Sight over forty...disposable patients with the toric lens to deliver clear, stable vision and...

Best of BritishGEMO Conference 2009

Academy of Vision Care™

Sight over forty

Autumn 09/Issue 06

11424 B+L Newsletter 6th edition [7]:Layout 1 2/10/09 10:58 Page 2

02

Dear Colleagues

CONGRESS REVIEW

GEMO Conference2009

PRESBYOPIA

Best of British

PRESBYOPIA

Sight over forty

ACADEMY OFVISION CARE™

MICS™ on tour


The Science ofCompliance

CONGRESS REVIEW

GEMO Conference2009

PRESBYOPIA

Best of British

PRESBYOPIA

Sight over forty


MICS™ on tour


The Science ofCompliance

Inside this issue at a glance...

I believe that success isachieved through closecustomer collaboration,product innovation andteamwork. With the contactlens penetration still less

than 7% of the UK population, the categorycontinues to offer a significant opportunity foryou to grow your contact lens business.

I join Bausch & Lomb at a busy time, whilst weprepare for the year ahead, and 2010 promisesto be a very positive year for us.

We have already made our commitment to theBCLA, as a Gold Sponsor for 2010. In addition toour sponsorship we are increasing our investmentsin educational programmes through the Bausch &Lomb Academy of Vision Care, to support UKPractitioners. We will shortly be launching a newwebsite, which will offer eye care professionalsgeneric, continuous education and professionaldevelopment to meet your individual needs.

In this edition of Visions, we take a special lookat the Presbyopic patient, and the multi-focalcontact lens market. The research indicates thatin 2010, around 11 million Europeans willdevelop presbyopia. Recognising andcapitalising on this untapped presbyopic marketwill not only help you to grow your practice,but also increase patient satisfaction. I hope youenjoy reading the articles on presbyopia, in thislatest edition of Visions!

Stuart Neilson, Business Unit ManagerVision Care

Bausch & Lomb extends a very warm welcome to a new member of the Vision Care team; Stuart Neilson. He has a wealth of commercialexperience spanning multiple industries including food, healthcare and optics where he has been working for the last five years.

We were pleased to see somany of you attend the 4thMICS™ symposium on ‘RealCases and Future Trends’ at the ESCRS meeting inBarcelona in September.

I can also confirm that over 200 of you havenow attended MICS™ training courses withBausch & Lomb in the UK during the last 12months so interest in MICS™ still appears tobe growing. See a review on pages 14/15.

Crystalens HD™ is still a very big focus for thesurgical team. How many of you I wonder, areaware of the British origins of this lens? In thearticle ‘Best of British’ on pages 6/7 we trackthe history of the Crystalens® design, startingright back at the very beginning with Sir HaroldRidley inventing the world’s first intraocularlens; followed by the concept of accommodationin the 1980’s through its various designs untilthe present day.

There are still a limited number of placesavailable at our Vitreoretinal symposium inAmsterdam on 18th November, the eveningbefore BEAVRS 2009, to register please go towww.stellarissymposium.eu

We will shortly be adding new courses andsymposia to our education portfolio, so pleaselook out for further updates on MICS™,Crystalens® and our Vitreoretinal portfolio atwww.academyofvisioncare.com

Craig Graham, Business Unit ManagerSurgical

As the Global Leader inOcular Nutrition, Bausch &Lomb supports OcularNutrition roundtablediscussions and researchworldwide. In France,

GEMO hosts a congress every year where thenewest ocular nutrition research is presented. The 2009 congress brought to light recentdevelopments in the role of omega-3, lutein,and zeaxanthin in macular health.

Our newest product Ocuvite® Complete has beenlaunched. It is an advanced antioxidant formulationthat was developed by Bausch & Lomb based onthe latest research in macular health and nutrition.It contains high quality omega-3 fatty acids, lutein,zeaxanthin, vitamins C & E, and zinc at levels thatare not easily achievable from a conventional diet,see details on page 5.

We are delighted with the enthusiastic responsefrom UK Ophthalmologists to the first in our seriesof Ocular Inflammation meetings, held on 9 September 2009. The next meeting will takeplace in Birmingham on 25 November 2009. The 2010 series will continue under the Academyof Visioncare™ banner, with meetings planned forManchester, Bristol, Southampton and Dunfermline.

The pharma team continues its support of anumber of regional meetings around the UK, andare delighted to support Tristan McMullan's firstNorthampton Eye Meeting on 20 November 2009,see details of all meetings on page 18.

Rob Wallace, Business Unit Manager Pharmaceuticals


03PRODUCT UPDATE

New ProductsBausch & Lomb are proud tohave launched two additionalaxes; 20º and 160º for SofLens® dailydisposable Toric for Astigmatism

Sterile single use Endgripping Forceps for Vitreoretinal surgery

NEWThese new additions to our parameter range means ECPs can now fit more of their dailydisposable patients with the toric lens to deliver clear, stable vision and exceptional visual quality.

SofLens® daily disposable Toric for Astigmatismis the only daily disposable for astigmatismthat delivers the complete visual performanceand all-day comfort your patients deserve.

Astigmatic patients may not see crisply andclearly, especially in low light, if fit with a daily disposable toric lens that does notreduce spherical aberration. New SofLens®

daily disposable Toric for Astigmatism lensesoffers you the unique opportunity to provideyour astigmatic patients with a morecomplete level of correction. The Advanced Lo-Torque design offers predictable orientationwith minimal rotation and improved comfort toensure easy fit and crisp, stable vision. The thin design and unique moisturising effect

Designed for safetyThe instruments perform at the same level of safety and efficiency as their reusableequivalents while offering the benefits of a single use device. The ergonomic shape of the squeeze handle allows for smoothtwisting in the desired position.

• Sterile single use product • First use performance each time • Reduced risk of infection and cross

contamination • Micro-forceps with endgripping platforms • Available in 23G (0.6mm) and 25G (0.5mm) • Colour coded handles

Placing the future at your fingertipsThe Storz® Ophthalmics brand offers a range of precision engineered and qualitymanufactured micro-surgical instruments toserve the needs of all ophthalmic surgeonsperforming the latest techniques.

Silicone TippedI/A HandpiecesBausch & Lomb (Surgical) are pleased toannounce the availability of newlydesigned I/A handpieces in the single useaccessories portfolio.

For most cataract surgeons thereis a greater risk of capsulerupture during cortex removalversus during emulsification ofthe nucleus. The new silicone tipI/A handpieces are designed forsurgeons who want superiorcontrol during cortical cleanupand reduced possibility ofcomplications.

Unlike a metal I/A tip, or ahandpiece with silicone sleeve,this handpiece offers:

• Fully coated silicone workingtip

• Avoids metal contact withcapsular tissue

• Reduces the risk of posteriorcapsule rupture

The flexible irrigation tubeprovides:

• A sealed wound, smoothirrigation and aspiration ports

• Eliminates the risk of sharpedges, often the case withmetal I/A handpieces

The absence of metal on the tip surface:

• Offers safety duringviscoelastic removal behindthe IOL

The adhesive properties ofsilicone:

• Facilitates cortex removaland dialing the IOL in thecapsular bag

The semi-transparentsilicone provides:

• Superior ability tosee through theinstrument, whichimproves safety

NEW

of Comfort Moist Technology will improvecomfort upon insertion and deliver exceptionalcomfort right through to the end of the day.

Don’t let your daily disposable astigmaticpatients go uncorrected. Fit them today withSofLens® daily disposable Toric for Astigmatism!


CONGRESS REVIEW 04

with neovascular AMD in one eye, receiving oralDHA (840 mg/day) or placebo over 3 years, for which the assessment of incident CNV in thefellow eye is the primary efficacy endpoint. 300patients were enrolled prospectively in a singlecentre at the Department of Ophthalmology atthe Hôspital Intercommunal de Créteil (Créteil,France). Subjects were examined at baseline, 6 months, 1 year, 2 years, and 3 years, end-visit.The following examinations were performed ateach visit: • Best-corrected visual acuity, intra-ocular

pressure, slit lamp examination, fundusphotography, and fluorescein angiography

• Multifocal ERG (electro-retinography) wasperformed at baseline and at the end-visit

• Changes in plasma lipoproteins, serum andred blood cell membranes (RBCM) EPA andDHA content were also determined as well as genotyping of apoE, an accepted genetic lipid-risk marker of AMD

• Safety was assessed by determining ocularand systemic tolerance to study treatment andincluded slit lamp examination, evaluation oflens opacity and measurement of IOP

Final results of the study will be available shortly.

