REFRACTIVELENS

VOLUME 16 ISSUE 4 APRIL 2011

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PublisherCarol FitzpatrickExecutive Editor Colin KerrEditors Sean Henahan Paul McGinn

Managing Editor Caroline BrickProduction EditorAngela SweetmanSenior Designer Paddy Dunne

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

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THIS MonTH...

Special Focus Refractive Lens 4 Cover Story: Surmounting difficulties with refractive lenses 8 Favourable results reported with multifocal IoL9 Good one-year results with light-adjustable lens10 Endothelial health a consideration after implanting phakic IoLs

ESCRS Winter Meeting Report 12 Coverage from the 15th ESCRS Winter Meeting in Istanbul

Cataract 14 Femtosecond lasers and cataract surgery

Refractive Laser 17 All-laser LASIK promising for myopic patients20 InTRACoR safe and effective treatment for presbyopia

Cornea 23 Corneal collagen cross-linking effective in children with keratoconus24 Intense pulsed light treatment may help clear meibomian gland

Glaucoma 26 Combined procedure may be effective in glaucoma management27 Tonometer provides new alternative IoP measurement

Retina 31 Microplasmin well tolerated by ocular structures32 Good results seen with bevacizumab for DME

Ocular 33 Changes to diagnosis of Marfan syndrome

News 34 EURETInA president looks forward to congress in London35 EUREQUo leads the way36 Preview of the joint SoE-AAo Congress

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Published byThe European Society of Cataract and Refractive Surgeons

Features 37 EU Matters 39 Book Review 40 Bio-ophthalmology 41 Industry news

42 Practice Development42 Journal Watch43 JCRS Highlights44 Calendar

With this month’s issue... ‘Current SurgiCal OptiOnS fOr ViSual rehabilitatiOn in KeratOCOnuS’

VOLUME 16 ISSUE 4 APRIL 2011

Cover image: Implanting the WIOL-CF IOL. Image courtesy of Ioannis Pallikaris MD, PhD

by José Güell

one of the great strengths of EuroTimes is that it allows me and my colleagues the opportunity to debate issues that we might not always consider in our day-to-day practice and that we would have not considered for

publication in a peer-reviewed journal.As a busy surgeon, you are constantly trying to do what is best

for your patients but you do not always get enough time to reflect on some of the bigger issues that may lie ahead.

That is why I am glad to see that this month’s EuroTimes discusses what’s next for refractive intraocular lenses. This Cover Story is based on some of the recent discussions held at the XXVIII Congress of the ESCRS in Paris where Dr Philippe Sourdille co-chaired a clinical research symposium on ‘New IOL Materials and Micro Designs’.

As Dr Sourdille points out in our Cover Story, patients having refractive lens surgery are much more demanding in terms of contrast and reading distance. our story also discusses some recent research presented at our recent Winter Meeting in Istanbul presented by oliver Findl MD and Ioannis Pallikaris MD, PhD. I have my own views on the best way forward and I would urge you to read our Cover Story and make your own mind up about where we are going or should be going with refractive IoLs.

This month’s issue of EuroTimes also features our regular updates on refractive laser, cornea, glaucoma and retina based on reports from the major international meetings we have attended in recent months. one of the fascinations of attending these meetings is that as soon as you leave one meeting you are preparing for another where the data or presentations you have discussed are being constantly updated.

I am just back from the 15th ESCRS Winter Meeting in Istanbul, Turkey which was an outstanding success thanks to yet another excellent educational programme which included a combination of well structured didactic courses with the active participation of our attendees in the free papers and posters sections, but also to the opportunity it offered us to meet some new colleagues from the east.

More than 1,600 delegates attended the meeting and I must offer particular thanks to my colleague Bekir Aslan, president of the Turkish Cataract and Refractive Society, who assisted the ESCRS in organising the meeting. As always we cannot be content to rest on our laurels and work is already well advanced for the XXIX ESCRS Congress in Vienna, Austria which for the first time will be held alongside the EuCornea meeting.

Last year in Paris we were delighted to work with our retina colleagues at the EURETInA Congress and this year we have an opportunity, as cataract and refractive surgeons, to work closely with our cornea colleagues.

More details of the XXIX ESCRS Congress and the 2nd EuCornea Congress will be published in EuroTimes in the coming months and also on our websites at www.escrs.org and www.eucornea.org.

Finally, I would urge you as always to read this month’s EuroTimes from cover to cover to make sure you do not miss out on the latest news in ophthalmology and if you have any views or observations, please contact us and share your thoughts.

VOLUME 16 ISSUE 4 APRIL 2011

EUROTIMES | Volume 16 | Issue 4

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editorial

the best way forwardsurmounting difficulties with refractive IoLs

José Güell

Clive Peckar

Emanuel RosenChairman

ESCRS Publications Committee

Ioannis Pallikaris

Paul Rosen

Medical Editors

International Editorial Board

EUROTIMESESC

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noel alpins australia

bekir aslan turKEY

bill aylward uK

peter barry irElaND

roberto bellucci italY

hiroko bissen-Miyajima JaPaN

John Chang CHiNa

Joseph Colin FraNCE

alaa el Danasoury sauDi araBia

Oliver findl austria

i howard fine usa

Jack holladay usa

Vikentia Katsanevaki GrEECE

thomas Kohnen GErMaNY

anastasios Konstas GrEECE

Dennis lam HONG KONG

boris Malyugin russia

Marguerite McDonald usa

Cyres Mehta iNDia

thomas neuhann GErMaNY

gisbert richard GErMaNY

robert Stegmann sOutH aFriCa

ulf Stenevi sWEDEN

emrullah tasindi turKEY

Marie-Jose tassignon BElGiuM

Manfred tetz GErMaNY

Carlo enrico traverso italY

roberto Zaldivar arGENtiNa

Oliver Zeitz GErMaNY

José Güell is president of the ESCRS

www.vsybiotechnology.com

by Sean Henahan

Patients having refractive lens surgery have high expectations 

In some ways standard cataract surgery has become the simplest form of refractive lens surgery. A typical cataract patient can expect to achieve

something like 20/20 uncorrected distance vision with monofocal intraocular lenses, perhaps with the added benefit of some pseudoaccommodation to help with near vision. This is a considerable advance from what a patient might have expected a few short years ago.

Patients today first receive better pre-op work-up thanks to advances in biometry. They then will receive a lens that may compensate for spherical aberrations, blocks potentially harmful UV light, and if necessary can also have astigmatism corrected either with a toric IoL, or surgical or laser enhancement on the cornea.

However, it is when surgeons attempt to provide useful vision at near, middle and far, either for cataract patients or for presbyopic younger patients with clear lens replacement that it becomes apparent there are still some significant obstacles ahead.

So-called premium lenses all come with compromises. The way forward will be about surmounting these difficulties.

Dr Philippe Sourdille, former president of the ESCRS, co-chaired a clinical research symposium on ‘new IoL Materials and Micro Designs’ at the XXVIII annual congress of the ESCRS in Paris last September. Multifocal IoLs offer many patients the chance for spectacle independence. But presentations at the symposium underscored problems with the multifocal lens approach, particularly greater rates of PCo, higher explantation rates - and a lot of dissatisfied patients.

“The Belgian 2008 national cataract registry showed an overall incidence of YAG capsulotomy of 47 per cent! We cannot afford to ignore this. The peer-reviewed literature confirms this growing incidence of PCo, and suggests it is related to small incision IoLs, where the rate is four times higher than with standard IoLs, and to multifocal IoLs where the rate is three times higher, even when the lens material is the same. The lens is the

same but the patients are not. Patients having refractive lens surgery are much more demanding in terms of contrast and reading distance,” Dr Sourdille told EuroTimes.

Dr Sourdille also noted that, in spite of significant improvements in IoL optics, materials, and designs, knowledge of the capsule itself is lagging behind. Knowing the size of the capsule, and where the IoL sits in the bag is very important for all lens implantation surgery, but is especially important when considering the use of accommodative IoLs now and in the future, he stressed.

“What we’re doing now with multifocal lenses or the so-called accommodative lenses is just an intermediate step to something hopefully in the future which will more completely resolve the problems of ametropia and presbyopia. The multifocal lenses of today clearly are an optical compromise, you have dysphotopsia, and you have loss of contrast sensitivity. Even though quite a few patients are able to tolerate that and

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a Lot doNe, More to do

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The multifocal lenses of today clearly are an optical compromise, you have dysphotopsia, and you have loss of contrast sensitivity

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Oliver Findl MD

The Belgian 2008 national cataract registry showed an overall incidence of YAG capsulotomy of 47 per cent! We cannot afford to ignore this

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Philippe Sourdille

Implanting the Crystalens HD IOL

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are very happy with these lenses, there is a significant number of patients that are not,” oliver Findl MD, consultant ophthalmic surgeon, Moorfields Eye Hospital, London, told EuroTimes.

The multifocal IoLs appear to have earlier and more PCo requiring YAG laser treatment. It may be that they don’t have more PCo than monofocal IoLs, but they have subtle PCo that for a monofocal lens would not be such a problem. But with a multifocal IoL splitting the light onto two or more foci, there is a loss in light intensity, so with even slight PCo, contrast sensitivity declines rapidly, and the patients are not happy, explained Dr Findl.

Better than monovision? Yes and no Before refractive lenses became available, lenticular monovision was one of the few choices available to presbyopes. Speaking at the 15th ESCRS Winter Meeting in Istanbul, Dr Findl presented a preliminary report from the Moorfields IoL study group comparing standard IoL monovision with multifocal IoLs in 212 cataract patients. Patients randomised to the monovision group underwent bilateral implantation of the Akreos Adapt Ao (Bausch + Lomb) single piece aspheric hydrophilic acrylic. Surgeons targeted the dominant eye for distance, aiming for 1.25 D difference between two eyes. The multifocal group underwent bilateral surgery with the Tecnis ZM 9000 (AMo) diffractive MIoL.

“Monovision has been around for quite a while and works very well clinically. But on the con side you can have reduced stereovision, because of anisometropia. Also, the near vision isn’t always that great. Many patients do well with multifocal IoLs, but the cons include reduced contrast sensitivity, dysphotopsia, and in the case of diffractive lenses, problems with intermediate vision."

A six-month follow-up evaluation including full ophthalmic examinations and a validated questionnaire showed that 25 per cent of the monovision patients reported being completely spectacle independent at all times, compared with 70 per cent of multifocal IoL patients, a highly statistically significant result.

However, when it came to IoL exchange, it was a different story. nearly five per cent of patients in the multifocal group required IoL explantation, and more patients in this group refused to undergo second eye surgery. The main reason for explantation was patient dissatisfaction, primarily related to dysphotopsia.

“This to us was quite an alarming result. We are still trying to interpret the results to find out why we have a much higher rate than we usually hear about at meetings. Although there was a survey published in 2008 showing a large increase in IoL exchange in the US. We know that 25 per cent of IoL exchanges in the US are for multifocal IoLs, even these lenses only account fro some five per cent of the total lenses used.“

Accommodative IOLs Accommodative IoLs offer the hope of good visual acuity at all distances without the compromises inherent in multifocal lens designs. By definition, such a lens should undergo a shift in movement of the optic, simulating natural accommodation. However,

the problem with so-called accommodative lenses on the market seems to be that they don't actually move much if at all.

The Crystalens IoL (Bausch + Lomb) is the first and so far only lens the US FDA allows to be labelled as an accommodative lens. Its mechanism of action is attributed to forward movement of hinged optics in response to ciliary muscle contraction. The lens has undergone several changes in design since its initial release. These include a larger optic, changes in the haptics, and most recently, the addition of a central 1.5mm near zone.

“The movement of the optic of this lens was never really shown in a peer-reviewed way with a precise and reproducible measurement technique. Its action is ascribed to some sort of bowing or bending of the IoL optic with some change in refraction of the lens. To the best of my knowledge, this hasn’t really been shown either,” said Dr Findl.

A study presented by Ioannis Pallikaris’ group at the Istanbul ESCRS meeting compared the effects of putting the Crystalens HD in the bag or in the sulcus. Both groups had equally good results for far and near and the pseudoaccommodative effect was obvious. The effect of the Crystalens as Prof Pallikaris presented during the congress is dual. The static component of pseudoaccommodation provides an increase in depth of focus ranging between 1 and 3 dioptres (pseudophakic pseudoaccommodation) while the dynamic component which can be proven by the use of the iTrace technology shows a forward movement of approximately 0.5 to 0.8 dioptres (pseudophakic accommodation).

other investigators report that the effect of this lens in short and very long eyes

has always been very similar. one would expect a greater effect in a hypermetropic eye because of the purported mechanism of the system.

nonetheless, many clinical researchers, including John A Hovanesian MD, UC Los Angeles, California, and Mark Tomalla MD Duisburg, Germany continue to report good visual outcomes with the Crystalens HD.

The Synchrony dual optic accommodating IoL (AMo) has two optics that work together under ciliary pressure to create a modest accommodative effect. A surprising bonus of the lens has been a very low incidence of PCo. This has been attributed to the way the natural shape of the lens keeps the capsule filled, possibly combined with its silicone material. With follow-up as long as five years the lens maintains its clarity with no fibrotic or regenerative PCo or ACo. UBM studies show some movement of the optics, with a small change in distance between the two optics.

The WIoL-CF (GelMed International) is a new IoL that seeks to imitate the natural lens, which it resembles in shape and size. The lens is 9.0mm in diameter and 1.0mm to 1.5mm thick. The anterior side of the lens has a meniscoid surface while the posterior surface is a hyperboloid. It fills the bag and its posterior surface comes into contact with posterior capsule. The IoL can be injected through a 2.8mm incision.

Ioannis Pallikaris MD, PhD Institute of Vision and optics, University of Crete School of Medicine, Heraklion, Crete, Greece presented the latest results with the WIoL at the ESCRS Winter Meeting in Istanbul. With up to one year of follow-up, 25 patients who received the lens showed improvements in visual acuity at near, middle and far distance. Most could read without spectacles.

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Crystalens HD in the bag implantation

Accommodating IOLs clearly represent the future of refractive surgery in the attempt to cure presbyopia

“Ioannis Pallikaris MD, PhD

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Cover StoryPhilippe Sourdille – philippe.sourdille@wanadoo.frOliver Findl – ofindl@googlemail.comIoannis Pallikaris – pallikar@med.uoc.grJosé Güell – guell@imo.es

contacts

He attributed the functionality of the lens to a combination of pseudoaccommodative effects associated with the interaction of the lens with the ciliary body, as well as the polyfocal design of the lens. no patient developed PCo. Wavefront studies show evidence of some movement of the lens, on the order of 1.18 dioptres.

