment epithelium
inflammation because both these
diseases can cause a sudden central
visual loss in young adults.10,11 In
these cases, OCT can be very useful
because it reveals the exact location
of the lesion and allows an accurate
follow-up.12,13
After around 6 months from the
first observation, the OCT showed an
atrophic area of the neurosensorial
retina where it had previously appeared
thickened (Figure 10). Ophthalmoscopy
appeared normal (Figure 11).
So we performed another visual
field analysis, this time using the
‘macula-threshold’ program of the
computerized perimeter Humphrey
HFA-II-I. This revealed an absolute
negative scotoma in the upper area of
the macular region (Figure 12). Visual
acuity was unchanged and the patient
referred to a subjective reduction of
the scotoma.
The clinical course of this disease
reflects what has been described in
the literature about acute macular
neuroretinopathy: the scotoma
Figure 8: Colour retinal retinography in typical acute macular neuroretinopathy (from: J. Donald and M. Gass, “Stereoscopic Atlas of macular diseases”, Mosby 1997).
Figure 9: OCT scan in a typical acute macular neuroretinopathy.
Figure 10: OCT after 6 months.
Figure 11: Colour retinography after 6 months.
Figure 12: ‘Macula-threshold’ visual feld analysis.
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35www.oteurope.com/retina
RETINA
persists but sometimes tends to
diminish. There has only been one
case, where the disease was bilateral,
when a complete visual recovery
has been reported in one eye and
persistent severe visual loss in the
other eye.14
Now, our patient is subjected to
regular controls with visit, OCT and
computerized perimetry that have
not changed. Moreover she lives a
normal life feeling the presence of the
scotoma less as time goes on.
References
1. M. Yanoff and J.S. Duker,
Ophthalmology: Expert Consult
Premium Edition: Enhanced
Online Features and Print (Yanoff,
Ophthalmology), 2008.
2. S.K. Vance et al., Retina, 2011;31:441–450.
3. H.D. Corver et al., Eye,
2007;21:1226–1229.
4. P.J.M. Bos and A.F. Deutmann, Am. J.
Ophthalmol., 1975;80:573.
5. S.D. Turbeville, L.D. Cowan and J.D.
Gass, Surv. Ophthalmol., 2003;48:1–11.
6. A.L. Yannuzzi, R.D. Guyer and W.R.
Green, Retina atlas; Medical Books,
1988.
7. D.M. O’Brien et al., Retina, 1989;9:281.
8. C. Maschi et al., Graefes Arch. Clin. Exp.
Ophthalmol., 2011;249:827–831.
9. N. Mamalis and M.J. Daily,
Ophthalmology, 1984;94:1209–1212.
10. J.D.M. Gaz and L.M. Hamed, Arch.
Ophthalmol., 1989;107:189.
11. A.E. Krill and A.F. Deutmann, Am. J.
Ophthalmol., 1972;74:193–205.
12. I.M. Neuhann et al., Graefes
Arch. Clin. Exp. Ophthalmol.,
2010;248:1041–1044.
13. G. Azar et al., Eur. J. Ophthalmol., 2012;
14 [Epub ahead of print]
14. M.H. Miller et al., Ophthalmology,
1989;96:265.
Authors
Dr Fabrizio Puce is a resident doctor
in the Ophthalmology Department at
S. Bartholomew Hospital, Sarzana, La
Spezia, Italy. He can be reached by E-mail:
Dr P. Lavezzari is a resident doctor
in the Ophthalmology Department at
S.Bartholomew Hospital, Sarzana, La
Spezia, Italy.
Dr Fabrizio Neri is chief of the
Ophthalmology Department at S.
Bartholomew Hospital, Sarzana, La Spezia,
Italy.
The authors do not have any commercial
or financial interest in any of the materials
or methods used in this study.
Have you
had similar
experiences? www.oteurope.com/discuss
Ophthalmology Times Europe is a comprehensive publication covering all of the latest developments within the ophthalmic industry with a broad focus on cataract, corneal and refractive surgery, as well as glaucoma and vitreoretinal conditions.