CARMA StudyThe recent CARMA study1,2 was presented by Dr. John Nolan of the Macular Pigment ResearchGroup, Waterford Institute of Technology,Waterford, Ireland. A Bausch & Lombsupplement containing lutein and zeaxanthinwas tested in the CARMA study, conducted byleading researchers at Queens University,Belfast, and the Waterford Institute ofTechnology. The CARMA study is a high qualitystudy testing supplementation with carotenoidsin patients with early AMD.

The results showed that the intake of theCARMA supplement preserved the quality ofmacular pigment. According to the outcomes ofthe study, the macular pigment of participantswho were assigned to placebo, declinedsteadily, whereas a modest increase in themacular pigment of the intervention group wasobserved. Beneficial effects on visual functionwere observed with increasing levels of serumlutein in CARMA study participants.

The CARMA study was conducted betweenOctober 2004 and March 2008, 433 participantsof average age 77 years were enrolled in thetwo study sites. Professor Chakravarthy and Dr.Stephen Beatty, both of whom are recognisedretinal specialists, led the study in theirrespective centres.

GEMO Conference 2009, Nice,France hosted by Bausch & Lomb

“I enjoyed the GEMOone day meetingvery much. It waswell organised withpresentations in bothFrench and English,and with superb livetranslations into bothlanguages.”

G.E.M.O (Groupe d’Experts en Micro-nutritionOculaire) is a panel of experts, comprised ofkey opinion leaders in ophthalmology,nutrition and epidemiology, who assess thecurrent evidence for ocular nutrition andapply it pragmatically to patient care.

“I enjoyed the GEMO one day meeting verymuch. It was well organised with presentationsin both French and English, and with superblive translations into both languages.

The scientific content was extremely good,with lectures covering the role of Omega-3fatty acids in physiology and with respect toAMD. Results from the CARMA carotenoidsupplementation trial were presentedsuggesting that lutein is definitely worth takingin AMD in addition to the AREDS formula.

By the end of the meeting I felt that we arestill in the process of unravelling thecomplex micro-environment in the retina butthat progress is being made. We should soonbe in a position to make recommendationsto patients about which nutrientsupplements are really worthwhile takingand which are not. Ultimately, we need tomove towards a programme of prevention ofAMD, and groups such as GEMO have a realcontribution to make towards this.”

Mr. Nigel DaviesConsultant Ophthalmologist, Chelsea & Westminster Hospital

Omega-3 fatty acidsThis was a key topic of the 2009 congress. Dr. Pascale Barberger-Gateau, Head of theEpidemiology Department at Victor SegalenUniversity in Bordeaux, presented recent datademonstrating the benefits of omega-3 insupporting human cognition and managingdepression.

Professor Eric Souied, Consultant Ophthalmologistat Creteil Hospital, France, presented preliminaryresults of the recent NAT-II study demonstratingthat supplementation with omega-3 fatty acidscan help in preserving sight.

The NAT-II study is a double-blind, prospective,randomised, parallel, comparative trial in patients

Delegates at the 2009 GEMO Conference



CONGRESS REVIEW 05

"AMD cannot be cured yet, but our presentstate of knowledge suggests that a high intakeof lutein and zeaxanthin can have a positiveimpact on the prevention of the disease.Therefore, the eye specific carotenoids are a central topic in AMD research. The results of the CARMA study show that a daily intakeof 12mg lutein and zeaxanthin, together with co-antioxidants, preserves the quality of themacular pigment and had beneficial effects on visual performance and morphologicalprogression of the disease.“

Dr. Stephen Beatty, Consultant Ophthalmologist,Waterford Regional Hospital


Ocuvite®

CompleteOcuvite® Complete is an advancedantioxidant formulation that wasdeveloped by Bausch & Lomb based on themost current research in macular healthand nutrition. It contains high qualityomega-3 fatty acids, lutein, zeaxanthin,vitamins C and E, and zinc at levels that arenot easily achievable from an average UKdiet. Ocuvite® Complete is for individualswho are concerned about maintainingmacular health and good central vision.

For samples, amsler grid keyrings, amslergrid tear-off pads and patient leafletsplease call 01732 368861

NEW

“Age-related Macular Degeneration(AMD) causes severe visual loss and isthe commonest cause of visualimpairment in the UK1,2 in the over 50sin the western world. Ocular nutritionalsupplements have been shown (in theAREDS Study3) to slow the progressionof dry AMD to more advanced stages.Such nutritional supplements should,therefore, be recommended topatients.”

(AMD Interim Guidelines: The RoyalCollege of Ophthalmologists InterimRecommendations for the Managementof Patients with Age-related MacularDegeneration)

References

1. Macular Society - www.maculardisease.org"Macular degeneration (MD) is the collectiveterm for over 1,500 conditions which affectcentral vision by damage to the macula, a small area of the retina at the back of theeye. It is estimated that there are over500,000 people with macular conditions inthe UK. Macular degeneration is the most common form of visualimpairment in the UK and throughout thedeveloped world"

2. RNIB - www.rnib.org.uk"It is the most common cause of poor sight inpeople over 60 but very rarely leads tocomplete sight loss because only the centralvision is affected."

3. The Age-Related Eye Disease Study (AREDS)(Arch Ophthalmology, Oct. 2001) wasconducted over 10 years by the US NationalEye Institute. The high-dose supplementformulation of vitamins C, E, beta-caroteneand zinc, which was tested in this study,was found to reduce the risk of progressionto advanced Age-related MacularDegeneration (AMD) by 25%, and reducethe risk of visual acuity loss by 19% forpatients with moderate to advanced AMD.The supplement used in this study wasprovided by Bausch & Lomb and is nowavailable in the UK under the brand namePreserVision®.

ARVO 2009 ConferenceA summary of the key topics from ARVO (Associationfor Research in Vision and Ophthamology), held inFort Lauderdale, USA on 3-7 May 2009, waspresented at the GEMO conference by Dr Niyazi Acar,PhD, Eye and Nutrition Research Group, UMR FLAVIC,NIRA (National Institute of Research on Agronomy),Dijon, France, and Dr Isabelle Aknin, Ophthalmologistand Nutritionist, Le Golfe Juan, France.

This was followed by presentations on nutritionand eye disease (cataracts, glaucoma,AMD, andDiabetic Retinopathy) by Dr Jean-Michel Lecerf,Dr Cécile Delcourt, Professor Alain Bron, and Dr Lionel Bretillon.

Overall, the conference provided an overview ofthe most recent studies supporting the role ofnutritional supplementation in preserving sight.

References1. *WHO, Fact Sheet N°282; November 20042. *Neelam K, Hogg RE, Stevenson MR, Johnston E, Anderson R,

Beatty S, Chakravarthy U. Carotenoids and co-antioxidants inage-related maculopathy: design and methods. OphthalmicEpidemiol. 2008 Nov-Dec;15(6):389-401

AMD the facts…• Age-related Macular Degeneration

(AMD) is an eye condition affectingthe macula, which is responsible forthe sharp, central vision needed forseeing objects clearly

• AMD is thought to affect up to half amillion people in the UK today, andoccurs in two forms – dry and wet

• Dry AMD is the most common,affecting 90% of all sufferers. It generally affects both eyes, butvision can be lost in one eye whilethe other seems unaffected

• Wet AMD is an advanced stage ofAMD, and occurs when abnormalblood vessels start to grow underthe macula, leaking fluid anddamaging it. With AMD, loss ofcentral vision can occur quickly


PRESBYOPIA 06

Best of British

Who could have guessed that the abovesimple question, posed by a medical studentin 1948, would have been so instrumental inchanging the way cataracts were treated for ever?