“I think this lens represents a very promising alternative. Accommodating IoLs clearly represent the future of refractive surgery in the attempt to cure presbyopia,” noted Prof Pallikaris.

Adjusting sphericity “Today we’re all aware that despite great improvements in IoLs and biometry, one-third of patients have 0.75 D or more of residual spherical error, with a similar number having 0.75 D of astigmatism,” Jose Guell MD, Universidad Autonòma de Barcelona, Spain, and current president of the ESCRS, told a session of the Istanbul conference.

Dr Guell provided an interesting update on the Light Adjustable Lens (Calhoun Vision), an IoL designed to correct less than perfect outcomes following IoL implantation. He reported that the indications for this lens are expanding so that should allow more options than correcting spherical problems.

The Light Adjustable Lens allows up to 2.0 D of UV light activated refractive adjustment following conventional cataract surgery. The lens is made of a proprietary silicone macromer. Targeted UV light changes the shape of the anterior face of the IoL. The adjustments take place one to two weeks after the surgery when vision has stabilised. The adjustment itself takes only two minutes. A day or two later, patients undergo the final ‘lock in’ treatment, Dr Guell explained.

“Burkhard Dick MD has reported long-term results with the Light Adjustable Lens for myopic and hyperopic adjustments. one year after the ‘lock in’, 99 per cent of patients were within 0.5 D of the planned correction. More recent reports on astigmatic correction are also promising, with 86 per cent achieving 20/20 or better final uncorrected vision, which compares favourably to the 38 per cent reported for toric IoLs in FDA studies,” Dr Guell noted.

“Astigmatic correction with the Light Adjustable Lens may prove especially useful in special cases such as post-LASIK, post-PRK, and post-RK. Biometry is usually much more difficult in such cases, so it often would not be feasible to retreat the cornea in these patients,” Dr Guell commented.

It appears the Light Adjustable Lens could also have potential use for treating presbyopia. one approach now being tried is adjustable monovision – in which the goal is to target the non-dominant eye to -1.25 D using light adjustment, with a standard lens in the other eye.

A second approach is to use a customised progressive add for a multifocal result.

This involves ‘adjusting’ a small add zone in the visual axis of the lens. This has the potential advantage over other multifocal IoLs of better predictability. The surgeon could increase power add with an adjustment if necessary after the initial surgery. Arturo Chayet MD and Dr Dick have both recently reported good preliminary results with this approach.

A third approach would involve adjusting spherical aberration to create intentional pseudoaccommodation. Initially suggested by Pablo Artal PhD, the idea is to induce changes in depth of focus by inducing changes in negative sphericity. This could allow for good binocular vision at near and far without residual myopia, Dr Guell said.

“These presbyopic approaches are highly promising. I am particularly in favour of the spherical aberration manipulation approach. I believe this offers the opportunity to improve final vision in many patients.”

A little further down the pipeline, the technology used in the Light Adjustable Lens could also be used for refilling the capsular bag along the lines proposed by okihiro nishi MD. A phakic IoL employing this technology is also under consideration.

Implanting the WIOL-CF IOL

These presbyopic approaches are highly promising. I am particularly in favour of the spherical aberration manipulation approach

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José Güell MD

“burkhard dick Md has reported long-term results with the Light adjustable Lens for myopic and hyperopic adjustments”José Güell MD

Don’t miss Istanbul Winter Meeting Report, see page 12

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Systane_Ad EUROTIMES 270x320®.indd 1 01/03/11 15:50

update

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EUROTIMES | Volume 16 | Issue 4

Surgeons implanting the Lentis MPlus multifocal IoL (oculentis) reported favourable impressions about this novel technology at the XXVIII

Congress of the ESCRS in Paris, France.Magda Rau MD, head of Eye Clinic Cham,

Germany, and Joao Póvoa MD, Department of ophthalmology, University Hospital of Coimbra, Portugal, reported three-month outcomes for small cohorts of bilaterally implanted cataract surgery patients. Their results showed the presbyopia-correcting IoL was providing both good visual function and quality of vision.

The Lentis MPlus is an acrylic, single-piece, pupil-independent, aspheric multifocal IoL designed based on a concept of rotational asymmetry. It combines an aspheric asymmetric distance vision zone and an embedded, sector-shaped near vision zone with +3 D of add (+2.4 D at the spectacle plane) to provide seamless transition between the two optical zones.

“The spherical centres of the two surfaces lie on the optical axis of the sector lens and the vertexes of both surfaces coincide with the origin. Consequently both principal foci of the lens are on its optical axis, and the light at the transition zones is refracted away from the optical axis. This should reduce glare and haloes, which in my opinion, is a great advantage of the lens,” said Dr Rau.

“our initial results are promising in showing a high rate of complete spectacle independence, good contrast sensitivity, no haloes, and no disturbing glare. Final assessment depends on data collection from more patients and longer follow-up.”

Dr Rau reported outcomes for 10 patients bilaterally implanted (mean age 67 years). In distance testing at three months postoperatively, mean UCVA was 0.69, mean BCVA was 0.78, and the mean correction was -0.43 D.

“These first procedures were completed over a short period of just two months at the

end of 2009, and without any individually modification in the recommended A-constant. We were targeting a refraction of -0.5 D to avoid a hyperopic outcome, and using the manufacturer’s recommended A-constant, some of the refractions ended up a little more myopic than we intended,” said Dr Rau.

“While at three months, it was difficult to correct the patients successfully to 1.0, in longer follow-up to six months, distance vision has improved. Postoperative refraction is difficult with this lens and so accurate IoL power calculation is important. now we are using an A-constant of 188.0 and are calculating power with a planned refraction around plano so as not to compromise distance vision,” she told EuroTimes.

The group had a mean intermediate UCVA of 0.88 and mean near UCVA of 0.76. Good functional results were also achieved in testing of reading speed with Radner charts under photopic conditions.

Contrast sensitivity was measured using functional acuity contrast method of Ginsburg, and the average contrast sensitivity curve was under normal area.

“These results are noteworthy considering our study group included some relatively older patients,” said Dr Rau.

Results from a questionnaire administered at three months showed a 10 per cent rate of glare. Complete spectacle independence was achieved by 60 per cent of patients, and the rest needed glasses only occasionally in special situations for distance (20 per cent) or reading small print (20 per cent). no patient needed glasses for desktop computer use.

Eight of the 10 patients were very satisfied with the optical results, one patient was satisfied, and one was dissatisfied

“Poor distance vision was the reason for the one patient’s dissatisfaction, but we have to keep in mind some of these first patients had a less than optimal refractive outcome,” said Dr Rau.

Dr Póvoa reported on another group of 17 patients (mean age 66, range) and compared their quality of vision outcomes with a control group of normal eyes without cataract. Mean distance BCVA for the MLentis Plus patients improved from 0.6 preoperatively to better than 1.0 at one and

three months. Their mean distance UCVA was 0.3 preoperatively and 0.9 at one and three months. At three months, mean near and intermediate UCVA were 0.8 and 0.6, respectively.

The researchers evaluated chromatic perception using a modified Cambridge Colour Test. This showed that chromatic discrimination in all three axes (protan, deutran, and tritan) was significantly impaired before cataract surgery compared with controls, but improved after the procedure so that one and three months postoperatively, there were no significant differences comparing the MLentis Plus group to the controls.

Contrast sensitivity was tested using Pelli-Robson charts and with a novel computerised psychophysical technique (Metrovision) that evaluated photopic and mesopic contrast sensitivity as well as glare.

“The computerised method offers a quantitative assessment of contrast sensitivity. Compared with traditional clinical semi-quantitative methods used to assess visual performance, it has an advantage because the testing steps can be calibrated and dynamically changed in a random manner, unpredictable to the observer. Therefore, it is less prone to artefacts,” said Dr Póvoa.

Both tests showed the cataract patients had significant contrast sensitivity and glare impairment prior to surgery compared with controls. All measurements in the MLentis Plus group improved by one month after surgery, and there was continued improvement in glare between one and three months.

By one month postoperatively there was no significant difference in mesopic contrast sensitivity (Metrovision) between the MLentis Plus patients and controls. However, statistically significant differences remained comparing the one and three-month postoperative results for the MLentis Plus patients and controls for the Pelli-Robson test and photopic contrast sensitivity and glare measured with the computerised method.

“Longer follow-up is required to determine to what degree these findings correspond to patient satisfaction,” said Dr Póvoa.

Magda Rau – rau@augenklinik-cham.deJoao Povoa – joaoalbertopovoa@gmail.com

cont

acts

NoveL MuLtIfocaL IoLearly results show optical design provides a full range of visionby Cheryl Guttman Krader in Paris

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ESCRS iLea rn P il o tTry out the new online academy for ophthalmologists

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Our initial results are promising in showing a high rate of complete spectacle independence...

“Magda Rau MD

Don’t miss EU Matters, see page 37

EUROTIMES | Volume 16 | Issue 4

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The light-adjustable intraocular lens (LAL®, Calhoun Vision) appears to be living up to its promise of eliminating refractive surprises in

both emmetropic and ametropic cataract patients, and the lens also has applications in the treatment of presbyopia, said H Burkhard Dick MD, Ruhr University Eye Clinic, Bochum, Germany.

“The LAL technology treats sphere, cylinder, spherical aberration and presbyopia with one IoL,” he told a session of the XXVIII Congress of the ESCRS.

The light-adjustable lens was developed by Dr Dan Schwartz and Dr Robert Grubbs, a nobel laureate in chemistry. The optic of the three-piece foldable silicone lens is composed of a material that allows adjustment of its refraction after implantation. The four basic components are an unpolymerised silicone matrix polymer, the polymerised macromer, a photo-initiator, and a UV-absorber at the back of the lens.

After undergoing implantation of the lens, patients must wear protective eyewear until adjustment and lock-in of the IoL’s refraction is complete, Dr Dick said. About

two weeks after implantation, a digital light-delivery device is used to adjust the IoL’s refractive power, irradiating either the centre or the periphery of the lens, depending on whether increasing or decreasing the IoL’s focusing power is necessary. on the following day, the entire lens is irradiated, which locks in the shape of the lens.

Good one-year results Dr Dick reported that since May 2008 he and Dr Fritz Hengerer MD have implanted the lens in 350 eyes, 220 that have had three months' follow-up and 125 of which had six months' follow-up. He noted that, overall, more than 98 per cent of treated eyes were within 0.25 D of the target refraction following the final lock-in.

Furthermore, in 110 eyes of 67 patients with 12 months' follow-up, the spherical equivalent was within one dioptre of target refraction in all cases, within half a dioptre in 99 per cent, and within 0.25 D in 95 per cent. In addition, UCVA was 20/30 or better in 99 per cent, 20/25 or better in 97 per cent, 20/20 or better in 86 per cent, and 20/16 or better in 26 per cent.

The LAL also achieved good results in 21 eyes of 21 patients with axial myopia. Their preoperative mean spherical equivalent was -2.21 D (range: -1.63 D to -12.38 D) and their mean axial length was 25.65mm (range: 24.13mm - 28.78mm). At 12 months’ follow-up all were within 1.0 D target refraction, 95 per cent were within 0.5 D, and 67 per cent were within 0.25 D. In addition, UCVA was 20/20 or better in 50 per cent, 20/16 or better in 17 per cent, and 20/25 or better in all eyes.

Similar results were achieved in 15 eyes of 15 patients with axial hyperopia. The patients had a mean axial length of 21.98mm (range 21.71mm to 22.20mm) and a mean spherical equivalent of +3.10 D (range: 1.25 D to 7.0 D). At 12 months’ follow-up, all were within 1.0 D of target refraction, 86 per cent were within 0.5 D, and 67 per cent were within 0.25 D. Furthermore, all were 20/30 or better, 67 per cent were 20/25 or better, and 27 per cent were 20/20 or better.

LAL shows potential in presbyopia The LAL may also be useful in the treatment of presbyopia, Dr Dick noted. There are several ways to take advantage of the IoL’s refractive adjustability and fine-tuning possibilities that could enable patients to have good near and distance vision. The approaches include adjustable monovision, the creation of a near add, and the creation of aspheric surface profile to increase depth of focus.

Adjustable monovision with the LAL is similar to most other monovision approaches. However, prior to locking in the refraction of the two eyes, the patient can decide whether to keep their

monovision as it is, undergo adjustment for more or less myopia, or opt instead for emmetropia in both eyes.

The customised near add (CnA) approach involves first adjusting for emmetropia in both eyes but then creating a near-add in the central part of the lens in the non-dominant eye. The aspheric profile involves the induction of negative spherical aberration to increase depth of focus. Several studies have shown that pseudoaccommodation correlates with negative spherical aberration and vertical coma.

of the three techniques CnA has been the most researched to date and has so far produced very encouraging results, Dr Dick said. For example, in 24 eyes of 24 patients in whom Arturo Chayet MD, Mexico, carried out CnA surgery, the uncorrected distance visual acuity in the non-dominant eye was 20/25 or better in 83.3 per cent of patients and the uncorrected near distance vision was 20/32 (J2) or better in 87.5 per cent at four-to-six months’ follow-up, Dr Dick noted.

other potential applications of the LAL include their use in eyes with difficult biometry after refractive surgery and for correcting higher-order aberrations. In addition, while at present cylinder can be adjusted by around 2.0 D, in the future there may be toric versions of the lens which will allow the finely tuned correction of greater amounts of astigmatism. Multifocal versions of the LAL may also become available, Dr Dick said.

“I predict that in years to come light-adjustable IoLs will become integral part of our surgical armamentarium,” he added.

H Burkhard Dick – burkhard.dick@kk-bochum.de

cont

act

LaL's broad raNgehopes of more predictable postoperative refractionby Roibeard O’hEineachain in Paris

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rEfracTivE lEns

EUROTIMES | Volume 16 | Issue 4

The battle between anterior and posterior chamber phakic intraocular lenses (IoLs) is fraught with questions over

stability, efficacy and safety – with both types of lenses promising all three. But the debate boils down to a single question: how much weight should surgeons attach to the risk of endothelial cell loss?

Thomas Kohnen MD, PhD, professor of ophthalmology and deputy chairman Goethe-University, Frankfurt, said iris-fixated anterior chamber lenses are safe and effective but require close monitoring because a number of studies have shown endothelium density can decline after three or four years.