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ES254405_OTE0613_035.pgs 05.23.2013 13:48 ADV blackyellowmagentacyan
36Ophthalmology Times Europe June 2013
GLAUCOMA
“Elevated IOP is an important risk factor for
glaucoma1–3 and glaucoma progression,”4 according
to Dr Katrin Lorenz (Department of Ophthalmology,
University Medical Center, Johannes Gutenberg-
University Mainz, Germany) when discussing the study
she recently led that investigated the tolerability and
safety of a 24-hour intraocular pressure (IOP) monitoring
diagnostic device.5
“The role of IOP fluctuation as an independent
predictive factor for glaucoma progression is still
controversial,”6–10 she added. “Goldmann applanation
tonometry (GAT) has been the most widely established
indirect method for measuring IOP for many decades and
is the gold standard.”11–14
The SENSIMED Triggerfish (Sensimed, Lausanne,
Switzerland) is a novel device that comprises a soft
disposible contact lens embedded with a telemetry
chip and strain gauge sensor for measurement of
circumferential changes close to the corneoscleral
junction correlated to variations in IOP, regardless of
the patient’s position and activity (Figure 1). “A 24-hour
monitoring device for use in patients would be helpful
to better understand IOP fluctuation in normals and
in glaucoma patients. Also, measurements could be
obtained with continuation of normal daily activities,” Dr
Lorenz said.
Testing tolerability
“We tested the first model for use in humans for the
first time in healthy subjects and in glaucoma patients
with the primary objective to investigate tolerability and
side effects of the device during and after a 24-hour
IOP monitoring period,” explained Dr Lorenz. Taking
both healthy subjects and glaucoma patients and
excluding anyone who had worn contact lenses before,
the team placed one sensor in each patient’s test eye
and performed examinations both before and after the
24 hour wearing period.
“To evaluate the level of discomfort of the device
in the study eye at 24 hours, a visual analogue scale
(VAS) was presented to the subject. VAS for each
subject was scored between 0 and 100 mm, the
number corresponding to the distance in millimetres
of the subject’s mark on the VAS line from the left
end. Secondary endpoints included best corrected
visual acuity (BCVA), pachymetry, epithelial defects,
conjunctival erythema and corneal topography,” she said.
“Additionally, subjects were asked to fill in a diary which
was collected at the end of the study.”
A test was also performed initially to ensure that
healthy and glaucoma patients could be analysed
together, as the device had never been formally tested in
healthy subjects before. Dr Lorenz explained that if the
glaucoma patients had demonstrated severe discomfort
in this trial there would have been some difficulty in
proving that it was not significantly associated with
ocular surface disease, therefore, healthy subjects were
required to be used as controls. “However, contrary to
our expectations, no significant differences between
the two groups could be demonstrated and both groups
were combined for analysis,” she asserted.
Good tolerability
“The level of discomfort while wearing the contact lens
was measured by VAS and was 24.3 for all subjects,
which we define as a good level of tolerability for a
contact lens,” said Dr Lorenz. “Most subjects were using
artificial tears and noticed red eyes when they woke up in
the morning, but felt quite comfortable.”
Slightly more discomfort was found in the glaucoma
patients as compared to healthy subjects (26.8 versus
21.8), however, this difference was not found to be
statistically significant. “These results may be explained
by the higher frequency of dry eye syndrome in glaucoma
patients and the regular use of anti-glaucomatous eye
drops.15 Previous studies show that ocular surface
disease is present in more than 50% of glaucoma
patients,”16 she continued.