However, this is just what happened whenStephen Perry, a medical student at St Thomas’Hospital in London, having observed Sir HaroldRidley completing a standard cataract asked“Do you intend to put a new lens in the eyeafter removing the old cloudy one?”

Since the 1930’s, Sir Harold Ridley had beenlooking for a ‘cure’ for aphakia but it was the‘Airplane Story’ from World War II that finally

provided the answer. A young fighter pilot, Flight Lieutenant Gordon ‘Mouse’ Cleaver, had hiseyes peppered with Perspex splinters from hiscanopy when his Hawker Hurricane was hit byenemy fire over France. It’s not clear exactlywhere Ridley saw Cleaver, probably at The RoyalLondon Ophthalmic Hospital (now Moorfields), but this patient provided him with the opportunityto observe the eye’s reaction to the material fromwhich IOLs would eventually be made.

Sir Harold’s encounter with the student gavehim the courage to proceed with his idea andon 29th November 1949, Sir Harold Ridleyimplanted the world’s first intraocular lens at St Thomas’ Hospital in London.

Forty years later in 1989, and once again in theUnited Kingdom, J. Stuart Cumming was on thebrink of developing a lens that he believed couldaccommodate just like the eye’s natural lens.

1980sIn 1989, a few of Stuart Cumming’s elderlypatients, who received plate haptic lenses thatwere 10.5mm long, reported that they could readeven though they were close to emmetropia.When sitting behind the phoropter and given theirmaximum distance correction, they could still readJ3 or better in dim light. He was also at that timeimplanting the three-piece SI18 lens (Allergan,Inc., Irvine, CA), and noticed at the slit lamp thatthe plate haptic lens optic appeared to vault muchfarther posteriorly in the capsular bag space than did the posterior-vaulted loop SI18 lens. The A-Constant of the plate haptic and SI18 lenseswere 119.0 and 117.2, respectively. The moreposteriorly vaulted lens design, however, would be expected to have the higher A-Constant2.

These findings, along with published data byThornton, Coleman & Busacca earlier that decade,suggested that forces within the eye tended tomove the plate haptic optic posteriorly, and theloop lens optic anteriorly. It seemed possible thatthese forces might also move the plate lens opticanteriorly with accommodation.

“Do you intend to put a new lens in the eye after removing the old cloudy one?1”

Dr Stuart Cumming (left), Mr Andy Corley (right), co-founders of EyeonicsEmmetropia The state of visionwhere an object atdistance is in sharpfocus with the eye’s lens in a neutral orrelaxed state or a fixed state created bythe implantation of a standard, non-accommodating IOL.

AphakiaThis medical term isused to describe theeye when it iswithout its crystalline lens either throughsurgical removal, congenital defect ordisease. Prior to the invention ofintraocular lenses, all cataract patientswere left in this state requiring them towear very high prescription glasses to see.


PRESBYOPIA 07

The first accommodatinglens was designed in1990 and implanted inthe eye of an 85 yearold lady in England on12th March 1991.

Alan Ritter, an ultrasound engineer who workedwith Cumming pre and post-operatively, measuredthe length of patients’ vitreous cavities. This smallstudy disclosed that the plate haptic lensesconsistently moved to the posterior part of thecapsular bag and shortened the vitreous 50% ofthe time, with the most anterior location only0.77mm in front of the original location of theposterior capsule. By contrast, the loop lensesshortened the vitreous cavity by only 20% of thetime, and lengthened it as much as 2.17mm. The spread of the plate haptic lens along the axis ofthe eye was 1.45mm, whereas that of the loop lenswas 3.15mm. Both of these 6 mm silicone opticlenses had the same refractive index and centrethicknesses of 1.3mm, and they were implanted inpatients in their 70s to replace crystalline lenses,approximately 5mm thick. Fibrosis, with ensuingshrinkage of the anterior capsule, caused posteriorvaulting of the optic of the plate haptic lens andpulled the posterior capsule tightly against theposterior surface of the optic.

As expected, subjects in the plate-lens grouphad superior UCVAs, because they had a muchshorter range of location along the axis of theeye compared with subjects in the loop-lensgroup. Additionally, the IOLs of the former groupfit tightly against the posterior capsule, thusstabilising the vitreous by maintaining it atclose to its pre-operative volume. This appearedto significantly reduce the incidence of retinaldetachment and posterior capsularopacification, which was less than 5% at 1 yearin the referenced studies.

He then measured the vitreous cavity lengthsand anterior chamber depths in the patientswho received plate lenses first, after instillingpilocarpine and, later, after instillingcyclopentolate. He found a 0.7mm averageanterior movement of the optic in 10 eyes.

These observations indicated to Cumming that afunctioning ciliary muscle was the onlymechanism that could account for his findingsand those published in the literature, and couldexplain why the optic could move in theseelderly patients’ eyes. By reducing the optic’sdiameter, the length of the plates could beincreased, thereby increasing the ability of the

optic to move. Thus, he hoped to design anaccommodating lens that would consistentlymove along the axis of the eye.

1990sThe first accommodating lens was designed in1990 and implanted in the eye of an 85 yearold lady at Bury General Hospital on 12th March1991. When examined on 25th July 1991, she demonstrated significant accommodationwith fogging. A-scans were than performed,first with her looking at distance, and then afterthe instillation of pilocarpine. Threeindependent scans showed an average increasein the vitreous cavity’s length of almost 2.5mmand shallowing of the anterior chamber byapproximately the same amount. These findings

conclusively showed that the ciliary muscle stillfunctioned in an elderly person and stronglysuggested that it would be possible to developan IOL that would consistently accommodate.In 1990, Stuart Cumming met Professor JochenKammann, MD, from Dortmund, Germany. Thetwo men worked in partnership over the next 9years, implanting seven lens designs, the first sixof which all demonstrated accommodation, boththrough patients’ ability to read at near throughtheir distance correction and by demonstratingoptic movement by means of A-scans withcycloplegia and, later, pilocarpine. The optic oftwo of the lens designs moved approximately1mm anteriorly after the administration of

pilocarpine. The designs were evaluatedsequentially. It took well over 12 months tochange the design to make new moulds,manufacture lenses of different powers, steriliseand package them, implant them, and observe

patients for possible complications. The patientswere carefully followed for a period of 3 months.

In 1998, Stuart Cumming joined forces with AndyCorley and formed Eyeonics Inc. The seventhCrystalens® design was first implanted in 1998.The plates were 10.5mm long, and the diameterfrom loop tip to loop tip was 11.5mm, with ahinge across the plate adjacent to the optic.

2000sThe Crystalens® received FDA approval inNovember 2003 with the AT45 model. This lensallowed the eye to focus on objects across abroad range of vision. It projected all availablelight received by the eye to a single focal pointand accommodated using the eye’s naturalfocusing mechanism.

In August 2005, the AT45SE came to the marketwith 360˚ square edge on the posterior side tohelp combat PCO and had availability in quarterdioptre steps in the most widely used powers toassist surgeons in targeting patient outcomesmore accurately.

The big change came with the FDA approval inNovember 2006 of the Crystalens® Five-O. This lens introduced an increased optic size from4.5mm to 5.0mm, a 12mm overall lengthavailable for larger eyes and a 17% greater hapticsurface area which provided greater stability.

The US market saw the launch of the currentCrystalens HD™ in June 2008, and in Europe inApril 2009. In continuing to model theCrystalens® after the natural human crystallinelens, the Crystalens HD™ is designed to mimicthe natural secondary mechanism of actionknown as accommodative arching. In theCrystalens HD™, the central portion of the lensis thicker than in the periphery, therebyincreasing the accommodative arching effect.

To date 150,000 Crystalens® lenses have beenimplanted world wide. To find out more, and tofind a surgeon near you, please visitwww.crystalens.com

References1. Sir Harold Ridley and his fight for sights by David J Apple MD2. Cataract & Refractive Surgery Today, Europe

Fogging A method of testingthe eye in whichaccommodation isrelaxed by overcorrecting the patient’svision with a convex spherical lens.