Despite this, Prof Kohnen says the hydrophobic lenses currently on the market are easy to implant and offer excellent stability, provided patients are carefully selected.

For Bruce Allan MD, Moorfields Eye Hospital, UK, angle-supported anterior IoLs carry too many long-term concerns and the jury is still out on new iris-fixated options. With posterior chamber lenses, he said, the endothelium eventually recovers from any initial trauma suffered during implantation, as with phacoemulsification, whereas problems can begin to emerge with anterior IoLs over time.

Unlike anterior chamber lenses, posterior chamber implants do not require continuous monitoring, according to Dr Allan, as they are not in contact with the endothelium.

“The absolute crux of the matter is long-term safety. The thing that swings it for me is what happens to the endothelium in the years following implantation,” he told the United Kingdom and Ireland Society of Cataract & Refractive Surgeons (UKISCRS) annual meeting in Brighton, UK.

Prof Kohnen said he has used both posterior and anterior chambers phakic lenses. “We know all phakic IoLs are very effective in treating refractive error but when problems arise they are mainly due to the positioning of the lens. And in my view the question of which lens is the best in terms of long-term outcomes brings us to the issue of complications,” he said.

Research on outcomes of iris-fixated lenses found they are safe and effective, Prof Kohnen told the meeting, but he acknowledged that some problems have emerged with inflammation in the eyes of patients who had the foldable lens implanted. He then discussed the evolution of a series of angle-supported foldable hydrophilic lenses, several of which have been withdrawn from the market due to endothelial cell loss and pupil ovalisation.

“There’s only one implant, the AcrySof Cachet, which should be implanted in the anterior chamber. I have to highlight this because it’s the future,” he said.

Unlike the anterior chamber lenses that were withdrawn, the Cachet lens is made of hydrophobic material. It is suitable for -6 D to -16.5 D and has an overall diameter of between 12.50mm and 14.00mm.

The exclusion criteria are important when using this lens, according to Prof Kohnen.

“You have to have a deep anterior chamber, so exclude anything less than 3.2mm. Astigmatism of more than 2.0 D is excluded because the lens cannot correct it. Patients should have no previous corneal or ocular surgery, and no history of glaucoma or any type of cataract. The most important factor for these patients is endothelial cell density,” he said. Prof Kohnen also advised colleagues that limbal relaxing incisions are also required in some cases.

A one-year study of the Cachet lens looked at 900 eyes and showed good predictability, safety and efficacy. Four-year data demonstrated UCVA of 20/20 or better in 60 per cent of cases, Prof Kohnen said.

“At five-year follow-up, we occasionally see very slight synechiae but we don’t see pupil ovalisation. The endothelial cell

density data demonstrates a four per cent loss after four years. But you have to take into account that there is also a natural loss over time by 0.5 per cent,” he said.

“For me, pluses for anterior chamber lenses include the fact that they are effective, predictable and stable. I also think that the new hydrophobic lenses have a very easy implantation process. It is a surgery that takes about 45 minutes – and so far the results have been very good.

“In short, I think that the anterior chamber lenses have an advantage in that they are easy to implant, but they have to be monitored for endothelial cell loss,” Prof Kohnen said.

Bruce Allan kept the focus on the endothelium but advocated for posterior chamber phakic IoLs, which he said offered better long-term outcomes. Data for the ICL lens revealed some trauma at the time of the initial surgery but endothelial loss “settles down to background rates by about year three or four”.

He said looking at other indices of endothelial health, such as coefficient variation and hexagonality, shows the overall quality of the endothelium improving between year one and year four.

Dr Allan said that some of the four-year data on the Cachet lens presented by Dr Kohnen was encouraging but noted that “all other anterior chamber lens implants don’t do so well.

“There’s no other angle-supported implant that has stood the test of time on the market. The I-Care is the best recent example of a lens withdrawn after encouraging one-year data was followed by dramatic losses at three years and is no longer available,” said Dr Allan.

The major drawback for posterior chamber implants is sizing.

“I’ve had to replace about five of the 200 I’ve done as there is currently no perfect way of sizing these lenses,” he said.

Dr Allan recommends doing a surgical peripheral iridectomy (PI) with the ICL lens to combat this. “YAG PIs are not large enough to prevent pupil block reliably in ICL implantation. one message I’d like to get across is that you must do a surgical PI if you’re using a posterior chamber lens,” he said.

Dr Allan acknowledged that the anterior chamber Cachet lens is easy to implant and to size but said posterior chamber lenses look better and have a much wider refractive range.

“For my money, I think that’s why I’m going to stick with the posterior chamber lens until there is more long-term data for the Cachet lens. I’d add one caveat: you’ve got to be able to do a tidy surgical PI. That’s the key ingredient if you’re going down the posterior chamber route.”

Thomas Kohnen – Kohnen@em.uni-frankfurt.deBruce Allan – bruce.allan@moorfields.nhs.uk

cont

acts

PhakIc IoLshow much weight should surgeons attach to the risk of endothelial cell loss?by Gary Finnegan in Brighton

10

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Dr Philippe Sourdille, former president of the ESCRS, co-chaired a clinical research symposium on ‘New IOL Materials and Micro Design at the XXVIII Congress of the ESCRS in Paris, France.

Dr Oliver Findl, chairman of the ESCRS Young Ophthalmologists’ Forum, talks with Dr Sourdille regarding problems with current IOL designs and ongoing efforts to design new IOLs to solve those problems.

Oliver Findl

Philippe Sourdille

We know all phakic IOLs are very effective in treating refractive error but when problems arise they are mainly due to the positioning of the lens

“

Thomas Kohnen MD, PhD

How do you design a phakic lens to last?

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Safety issues in cataract and refractive surgery were the subjects of the Poster Prize winners' presentations at the 15th ESCRS Winter Meeting. The ESCRS awards the prizes at its annual winter meeting for the best posters in the Refractive and Cataract Category. The authors of the wining presentations each receive a prize of €1,000.

George Kymionis MD, Greece, received the prize in the Refractive Category for his presentation titled “outcomes of corneal collagen cross-Linking with riboflavin and ultraviolet A irradiation in keratoconic patients with thin corneas”.

The study involved a prospective case series of 14 eyes of 12 patients with progressive keratoconus and a corneal thickness less than 400 microns at its thinnest point. All underwent uneventful corneal collagen cross-linking.

At 12 months’ follow-up, assessment of the corneal

endothelium with a modified confocal scanning laser ophthalmoscope (Heidelberg Retina Tomograph II/, Heidelberg Engineering) showed that the mean endothelial cell count had fallen significantly, from a preoperative value of 2732.57 cells/mm2 to 2449.21 cells/mm2 (p<0.01), the study’s authors noted.

on the other hand, visual acuity improved moderately, from 0.25 to 0.27 in the case of uncorrected visual acuity and from 0.40 to 0.49 in the case of corrected visual acuity, they pointed out. In addition, mean keratometry readings decreased from 51.99 D to 49.33 D at the last follow-up. Moreover, there were no intraoperative or postoperative complications.

The recipient of the Poster Prize in the Cataract Category was Ulviye Yigit MD, Turkey, for “Evaluation of

changes in oCT Macular thickness following uneventful phacoemulsification surgery”.

Her presentation described the results of a study which suggested that even in the absence of intraoperative complications there can still be a significant increase in macular thickness. The prospective study included 100 eyes of 50 patients without any ocular co-morbidities who had undergone uneventful cataract surgery. Their fellow eyes formed the control group.

The researchers found that there was a significant difference between the mean change in macular thickness occurring between the first day and first month in the operated eyes (2.64 microns) compared to that occurring in the control eyes (0.34  microns) in the control group (p> 0.05).

Poster Competition Prize Winners

EUROTIMES | Volume 16 | Issue 4

ESCRS president Jose Guell has said the decision to hold the 15th ESCRS Winter Meeting in Istanbul, Turkey is another important

development in the society’s policy of

extending its membership and activities to eastern Europe and the surrounding region.

The meeting was attended by more than 1,600 delegates, a record attendance for any ESCRS Winter Meeting.

“Last year we met in Budapest,” said Dr Guell. “This year we meet in Istanbul. This is the first time that an ESCRS meeting has taken place in Turkey and we are delighted to be joining with our colleagues from the Turkish ophthalmological Society, Cataract and Refractive Society Division, for our first event together,” he said.

Scientific Programme “over the past several years we have been developing the ESCRS Winter Meeting by extending our didactic programme. This programme now includes a Basic optics Course, and Cataract, Refractive and Cornea didactic courses. We hope these courses will offer a valuable opportunity for residents and those in training to gain a deeper understanding of the basics in the different sub-specialties,” he said.

Dr Guell said the Programme Committee had planned a full Scientific Programme over the course of the meeting which includes four symposia, live surgery, free paper sessions and eposter presentations. There is also a broad range of surgical skills training courses scheduled throughout the three days.

Dr Guell said he was also delighted to report that the Middle East Africa Council of ophthalmology (MEACo) had co-organised with the ESCRS the Saturday symposium ‘Cataract Surgery in the Diseased Eye’, and he thanked MEACo for its input and participation.”

Improving communication Dr Guell thanked Bekir Sitki Aslan for his assistance in developing the programme and also his colleagues in Cerrahpaşa Medical Faculty Eye Clinic for their organisation of the live surgery session on Saturday afternoon. He said with the help of Dr Aslan and his colleagues they had developed a very exciting programme for the meeting which should ensure lively debate.

Dr Aslan, president of the Turkish Cataract and Refractive Society, has also welcomed the new alliance that is being formed among ophthalmologists through the European region because of the ESCRS’s decision to move the Winter Meetings to the eastern regions.

“I would like to extend our gratitude to the Board Members of ESCRS who kindly asserted their great will and wish to join east and west with the words of science to help humanity,” said Dr Aslan. “Certainly this meeting will fulfil the needs of every fellow ophthalmologist scientifically and socially, since this meeting has the purpose to improve communication between the scientific community and society; to promote contacts among various associations and among ophthalmologists engaged in producing science and technology.”

Charitable initiative In conclusion, Dr Guell drew attention to the ESCRS’s new initiative to support the work of charities in Africa. “Clean water and sanitation facilities are basic requirements for life and the charity oxfam is known for its expertise in this area. ESCRS will be supporting a project to bring clean, safe drinking water to the people in the Kitgum district of Uganda. Ethiopia has one of the highest blindness prevalence rates in the world and we will also be supporting an oRBIS project to develop paediatric eye care in the north-west region of the country.

weLcoMINg New east-west aLLIaNce

12

15Th Escrs WinTEr mEETingreport

Bekir Aslan, president of the Turkish Cataract and Refractive Society, welcomes José Güell, president of the ESCRS, to Istanbul at the 15th ESCRS Winter Meeting

by Robert Henahan

A new approach to central corneal reshaping which involves intrastromal shrinkage and collagen cross-linking may provide an alternative to corneal ablative techniques in myopic eyes, said John Kanellopoulos MD, Greece, at the 15th Winter Meeting of the ESCRS.

The technique involves the utilisation of a cooled sapphire applanation disc and a continuous wave infra-red laser to create three concentric ring-like areas of intrastromal shrinkage treatments, followed by corneal collagen cross-linking using 0.1 per cent riboflavin solution and 10mw/cm2 UV irradiation.

“Depending on the placement of these pre-determined rings you can get considerable corneal flattening with no epithelial defect, and that is the big difference between this and other thermal procedures,” he said.

He noted that in a laboratory study in which he carried out the procedure in 12 cadaver corneas pre- and postoperative evaluation with placido disc topography, Pentacam tomography showed significant uniform cornea flattening of 4.0 D to 8.0 D in a round central zone 5mm in diameter. In addition, biomicroscopy and fluorescein dye staining showed mid-stromal whitening, but no epithelial defect, while cornea oCT revealed stromal hyperreflectivity at 50 to 350 microns depth.

He added that he has also recently carried out the procedure in a keratoconus patient who was awaiting a keratoplasty procedure. He noted that Bowman’s membrane and the epithelium of the patient’s eye remained intact. Moreover the shrinkage effect was undiminished at a year’s follow-up.

“This novel, minimally invasive laser and cross-linking technique may provide an alternative for myopic cornea correction without tissue removal. Further studies are required to validate the efficacy and long-term stability of these findings,” Dr Kanellopoulos added.

Corneal shrinkage

EUROTIMES | Volume 16 | Issue 4

13BreakIng news

The new optiVis™ diffractive/refractive multifocal IoLs can provide cataract patients with a broad range of vision with greater depth of focus than is the case for a purely diffractive multifocal, said Matteo Piovella MD, Centro Microchirurgia Ambulatoriale, Monza, Italy.

"The optiVis represents a new concept in multifocal IoL optics, combining benefits of both diffractive bifocal and progressive refractive designs, providing near, far, and intermediate vision in one IoL,” Dr Piovella told the 15th ESCRS Winter Meeting.

He presented results of a study involving 72 eyes of 36 patients with a mean age of 70.43 years who underwent bilateral implantation of the optiVis lens. At six months' follow-up, mean uncorrected distance visual acuity was 0.93 and best corrected distance visual acuity was (0.99) and the mean spherical equivalent was -0.11 D. In addition, mean uncorrected binocular vision was 20/40 (J4) at 40cm and 70cm, he noted.

“Clinical results demonstrate good patient satisfaction with bilateral implantation of optiVis™, good distance and near vision, and functional intermediate vision. optiVis™ is to be indicated for bilateral implantation,” Dr Piovella said.

Dr Piovella said that the optiVis™ multifocal IoL is an advanced generation apodised diffractive and progressive refractive optics for near, distance, and intermediate vision. It has refractive-diffractive posterior surface design with 2.8 D effective add power, a progressive central portion 1.5mm in diameter to allow for depth of focus at far and intermediate foci. Furthermore, the lens has an apodised diffractive bifocal portion 3.8mm in diameter and a non-prolate aspheric periphery to improve image contrast at distance.

“Through-focus response (TFR) curves for optiVis™ from optical bench testing shows a broad distance focus peak relative to other diffractive multifocal IoLs predicting greater depth of focus into the intermediate range and more forgiving distance power calculations and sharp near focus peak similar to simple diffractive bifocal IoLs,” Dr Piovella added.

New apodised lens

John Kanellopoulos

Matteo Piovella

update14

caTaracT

EUROTIMES | Volume 16 | Issue 4

Femtosecond lasers are all set to change the way that cataract surgery is performed, giving surgeons the ability to create a variety of lens fragmentation patterns which can assist in lens removal with the use

of little or no phacoemulsification energy and reducing the impact of ultrasound energy on ocular structures, according to William Fishkind MD.