There were statistically significant changes found after
the patients had worn the device in corneal topography
for horizontal radii, objective and subjective refraction
By Felicity Thomas
Reviewed by Dr Katrin Lorenz
Continous IOP monitoringInvestigating tolerability of a diagnostic device in healthy and glaucomatous patients
In short...Elevated IOP is an important risk factor for glaucoma and
glaucoma progression, however, measurement of IOP
in a continuous 24-hour period has until now only been
possible in costly specialized centres. A novel device
comprising a soft disposible contact lens embedded with a
telemetry chip and strain gauge sensor has been developed
to enable continuous monitoring of IOP while the patient
is performing everyday activities. In this article, Dr Lorenz
discusses her recent study investigating the tolerability of
this device in glaucomatous and healthy patients.
ES254413_OTE0613_036.pgs 05.23.2013 13:52 ADV blackyellowmagenta
37www.oteurope.com/glaucoma
GLAUCOMA
(sphere, cylinder and degree), BCVA,
conjunctival oedema, conjunctival
erythema, epithelial micro-defects
and lid oedema.5 “Deterioration of
BCVA probably results from changes
in epithelial micro-defects and corneal
topography and also due to irritation by
removal of the device. All these changes
are transient and may be considered
as not clinically significant,” Dr Lorenz
explained.
“Most of these changes may also
occur during 24-hour IOP profiles in a
sleep laboratory due to repeated topical
anaesthesia and GAT,” she added. “One
glaucoma patient received a 24-hour
IOP profile in the non-study eye in
our sleep laboratory during the study.
Epithelial defects changed from grade 1
(both eyes) to grade 2 in the non-study
eye while it remained stable in the study
eye. Worsening of epithelial defects is
quite common after repeated topical
anaesthesia and GAT.”
Additionally, Dr Lorenz revealed
that in this study the vast majority of
glaucoma patients (95%) would agree
to use the device again, which may
indicate a preference for this method
over analyses performed in a sleep
laboratory.
Increasing interest
“Twenty-four-hour IOP profiles are of
increasing interest. However, they are
only possible in specialized centres
with a sleep laboratory,” said Dr Lorenz.
“These profiles are not only associated
with high costs, they only partially
reflect IOP measurements in everyday
life.”17,18
Based on the results of this study,
the VAS scores and the willingness
of the glaucoma patients to repeat
the IOP profile with this device, the
subjective tolerability was shown to be
good in healthy subjects and glaucoma
patients. However, Dr Lorenz asserted
that further studies are needed to
investigate if this device is helpful
in daily routine. “Verification of the
relationship between the device output
and IOP is still an unsolved problem. This
validation is needed,” she said.
“Although researchers and clinicians
recognize the need for continuous IOP
monitoring of patients with glaucoma,
no clinical tool has been available until
now.19 The SENSIMED Triggerfish offers
the possibility to monitor IOP in daily life,
including office hours, sports and sleep.
No other devices are commercially
available so far,” Dr Lorenz concluded.
Acknowledgments
This editorial has been written based on
a recently published study:
Katrin Lorenz, MD, FEBO, Christina
Korb, MD, Nicola Herzog, MD, Jan M.
Vetter, MD, FEBO, Heike Elflein, MD,
Munir M. Keilani, MD, and Norbert
Pfeiffer, MD, Journal of Glaucoma,
2013;22(4):311–316. Dr Lorenz also
revealed that a further monocentric
study has been completed comparing
48-hour IOP monitoring with this device
with the gold standard. In this trial
the contact lens sensor was placed in
one eye and Goldmann applanation
tonometry (sitting measurements) and
Perkins tonometry (supine position)
were performed in the fellow eye
every two hours in a crossover design.
The initial results of this study were
presented at the ARVO meeting in
Seattle, Washington, USA.
References
1. A. Sommer, Curr. Opin. Ophthalmol.,
1996;7:93–98.
2. M.C. Leske et al., Arch. Ophthalmol.,
2002;120:954–959.
3. M.O. Gordon et al., Arch. Ophthalmol.,
2002;120:714–720; discussion 829–730.
4. M.C. Leske et al., Arch. Ophthalmol.,
2003;121:48–56.
5. K. Lorenz et al., J. Glaucoma,
2013;22(4):311–316.
6. B. Bergea, L. Bodin and B. Svedbergh,
Ophthalmology, 1999;106:997–1004;
discussion 1004–1005.