AccommodativeArching A beneficialdeformation of theeyes natural lens that occurs whenfocusing on near objects which changesthe curvature of the lens and thusincreases its overall power.

Phoroptor This is an instrumentcommonly used byeye care professionalsduring an eye examination, containingdifferent lenses used for refraction of theeye during sight testing, to measure anindividual's refractive error and determinehis or her eyeglass prescription.


PRESBYOPIA 08

Getting started with Crystalens HD™ Five recommended guidelines for success during your initial 10 eyes1. Pre-operative measurements• Use the IOL Master (Carl Zeiss Meditec, Jena, Germany) or manual keratometry to obtain keratometry (K) readings before applying any

eyedrops, applanation or corneal manipulation• For contact lens wearers, contact lenses must be removed for the appropriate amount of time to allow the cornea to return to a stable state • Use the IOL Master, or immersion ultra sonography to measure axial length• Make sure the axial lengths and K readings correlate with the patient’s oldest known refraction

2. Targeting• Utilise the Crystalens® nomogram for eyes 22mm or shorter• Dominant eye: Target slightly plus (between plano and +0.25). If the calculation does not predict plano, select the lens power that predicts

the first plus above plano• Non-dominant eye: Target slightly minus (between plano and -0.25). If the calculation does not predict plano, select the lens power that

predicts the first minus below plano

3. Lens power calculations• The SRK-T formula will be used for eyes with axial lengths measuring 22.01mm or longer, and the A-Constant for the Crystalens HD™

(HD500 and HD520) is 119.00• The Holladay II formula will be used for eyes with Axial Lengths measuring 22mm or shorter and in eyes with mena K flatter than 42.00D or

steeper then 47.00D, independent of axial length• Anterior chamber depth for the Crystalens HD™ is 5.55

4. Submit printouts• Submit both the Bausch & Lomb-Datalink pre-operative form and the A-scan or IOL Master printouts to your Crystalens® outcomes specialist

for verification of IOL powers - please indicate your lens choice and predicted outcome

5. Surgical and post-operative care, follow-up• Create a symmetrical capsulorhexis measuring 5.5 to 6mm• One day and 10 to 14 days post-op, perform testing listed on the Bausch & Lomb form and submit findings via Surgivision Datalink• Remember to measure intermediate acuity using the intermediate scale, distance corrected near visual acuity, and visual acuity in both eyes • Remember to verify refractive findings with a cycloplegic refraction when visual acuities and refraction do not correlate, or if near visual acuity is

not J3 or better

At age 72, I was frequently asked, “As a3.00 D hyperope, why haven’t you beenimplanted with the Crystalens®?” I finallydecided that I should put my eyes where mymouth was.

The next task was to carefully select thesurgeon. I have many friends with whom I hadbeen in surgery — all were excellent surgeonswho wanted to operate on me. However, I wasconcerned that I might become part of theiradvertising campaign since it is legal toadvertise as a physician in the United States. I had been in surgery several times with mygood friend Alan B. Aker, MD. Not only is hean excellent surgeon, but he also does notadvertise. I asked Dr. Aker if he would do mysurgery, and he kindly agreed.

We selected lens powers of 23.00 D for theright eye and 23.50 D for the left non-dominant eye so that the post-operative

refractions would be plano and -0.50 D,respectively. I reported for surgery on April 27,2005, for the first (left) eye. I was 72 years old.Dr. Aker implanted the 23.50 D Crystalens® AT45.

Dr. Aker implanted the second 23.00 DCrystalens® AT45 in my right eye on May 4,

The Crystalens® - through my own eyes

Dr Alan Aker (left) and Dr Stuart Cumming(right) – one day after Crystalens® implantationin Dr. Cumming’s second eye

2005. Both surgeries were withoutcomplications. Atropine 1% was instilled theday of surgery and 1 day post-operatively.

Immediately post-operatively, my pupil waswidely dilated, and I found it difficult to drive atnight because of the glare and halos.Fortunately, it appears that the effect of atropinein elderly patients significantly wears off in 3 to4 days. After this time, I was free from glare,and the pupil was down to about 3 to 4mm.

By day 4 post-operatively of the second eye, I was seeing well in each eye without glare atnight. My UCVA was 20/30 and J3 at 1 weekpost-op in each eye. At 2 weeks, my BCVAwas 20/20, and my UCVA in both eyes was20/25 and J2. I had a vertical diplopia thatwas relieved by tilting my head down, whichgradually improved over 4 weeks. I assumethat the peribulbar injection penetrated thesuperior rectus.


PRESBYOPIA 09

I am delighted with the results. My near visiongradually improved during the first 12 months.Now, most of the time I am without my 1.00D reading glasses, which I wear only when Isit down to read for a prolonged period. Thecomputer is also crystal clear without glasses.

I am finally functioning 90% of the timewithout glasses or contact lenses. My visionis as you would expect it to be if I were 35years old, and I can usually read the menuwithout glasses in a dimly lit restaurant. I have no loss of contrast and do not takemy reading glasses to restaurants. There isno glare or halos, and I have never seenshadows of the edge of the 4.5 mm, 0.9 mmcentrally thick optic, which is located deepin the eye, in the posterior part of thecapsular bag. At my age, the bag is onaverage 5 mm deep. My refraction onSeptember 28, 2005, at 5.5 months post-op,is listed in Table 1.

I play golf, and in myfoursomes there areusually eightCrystalens® eyeskeeping their eyes onthe ball and markingtheir cards withoutglasses. Like me, theyare all happy withtheir vision.

Dr.Cumming’s right eye, taken 1 day post-operatively

In late 2006, my near visual acuity wasgetting worse; however, my distance visionwas still 20/20 in the right eye and 20/30 inthe left eye without correction. I was visitingHarvey Carter, MD, at Carter Eye Centre inDallas, and after examining me he suggested I should have a posterior capsulotomy in botheyes, which he performed the same day. My near UCVA immediately returned to J3 andJ1 in my right and left eyes respectively.

OD -0.25 -0.25 x 180˚ (20/20)

OS -0.75 -0.50 x 180˚ (20/20)

UCVA OD: 20/20 OS: 20/30

Near UCVA OD: J3 OS: J1

Refraction at 5.5 months postoperativeRefraction at 5.5 months postoperative

Table 1

Crystalens HD™ now in quarterdioptre stepsBausch & Lomb (Surgical) are happy to announce that it has received approval from the Food and Drug Administration (FDA) to market the Crystalens HD™ in quarter dioptre steps. This announcement comes as the Crystalens HD™ celebrates its 1st anniversary sincereceiving the "Gold Standard" FDA approval, for proof of clinical effectiveness.

Dr. John Hovanesian, a principal investigator inthe FDA study and clinical instructor at the JulesStein Eye Institute, UCLA in California, said: “If Iwere a patient having cataract surgery, I wouldwant an IOL that projects 100% of available lightto a single point of focus in the eye, and alsoprovides a broad range of distance, intermediateand near vision. The Crystalens HD™ is the bestavailable lens to achieve that goal. There is noquestion that the Crystalens HD™ is my lens of

choice for presbyopia correction in patients withcataracts, and the addition of quarter dioptreswill only enhance my ability to target and givepatients the best possible outcomes with theCrystalens HD™.”

Quarter dioptres will be available for theCrystalens HD™ for models HD500 and HD520 inthe 18-22 range. Bausch & Lomb expects to makeavailable the dioptres in a wider range by theend of the year.

NEW

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PRESBYOPIA 10

Sight over fortyDemographic Opportunity - we are rapidly approaching a worldwide population of 1.5 billionpresbyopes1. The presbyopic population is growing faster than the population as a whole.

Clearly, as an increasing number of ourpatients live longer and have more activelives, growth in this patient segment willremain robust for years ahead. Patientinterest in multi-focal contact lens correctionwill substantially increase in most of ourpractices as a result of consumer advertising,word of mouth, and trade advertising of newtechnology.