“Ultra-short pulse lasers can create precise cuts in tissue with minimal collateral damage and significantly reduce the

ultrasound energy required for nucleus removal. our study showed that different algorithms with the LensAR Laser System (LensAR, Inc.) have different effects across the range of cataract grades, with 25 per cent of cases requiring little or no ultrasound,” he told delegates attending the XXVIII Congress of the ESCRS.

Dr Fishkind, co-director of Fishkind and Bakewell Eye Care and Surgery Center in Tucson, Arizona, and clinical professor at the University of Utah, explained that the LensAR Laser System integrates propriety ocular measurement and 3D laser scanning technologies with an advanced tissue-cutting laser. The laser has received FDA 510(k) clearance for use in anterior capsulotomy and is awaiting approval for lens fragmentation and corneal incision creation.

“The system is used to create anterior capsulotomies and laser lens fragmentation. The beauty of this approach is that the capsulotomy can be set for any size and centration that one desires. once the capsulotomy is created all it takes is a gentle lift to remove it,” he said.

Because the optimal size and shape for removal of nuclear particulates is unknown, Dr Fishkind’s study set out to evaluate the effectiveness of different algorithm patterns – “cubes”, “spheres” and “pies” – for laser lens fragmentation.

He added that the optimal pattern of fragmentation may vary with cataract grade and surgeon preference. Some 32 patients underwent laser capsulotomy only and 87 patients underwent laser capsulotomy and lens fragmentation.

“The results essentially showed that energy into the eye (CDE) was reduced overall by more than 35 per cent and there was a significant reduction in CDE using all algorithms. The preferred algorithm, which was the “pies” pattern reduced CDE by as much as 60 per cent and 97 per cent for different grades of cataract,” he said.

Dr Fishkind noted that even harder lenses could be effectively fragmented and aspirated using the femtosecond laser.

“We were encouraged to see that some grade +3 and +4 cataracts could be removed by aspiration only after laser fragmentation. The precise linear cuts allowed propagation of cleavage through the lens while non-linear shapes could also be sized appropriately for easy break-up and aspiration. The thing to remember is that this approach is not eliminating the use of power completely, but rather changing it from one format to another,” he said.

Dr Fishkind said that the femtosecond laser freed surgeons from the need to use phaco energy at all for softer nuclei, while with harder nuclei it permitted them to significantly reduce the amount of ultrasound energy being used. He suggested that this trend was sure to continue in the near future.

“I think we are probably at the beginning of a revolution in the way that we remove cataracts in the next five years and there is a good potential that femtosecond laser disruption may become the accepted method for cataract treatment in the near future. one of the advantages of this technology is that it should help us centre lenses, remove the cataract with less tears to the capsule and less vitreous loss and therefore improve our efficiency and decrease the risk,” he said.

William Fishkind MD – wfishkind@earthlink.net

cont

act

begINNINg a revoLutIoNfemtosecond lasers target massive cataract marketby Dermot McGrath in Paris

See www.escrs.org for details

The John Henahan Prize 2011

My Best Teacher

The prize is named in honour of John Henahan the founding editor of EuroTimes, who edited the magazine from 1996 to 2001.

a €1,000 travel bursary to the XXIX Congress of the ESCRS in Vienna and a special trophy

Young ophthalmologists, aged 40 or under, are invited to write about their memories of their Best Teacher in medical school or residency.

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EUROTIMES | Volume 16 | Issue 4

All-laser LASIK with the Ziemer LDV femtosecond and the Allegretto Wave Eye-Q lasers provides highly satisfactory

visual outcomes in myopic patients, said Ali Mearza FRCophth at the XXVIII Congress of the ESCRS.

The six-month results of a prospective study involving 153 patients with myopia or myopic astigmatism who underwent the all-laser treatment showed that UCVA was 20/20 or better in 96 per cent of patients and 20/25 or better in 99 per cent of patients, and no patients lost any lines of BCVA.

In addition, the postoperative spherical equivalent refraction had a mean value of -0.26 D and ranged from -2.0 D to 0.63 D. Furthermore, 92 per cent were within 0.50 D of target refraction, and 99 per cent within 1.0 D of intended refraction.

Dr Mearza noted that the preoperative spherical equivalent refraction of the patients in the study ranged from -0.25 D to -10.13 D and had a mean value of -3.67 D. Postoperative refraction has remained stable in all patients including those followed for 12 months, he added.

“We have done many more patients since we submitted our abstract for this presentation and the results have been consistently showing very good stability for three months, six months, one year and all the way up to one-and-a-half years,” Dr Mearza said.

All patients in the study underwent LASIK with flaps created by the Ziemer LDV femtosecond laser and ablations performed with the Wavelight Allegretto Wave® Eye-Q

laser (Alcon) using the standard aspheric algorithm. Most of the flaps in the study were 110 microns in thickness but some were 140 microns in thickness.

Dr Mearza noted that the Ziemer LDV is a relatively new femtosecond laser. It is quite compact and very mobile with wheels that enable it to be moved easily from room to room. In addition, the manoeuvrability of the laser’s handpiece eliminates the need to move either the patient or the laser before performing the excimer ablation.

Furthermore the LDV laser uses low energy levels compared to other femtosecond lasers. As a result, the flap/stroma interface is smoother and the flaps are easier to lift, he said.

In addition, there is now an upgrade to the LDV femtosecond laser available called the Crystal Line. It has enhancements designed to improve the precision and speed of flap creation.

Dr Mearza noted that the Allegretto Wave Eye-Q excimer laser is FDA-approved for correcting up to -12.0 D of myopia, 6.0 D of astigmatism, and up to +6.0 D of hyperopia.

It is a 400 Hz laser with a 400 Hz eye-tracker, and can deliver one dioptre of correction in just two seconds with a 6.5mm optical zone. The reduction in treatment time provides a shorter, more comfortable procedure for the patient, he said.

The Allegretto can be used with several different LASIK algorithms, including standard aspheric, topographically guided, and wavefront-guided ablations, he added.

In summary, the Allegretto combined with the Ziemer LDV is an excellent combination providing very good and consistent results.

contactAli Mearza – ali@eyedoc.eu.com

feMto-fLaP LasIkLdv laser produces promising results with allegretto laser in LasIk proceduresby Roibeard O’hEinechain in Paris

17

rEfracTivE lasErupdate

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Allegretto Wave Eye-Q excimer laser

Dr Mearza noted that the Allegretto Wave Eye-Q excimer laser is FDA-approved for correcting up to -12.0 D of myopia...

“

Ali Mearza FRCOphth

EuropEan SociEty of cataract & rEfractivE SurgEonS

SYMPOSIA TOPICSnCataract and Endothelium (Joint Symposium with EuCornea)

nFemtosecond Cataract Surgery

nRefractive Adjustments after Ocular Surgery

nDecision-making in Presbyopia

nAnterior Segment Reconstruction

preliminary programme online at:

www.escrs.org

17-21 SEPTEMBERREED MESSEVIENNAAUSTRIA

Programme Chairpersons: Keith Barton, UK

Anton Hommer, Austria

ESCRS GlauComa DayScientific programme organised by European Glaucoma Society

Friday 16 September 2011Reed Messe

Vienna, Austria

Immediately preceding the XXIX Congress of the ESCRS

EUROTIMES | Volume 16 | Issue 4

The InTRACoR® procedure (Technolas Perfect Vision) appears to be a safe and effective treatment for presbyopia, providing good

reading vision for most patients, with a fast and painless recovery and good refractive stability, said Mike P Holzer MD, University of Heidelberg, Germany.

He noted that in 25 patients who have undergone the InTRACoR procedure at his centre between July and September 2008 as part of a multicentre study, the median uncorrected near visual acuity improved from 20/100 to 20/30, which is the visual acuity necessary to read newspaper print, he said.

“Refractive outcomes were stable for over 24 months and patients gained four to five lines of near visual acuity. In addition, postoperative recovery was fast and painless, and to date there has been no regression or weakening of the cornea,” Prof Holzer reported at the XXVIII Congress of the ESCRS

The procedure involves the use of femtosecond laser to cut five concentric circular intrastromal rings in the central cornea, he noted. The intrastromal cuts increase progressively in diameter

from the centre by around 200 microns. The result is an alteration of corneal biomechanics, which allows the central cornea to be pushed forward, steepening it and thereby changing the eye’s refraction, he explained.

“The procedure takes only 20 seconds to perform and does not require any flap. So we do not cut into the corneal epithelium or Bowman’s membrane, and the surface is maintained intact,” Prof Holzer said.

The patients in his centre’s subgroup included 18 men and seven women aged 47 to 67 years. All required a near add of at least 2.0 D. Their median preoperative spherical equivalent was +0.63 D and postoperatively +0.25 D.

All underwent the InTRACoR treatment in their non-dominant eye with the Technolas Perfect Vision 520F femtosecond laser, with the depth of the intrastromal circular cuts based on the preoperative pachymetry.

Majority gain good reading vision At two year’s follow-up logMAR uncorrected near visual acuity was 0.3 or better in more than 80 per cent and 0.5 or better in almost 90 per cent. In addition, 60 per cent achieved 0.2 or better, nearly 50 per cent achieved 0.1 or better and 20 per cent achieved 0.0 or better, he said.

Furthermore, all patients gained lines of uncorrected near visual acuity, although there was some variation in the number of lines gained. overall, patients gained between four and five lines, he said.

Patients also had a significant improvement in their scores on the Radner Reading chart, Prof Holzer noted. Preoperatively, they had a median logRAD score of 0.52, compared to 0.30 at 12 months’ follow-up, he said. Although there was no statistically significant difference between the mean pre- and postoperative reading speeds, patients

were able to read smaller texts than they were preoperatively.

The median logMAR distance-corrected near visual acuity at the 24-month follow-up was 0.2.

In addition, patients had significantly better uncorrected intermediate visual acuity in their treated eye than in their untreated eye. At 24 months’ follow-up, the treated eyes had a median visual acuity of 0.1 logMAR, compared to 0.3 in the untreated eyes, Prof Holzer said.

Corneal topography performed with a Pentacam (oculus) showed a central steepening in most of the cases. Another finding was that the corneal asphericity changed to more negative Q values. In addition, wavefront measurements showed a reduction in spherical aberrations and changes in coma.

“The change in coma is probably due to the fact that in this cohort we centred the treatment on the visual axis rather than the entrance pupil,” Prof Holzer said.

Testing with C-Quant stray light measurement device showed no significant changes between pre- and postoperative measurements. The main optical phenomenon was the appearance of rings around bright lights at nighttime, although that faded over time, he said. However, he cautioned against performing bilateral InTRACoR procedures, in case the patient found the effect disturbing.

otherwise there did not appear to be any major safety concerns, he said. There was no endothelial cell loss and intraocular pressure remained unchanged, he pointed out. In addition, because of the non-invasive nature of the procedure, it entails a very low risk of infection, he noted.

Mike P Holzer – mike.holzer@med.uni-heidelberg.de

cont

act

PresbyoPIa uPdatetwo-year results for near and intermediate corneal femtosecond laser procedureby Roibeard O’hEineachain in Paris

20

rEfracTivE lasErupdate

Refractive outcomes were stable for over 24 months and patients gained four to five lines of near visual acuity

“Mike P Holzer MD

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Corneal collagen cross-linking is both safe and effective in children with progressive keratoconus, according to a number of studies

presented at the Aegean Cornea X meeting.“This is significant because keratoconus

progresses more rapidly in children than it does in adults and using corneal collagen cross-linking in children may reduce the need for early penetrating keratoplasty,” said Beatrice E Frueh MD, University Hospital Bern, Switzerland.

Dr Frueh said that while the initial results indicated that younger patients may benefit from the stabilising effects of cross-linking on the cornea, further research was needed to establish just how safe and effective the treatment was over the longer term.

“While cross-linking appears to be safe, and arrests the progression of the disease, there are still questions that need to be answered. When we treat such young children with cross-linking will we need re-treatments at a later stage, and also should we perform collagen cross-linking in children with keratoconus before a progression is apparent if the child is very young?” she asked.

Dr Frueh presented the results of a prospective study of cross-linking procedures in 14 eyes of 12 patients under the age of 18. Manifest refraction, corneal topography and Pentacam were performed preoperatively and at one, four and 12 months postoperatively. Inclusion criteria were patients with progressive keratoconus and a minimum central corneal thickness of 400 microns. Three patients had undergone previous penetrating keratoplasty in their fellow eyes for hydrops. The mean age was 14.2 years and the mean follow-up was 17 months with a minimum follow-up of 12 months.

The procedures were all done under

topical anaesthesia, except for one Down’s syndrome patient who received general anaesthesia. All eyes underwent corneal cross-linking with photosensitizing riboflavin solution and subsequent exposure to an ultraviolet light source for 30 minutes.

Dr Frueh noted that the progression of keratoconus was arrested in every patient. The best-spectacle corrected visual acuity at 12 months showed an improvement of two or more lines in two eyes, a loss of two or more lines in two eyes and remained unchanged in seven eyes.

The mean spherical equivalent and mean cylinder remained stable over the follow-up period. The keratometry values showed no significant change from the preoperative measurements to the four-month follow-up point, and the thinnest point as measured by Pentacam also showed that the corneal

thickness remained unchanged over the follow-up period.

In a separate presentation, Adel Barbara MD, Hadassah Optimal, the refractive surgery center of Hadssah Hospital, Haifa, Israel, echoed Dr Frueh’s positive assessment of corneal collagen cross-linking in younger patients.

“Corneal collagen cross-linking was shown to be safe and effective in stiffening the cornea and halting the progression of keratoconus in our group of patients, although we do need further studies with longer follow-up to confirm these initial findings. The results are similar to the results achieved thus far in adults but with less improvement in astigmatism in younger patients,” he said.

Dr Barbara noted that while studies of corneal cross-linking have shown a significant increase since Theo Seiler’s seminal publication in 2003, almost all of these have been exclusively devoted to trials in adult patients.

“In 2005 there were only six publications on corneal cross-linking compared to more than 49 in 2009. These results confirm the positive outcomes in terms of arresting keratoconus, with improvement in UCVA and BCVA in most cases, a lowering of maximum K values and a reduction of higher order aberrations."