7. S. Asrani et al., J. Glaucoma,
2000;9:134–142.
8. B. Bengtsson and A. Heijl, Graefes Arch.
Clin. Exp. Ophthalmol.,2005;243:513–518.
9. L. Daugeliene, T. Yamamoto and Y.
Kitazawa, Graefes Arch. Clin. Exp.
Ophthalmol., 1999;237:105–108.
10. K. Nouri-Mahdavi et al., Ophthalmology,
2004;111:1627–1635.
11. J.D. Brandt, Curr. Opin. Ophthalmol.,
2004;15:85–89.
12. I. Dielemans et al., Graefes Arch. Clin. Exp.
Ophthalmol.,
1994;232:141–144.
13. H. Goldmann and T. Schmidt,
Ophthalmologica, 1957;134:221–242.
14. I.F. Wessels and Y. Oh, Arch. Ophthalmol.,
1990;108:1709–1712.
15. H. Uusitalo et al., Acta Ophthalmol.,
2010;88:329–336.
16. E.W. Leung, F.A. Medeiros and R.N.
Weinreb, J. Glaucoma, 2008;17:350–355.
17. P. Fogagnolo et al., Invest. Ophthalmol.
Vis. Sci., 2009;50:2209–2215.
18. T. Haufschild, S. Orgul and J. Flammer,
Am. J. Ophthalmol., 2006;142:179–181.
19. A.J. Sit, J. Glaucoma, 2009;18:272–279.
Figure 1: A patient wearing the device.
Special contributor
Dr Katrin Lorenz is head of the
clinical trial site in the Department of
Ophthalmology, University Medical Center,
Johannes Gutenberg-University Mainz,
Germany, and specialized in clinical trials.
She may be reached by E-mail:
Dr Lorenz stated that for the study discussed
in this article the authors received a research
grant and travel support by Sensimed AG.
Have you used this
device?
www.oteurope.com/discuss
ES254412_OTE0613_037.pgs 05.23.2013 13:52 ADV blackyellowmagentacyan
38Ophthalmology Times Europe June 2013
GLAUCOMA
Ocular surface disease (OSD) comprises dry
eye, lid disease, conjunctivitis and keratitis.
The high prevalence of OSD in glaucoma patients1
is primarily attributed to the use of the commonly
used preservative Benzalkonium Chloride (BAK),2
and hence the severity of OSD increases with
the cumulative number of medications.3 Not only
does OSD cause significant morbidity,2 but is also
compromises treatment compliance,4 quality of
life5 and surgical outcomes.6
Case series
We describe a series of four patients, referred
to our tertiary surgical glaucoma service, with
inadequately controlled POAG and symptomatic
OSD. All of the patients reported good compliance
with their glaucoma treatment prior to referral
to the glaucoma service. A combination
approach was used to manage the OSD (Table 1).
Preservative-free topical anti-glaucoma
medications were used as deemed appropriate
by the clinician. The latter three interventions, in
Table 1, were used in all patients.
Treatment resulted in improved intraocular
pressure (IOP) control in all four patients (Table 2).
There was no deterioration in visual field or
change in optic disc appearance throughout the
study period. Furthermore, a marked symptomatic
and clinical improvement in the ocular surface
with reduction in hyperaemia, meibomian gland
dysfunction and superficial keratopathy was noted
following treatment.