We need to be ready to help our patients reapthe benefits of new and emerging contact lenstechnologies for presbyopic correction. Ourmarket research shows only one in 10 of thevision corrected population age 50-64 wearcontact lenses; and of those, one-third ofmonovision wearers and one-third of regularcontact lens wearers would be willing to wearmulti-focal contact lenses2. When we advertiseour multi-focal contact lenses, your patientsrespond.

The ageing eye The anatomical changes which cause presbyopiaare well acknowledged. In childhood, thefocusing ability of the eye is provided by aflexible lens within the eye that is controlled bya series of surrounding muscles. When a personwants to see something up close, the overallfocusing power of the eye needs to increase.This is achieved by the flexing of these internaleye muscles which causes the shape of the lensto change to allow for ‘near’ vision.

The lens itself is very flexible at birth, whichmeans that it has a very wide range of focusingability. This is one of the reasons why childrenare able to sit very close to the televisionwithout discomfort, as well as colour withcrayons with their noses almost touching thepage. If a person wishes to view an object in

With age, the lens thickensand its increasing bulkmeans that it becomesinflexible, which in turndirectly impacts on theability to focus close up.

11424 B+L Newsletter 6th edition [7]:Layout 1 2/10/09 10:58

PRESBYOPIA 11

the distance, the muscles relax, the lens revertsto its original shape and the target comes intoview. All of these changes are madeinstantaneously and accurately.

With age, the lens thickens and its increasingbulk means that it becomes inflexible, which inturn directly impacts on the ability to focusclose up. People in their twenties and thirtiesare generally unaware of any changes, becausethe increasing rigidity of the lens only affectsobjects which are very close to – perhaps (10-20cm) away from the face. However, whenpeople reach their forties, the lens is able tochange its shape to a more modest degreewhich means items at arm’s length are clearlyvisible, but some tricky ‘near’ tasks such asreading small print in dim conditions orthreading a needle become difficult. You canoften identify a person experiencing presbyopiawhen dining in a restaurant if he or she isholding the menu at arm’s length!

At age fifty plus, there is essentially noflexibility left in the eye’s lens and for manypeople, near work is not possible without theassistance of some ‘refractive correction’ whichis usually in the form of spectacles or contactlenses. Whilst these changes happen toeveryone, the precise effects can differdepending on whether the person is short orlong-sighted. For example, people who arelong-sighted are often affected earlier in life.Those who are short-sighted struggle withdistance vision under normal circumstances,

Shaving

Sport / exercise

Applying make-up

Travelling

Driving

Reading a wrist watch

Writing cheques / paying bills

Using a PC

Reading a mobile phone

Craft / sewing

reading papers / books / mags

Reading food labels

Reading medicine labels

15%

19%

21%

33%

33%

38%

49%

52%

58%

65%

71%

77%

78%

but have an in-built advantage for ‘near’vision. They require less use of the eye’s lensand can often read close up for many moreyears than their friends who are neither longnor short-sighted.

AppearancesThere are many age-related conditions suchas memory loss that cause great concernfor people. Yet when we focus specificallyon the visual signs of ageing, concernsrelating to eyesight are at the forefront ofpeople’s minds. In fact, almost twice asmany people worry about dependence onglasses than going grey or developingwrinkles.

Impact of presbyopia on daily lifeLeisure research indicates that dailyactivities such as reading are negativelyimpacted by presbyopia3. Nearly 80% ofpeople with presbyopia struggle to readmedicine and food labels. Clearly, thepotential ramifications of someone takingan incorrect medicine or dosage could bevery serious.

Almost half (49%, Figure 1) of sufferershave difficulty writing cheques or payingbills and more than one in five have evengone so far as to sign a bill or credit cardslip without being able to read thecontents, putting themselves at risk fromerror or fraud. Nearly 60% of sufferersadmit they struggle with daily tasks, suchas using a mobile phone, which can provefrustrating. Meanwhile, 40% of sufferersfind it difficult to read their wrist watch.

It is concerning that patients are unawareof vision correction solutions available tohelp them to overcome these difficulties.

Figure 1 Which of the above activities do you feel are affected by the problems you have focusingon objects close up?

57%

43%

68%

32%

65%

35%

62%

38%

60%

40%

58%

43%

53%47%

32%

68%

Regular Eye Tests (Every 0 to 2 years) Infrequent Eye Tests (Every 3 or more years inc never) Never had an eye test

Over

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Italy

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10%

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50%

60%

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8% 4%

22%

8%2%

10%

4%7%

Figure 2 – Regular vs Infrequent eye test

One-third of monovisionwearers and one-third ofregular contact lenswearers would be willingto wear multi-focalcontact lenses2.

We focus specifically on the visual signs ofageing, concernsrelating to eyesight areat the forefront ofpeople’s minds.

Nearly 80% of peoplewith presbyopiastruggle to readmedicine and foodlabels clearly.


PRESBYOPIA 12

Products AvailableSpectaclesDevelopments in contact lensmanufacturing, design and materials meanthat there is a whole array of products forthe presbyopic patient. Meanwhile moderntitanium spectacle frames are so light that itis almost impossible to tell that they arebeing worn.

Pros• Modern titanium frames are very light to

wear and often visually appealing

• Recent technology now allows for moreattractive lenses even for strongerprescriptions

• Spectacles can help create a certain look,becoming a fashion accessory

Cons• Some find glasses uncomfortable to wear

• Can be restrictive in certain daily lifescenarios, for example while playing sport,when needing UV protection or whenapplying make up

Multi-Focal Contact LensesMulti-Focal and bifocal contact lenses workby producing a clear distance focus and aclear near focus on the retina. Fortunately,the brain is a brilliant vision processor andcan quickly adapt to the vision provided bythese types of lenses.

Pros• Peripheral vision is unaffected and is usually

enhanced due to the panoramic visionprovided by contact lenses when comparedwith the restriction of a spectacle frame.

• Ideal for patients who are wearing visioncorrection products for the first time, whoare not used to wearing glasses.

• Enables daily life activities such as playingsports, telling the time on a watch, using amobile phone or applying make up in themorning.

• The idea of being able to read withoutspectacles is ideal for social occasions.

Cons• The usual prescription suitability applies.

Astigmatism requires consideration withrespect to lens type. For patients whosedistance prescription requires moresophisticated contact lenses, soft multifocalcontact lenses are not as widely available.

• It may take some patients a few days toadapt to wearing the lenses.

Often, people experiencing presbyopia do notfully understand their progressively changingvision and worry that wearing spectacles willmake, or has made, their eyes worse. Whilstrefusing to wear vision correction does not slowdown or speed up the development ofpresbyopia, it is certainly inconvenient for thoseaffected, something that can be avoided whenthere are so many options for the correction of‘near’ vision problems.

People in the UK have their eyesight checkedmore regularly than anywhere else in Europe(Figure 2), with two out of three of thosesurveyed getting their eyes tested at least onceevery two years.

Those in their 40’s get on very well with Multi-Focal contact lenses, and if you startfitting them early, they can progress easily in to a higher add as they enter their 50’s. This will also keep these patients from droppingout, and endear them to you and your practice.

Patient OpportunityTwo recent studies point to the success that can be achieved with the Bausch & Lomb Multi-Focal contact lenses. Richdale found that 76% of her subjects preferred SofLens®

Multi-Focal lenses to monovision correction4.High contrast acuity was good (20/20 “atleast”) at both ‘distance’ and ‘near’ and stereo-acuity was far better with Multi-Focal lenses.Patients had a slight reduction in low contrastacuity with the Multi-Focal lenses at ‘near’(20/32 vs 20/28 with monovision). A more recent study also found stereo-acuitybetter with PureVision® Multi-Focal lenses5. In addition, the range of ‘near’ vision wasbetter for the patients wearing the Multi-Focallenses. While these researchers found somedifferences in visual acuity, ‘distance’ and ‘near’acuity was good, and contrast sensitivity wasnot significantly different.

The authors commented that the PureVision®

Multi-Focal lenses “can potentially provide abetter balance of real-world visual functionbecause of minimal binocular disruption.” The Bausch & Lomb multi-focal lenses in thesestudies shared the centre-near aspheric designthat also controls spherical aberration to expandthe range of clear vision.