Dr Barbara’s own retrospective study included 24 patients younger than 18 years of age, 22 males and two females, with a mean follow-up of 14.5 months. Indications were progressive keratoconus, subjective loss of visual acuity, increased cylinder, frequent changes in glasses, and topography changes.

“The results showed no progression of keratoconus, a statistically significant improvement in uncorrected and best corrected visual acuity, reduced astigmatism, and no change in keratometry readings. We experienced one case of keratitis, which was treated successfully by topical antibiotic. There was also some transient haze in most of the cases,” concluded Dr Barbara.

In a brief discussion after Dr Barbara’s presentation, moderator Theo Seiler MD remarked that in his experience many, if not all, children with rapidly progressive keratoconus were eye-rubbers and that treating any underlying allergic disease may avoid the need for a cross-linking procedure in such patients.

“Standard keratoconus often starts in puberty, but if we have children coming in with keratoconus which is heavily progressive, even within six months, if we look carefully at these cases they are usually rubbing their eyes,” he said.

Collagen Cross-linkingarresting keratoconus in childrenby Dermot McGrath in Crete

EUROTIMES | Volume 16 | Issue 4

Beatrice E Frueh - beatrice.frueh@insel.chAdel Barbara - Adelbarbara@yahoo.com

cont

acts 23

CORNEAUpdate

In 2005 there were only six publications on corneal cross-linking compared to more than 49 in 2009

“Adel Barbara MD

Corneal haze after cross-linking

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EUROTIMES | Volume 16 | Issue 4

Rolando Toyos - rostar80@gmail.com

cont

act

intense pulsed lightskin treatment appears to clear meibomian glandby Howard Larkin in Paris

CORNEAUpdate24

Tear Film:n Lipid Layer (anterior layer)n Polar (adjacent to aqueous layer) and Non Polar (outermost) sections n Two major functions - Prevention of Evaporation – Tear Breakup Time - Maintenance of a Smooth Ocular Layer for optical clarity

Meibomian gland dysfunction – Leading cause of evaporative dry eye

Clinical signs of MGD (left to right): SPK, poor tear film, rapid TBUT

Intense pulsed light treatment, long used for treating the skin condition rosacea, also may be effective for treating dry eye associated with meibomian gland

dysfunction (MGD), according to studies by Rolando Toyos MD, Memphis, Tennessee, US. In his most recent study, presented at the XXVIII Congress of the ESCRS, Dr Toyos treated 15 patients with MGD and symptomatic dry eye who had a tear-film break-up time of less than six seconds. Patients received two to four treatments, depending on when symptoms improved. One month after the final IPL treatment, all eyes showed improved TBUT, averaging just over five seconds longer, ranging from three to 12 seconds longer.

Subjectively, all 15 patients also reported improvement in dry eye symptoms, with two reporting that one eye improved more than the other, Dr Toyos said. Typically, patients reported relief immediately following the final procedure as well as in the following weeks. Dr Toyos also observed reductions in objective MGD signs, including reduced lid telangectasia, fewer blocked meibomian glands and less-inflamed lid margins.

“Over the past eight years, we have improved the intense pulse light system, and have produced one that works well for the treatment of meibomian gland dysfunction,” said Dr Toyos, who is a consultant for DermaMed International (Lenni, Pennsylvania, US), which manufactures the IPL device.

Heat and light Dr Toyos began investigating IPL treatment for dry eye in 2002 when he noticed that patients treated

for rosacea often reported improvement in dry eye symptoms. In a 2006 contralateral eye study in 100 patients, he found the IPL-treated eyes had significantly longer TBUT after the third and fourth treatments. However, the effect was less than in the current study, possibly because it was an earlier device that was less effective in reaching the eyelid, he said.

IPL uses a filtered xenon source to expose skin to millisecond-length bursts of light in the 500 to 800 nm range, which is the peak absorption range for oxyhemoglobin and near peak for melanin. The light penetrates deeply into the papillary epidermis, reaching the abnormal blood vessels associated with both rosacea and MGD.

“When you flash this light at a blood vessel it is absorbed by blood cells and coagulates the blood vessel,” Dr Toyos explained.

He believes the heat of photocoagulation also melts abnormal meibomian secretions, allowing them to be expressed with pressure, which unblocks the glands.

The immediate effect is like the most intense and effective warm compress these patients will ever get,” Dr Toyos said. Shutting off the blood vessels also may reduce the inflammatory mediators they secrete, which block the glands.

Dr Toyos is examining the possible impact of IPL on demodex mite infestations and bacteria on the eyelid. Some studies also suggest that IPL decreases interlukin-9, which has been associated with improved meibomian gland function. Other unknown factors may also be at play, and further study is needed to confirm the mechanism of action, he said.

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References: 1. Denis P, Gandolfi S et al. Poster presented at: European Glaucoma Society (EGS), 9th Congress; September 12-17, 2010; Madrid, Spain. 2. Yildirim N, Sahin A et al. J Glaucoma 2008; 17: 36-39. 3. Parrish RK, Palmberg P et al. Am J Ophthalmol 2003; 135: 688-703. 4. Netland PA, Landry T et al. Am J Ophthalmol 2001; 132: 482-484.

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

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EUROTIMES | Volume 16 | Issue 4

A technique called “visco-trab”, which combines elements of trabeculectomy and viscocanalostomy, can provide

a significantly greater reduction in IOP than trabeculectomy alone, with fewer complications, according to the results of a contralateral eye study presented by Tarek Eid MD at the 9th European Glaucoma Society Congress.

“Combined visco-trab starts as a viscocanalostomy procedure and ends up as a trabeculectomy, with tight closure of the lamellar flap. The rationale behind this combination is to achieve maximum IOP reduction for eyes with advanced glaucoma and to lower the early postoperative complications of both trabeculectomy and viscocanalostomy,” said Dr Eid, Magrabi Eye and Ear Centre, Jeddah, Saudi Arabia.

The pilot study involved 18 patients with bilateral advanced glaucoma who underwent the combined viscocanalostomy-trabeculectomy surgery in their right eye and trabeculectomy alone in their left eye. The glaucoma procedure was combined with cataract removal and IOL implantation in six eyes undergoing the combined procedure and in seven eyes undergoing trabeculectomy alone.

The patients in the study had a mean age of 64 years, 13 had primary open-angle glaucoma, three had primary angle-closure glaucoma, one had low tension glaucoma, and one had juvenile glaucoma.

Dr Eid noted that the mean cup-disc-area ratio was 0.92 in both groups of eyes and the average visual field mean deviation was 20.9 dB in the combined procedure group and 20.8 dB in the trabeculectomy group. Preoperatively, two thirds of eyes in each group were receiving three or more glaucoma medications. The mean preoperative IOP was 26.3 mmHg in the visco-trab group and 25.4 mmHg in the trabeculectomy group.

Lower IOP, fewer complications Throughout a follow-up period of 14.9 months in the visco-trab group and 13.7 months in the trabeculectomy group, the  mean IOP was significantly lower in the visco-trab group, with mean reductions of 15.7 mmHg (52.5 per cent)  and 11.4 mmHg (43.0 per cent) respectively, in the two groups, Dr Eid said. 

The difference between the two groups

reached statistical significance at one week and three months postoperatively (p<0.05), he pointed out. The IOP at those time points was 7.2 mmHg and 10.6 mmHg, respectively, in the visco-trab group, compared to 9.8 mmHg and 13.6 mmHg, respectively, in the trabeculectomy group, he continued.

Furthermore, at the last visit, 83.3 per cent in the visco-trab group achieved the target IOP of 14 mmHg or less without glaucoma medication, compared to only 55.6 per cent in the trabeculectomy group, he said. However, similar proportions of the visco-trab group and the trabeculectomy group, 94.4 per cent and 88.9 per cent, respectively, achieved target IOP with or without glaucoma medication, he noted.

In addition, early postoperative complications such as anterior chamber shallowing and choroidal effusion were greater in severity after trabeculectomy than after visco-trab. Furthermore, only one eye in the visco-trab group required postoperative surgical intervention, to re-position an IOL, compared to four eyes in the trabeculectomy group.

The postoperative surgical interventions in the trabeculectomy group were anterior chamber reformation in two eyes, choroidal drainage in one eye; and conjunctival suturing for leakage in one eye.

He noted that during the first postoperative month, only four eyes required laser suture lysis in the visco-trab group compared to seven in the trabeculectomy group. Postoperatively, visual acuity was the same as preoperatively or improved by more than one line of Snellen acuity for both groups, he added.

“The controlled hypotony produced by enhancing internal filtration and limiting external filtration plays a major role in achieving a maximally low IOP during the early postoperative period without pressure spikes or severe complications related to excessive filtration,” Dr Eid said.

The visco-trab procedure Dr Eid said that he performed combined visco-trab in the superotemporal or superonasal quadrant, in order to avoid perforating scleral vessels. He commences the procedure with the creation of a fornix-based conjunctival flap and subconjunctival application of mitomycin-C 0.3 mg/ml for three minutes. He then dissects a 4.0mm x 4.0mm lamellar flap scleral flap to within 1.0mm of clear corneal tissue.

He then dissects a second deeper rectangular flap 0.5mm inside the border of the first flap, creating a scleral pocket which leaves only a thin translucent layer of sclera overlying the choroid. After continuing the dissection until he can visualise and then de-roof Schlemm’s canal, he uses a specially

designed viscocanalostomy cannula (Alcon/Grieshaber) to inject sodium hyaluronate 1.0 per cent (ProVisc, Alcon) into the canal.

He concludes the procedure with a transverse incision in the floor of Schlemm’s canal, the excision of a trabeculocorneal segment approximately 1.5mm in length and 3.0mm in width, a peripheral iridectomy, and watertight closure of the lamellar scleral flap with four 10/0 nylon sutures.

He noted that visco-trab is actually easier than viscocanalostomy because the dissection does not extend over Descemet’s membrane where the majority of macroperforations occur.

“Combined viscocanalostomy-trabeculectomy was efficacious in the management of highly advanced glaucoma, reducing IOP to a maximally low target level during the early postoperative period. Its safety was indicated by the reduction of the postoperative pressure spikes and the devastating complications related to excessive external filtration,” Dr Eid concluded.

Tarek M Eid - tarekmeid@hotmail.com

cont

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dual approaCh Combining viscocanalostomy with trabeculectomy may prove a useful optionby Roibeard O’hEineachain in Madrid

26

GlAuCOmAUpdate

A

C

E

G

B

D

F

HSteps of VISCO-TRAB operation: (A) subconjunctival Mitomycin C, (B) a 4x4mm lamellar sclera flap, (C) outlining deep sclera flap,

(D) Schlemm’s canal (SC) deroofing and Descemet’s membrane exposure, (E) Viscodilation of SC, (F) incision of SC floor, (G) penetrating sclera-keratectomy, (H) tight flap closure.

Its safety was indicated by the reduction of the postoperative pressure spikes and the devastating complications related to excessive external filtration

“

Tarek Eid MD

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EUROTIMES | Volume 16 | Issue 4

A new contact tonometer with the potential to be less affected by variations in corneal thickness and curvature can provide IOP

measurements that meet the International Standard Organization’s (ISO) accuracy standards, according to a study presented by Gauti Jóhannesson MD at the 9th European Glaucoma Society Congress.

“The servo-controlled device uses a novel tonometry method called applanation resonance tonometry (ART). It is based on the Doppler principle and derives its measurements from the relationship between the force applied and the amount of area contacted, which is in turn proportional to the intraocular pressure (IOP),” said Dr Jóhannesson, Umeå University Hospital, Umeå, Sweden.

He noted that previous research has shown that manual ART fulfills the ISO’s standard for tonometers. The device has a force transducer which continuously measures the force needed to applanate the cornea and simultaneously registered the contact area through detection of frequency shifts with a resonator sensor, he added.

The ART technique has two available analysis procedures. One is dynamic and measures IOP during the indentation phase and the other is static and provides a Goldmann-like measurement during two seconds of full applanation, Dr Jóhannesson explained.

The prospective single-centre study involved 152 eyes of 77 patients divided into three groups with different IOP profiles. They underwent IOP measurements with Goldmann applanation tonometry (GAT), servo-controlled ART and manual ART, six times per method in a standardised order. The researchers designed the study according to the ISO requirements and defined precision as the standard deviation of difference against GAT.

The patients’ mean IOP as measured by GAT was 19.1 mmHg (range: 10–37 mmHg). The precision of the manual ART tonometer was 2.3 mmHg for both dynamic (r = 0.91) and static (r = 0.92) analyses. The precision of servo-controlled ART tonometer was 2.9 mmHg for dynamic analyses (r = 0.86) and 2.5 mmHg for static analyses (r=0.90) (see figure).

The lower accuracy of the servo-controlled device’s dynamic measurements resulted from a shakiness of the motor. In the device’s latest design, the researchers have made the motor steadier by decreasing the probe velocity and reducing the accelerations, making the applanation more similar to the manual applanation.

“This study confirms that the ART methodology is feasible. The further developed manual ART fulfilled the ISO standard with both the dynamic and the static analysis techniques. The newly developed servo-controlled ART was close to fulfilling the standard using the static analysis technique, but failed in the group with the highest IOP range. Furthermore, servo-controlled ART has the potential to provide a more user-friendly form of tonometry, but further development is needed,” Dr Jóhannesson concluded.