Discussion
OSD caused by the long-term use of topical
anti-glaucoma medication, can lead to
conjunctival inflammation, foreshortening
and shrinkage12 and severe symptomatic
cicatrisation, which is indistinguishable from
ocular cicatricial pemphigoid (OCP). The terms
drug-induced cicatricial conjunctivitis (DICC) and
pseudopemphigoid have been used.13
As discussed glaucoma therapy causes OSD,
however, it is also apparent that severe OSD in
turn exacerbates glaucoma. The prevalence of
glaucoma in patients with severe OSD has been
found to be 65.7%.14 Proposed mechanisms for
raised IOP in patients with OSD are increased
conjunctival inflammation in patients using
anti-glaucoma medications, vascular aetiologies
and inflammation of the trabecular meshwork,
and in addition inflammation and scarring of
the episclera and sclera thereby impairing the
outflow facility of the eye.15 In support of this
inflammatory theory, a higher rate of inflammatory
cell infiltrates and fibroblasts have been found in
conjunctival and trabeculectomy tissue samples
from patients who are chronically exposed to
preserved glaucoma medications.16
The aim of our treatment approach was to
break the destructive cycle of events (OSD may
potentiate glaucoma and vice versa) and achieve
improved IOP control and a healthy ocular surface.
In all four patients an improvement in the OSD
By Ruchika Batra,
MRCOphth, Rajen Tailor,
FRCOphth, and Shabbir
Mohamed, FRCSEd
Ocular surface disease exacerbated glaucomaThe rationale for optimizing the ocular surface in glaucoma patients
In short...The authors describe a case series of four patients
with inadequately controlled POAG and symptomatic
OSD in whom management of the OSD led to improved
IOP control, raising a new argument for maintaining
increased awareness of the signs and symptoms of
OSD in patients with glaucoma.
“Not only does OSD cause
significant morbidity, but is
also compromises treatment
compliance, quality of life and
surgical outcomes.”
ES254419_OTE0613_038.pgs 05.23.2013 13:52 ADV blackyellowmagenta
39www.oteurope.com/glaucoma
GLAUCOMA
Table 1: Interventions to treat the OSD.
Intervention Rationale
1. Anti-glaucoma medications were changed to preservative-free preparations.
• BAKproducesseverechangesinepithelialcells,includingloss of microvilli, disruption of plasma membranes and desquamation of the top two layers of cells.7
Reducing BAK may improve OSD.8
2. Oral doxycycline (50 mg once daily for 3 months).
• Anti-inflammatoryactionduetotheinhibitionofT-cellactivation and chemotaxis, the downregulation of proinflammatory cytokines (TNFa and IL-1b) and the inhibition of matrix metalloproteinases that have been pathologically activated.9
• Doxycyclinecausesdestructionofmigratorykeratocytesorfibroblasts responsible for scar tissue formation, promoting epithelialization.10
3. Topical carmellose sodium (celluvisc) 0.5% 4–6 times daily for continued use.
• Topicalpreservativefreelubricationusedregularlymayimprove ocular surface health.11
4. Lid hygiene measures comprising twice daily lid margin massage using a hot moist face towel.
• Lidmassageanecdotallyimprovesmeibomianglandfunctionand may improve ocular surface blood flow.
Table 2: IOPs before and after treatment.
Case Range of IOPs 1 year prior to referral
(mmHg)
Highest recorded IOP
IOP at presentation to tertiary glaucoma clinic (mmHg)
Post treatment IOP (mmHg) at number of months (m) after intervention
1 R 15–20
L 15–20
R 28
L 42
R 14
L 19
R 13
L 13
3 m
R 10
L 11
8 m
R 8
L 11
14 m
R 9
L 9
19 m
2 R 24–30
L 24–28
R 26
L 28
R 24
L 24
R 16
L 16
3 m
R 14
L 10
9 m
R 15
L 14
17 m
3 Unknown Unknown R 20
L 19
R 12
L 13
3 m
R 12
L 12
8 m
R 15
L 15
12 m
4 R 16–30
L 16–26
R 34
L 36
R 30
L 20
R 18
L 18
2 m
ES254420_OTE0613_039.pgs 05.23.2013 13:52 ADV blackyellowmagenta
40Ophthalmology Times Europe June 2013
GL AUCOMA
resulted in an improvement in the
IOP control and stabilization of the
visual field. This obviated the need
for surgical intervention, during the
study period. We feel our approach
was successful possibly due to
decreased inflammation of the
trabecular meshwork, conjunctiva,
episclera and sclera leading to
improved outflow facility of the eye.