Business OpportunityWhen fitting and treating presbyopes, a happypresbyopic multi-focal contact lens wearer is aloyal patient who is willing to refer otherpresbyopes for the opportunity to see well atdistance and near with contact lenses. Bausch &Lomb is committed to helping the eye carepractitioner provide the best vision solutions foryour patients throughout their lives.

Monovision Contact LensesMonovision is a system of contact lensfitting where one lens power is enhancedfor reading vision. That is, one eye iscorrected for distance vision and the otherfor near vision.

Pros• Peripheral vision is unaffected and is usually

enhanced due to the panoramic visionprovided by contact lenses when comparedwith the restriction of a spectacle frame.

• Monovision can be used with all types ofcontact lenses, including lenses that correctastigmatism, as it is simply theenhancement of the power of one of thelenses that achieves the visual results.

Cons• The eye works more or less alone with

monovision, meaning the wearer may haveto adjust the head position more often tosee. He or she may also lose some depthperception.

• As the eyes adjust to the new lens powers,a period of time may be necessary tobecome familiar with the lenses.

• Because correction is provided only forreading and long distance vision,intermediate vision (at approximately onemetre in distance) may not be as clear aswith multifocal contact lenses.


ACADEMY OF VISION CARE™ 13

Bausch & Lomb Multi-Focal designlenses are easy to fit!

The final prescription can be achieved for 9of 10 patients within only one return visit4.

Overall 77% of patients preferred the Bausch &Lomb Multi-Focal lens compared to theirprevious lens.6**

Bausch & Lomb Multi-Focal lenses providedbetter near vision for approximately 90% ofwearers compared to their previous type oflens type.6

Over 80% of patient considered that their lenscomfort was as good or better than theirprevious lens type across a range of comfortparameters.6

References1. (Holden et al., Archives of Ophthalmol, 2008)2. Bausch and Lomb, Data on File3. Bausch and Lomb, 1,410 adults interviewed, Data on file.4. Personal correspondence about fitting results data from

study reported in Richdale K, et al: Comparison ofMultifocal and Monovision Soft Contact lens Corrections inPatients with Low-Astigmatic Presbyopia. Optom Vis Sci;83:266–273, 2006.

5. Gupta N, Naroo S, and Wolffsohn J: Visual Comparison ofMultifocal Contact Lens to Monovision. Optom Vis Sci;86(2): 98-105, 2009.

6. A total of 238 patients from 12 countries participated inthe study throughout 2006. Of the 238 patients, 87 wereexisting wearers of the Bausch & Lomb SofLens Multi-Focallenses, 44 were using an alternative multi-focal or bifocallens, 40 were using single vision lenses, 24 were usingother brands or non-brand specific lenses and 35 werespectacle wearers. Previous correction information was notavailable for 8 patients.

**Previous lens type SofLens Multi-focal, Focus Progressive,Acuvue Bifocal, Proclear Multi-Focal, Rythmic, various brands.


Often theatre staff find the move to a MICS™approach rather daunting.Mina Ward’s presentationon moving yourdepartment to MICS™showed how you canmake the move costneutral, and that in herexperience, barring aminimal change to

instrument sets, the transition has less of animpact than you might think.

Education and communication is key to anychange within a department and this is why we encourage both surgical and clinical staff toattend our MICS™ courses. As Mina points out“It’s not an individual that needs to change, you need to work as a team”.

The theatre staff that attended on the day foundit refreshing to have a portion of the daydedicated to MICS™ from their point of view.

Richard Packard concluded the day’s presentationsby giving a thorough description of both theCoaxial and Bimanual MICS™ techniques, payingcareful attention to the consideration of everyfacet of the surgery. This began with the choiceof incision size and the proper construction ofcorneal wounds, through to the matching ofappropriate instrumentation and fluidics, andfinally the cortical clean-up and implantation of a MICS™ lens.

The audience found it extremely beneficial tohear Richard’s tips for each stage of the cataract


MICS™ on tour

Richard B. Packard, MD, FRCS, FRCOphth

0.5

3.2 2.5

X Incision size in mm

Y In

duce

d as

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Induced astigmatism from temporal wounds

Over 100 people have already attended theBausch & Lomb MICS™ courses this year andthese have proved a great success. Our MICS™Tutors, Richard Packard and Mina Ward, haverecently transitioned the Prince Charles EyeUnit in Windsor to MICS™ and gave advice,suggestions and solutions to issues that theunit was previously facing.

Please find below a brief overview of our Bausch& Lomb MICS™ Course held recently in Leeds togive you an insight into the day’s events.

Richard Packard started by talking about thehistory of MICS™ over the past forty years. From the first phaco-emulsification performedby Charlie Kelman in 1967 which gave us SICS(Small Incision Cataract Surgery), through to sub1mm MICS™ (Micro Incision Cataract Surgery)performed by Amar Agarwal today. MICS™ wasa term originally registered as a trade mark byJorge Alio, a surgeon from Alicante, Spain, forsurgery through sub 1.5mm incisions, but mostpeople now consider anything that is sub 2mmto mean MICS™.

There are two different approaches to usingMICS™, with both Coaxial MICS™ (CMICS) andBiaxial MICS™ (BMICS). There are advantagesand disadvantages with both options havingprotagonists and antagonists. However, CMICSseemed to be the audience’s preference withdelegate feedback containing such comments as ‘a change to CMICS is imminent [in mytheatre]’ and ‘CMICS does not require additionalclinical skills’.

Protected wounds due to sleeve

Less changes in technique andequipment

Ability to use established IOLtechnology

Minimal astigmatism when wound notenlarged for IOL insertion

Better tissue manipulation due toseparated irrigation andaspiration/phacoemulsification

Better visibility due to no sleeve

Ability to use new IOL technology

No astigmatism if MICS™ IOL used

Advantages of CMICSAdvantages of CMICS Advantages of BMICSAdvantages of BMICS

Mina Ward, ClinicalLead Practitioner

‘MICS™ is the way forward’


Is surgically induced astigmatism dependent on incision size and site?A. Castillo UK, B. Redmill, B. Attrup

Purpose: To evaluate the results of refractive outcome with reference to induced astigmaticerror and post-operative astigmatism by comparing incision size and incision site.

Setting: Department of Ophthalmology, Lincoln County Hospital, Lincoln, UK.

Methods: In this 1365 case evaluation, patients had cataract surgery with either superior ortemporal clear corneal incisions and either sub 2mm incisions and a Bausch & Lomb Akreos®

MI60 implant or a 3mm incision with a Bausch & Lomb L161AOV implant. Measured outcomeswere astigmatic error induced as measured by vector analysis and post-operative astigmatism as measured from post-operative refraction. Data collected included pre-operative vision, pre-oprefraction, pre-op K readings, pre-op axial length, lens type implanted, lens power implanted,predicted refraction, A-Constant, incision size, incision site, post-op vision, post-op refraction,patient satisfaction and surgical complications.

Results: Data for 285 procedures using an Akreos® MI60 lens implant (Bausch & Lomb) wereanalysed. 219 cases used temporal clear corneal incisions and 66 cases used superior clearcorneal incisions. Data for 1080 procedures using a L161AOV lens with 690 temporal and 390superior incisions. 2 way ANOVA statistical analysis showed that significantly less astigmatismwas induced with the sub 2mm incisions as measured by vector analysis (%variation 0.48, p value 0.0101). It also showed that post-operative astigmatism was significantly less fortemporal incisions (%variation 0.39, p value 0.0215).

Conclusions: Micro incision sub 2mm cataract surgery significantly reduces the amount of inducedastigmatism as measured by vector analysis. Temporal clear corneal incisions lead to significantlyless post operative astigmatism than superior clear corneal incisions.

ESCRS Abstract, Barcelona 2009


removal and had the opportunity to exploreother aspects in a Question and Answer sessionat the end of the day.