27

new tonometerservo-controlled tonometer provides new alternative iop measurementby Roibeard O’hEineachain in Madrid

GlAuCOmAUpdate

Intraocular pressure measured on 152 eyes with ARTservo and GAT. The linear regression shows a correlation of R = 0.90

Servo-controlled ART has the potential to provide a more user-friendly form of tonometry, but further development is needed

“

Gauti Jóhannesson MD

Gauti Jóhannesson - gauti.johannesson@ophthal.umu.se

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SUNDAY 29 MAY 11.00 – 13.00AMD IIchairperson: G. Richard gErmaNy

MAIN SESSION 13

SUNDAY 29 MAY 11.00 – 13.00 coMPlIcATIons oF hIGh MyoPIAchairpersons: A. Gaudric FraNCE, s. chang usa

26–29 May 2011

QUEEN ELIZABETH II CONFERENCE CENTRELONDON, UK

LONDON 201111TH EURETINA CONGRESS

07.00

08.00

09.00

10.00

11.00

12.00

13.00

14.00

15.00

16.00

17.00

18.00

19.00

20.00

COFFEE BREAK

COFFEE BREAK

COURSE 13ARMD

ALCONSATELLITE MEETING

THEASATELLITE MEETING

NOVARTISSATELLITE MEETING

fan club

FLUID DYNAMICS SYMPOSIUM

FREE PAPERS 8Ant/Posterior

Segment Surgery/Uveitis/Intraocular

Tumours

COURSE 18Surgical Approach

to Vitreoretinal Interface

COURSE 19Bimanual VitrectomyTechniques in MIVS

Surgery

COURSE 21Managing DiabeticMacular Oedema

COURSE 20Tips & Tricks in Minimal

Invasive Vitrectomy

COURSE 15New Strategies

in Ocular Trauma

COURSE 17Uveal Melanoma

COURSE 14Intravitreal

Therapy

COURSE 16Avoiding

Complications in Vitrectomy Surgery

SURGICAL SKILLS

COURSES

GENERAL ASSEMBLY

MAIN SESSION 9Diabetic

Retinopathy

MAIN SESSION 10

Vascular Diseases

MAIN SESSION 7Innovative

Vitreoretinal Surgery

MAIN SESSION 8Anterior/Posterior

Segment Surgery

CHURCHILL WHITTLE MOUNT BATTEN WESTMINSTER HENRY MOORE WETLABS

SATURDAY 28 MAY

INSTRUCTIONAL COURSES

FREE PAPERS 6Vascular Diseases

& Diabetic Retinopathy

FREE PAPERS 7Vascular Diseases

& Diabetic Retinopathy

FREE PAPERS 9AMD

D.O.R.CSATELLITE MEETING

BAYERSATELLITE MEETING

08.00

09.00

10.00

11.00

12.00

13.00

14.00

COFFEE BREAK

COURSE 22Modern OCT

Imaging

COURSE 23Vitreoret

complicationsCataract Surgery

COURSE 24Fluorescein

& ICG-angiography

MAIN SESSION 11AMD I

MAIN SESSION 12

AMD II

CHURCHILL WHITTLE MOUNT BATTEN WESTMINSTER

SUNDAY 29 MAY

FREE PAPERS 10Vascular Diseases

& Diabetic Retinopathy

FREE PAPERS 11Vitreoretinal

Surgery

MAIN SESSION 13Complications of

High Myopia

Full DAy couRsEs1. uveitis course Organisers: C. Pavesio uk, C. Herbort sWitZErLaND

2. Retinal Detachment course Organiser: I. Kreissig gErmaNy

InsTRucTIonAl couRsEs1. Macular Dystrophies Organiser: E. Souied FraNCE

2. ‘Wacker-course’ German Retina society Organisers: D. Pauleikhoff gErmaNy, H. Heimann gErmaNy

3. screening for Diabetic Retinopathy Organiser: C. Egan uk

4. Macular oedema Organiser: P. Tranos grEECE

5. Proliferative Diabetic Retinopathy Organiser: A. Laidlaw uk

6. What, When and how: surgical Discussions Organiser: C. Mateo sPaiN

7. Advanced ocT Organiser: A. Polito itaLy

8. Electrophysiology of Vision Organiser: G. Holder uk

9. simple Approach to PVR Management Organiser: B. Corcóstegui sPaiN

10. how to Read Autofluorescence Images Organiser: F. Holz gErmaNy

11. Vitrectomy in Diabetes Organiser: A. Laidlaw uk

12. screening and Management of RoP Organisers: A. Kychenthal ChiLE, G.Caputo FraNCE

13. Important Diagnostic Features for Treatment of ARMD

Organiser: G. Soubrane FraNCE

14. Guidance in Intravitreal Therapy Organiser: U. Schmidt-Erfurth austria

15. new strategies in ocular Trauma Organiser: C. Forlini itaLy, F. Kuhn usa

16. Avoiding complications in Vitrectomy surgery Organiser: P. Sullivan UK

17. current Management in uveal Melanoma 2011 Organiser: D. Pelayes argENtiNa

18. surgical Approach to the Vitreoretinal Interface Organiser: P. Brazitikos grEECE

19. Bimanual Vitrectomy Techniques in MIVs surgery Organiser: T. Nikolakopoulos grEECE

20. Tips and tricks in Minimal-Invasive Vitrectomy Organiser: C. Pruente austria

21. Managing Diabetic Macular oedema: Pearls and Pitfalls

Organiser: E. Midena itaLy

22. Modern ocT Imaging: clinical Value and scientific Perspectives

Organiser: U. Schmidt-Erfurth austria

23. Vitreoretinal complications of cataract surgery Organiser: B. Little uk

24. Fluorescein and IcG-angiography - Interpretation and Diagnosis of Macular Diseases

Organisers: D. Pauleikhoff gErmaNy, G. Staurenghi itaLy

n Congress Registration

n Full Programme Info

n Membership Application

n Courses and Wetlab Bookings

n Hotel Bookings

n EURETINA Brief

Available at www.euretina.org:

The 2011 EURETINA Innovation Award will take place on Friday 27 May at 14.00-16.00 in the Churchill Auditorium.For more information see: www.euretina.org/Innovation/default.asp

2011 KREISSIG AWARDFRIDAy 27 MAy 11.00 – 12.00

ThE sPEcTRuM oF VITEllIFoRM lEsIons

In ThE MAculAlawrence A. yannuzziusa

ThuRsDAy 26 MAy 16.15 – 16.35

MoDERn DIREcTIons FoR ThE suRGERy oF DIABETIc RETInoPAThyBorja corcosteguisPaiN

EURETINA LECTURE

11TH EURETINA

satel

lite

educatio

n p

ro

gramme

EUROTIMES™

SATELLITE EDUCATION PROGRAMME

Friday 27 may

Morning Symposia

10.00 - 11.00

Point - Counterpoint - Structure vs. Function in Diabetic Macular EdemaRoom: Whittle

Sponsored by

lunchtime Symposia

13.00 - 14.00

allergan satellite meetingRoom: Whittle

Sponsored by

13.00 - 14.00

Shining a Light on Innovation in Vitreo Retinal SurgeryRoom: Mount Batten

Moderator: C. Awh USA

Sponsored by

evening Symposia

18.00 - 19.30

novartis satellite meetingRoom: Whittle

Sponsored by

Saturday 28 may

Morning Symposia

10.00 - 11.00

Managing Challenging Cases in Medical and Surgical RetinaRoom: mount batten

Moderator: A.Augustin GERMANY

Sponsored by

10.00 - 11.00

Are nutritional supplements useful in AMD?Room: Westminster

Moderator: A.Leys BELGIUM

Sponsored by

lunchtime Symposia

13.00 - 14.00

novartis satellite meetingRoom: Whittle

Sponsored by

13.00 - 14.00

D.O.R.C satellite meetingRoom: Mount Batten

Sponsored by

evening Symposia

18.00 - 19.30

An Update on VEGF Trap-EyeRoom: Mount Batten

Sponsored by

register your interest online at

www.euretina.org

EUROTIMES | Volume 16 | Issue 4

Microplasmin (ThromboGenics NV) may provide a safe, efficient and less invasive means of treating focal

vitreomacular adhesion (fVMA) which is implicated in many back-of-the-eye diseases, according to a study presented by Victor H Gonzalez MD at the 10th EURETINA Congress. “Focal abnormal vitreoretinal adhesion is implicated in many retinal pathologies that we see in our clinics on a daily basis such as vitreomacular traction syndrome, macular hole, macular pucker, proliferative diabetic retinopathy, proliferative vitreoretinopathy (PVR), diabetic macular oedema (DME) and exudative age-related macular degeneration,” he said.

Dr Gonzalez, Valley Retina Institute, Texas, noted that preclinical studies have already confirmed microplasmin’s intended effect in vivo. “Human post-mortem and in vivo experiments in four animal models demonstrated well-tolerated and dose-dependent pharmacologic vitreolysis with detachment of vitreous gel from the retinal surface and liquefaction of the vitreous gel,” he said.

He added that four phase II microplasmin studies have now been completed, showing that the drug is generally safe and well tolerated with good evidence of intended biologic effect in terms of the non-surgical resolution of focal vitreomacular adhesion and non-surgical full-thickness macular hole closure. To further test the safety and efficacy of microplasmin, two parallel phase III studies MIVI-006 and MIVI-007 were conducted in the US and Europe respectively, said Dr Gonzalez, who presented the MIVI-006 trial results.

Dr Gonzalez noted that both studies had the same design: a randomised, double-masked trial in which patients with symptomatic focal vitreomacular adhesion, defined as patients with vitreomacular traction or full thickness macular holes less than 400 microns, were randomised to either intravitreal microplasmin injection or placebo injection.

The primary endpoint of both trials was the non-surgical resolution of focal vitreomacular adhesion one month after a single injection of microplasmin, as assessed using optical coherence tomography (OCT).

Secondary endpoints included the

proportion of patients with total posterior detachment at day 28 as determined on clinical examination and ultrasound by the investigator, and the proportion of patients with non-surgical closure of full thickness macular holes as determined by a central reading centre on submitted optical coherence tomography.

The study successfully met its primary endpoint, said Dr Gonzalez, with 27.7 per cent of the 220 microplasmin treated patients achieving resolution of their fVMA at one month, compared to 13.2 per cent of the 106 patients who received a placebo injection.

Dr Gonzalez said that microplasmin’s major effect on vitreolysis seems to occur within the first week of the initial injection.

“Some patients did show a small improvement after the first week, but the majority of the response was evident earlier in the treatment. When we conducted an analysis to see if there were any factors that determined which patients had a more favourable outcome on resolution of focal vitreomacular traction, it appears that the presence of epiretinal membranes tend to have a negative effect on the response. Furthermore, the size of the area of the focal vitreomacular adhesion was important, with patients in which the affected area was less than 1,500 microns responding better to treatment compared to those with larger areas of adhesion,” he said.

The trial also evaluated the visual acuity (VA) of patients. This analysis showed that at the end of the study 25.5 per cent of the microplasmin treated patients had achieved at least a 10 letter improvement in VA without the need for vitrectomy. This compares to only 11.3 per cent of the patients who received a placebo injection.

At day 28 there was a statistically significant difference in developing posterior vitreous detachment in the microplasmin treated patient group compared to placebo, said Dr Gonzalez. He also emphasised the positive results of the microplasmin group in the non-surgical resolution of full-thickness macular holes. In this group, 45.6 per cent of the 52 patients were cured by a single 125μg injection of microplasmin without the need for vitrectomy in the six months' follow-up period compared to 15.6 per cent of the 32 patients in the placebo group.

31

miCroplasmingenerally well tolerated by ocular structures by Dermot McGrath in Paris

Victor h Gonzalez - maculadoc@aol.comcontact

REtiNAUpdate

Intravitreal bevacizumab (Avastin, Roche) significantly improved vision over the long term for patients with clinically significant diabetic

macular oedema (DME) compared with macular laser therapy, according to a study presented at the 10th EURETINA Congress.

“Our small study provides evidence to support the use of bevacizumab in patients with centre-involving clinically significant macular oedema without advanced macular ischemia,” Philip G Hykin FRCS, FRCOphth, told delegates.

Dr Hykin, Moorfields Eye Hospital, London, presented the two-year results of a single centre randomised study comparing bevacizumab versus macular laser therapy in DME.

Eighty eyes with centre-involving CSME and at least one prior macular laser therapy were randomised to 1.25mg in 0.05ml intravitreal bevacizumab injections every six weeks with a minimum of three injections and a maximum of 18 in the first 24 months, or to laser therapy which included four monthly modified ETDRS macular laser photocoagulation sessions to a maximum of seven treatments.

The primary endpoint of the study was the difference in best-corrected visual acuity between the bevacizumab and laser arms at week 52, said Dr Hykin. Secondary endpoints included the percentage of patients with a gain of more than 10 letters and a reduction in mean OCT central macular thickness between the two groups.

Key inclusion criteria were centre-involving clinically significant DME with OCT central macular thickness greater than 270 microns, best-corrected visual acuity between 6/12 and 3/60, and at least one prior macular laser therapy. Patients were excluded if the greatest linear dimension of the foveal avascular zone exceeded 1,000 microns, or if they had severe perifoveal capillary dropout as determined by ETDRS standard photo comparison. Patients with vitreomacular traction or co-existing ocular disease were excluded.

Dr Hykin said that two further treatments were given after the initial three bevacizumab loading doses if the central macular thickness was greater than 270 microns. Additional as-needed treatments were given if the macular thickness was greater than 20 microns above thinnest recorded.

A total of 42 patients were included in the bevacizumab arm and 38 in the laser arm. After two years, the mean number of bevacizumab injections was 13, with nine injections in year one, and four in year two. The mean therapy in the laser arm was four laser treatments, three in year one and one in year two.

The primary endpoint at 12 months showed a median visual acuity gain of eight letters in the bevacizumab group compared to a loss of 0.5 letters in the laser group. At two years, the mean best-corrected visual acuity gain was nine letters in the bevacizumab group versus 2.5 letters in the laser arm.

“The difference between the groups was slightly less than at year one, but was still statistically significant and due to a small improvement in the laser group partly due to dropout of worse cases and probably the durable effect of laser,” said Dr Hykin.

Dr Hykin noted that there was a small increase in mean BCVA in the bevacizumab arm through the second year of the study, and no patient in this arm lost 15 letters or more during the two-year follow-up period. Approximately 30 per

cent of bevacizumab patients gained about 15 letters and 50 per cent gained 10 or more letters. Although a clear change in OCT central macular thickness between the two groups was seen at 12 months, this was not statistically significant at 24 months.

Dr Hykin said that the study was too small to draw conclusions regarding safety, although no increase in macular ischemia occurred. He noted that adverse events were typically injection related.

“With this regimen, the BCVA letter score at 24 months for bevacizumab treated patients was 6.5 letters better than laser treated patients and the mean BCVA was 8.7 letters better than baseline. Secondary endpoints were largely consistent with this and the study supports the longer-term use of bevacizumab in clinically significant macular oedema,” he said.

Dr Hykin added, however, that he believed that there was still a role for laser therapy in the treatment of DME.

“I think what recent studies show collectively is that laser is probably slightly better in the long term than we perhaps give it credit for. Maybe we should bear in mind laser treatment as a long-term therapy, maybe in combination with these drugs as we try to give injections less frequently over the long term,” he said.