If glaucoma filtration surgery
is subsequently required in our
patients, the improvement in the
ocular surface may contribute
to the increased likelihood of a
successful surgical outcome.
It may be argued that the
reduction in IOP may have been
due to improved compliance with
treatment for two reasons; firstly
as patient care was transferred
to a specialist consultant-led
glaucoma service and secondly due
to a reduction in ocular discomfort
following treatment of the OSD.
We feel that these scenarios are
unlikely because all four patients
reported good compliance with
treatment prior to being referred
to the service. Furthermore, we
recognize the limitations of our
small retrospective clinic-based
observation and the need for large
robust randomized studies to test
our hypothesis.
Nevertheless, we feel that this is
an important finding in a group of
patients in whom management can
be challenging; glaucoma in patients
with severe OSD is often refractive
to medical therapy14 and the surgical
success of glaucoma filtering surgery
is compromised in this group.17 Our
study raises a new argument for
maintaining increased awareness
of the signs and symptoms of OSD
in patients with glaucoma and
emphasizes the importance of
timely diagnosis and treatment of a
phenomenon we describe as ‘OSD
exacerbated glaucoma’.
References
1. E.W. Leung, F.A. Medeiros and R.N.
Weinreb, J. Glaucoma,
2008;17:350–355.
2. P.J. Pisella, P. Pouliquen and C.
Baudouin, Br. J. Ophthalmol.,
2002;86:418–423.
3. R.D. Fechtner et al., Cornea,
2010;29(6):618–621.
4. A. Chawla, J.N. McGalliard and M.
Batterbury, Acta Ophthalmol. Scand.,
2007;85:464.
5. B. Pouyeh et al., Am. J. Ophthalmol.,
2012;153(6): 1061–1066.
6. D.C. Broadway et al., Arch.
Ophthalmol., 1994;112:1446–1454.
7. M.B. Sherwood et al., Ophthalmol.,
1989;96:327–335.
8. N. Jaenen et al., Eur. J. Ophthalmol.,
2007;17:341–349.
9. A.N. Sapadin and R. Fleischmajer,
J. Am. Acad. Dermatol.,
2006;54(2):258–265.
10. V.A. Smith and S.D. Cook, Br. J.
Ophthalmol., 2004;88:619–625.
11. M.A. Sanchez et al., Cornea,
2010;29(2):167–171.
12. I.R. Schwab et al., Ophthalmol.,
1992;99:197–202.
13. T.J. Liesegang, Cornea,
1998;17(6):574–583.
14. J.H. Tsai et al., Cornea,
2006;25(5):530–532.
15. J. Tauber, A. Melamed and S. Foster,
Ophthalmol., 1989;96:33–37.
16. C. Baudouin et al., Ophthalmol.,
1999;106:556–563.
17. M.J. Lavin et al., Arch. Ophthalmol.,
1990;108:1543–1548.
Authors
Ruchika Batra, MRCOphth, is a speciality
registrar at the University Hospital
Birmingham, UK. She may be reached by
E-mail: [email protected]
Rajen Tailor, FRCOphth, is a speciality
registrar in ophthalmology at the
University Hopsital Birmingham, UK.
Shabbir Mohamed, FRCSEd, is a
consultant ophthalmologist at the
University Hospital Birmingham, UK.
None of the authors have any financial
disclosures pertaining to the subject
matter of this article.
Do you agree?
www.oteurope.com/discuss
“The aim of our
treatment approach
was to break the
destructive cycle
of events (OSD may
potentiate glaucoma
and vice versa) and
achieve improved IOP
control and a healthy
ocular surface.”
“Our study raises a
new argument for
maintaining increased
awareness of the signs
and symptoms of OSD in
patients with glaucoma
and emphasizes the
importance of timely
diagnosis and treatment
of a phenomenon
we describe as ‘OSD
exacerbated glaucoma’.”
“…glaucoma therapy
causes OSD, however,
it is also apparent
that severe OSD in
turn exacerbates
glaucoma.”