Bausch & Lomb have run MICS™ courses acrossthe UK during 2009 in London, Leeds,Edinburgh, Manchester, Bristol and Birmingham.From the feedback we have received so far thisyear, 90% of attendees said they would happilyattend another Bausch & Lomb education eventin the future.

We have, therefore, planned further newcourses for next year so please visitwww.academyofvisioncare.co.uk/events tofind out more details.

‘MICS™ has a positiveimpact on astigmatismand wound healing’

Course feedback and commentsThe courses were rated on average at4.25 out of 5, with the history of phacoreceiving the highest score of 4.44

87.5% of you said that you wouldattend another Bausch & Lombeducational event

‘If you can send me details of yourManchester course, I would like more ofmy staff to attend’

‘CMICS does not require additionalclinical skills’

‘MICS™ has a positive impact onastigmatism and wound healing’

‘An opportunity to see others performsmall incision surgery’

‘MICS™ is the way forward’

‘I found it useful to learn how to inducechange/persuade the theatre team tochange’

‘MICS™ does not require extrainstrumentation’

‘Helpful tips on lens insertion’

‘A change to CMICS is imminent’

Refractive outcomes following micro-incision cataract surgery lens implantation

S. Prasad, U. Saeed, S. Awotesu, B.V. Kumar

Purpose: To find out refractive outcomes after bimanual micro incision cataract surgery and lensimplantation.

Setting: Department of Ophthalmology, Arrowe Park Hospital, Wirral University Hospital NHStrust, Wirral, Cheshire CH49 5PE

Methods: Retrospective collection of data of patients undergoing bimanual MICS™ was donefrom Electronic patient records (Medisoft). Pre-operative biometery and keratometry wereperformed with IOL master using an adjusted A-Constant 118.5. Surgery was carried out withtwo superior clear corneal 1.6mm incisions at 10 o'clock and 2 o'clock positions. Bimanualcataract surgery was carried out with a sleeveless phaco-emulsifier hand-piece and an irrigatingchopper. Irrigation aspiration was carried out by a bimanual irrigation aspiration system. Anintraocular lens (Bausch & Lomb Akreos® MI60) was inserted in the capsular bag after enlargingthe wound to 1.8mm and using wound assisted injection technique. The post-operative refractionand complications were noted.

Results: Data regarding 49 eyes of patients who underwent cataract surgery was collected andanalysed. All patients underwent bimanual MICS™ with no intra-operative complications noted.Simultaneous refractive procedures like arcuate keratotomy or limbal relaxing incision were notperformed. The average deviation from predicted refraction based on SRK-T readings were+0.162 dioptres in spherical equivalents (standard deviation 0.62). Minimum deviation of 0 andmaximum deviation of +1.88 dioptres was seen. Average change in astigmatism was calculatedto be -0.08 dioptres. (Standard deviation was 0.69 with a calculated median of 0). Maximumchange in astigmatism induced ranged from +1.75 dioptres to -1.5 dioptres.

Conclusions: Bimanual micro-incision cataract surgery (sub 2mm) can be successfully carried out with small changes in incision induced astigmatism. The A-Constant may be personalised fora particular surgeon and IOL, if the biometery parameters remain consistent. The A-Constant forthis particular lens was adjusted with good refractive results.

ESCRS Abstract, Barcelona 2009

CMICS

BMICS


Steve Martin, Director of Influence at Work (UK)


The Science of ComplianceIn the third of our series of articles on ‘the role of influential communication’ Steve Martin and Nick Pope continue their look at ‘the role of persuasion’ and considerthe influence of others on the decisions we make.

For over sixty years persuasion researchershave studied the influence process and foundthat anyone can significantly increase thelikelihood that others will be persuaded bytheir requests, messages and advice byemploying one or more of the six universalprinciples of influence.

These principles are:

Social proof - people behave in a similarway to others who are like them

Reciprocity - obligates people to do forothers what they have done for them

Consistency - causes people to act in linewith previous commitments even if demandsescalate

Authority - people defer to those withexpertise and credibility to guide theirdecisions

Liking – people are influenced more bythose whom they like, and who like them

Scarcity - opportunities appear morevaluable when they appear less available

Although there is little doubt that other people’sbehaviours are a powerful source of socialinfluence, in studies when people are askedwhether other people’s behaviour influences theirown, they will often insist that it does not, butexperimental social psychologists know better.

One of the simplest demonstrations of thepersuasiveness of others’ behaviour over ourown, was a classic study that was originallyconducted almost 60 years ago. PsychologistStanley Milgram simply asked one of his studentsto stand on a busy street corner and look up inthe air. While the student was staring into space,Milgram stood on the other side of the road andcounted the number of passers-by who stoppedand looked into the air too. The result? Very fewuntil Milgram made one small change.

Instead of asking one student to stand on thebusy street corner and stare into the air hearranged for a group of five students to do so.

Now some 400% more passers-by stopped andstared into space for no other reason than‘everyone else seemed to be doing it’.

So the behaviour of an initial group can causemany others to be persuaded to behave in thesame way – especially when information islacking or people are uncertain. Even thoughmost of us would prefer not to admit it, this herd-like following of others is a veryefficient shortcut to a (generally) good decision. For example, imagine you are on holiday andlooking for a good place to eat one evening.One way of choosing a restaurant is to look inyour guidebook for a recommendation. But what if nothing in your guidebook appealsto you? Or what if you don’t have a guidebook?What would you do?

Maybe you might find yourself being drawntowards the busiest restaurant. You think “ifeveryone else is eating there then it must bethe best place for me to eat too”. Your decisionhas been influenced by the behaviour of others– a phenomenon called social proof.

Unfortunately for Eye Care Professionals, when anindividual is trying to decide which optician theyshould make an appointment with, they are

unlikely to witness a lengthy queue outside onespecific practice that provides them with socialproof information that this is the place to go.

So does this mean that because other people’sbehaviours are unlikely to be witnessed first-handin the world of optometry and ophthalmology that social proof cannot be employed by Eye CareProfessionals? We think not.

Results from numerous studies confirm that we don’t necessarily need to see peoplebehaving in a certain way to follow theirbehaviour. We just need to know of informationthat they have behaved in a particular way. In one study persuasion researcher RobertCialdini was able to increase by 26% thenumber of hotel guests who were willing toreuse their towels by simply informing guests,

Nick Pope, Global Director of Learning and Sales Training at Bausch & Lomb

Results from numerousstudies confirm that we don’t necessarilyneed to see peoplebehaving in a certain wayto follow their behaviour.



via a commonly used card in hotel bathrooms,that the majority of other guests who had been staying in the hotel had also reused their towels. An entirely honest and effectivestrategy that was costless to implement.Therefore, informing patients of your mostpopular lenses, solutions and spectacles can be a very productive and persuasive thing to do assuming that those choices are potentiallyright for them too.

Research into the social proof phenomenonshows that when people are anxious oruncertain they are especially influenced bysocial proof. As a result, an eye carepractitioner who gently points out that “otherpatients like them often feel nervous at thestart of the exam but quickly find they are ableto relax” is providing some very important andpotentially persuasive words of comfort to anuncertain or anxious patient.

The social proof approach should also beeffective when it comes to helping patientsmake choices, say between lenses and

in such cases it would be most persuasive topoint out the number of other youngprofessionals you have on your patient listwho have chosen these lenses. The evidenceshows that the ‘people like me’ approachdoesn’t just hold for age and profession butcan hold for other characteristics such as theirgender or sports interests. For this reasonalone it can be very useful to pass oninformation about individual patients you haveexamined to colleagues who are responsiblefor talking about the products and servicesyou offer. By doing this you will ensure thatthey can select the most relevant social proofinformation to provide to patients.

Steve Martin, Director of Influence At Work (UK),

co-author of the international bestseller Yes!

50 Secrets from the Science of Persuasion.

Nick Pope, Global Director of Training at

Bausch & Lomb

spectacles. For example, pointing out to newlydiagnosed presbyope patients that otherpresbyope patients are increasingly turning tomulti-focal lenses rather than spectaclesprovides important information of how othershave acted in the past.