BevaCizumaB for dmetwo-year study results compare bevacizumab versus macular laser therapy in diabetic macular oedema

EUROTIMES | Volume 16 | Issue 4

Philip G hykin - philiphykin@aol.com

cont

act

32

by Dermot McGrath in Paris

REtiNAUpdate

“podcastEU

ROT

IMES

ESCRS

™

ESC

RS ™

MENU

EUROTIMES

Listen to our podcasts at

Eye Chat with Oliver Findl

www.eurotimes.org

Podcasts are alsoavailable on iTunes

In an interview with Dr Oliver Findl,

chairman of the ESCRS Young

Ophthalmologists’ Forum, Ridley Medal

recipient Prof David Spalton discusses

the symphony of factors influencing PCO

development, common treatment issues,

and new technology on the horizon aimed

at preventing the problem.

Prof Spalton also talks about early

influences on his life in ophthalmology

Oliver Findl

David Spalton

Maybe we should bear in mind laser treatment as a long-term therapy, maybe in combination with these drugs as we try to give injections less frequently over the long term

“

Philip G Hykin FRCS, FRCOphth

Don’t miss Practice Development, see page 42

EUROTIMES | Volume 16 | Issue 4

Update

OCulAR

New diagnostic criteria places increased emphasis on subluxed lenses in the diagnosis of Marfan syndrome, a multisystem

connective tissue disorder. The condition is associated with mutations in the fibrillin-1 gene (FBN1) and includes a series of ocular symptoms.

The revised Ghent criteria agreed after a consensus meeting in 1996 has improved clinical diagnosis of Marfan syndrome (De Paepe et al 1996 Am J Med Genet 62:417-426). However, these have now been updated in an effort to make the diagnostic criteria more sensitive, giving more weight to the ocular and cardiac problems in distinguishing Marfan syndrome from other similar genetic disorders (Loeys et al 2010 J Med Genet 47: 476-485).

Leema Robert, consultant clinical geneticist at Guy's and St Thomas' Hospital in London, said bilateral ectopia lentis exists in around half of all cases, with myopia present in 28 per cent. Retinal detachment and glaucoma can also be seen in untreated individuals.

“The new Ghent nosology makes ectopia lentis a more important diagnostic feature so ophthalmologists will receive more referrals asking them to look for subtle signs of lens dislocation,” Dr Robert told the United Kingdom & Ireland Society of Cataract and Refractive Surgeons (UKISCRS) Annual Meeting in Brighton.

She added that while ectopia lentis had become a major criterion for the clinical diagnosis of Marfan syndrome, other ocular features are also important. These include flat corneas and increased length of the globe causing myopia.

Marfan syndrome is inherited as a dominant trait, meaning symptoms occur in people who inherit the faulty FBN1 gene from either parent. Those affected by the disease are typically tall with long limbs and long thin fingers.

The most serious risks for people with the condition arise from defects of the heart valves and aorta but it can also affect the lungs, spinal cord, palate and vascular tissues.

Dislocation of the crystalline lens can occur in one or both eyes and are often diagnosed by an ophthalmologist or optometrist using a slit-lamp biomicroscope. Although previously described that the dislocation is superotemporal in Marfan syndrome,

unlike the inferonasal dislocation seen in the similar condition, homocystinuria, this distinction is no longer so clear cut.

Dr Robert said differentiating between Marfan syndrome and related conditions such as Beal syndrome, cystathione beta-synthatase deficiency, and Weil Marchesani syndrome requires considerable clinical expertise. Marfan syndrome is the most common of these conditions, she noted, but all share similar characteristics.

“Isolated ectopia lentis without the cardiac manifestations of Marfan syndrome is also known to be associated with mutations in the FBN1 gene leading to some overlap in the criteria for diagnosing these conditions,” she said.

Deeper understanding of these genetic illnesses has led experts to draw up best practice guidelines on the detection, treatment and follow-up of patients. However, there are question marks over whether the recommendations are practical as there are significant financial implications with increased need of genetic testing.

“The literature recommends annual ophthalmology assessment in children [with Marfan syndrome], as well as regular orthoptic review, but it's for you to judge whether that is feasible. Vitreo-lensectomy with laser prophylaxis is also advised to prevent retinal detachment, and correction of visual acuity in severe myopia has also been recommended with long-term follow up,” Dr Robert told the UKISCRS meeting.

Annual reviews should be recommended and implemented for an affected individual with this condition until they reach 20 years of age but the frequency of surveillance can be reduced in those affected individuals with Marfan syndrome who are older than 20 years of age, she said.

contactleema Robert – leema.robert@gstt.nhs.uk

diagnosisophthalmologists can expect increase in referrals for identifying ectopia lentisby Gary Finnegan in Brighton

33

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The new Ghent nosology makes ectopia lentis a more important diagnostic feature...

“Leema Robert

EUROTIMES | Volume 16 | Issue 4

It is with great pleasure that I look forward to the 11th EURETINA Congress, which will take place at the Queen Elizabeth II Conference

Centre, London from 26-29 May 2011. The Programme Committee has been working very hard to produce another exciting Scientific Programme, taking into account the very useful feedback we have received from delegates after the Paris congress. The main sessions will feature world leaders from the field of medical and surgical retina. We are delighted to be able to include keynote lectures from Larry Yannuzzi and

Borja Corcóstegui, and have several new additions to the programme, including a joint symposium with the American Society of Retinal Specialists. Popular items such as the Amsterdam Retina Debate and the FAN club are included, as are a full range of popular Surgical Skills training courses and other instructional courses. Free Papers, Electronic Posters and Video Presentations will complete the programme.

The 2011 congress will also mark the inauguration of the EURETINA Innovation Awards, and the programme will include a session presenting the final shortlist of

innovative and creative applications being reviewed and graded for their scientific potential. The overall winner will be announced during the congress and further information is available on the EURETINA website.

Last year’s EURETINA congress in Paris attracted a record attendance of more than 2,700 delegates, and was our most successful congress in our 10-year history. Our ambition for London is to build on that success, and create a meeting that meets the very highest standards of scientific and educational excellence.

This will be my last congress as president of EURETINA. I have thoroughly enjoyed my time in office, and the experience of working with so many dedicated and talented colleagues will stay with me forever. I am delighted to be handing over the presidency to my good friend and colleague Gisbert Richard.

Gisbert was the driving force behind the formation of the society and brings a wealth of experience and knowledge to the office.

I look forward to working with him in the service of EURETINA.

Finally, with over a month to go before we officially open the 11th EURETINA Congress, I urge those of you who have not officially registered to do so by visiting our website at www.euretina.org.

London is an exciting city, and our congress will be taking part in the very heart of it. On behalf of the EURETINA Board and Programme Committee I encourage you to join us for what promises to be yet another landmark congress.

register now11th euretina Congress in london features world leaders in medical and surgical retinaby Bill Aylward, president EURETINA

34 News

EuREtiNA

I encourage you to join us for what promises to be yet another landmark congress

“Bill Aylward, president EURETINA

EUROTIMES | Volume 16 | Issue 4

Out of 16 EU-funded health information pilot projects presented at a November European Agency for Health

and Consumers (EAHC) workshop, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) stood out. EUREQUO was the only one that collected clinical data directly at the source – from front-line providers. All the others relied on indirect data from hospitals, existing regional or national sources, or literature reviews.

“Everyone wants [direct clinical] data because it is more reliable and it is also easier to relate it to benefits for patients, but it is difficult to collect,” says Mats Lundström MD, Karlskrona, Sweden, who presented the EUREQUO project to EAHC’s experts group on health information. “In that sense, we are the icebreakers.”

The pilot projects presented ranged from creating uniform definitions for reporting avoidable mortality and morbidity, to monitoring cardiac outcomes, diabetes treatment and the availability of primary care services. The European Union funds these health indicator and information network development projects through EAHC as part of its effort to improve care and health outcomes in all countries, and to support cross-border care.

Collecting real-time specifics on surgical technique, equipment, patient condition and outcomes gives surgeons and physicians the detailed benchmarks they need to continually improve performance, says Prof Lundström, who pioneered outcomes research with the Swedish National Cataract Registry. EAHC plans a conference this summer to investigate creating clinical data registries for other specialties, he adds. “What we have in EUREQUO is something they strive for.”

Sustaining the effort One issue with grant-sponsored pilot programmes is they often die when the funding ends. The current €900,000 EU grant will support EUREQUO through mid-2011. ESCRS has committed funds to continue an additional three years. By that time, Prof Lundström believes EUREQUO will have enough momentum to sustain itself.

“By the end of the pilot project in

June 2011, I think we will have 600,000 to 700,000 cases in the database. That is because we are connecting legacy systems like the Swedish and Dutch national registries, and large EMR systems with databases at clinics and hospitals,” Prof Lundström says. Linking with electronic medical records is essential to eliminate re-entering data, which most participants won’t do. Some grant funds left over from setting up national registries will be used in the project period to build interfaces with EMR systems that automate reporting.

Aside from Sweden and the Netherlands, which report nearly all their cases through their national registries, EUREQUO participation is highest in Spain, Austria and the UK, Prof Lundström says. Clinics in these countries tend to have advanced EMR systems. As more practices adopt EMR using standardised data elements, such as ICD-10 and SNOMED, the volume and granularity of data reporting are likely to increase.

“Of course it is in the interest of every surgeon to try to improve,” Prof Lundström says. “And the movement toward showing your results will continue. The patients, the healthcare authorities, the media, the payers – everyone wants to find out what is useful.”

35

impressing the eudetailed information from front-line providers could be future of health indicator reportingby Howard Larkin

News

EuREQuO

European Registry of Quality Outcomes for Cataract & Refractive Surgery

EUREQUO

By the end of the pilot project in June 2011, I think we will have 600,000 to 700,000 cases in the database

“Mats Lundström MD

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EUROTIMES | Volume 16 | Issue 4

Q: What are the origins of the European Society of

Ophthalmology (SOE) and how is the organisation enhancing the development of ophthalmology in Europe? The SOE was founded in 1956, with the aim “to promote ophthalmology in Europe and to stimulate co-operation between European ophthalmologists and between their national societies”. Over the past 55 years, SOE has grown from a relatively small society into a conglomerate of national societies of all 40 European countries, representing more than 40,000 European ophthalmologists.

Today, the society’s mission is to become the central point of European ophthalmology primarily through education and communication but also by fostering closer collaboration with sub-specialty societies and supranational organisations within Europe and beyond.

Q: What will be the main highlights of the congress?

The highlights of the Scientific Programme will include the special session with Stuart Fine: Lucentis vs Avastin for wet AMD – the CATT results. This is the NIH sponsored Comparison of AMD Treatment

Trials (CATT). The outstanding keynote lectures and many symposia, which are organised together with all major European sub-specialty societies and supranational organisations. The European University Professors of Ophthalmology (EUPO) course for ophthalmologists and residents takes place during the first two days of the Joint SOE-AAO congress. It will focus on glaucoma and uveitis.

Q: What are the keynote lectures and what topics will they be

addressing?The keynote lectures are: Wolfgang Drexler: “Pushing the frontiers of retinal OCT”. Prof Drexler plays a

leading role in the development of optical coherence tomography. He spent two years at MIT and was four years at the Christian Doppler Laboratory for laser development and their application in Medicine.Anders Heijl: “Lessons from the Early Manifest Glaucoma Trial”. Prof Heijl and his research group have invented and developed the Statpac and other programmes for perimetry. He initiated and has served as study director of the Early Manifest Glaucoma Trial.Shigeru Kinoshita: “Towards Sophisticated Therapeutic Modalities for Corneal Diseases”. His groundbreaking work on the movement of corneal epithelium has shed new light on the importance of

limbal epithelium. His group has recently established the system of cultivated mucosal epithelial stem cell transplantation.Jonathan Trobe: “The Management of Optic Neuritis - Why is There so Much Controversy? Jonathan Trobe is head of neuro-ophthalmology and professor of ophthalmology and neurology at the University of Michigan Medical Centre. He has an outstanding reputation for his scholarly approach and his teaching skills. Prof Trobe will discuss the management of patients with optic neuritis, a topic that remains controversial.

Q: How will this meeting be different from previous

meetings?We have more to offer to our patients. Great advances in patient care are occurring. With the many invited speakers this Joint congress will be the best educational opportunity in the world. The congress will serve many, ranging from sub-specialists and comprehensive ophthalmologists to residents and allied health.

Q: What do you hope ophthalmologists will learn

from this meeting?Great advances in patient care are occurring. From the outstanding keynote speakers, many symposia which are organised together with all major European sub-specialty societies and supranational organisations the participants will learn the latest diagnostic and therapeutic procedures in the world. This will help them to provide the best possible eye care to their patients.

Q: Why did you choose Geneva as the venue for this meeting?

Geneva is a very safe, charming and great location for our joint congress. Located in the centre of Europe, Geneva is easy to reach from anywhere in the world. The Joint Congress of SOE/AAO 2011 of the SOE will take place at the Geneva Palexpo. The Palexpo is not only ideal for our scientific sessions, but also has plenty of space and the appropriate up-to-date facilities for a large commercial exhibition.

stimulating Co-operation

36

Prof Gabriel van Rij, president of the European Society of Ophthalmology (SOE), previews the 18th Joint SOE-AAO Congress which will be held from 4-7 June 2011 in Geneva, Switzerland

News

18th JOiNt SOE-AAO CONGRESS

EUROTIMESESC

RS ™

Türkiye

Visit: www.eurotimesturkey.org

Aerial view of Geneva, Switzerland

EUROTIMES | Volume 16 | Issue 4

The European Union (EU) has adopted landmark legislation to facilitate patients who require ophthalmic and other medical care

outside their home country.Under the EU's Directive on Cross-

Border Healthcare, EU citizens will have an unquestioned legal right to travel to another EU country if their own country cannot meet their medical needs and to have that medical care paid for by their home country.

EU countries will have two-and-a-half years to transpose the provisions of the directive into their own national legislation.

In enacting the directive, the EU has attempted to codify a number of decisions by the EU’s highest court, the European Court of Justice. Those decisions followed reviews by the court of a number of cases brought by patients who were denied reimbursement from their home country for medical care they obtained in another EU country. In its decisions, the Court of Justice endorsed the right of patients to seek healthcare throughout the EU and have that care paid for by their home country if the care was medically necessary and the care was unavailable or not available within a reasonable time in their home country.

According to the EU, the new directive balances the right of patients to gain access to the best healthcare in the EU with the right of EU countries to organise their own health services as they deem most appropriate.