ES254421_OTE0613_040.pgs 05.23.2013 13:52 ADV blackyellowmagentacyan
41www.oteurope.com/glaucoma
GLAUCOMA
An estimated 79.6 million people will have
glaucoma by 2020,1 and the disease already
accounts for over 10 million visits to physicians
each year.2 Primary open-angle glaucoma is a
slowly progressive disease characterized by
degeneration of retinal ganglion cells with loss of
the retinal nerve fibre layer (RNFL) and thinning
of the neuroretinal rim of the optic nerve head.
However, new information indicates that current
rim measurements lack a solid anatomical
foundation and may not accurately reflect rim
width.
Current optic disc margin-based neuroretinal rim
estimates assume that the clinically visible disc
margin is the true anatomic border of the rim tissue
from which width, area or volume measurements
can be made. Professor Claude Burgoyne, myself,
and colleagues3,4,5 recently co-localized stereo
optic disc photographs to spectral-domain optical
coherence tomography (SD-OCT) and found that:
1) the clinically identified disc margin is rarely
a single anatomic entity or an identifiable
anatomic junction;
2) in some regions, Bruch’s Membrane extends
internally toward the centre of the optic nerve
head and is clinically and photographically
invisible; and
3) rim width measurements made in the plane
of the perceived disc margin are inaccurate
compared to those that take into account the
orientation of the overlying rim tissue.
The scientists developed a new, objective
method for measuring the rim that uses the Bruch’s
Membrane opening (BMO), a logical anatomical
outer border of the rim. With the Spectralis SD-OCT
(Heidelberg Engineering GmbH, Heidelberg,
Germany), a measurement is made from the BMO to
the nearest point on the internal limiting membrane
(ILM) quantifying the cross section of the nerve
fibres exiting the eye also referred to as BMO-based
minimum rim width (BMO-MRW).
Other studies by the same group found that
BMO-MRW measurements deviated regionally
and significantly from conventional rim margin
measurement.4 The BMO-MRW measurements
are more accurate because they are based on an
identifiable border of the rim and take into account
its varying trajectory relative to the point of
measurement. The investigators also demonstrated
that use of the BMO-MRW measurement translates
into significantly enhanced diagnostic precision
compared to the currently used cSLO or SD
OCT-based optic nerve head and RNFL thickness
parameters. At 95% specificity, the sensitivity of
RNFLT measurements ranged from 31% to 59%,
compared to the BMO-MRW measurement, whose
sensitivity ranged from 54% to 79%, a significant
improvement.
Heidelberg Engineering is currently working
with the investigators to develop software for the
Spectralis that will employ this new neuroretinal
rim analysis.
References
1. H.A. Quigley and A.T. Broman, Br. J. Ophthalmol.,
2006;90(3):262–267.
2. Center for Disease Control and Prevention/National
Center for Health Statistics, 2010 & 1995. Viewed April 20,
2013 at http://www.cdc.gov/nchs/data/hus/hus10.pdf
3. B.C. Chauhan et al., Ophthalmology, 2013;120:535–543.
4. A.S. Reis et al., Invest. Ophthalmol. Vis. Sci.,
2012;53:1852–1860.
5. A.S. Reis et al., Ophthalmology, 2012;119:738–747.
By Professor
Balwantray Chauhan
Enhanced detection of open-angle glaucomaUsing an anatomically accurate OCT-derived neuroretinal rim
parameter
Author
Professor Balwantray C. Chauhan, PhD, is Mathers
Professor and Research Director, Department of
Ophthalmology and Visual Sciences,Dalhousie University,
Halifax, Nova Scotia,Canada. He may be reached by E-mail:
ES254432_OTE0613_041.pgs 05.23.2013 13:54 ADV blackyellowmagenta
42Ophthalmology Times Europe June 2013
PRODUCT PROFILES
Continuous IOP monitoringThe Sensimed Triggerfish is a soft hydrophilic silicone lens embedded with a
miniaturized telemetric sensor.