Additionally, evidence from social proofstudies show that the more tailored the socialproof information provided is for ‘people likeme’, the more persuasive it becomes. For example, imagine you believe that ayoung professional patient of yours is mostsuited to daily disposable contact lenses, and

The evidence shows that the ‘people like me’approach doesn’t justhold for age andprofession.

Pointing out to newlydiagnosed presbyopepatients that otherpresbyope patients areincreasingly turning tomulti-focal lenses ratherthan spectacles.


Bausch & Lomb supports new ‘Eye Meeting’ atNorthamptonBausch & Lomb is delighted to be a jointsponsor of the inaugural ‘Northampton EyeMeeting’, to be held on Friday 20th November2009 at Highgate House, Creaton,Northamptonshire.

Mr Tristan McMullan, Northampton’s ConsultantOphthalmic and Oculopastic surgeon, has attractedsome excellent speakers throughout England forthis meeting. The meeting will cover orbit,lacrimal, glaucoma and uveitis, and will giveconsultants and juniors an up to date assessmentof progress from leaders in these fields.

The meeting is to be held at Highgate House inCreaton, which is an excellent setting withineasy access of the M1 and A14. The fees havebeen kept down to as low as £40 (includinglunch) due to the generous sponsorship by MSDand Bausch and Lomb.

To register your interest in attending, send anemail to [email protected] with thesubject heading “Northampton Eye Meeting”,providing your name and telephone number.

Mr McMullan is a Consultantat Northampton GeneralHospital NHS Trust. He spent 11 years trainingas an ophthalmologist withextensive sub-specialisationin oculoplastics in both theUK and the USA.

In the UK, Mr McMullan honed his skills innon-cosmetic surgery, and whilst in the Stateshe refined his expertise in cosmeticprocedures at the Center for FacialAppearances, home to two of the leadingophthalmic plastic surgeons in America.

His training on both sides of the Atlantic hasenabled him to choose the best practice andtechniques from both. He applies theprinciples of cosmetic surgery to functionalsurgery and vice versa to optimise results.

A Cambridge graduate with a PhD inmolecular genetics, Mr McMullan hasretained an interest in research, both clinicaland scientific. He has published numerouspeer-reviewed papers and presented atnational and international conferences. Mr McMullan is a member of the BritishOculoplastic Surgery Society.

Don’t forget you can receive 5.5 CPDAccreditation points by attending this meeting.

Don’t forget you can receive 5.5 CPDAccreditation points by attending this meeting.


Mr Tristan F W McMullan MA PhD FRCOphthConsultant Ophthalmic and Oculoplastic surgeon

• Orbital trauma• The immunological basis of thyroid

orbitopathy• Medical orbital decompression for thyroid

eye disease - why, how and with what• Surgical orbital decompression for thyroid

eye disease - when and how• The assessment of epiphora• Update on lacrimal surgery• Lacrimal gland tumours

Professor Philip Murray, Professor of Ophthalmology

Talks at the Northampton Eye Meeting to include:• Fillers to the upper lid• Non-surgical tear trough and mid-face

rejuvenation• Uveitis• Choroiditis• Factors affecting conjunctival healing in

glaucoma surgery• The optometrist’s role in the management of

glaucoma, within and without the hospitalsetting – a nice touch

Management of Ocular InflammationWednesday 25th November 2009Austin Court, Birmingham

Chair: Professor Philip Murray

Speakers: Mr Miland Pande, Mr John Dart,Professor Harminder Dua, Mr Stephen Tuft, Professor Peter Shah

Email: [email protected]


LETTERS 19

Have your say...

“Working in the Lincoln area I am very lucky tohave the support of our local optometrists whohave committed to providing the local cataractservice with feedback on patients’ refractiveresults, following phacoemulsification.

Using data the optometrists have provided, we have been able to refine some of ourpractices in theatre, and one of the mostimportant of these, I feel, is the optimisationof the A-Constant used for intraocular lenses.Whilst lens manufacturers do their best toprovide us with an accurate A-Constant, it is often based on laboratory studies and it is imperative that each of us adjust our A-Constant to perfect the refractive outcomes.

Do you have an interesting topical news

story to tell, or a worthy article that you

would like to share with the rest of the

readers. We would very much like to hear

from you. Please send your letters (including

your full name, email, postal address and

postcode) to Jill Collishaw, Visions Editor

at: [email protected] or by post

using the address on the back cover.

Your opinion is greatly valued…

In a recent study in Lincoln County Hospital, we found that by using the refractive outcomedata from patients receiving the Bausch & LombMI60 lens, we could adjust the manufacturers’A-Constant (from 118.4 to 119.0 in thisinstance) to leave 91.4% of patients within 1 dioptre of predicted refractive outcome.Resulting in an 8.3% increase on using themanufacturers’ A-Constant.

I would highly recommend that every surgeoncarries out a similar review to ensure that theyare giving their patients the very best result.”

YoursAndrew Castillo

Response by ‘Visions’Thank you Andrew for your letter and for yourcomments on A-Constant. We agree thatoptimisation of the A-Constant of a lens is veryimportant. Bausch & Lomb, as manufacturers,provide an A-Constant based on our laboratoryexperiences and insight into the design and lensmaterial as a basis for your calculations.However, we cannot take into account everyfactor of a surgeon’s individual approach andoften technique, method of biometry and choiceof lens calculation formula will have an effect onthe best A-Constant for the lens. As standard

Andrew CastilloConsultant Ophthalmologist, Lincoln County Hospital

Paul UrsellConsultant Ophthalmologist, St Helier Hospital

“I was recently offered the chance by B&L tobe the first in the UK to trial a new design of your single use irrigation handpiece. This new variation has an entirely silicone tip surrounding a metal aspiration tube.

I was keen to see whether this design wouldoffer significant improvements over thecurrent metal tipped designs whilst curious asto whether a silicon formed tip would deformunder vacuum.

I performed ten surgeries with the handpiecesand was very impressed. The tip is extremelysafe to use in capsule polishing and corticalclean-up as at no time is there any metal orsharp port edges in contact with the capsularbag. It is also robust enough not to deformunder vacuum or during port occlusion and beused for IOL manipulation. I also let two ofour junior staff try the handpieces and theyfelt very reassured by the safety of thesilicone design, especially when an occasionalsnagging of the capsule occurred.

I think this technology offers significantbenefits in safety to all surgeons, bothtrainees and consultants, and haverecommended we move to it immediately inmy theatre.

Thank you for allowing myself and the team atSt Helier Hospital to be the first to have a go.”

RegardsPaul Ursell

practice, Bausch & Lomb print the A-Constant forA-Scan biometry on our packaging of each IOL.

For those hospitals that use the Zeiss IOLMaster, the website for the User Group forLaser Interference Biometry (ULIB) ishttp://tinyurl.com/fb3sx. This websiteprovides guidance on A-Constant for otherlens calculations formulae based on a patient’srefractive outcomes. IOL Master users areencouraged to upload their results to this siteto help refine the A-Constant for each lens.


Bausch & Lomb IncorporatedBausch & Lomb House106 London RoadKingston-upon-ThamesSurrey, KT2 6TN, UK

Tel: 020 8781 2900Fax: 020 8781 2901Website: www.bausch.co.uk

™ and ® denotes trademark and registration mark of Bausch & Lomb Incorporated. © Copyright 2008 Bausch & Lomb Incorporated. All rights reserved.

www.bausch.co.uk

Did you know?

The largest eyeball ever to be studied on the planet belonged to a Colossal Squid

(Mesonychoteuthis hamiltoni) which was recovered in New Zealand. At 27 centimetres

(11 inches) across the eye dwarfs our human equivalent many times over. The squid's

crystalline lens was 5 centimetres across and split into two parts; a common feature

in cephalopods.

Speculating on the size to which these elusive creatures grow, scientists believe that

their eyes may be anything up to 45 centimetres (18 inches) wide, which would make

them roughly the same size as a watermelon, with a lens equivalent to an orange!


Sight over forty...disposable patients with the toric lens to deliver clear, stable vision and...

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Transcript of Sight over forty...disposable patients with the toric lens to deliver clear, stable vision and...