Patients can wear the lens for up to 24 hours and can perform every day
activities, including sleeping. An adhesive antennae is worn around the eye
and is connected to a portable recording device.
The data collected from the device is then transferred to the practitioner’s computer for analysis. This complements
punctual tonometer readings to offer a qualitative profile of a patient’s IOP and thus optimization of glaucoma management.
Please visit www.sensimed.com for more information
Anterior and posterior segment surgeries
The Megatron S4, from Geuder, is designed for both
anterior and posterior segment surgeries.
The system is able to perform biaxial and coaxial
phaco microsurgeries, as well as high-speed
vitrectomies. A range of magnetic and pneumatic
vitreous cutters can also be completed.
Megatron S4 features a Hybrid Pump System that
offers three types of vacuum modes with just one
cassette — Peristaltic, Venturi and Venturi Effect
for the immediate build up of vacuum.
Another feature is the Inview Display, which
enables the surgeon to view all relevant surgical
parameters dynamically into the microscope.
This system has now been authorized for the
market in Brazil. Please visit www.geuder.de for
more information
Dual OVD packAMO has launched the Healon
Duet Dual Pack ophthalmic
viscosurgical device (OVD).
The Healon cohesive and
Healon EndoCoat dispersive OVDs
are used in cataract extraction
and IOL implantation.
Healon EndoCoat OVD is injected into the eye to protect
and coat the eye during surgery, enabling surgical clarity
and reducing trauma to the inside layer of the cornea and
surrounding tissues. Healon OVD provides high viscosity to
maintain space in the posterior chamber of the eye and helps
to facilitate IOL implantation after cataract removal.
For further information please go to www.abbott.com
Blepharitis treatment range The Blepharitis Relief Kit, available
from Altacor, is designed to assist
in clearing the meibomian glands
and optimizing lid hygiene.
Featuring a BlephaMask, a
reusable eye mask that holds
temperature for up to 10 minutes,
the kit also features a temperature
indicator that informs patients
when the mask is the right temperature. With both the BlephaMask
and the BlephaCura liposomal suspension the meibomian glands are
cleared, debris is removed from the lid margins and bacterial count is
reduced.
Please go to www.altacoreyeproducts.com for more details.
Scanning laser delivery system The TxCell Scanning Laser Delivery System, offered by Iridex, is available for several laser
photocoagulation procedures. Combined with the Iridex IQ 532 or IQ 577 lasers provides the
ophthalmologists with three laser modalities. This includes multi-spot scanning, single-spot standard and
MicroPulse Laser Therapy (MLT).
The company reports that through adopting MLT, the TxCell delivers effective clinical results, ease of
use and more efficient use of time.
Visit www.iridex.com for further details.
ES254436_OTE0613_042.pgs 05.23.2013 14:02 ADV blackyellowmagentacyan
Post-op predictability you can
count on with the EX-PRESS™
Glaucoma Filtration Device.
The peace of predictability.
© 2011 Novartis AG 7/11 EXP10587JAD-EU
ES254234_OTE0613_CV3_FP.pgs 05.23.2013 02:27 ADV blackyellowmagentacyan
F A M I L Y O F I O L S
Multifocal Toric Multifocal Toric MonofocalPreloaded
The TECNIS® family of IOLs: Proven performance and outcomes. Invaluable peace-of-mind.
You deserve some inner peace. And that’s what you get with the broad portfolio of TECNIS® aspheric IOLs. The proven combination of optics, material, and design associated with TECNIS® IOLs continues to help you provide patients with predictable, high-quality outcomes.
When it comes to peace-of-mind, the choice is clear.
Visit www.tecnisiol.com to learn more.TECNIS is a trademark owned by or licensed to Abbott Laboratories, its subsidiaries or affiliates. ©2012 Abbott Medical Optics Inc.www.AbbottMedicalOptics.com / 2012.11.14-CT81
ES254224_OTE0613_CV4_FP.pgs 05.23.2013 02:26 ADV blackyellowmagentacyan