Among the highlights of the directive:n Patients may obtain medical care in

another member state and receive reimbursement for what they pay based on the appropriate level of reimbursement applicable in the home country if the medical care had been provided within its own borders;

n EU countries may decide to pay the healthcare provider in the country of treatment directly instead of reimbursing their citizens for the cost of what they pay to the provider;

n EU countries may, to ensure permanent access to a balanced range of high-quality treatment, to control costs, or to avoid any waste of resources, limit reimbursement of patients who obtain medical care outside their borders;

n To manage the possible outflow of patients, EU countries may introduce a system of prior authorisation to other EU countries. Such a system, however, is limited to medical care that is otherwise subject to strict regulation, such as care that requires an overnight stay in hospital or medical care that involves highly specialised and cost-intensive medical infrastructure or equipment, medical care that involves treatments presenting a particular risk for the

patient or the population, or medical care which would be provided by a healthcare provider which raises serious quality and safety concerns;

n To manage incoming flows of patients, EU countries may also adopt measures limiting access to treatment, if such measures are necessary to ensure sufficient and permanent access to healthcare within its own borders. Such limits must be justified by requirements that ensure permanent access to a balanced range of high-quality treatment, control costs, or avoid waste of resources;

n To enable patients to make an informed choice about obtaining care outside their own country, EU countries must establish national contact points to provide patients with practical information on potential healthcare providers outside of their borders and also provide information about

quality and safety of procedures, and accessibility of hospitals for persons with disabilities;

n EU countries may refuse prior authorisation of treatment outside of their borders if the patient seeking cross-border healthcare will be exposed to an unacceptable safety risk, if the general public will be exposed to a substantial safety hazard, if the healthcare is to be provided by a healthcare provider who raises serious quality or safety concerns, or if the healthcare can be provided within the country’s own territory within a medically justifiable time limit.

To help strengthen access to care, the directive also encourages each EU country to establish national agencies to coordinate e-health initiatives and the diagnosis and treatment of rare diseases.

Also, the directive provides that, as a general rule, if a pharmaceutical product is authorised to be marketed on its territory, a member state must ensure that prescriptions issued for such a product in another member state can be dispensed in its territory in compliance with its own national legislation.

Despite its comprehensive nature, the directive does not include all aspects of cross-border medical care. For example, the sale of medicinal products or medical devices over the Internet, the provision of long-term care services in residential homes, and the access and allocation of organs for transplantation fall outside the scope of the directive.

Although the vast majority of EU’s 27 countries voted in favour of the directive at a meeting in Brussels on February 28, four governments – Austria, Poland, Portugal, and Romania – voted against the directive. One country, the Slovak Republic, abstained.

In opposing the directive, the governments of Poland, Portugal, and Romania complained that the directive did not go far enough to protect patients or their health systems. The directive “does not provide a sufficient guarantee of a high level of quality and safety to patients wishing to receive cross-border healthcare and does not entirely respect the responsibilities and competences of the member states in relation to the organisation and planning of national health systems,” the three governments said in a joint statement.

Eu mAttERSFeature

new frontierseu erases national borders for access to ophthalmologistsby Paul McGinn

37

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EUROTIMES | Volume 16 | Issue 4

Raised expectationsTechnologyandinnovativetechniquesallowthedevelopmentofpersonalisedapproaches“Astigmatism is not a new topic, nor is it a fascinating one for most ophthalmologists.”

It is hard to imagine a more modest introduction than that, yet these are the opening words of the preface of this book. And yet the authors have method in this seemingly apologetic stance. Patient expectations after cataract surgery are beginning to rival those of laser surgery. In the context of these increasing expectations, practitioners are rightly concerned with each aspect of outcomes.

An increasing concern with outcomes marks the development of any medical technology. Initially it is simply enough that a wonderful new technology is introduced at all. Over the years, we get first scare stories, then a correction to a more realistic view of a given technology. It is a pattern we see throughout the history of modern medicine.

There are a wide range of books available now on almost every aspect of ophthalmic practice. Clearly each text has to come somewhere in the balancing act between specificity and generality. There are many excellent vade mecum, one-stop-shop references available. Then there are the more targeted, focused texts, in which an individual clinical area or presentation is given close attention. This book falls squarely into this latter bracket.

Technology and innovative techniques allow the development of personalised approaches, tailored to different presentations. Bonnie A Henderson and James P Gills have assembled a team of expert contributors, largely from the US, but also from Germany, Spain, and Brazil, to provide a comprehensive guide to this topic. The chapters are written by teams of authors, or individual contributors. They are generally extremely clearly written and full of down-to-earth, pragmatic advice directly applicable in clinical settings.

The book is divided into six sections. The first consists of a single chapter, an overview of the surgical correction of astigmatism. This gives an overview of the optics, the history, and the development of surgical approaches to the condition. The second deals with

perioperative considerations, relating to the diagnosis and the approach to the surgical correction of astigmatism at the time of cataract surgery. The third section is on corneal surgical correction, and the fourth on managing astigmatism in cataract surgery.

The final two sections deal with correcting astigmatism with toric lenses and managing irregular astigmatism respectively. Overall, compared to the first edition there are many new topics covered; the diagnosis of astigmatism, the approach to and timing of surgical correction, a consideration of astigmatism by laser keratectomy, IOL calculations with previous refractive surgery, marking alignment instrumentation, and discussions of innovative techniques such as collagen cross-linking.

The book is handsomely illustrated and filled with handy tables; overall, there are more than 200 colour images and 35 tables. It is quite large and would not exactly be portable around the wards; it would be most appropriate as a reference text in the consulting room or the surgical annexe. It would be a useful addition to the libraries of corneal and refractive surgeons.

39

BooKs EDIToR: Seamus Sweeney

PuBlIcATIonA complete SurgicAl guide for correcting AStigmAtiSm: An ophthAlmic mAnifeSto (Second edition)

EDITED By Bonnie A henderSon & JAmeS p gillS, SlAcK inc.

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

BOOk REviEwFeature

2nd EuCornea Congress

Vienna, Austria16–17 September 2011

www.eucornea.org

Vienna

Immediately preceding the XXIX Congress of the ESCRS

EUROTIMES | Volume 16 | Issue 4

Researchers from University College London and the Moorfields Eye Hospital have announced results of research studies that demonstrated the feasibility of cone transplantation into the

adult retina.The research used embryonic and post-natal sourced

photoreceptor cells as the donor population for transplantation into two animal models of Leber congenital amaurosis. The results hold promise for future therapeutic applications for human blindness.

Research on cell transplantation has advanced significantly in recent years. In respect of retinal cell transplantation it has turned out that timing – in respect of developmental stage of the donor cell – is a critical factor in success.

Timing of photoreceptor genesis now appears to be a key component on whether or not integration occurs and on what kind of cell develops from the donor. In a previous study, it was demonstrated that rod precursor cells were capable of integration into both adult and degenerating retinae if taken from a developing retina at the right time – a time coincident with a peak in rod differentiation. However, while providing new rods is of clear value, providing new cone photoreceptors, given their function in human vision, would likely have a more significant impact in the treatment of several retinal degenerative disorders.

To get from a retinal precursor to either a mature rod or a mature cone photoreceptor cell requires the histogenesis of seven different sequential, and sometimes overlapping, cell types. Cones make their appearance at embryonic day 10, peaking at about embryonic day 14 or 15, while rods stretch out their appearance across a longer period of time peaking in the early post-natal period. The final fate of the various cone cell types may be delayed out to post-natal day four to 13 which suggests a degree of plasticity – the system, as it were, appears to keep the options open until relatively late, possibly to accommodate necessary adaptations to the local micro-environment.

So how does one get the “right” type of cells for transplantation? Generating photoreceptors in vertebrates is controlled by the homeodomain “transcription factors” Otx2 (orthodenticle homeobox 2) and Crx (cone rod homeobox). The transcription factors act almost as team coaches instructing which genes should be turned on or off and when. Crx for instance is turned on at a point in development at which either a rod or cone fate will be determined and so Crx can be used as a flag to identify that population of cells which one way or another will become either a rod or a cone cell. The research team used transgenic animal models engineered to facilitate the isolation of Crx expressing cells from the retina (through use of GFP [green fluorescent protein]).

As one of the earliest photoreceptor markers, Crx can be used to identify cells poised for either a cone or rod photoreceptor cell fate. Using a flow cytometry cell sorting process the research team were able to build populations

of post-mitotic photoreceptor cells at different time points from embryonic day 12.5 through to post-natal day three. The experiments represented the first demonstration of how flow sorted photoreceptors behaved in the live retina, in addition to comparing them at different stages of maturity. Transplantation of such cell populations showed that integration of donor cells into the host retina increased with advanced age of the donor cells however, the majority of these older cells differentiated into rods.

Contrastingly, cone cell integration efficiency appeared to be inversely correlated with the increased age of the donor cells – embryonic sourced cells led to a higher number of cones in the host than did post-natal sourced cells. Integration of rod photoreceptors appeared to be 10 times more efficient when using post-natal donor cells rather than embryonic donor cells. When embryonic donor cells were used as the source there was a higher proportion of cone cells among the total integrated photoreceptor cell population. In summary, integration appears to be more efficient when using post-natal donor cells which result in a higher number of rod photoreceptors however, using embryonic donors appears to increase the proportion of cone photoreceptors. In essence, timing is key and knowledge of which stage the donor cell is at along the differentiation path determines the proportion of rod and cone photoreceptors that will appear in the recipient retina following transplantation.

The research team commented that their findings “contrasted with previous assumptions that the adult retina was a non-permissive environment for the integration of new photoreceptors and their incorporation into the existing retinal circuitry.” The study therefore provides a key proof-of-principle for the use of embryonic stage photoreceptor precursors capable of efficient integration into a diseased retina.

In addition, it appeared that integration was a function not just of the developmental stage of the donor cell but also a function of the host environment. Subjects with a damaged retina showed a 10-fold higher increase of differentiated cone cells following transplantation compared to transplantation into normal retina. But how do the transplanted cells know this? Presumably there are some environmental cues that direct the incoming cells to a cone fate or maybe there are diffusible signals that impact on the developmental fate of the incoming donors? Right now it is not known how this works but clearly the medical significance is that the approach may find utility in application to retinae where disease onset has already occurred.

Further details on the research can be found in Human Molecular Genetics, 2010;19:4545-4559.

Cone Cell transplantationtiming is critical factor in success of retinal cell transplantation by Gearoid Tuohy

40 Feature

BiO-OphthAlmOlOGy

ESCRSMembershipSee the benefits!

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EUROTIMES | Volume 16 | Issue 4

oCulus pentacam hr certified for ChinaOculus Optikgeraete GmbH has received an SFDA certificate for the HR-version of their Pentacam®. This allows full marketing and sales on the growing market of the PRC, after the intensive scrutinising has successfully been passed. “The Pentacam® was the first rotating Scheimpflug camera on the world market giving 3-D views of the anterior segment,” said a company spokeswoman. “The product family has grown and meanwhile covers a wide range of applications addressing the need of the general ophthalmologist to get an overview as well as the specialists’ questions for support in detailed analysis.”n www.pentacam.com 

41Feature

iNduStRy NEwSRecent developments in the vision care industry

global licensing agreement for kerasoftBausch + Lomb has recently announced a global licensing agreement with UK-based UltraVision CLPL to market and sell KeraSoft® soft contact lenses throughout the world, through the network of Bausch + Lomb lab channel partners.

KeraSoft patented technology allows for custom-made contact lenses for irregular corneas and keratoconus. As part of the agreement, Bausch + Lomb acquired the KeraSoft trademark.The announcement was made at the Global Specialty Lens Symposium in Las Vegas. The global roll-out of KeraSoft lenses will begin later this year and will be executed around the world in phases.

“This technology has totally transformed my view of contact lens management of keratoconus and irregular cornea patients. The visual results and enhancement of life are true advances,” said Joseph Barr, OD, MS, FAAO, vice-president, global clinical & medical affairs and professional services, Vision Care, Bausch + Lomb.

new visumax option: incision for iCrThe creation of corneal tunnel incisions for the insertion of intrastromal ring segments will benefit from the performance of Carl Zeiss' 500 kHz femtosecond laser, according to a company spokeswoman.

“Maximum incision precision and unsurpassed degrees of freedom in tunnel preparation are impressive. What is unique is that in addition to making 360° incisions, tunnel segments of between 90° and 270° can also be created with a large degree of flexibility. Unnecessary incisions are avoided, thus maintaining corneal integrity as much as possible,” she said.

Carl Zeiss says the tailored incision is created by setting inner and outer diameters, setting separately the incision depth at the inner and outer diameter of the ring tunnel, and entering the desired lower and upper width of the access incision.

“In addition, zero, one or two access incisions can be set. Outstanding feature: the innumerable incision parameter variations that are possible enable not only countless different width, depth and inclination positions of the tunnel incision, but even a cutting pattern and subsequent ICR implantation parallel to the posterior surface of the cornea,” said the spokeswoman. “As the special curvature of the contact glass is adapted to the corneal surface, the shape of the cornea remains almost unchanged, even during the execution of the scanning pattern. Cutting artefacts are avoided, as are unnecessary increases in intraocular pressure, traumata and temporary vision loss.”

escrs on your timeSymposia, free papers, videos and more from

ESCRS Congresses in your home

escrs on demandVisit www.escrsondemand.org

XXVIII Congress of the ESCRS,Paris, France

and 15th ESCRS Winter Meeting, Istanbul, Turkey

Now Online

EUROTIMES | Volume 16 | Issue 4

This year's ESCRS Practice Development Programme will run over three full days at the XXIX ESCRS Congress in

Vienna, Austria to allow more time for debate and discussion of the key issues facing ophthalmologists in their practices.

On Saturday September 17, Rod Solar of LiveseySolar Practice Builders will moderate a workshop on Marketing your Practice.

This will be an interactive workshop where Mr Solar will advise delegates on addressing key marketing functions in their individual practices.

There will also be breakout sessions where workshop participants can discuss some of the challenges they face in establishing a marketing strategy, tailored to their individual practices.

On Sunday September 18, Paul McGinn, barrister at law and EuroTimes editor; Tom Harbin MD, author of What Every Doctor Should Know but Was Never Taught in Medical School; and Kris Morrill, director KAM Communications

will moderate the second workshop on Managing Your Practice.

Again, this will be an interactive workshop where the moderators will advise delegates on addressing key management functions in their individual practices.

There will also be breakout sessions to allow participants to discuss and attempt to resolve some of the challenges they

face in establishing a management plan, tailored to their individual practices.

“Often physicians have no idea what their economic potential is or how to finance a practice that will meet their potential,” says Dr Harbin.

During the workshop, Dr Harbin will also stress the need for doctors to put in the effort to develop the skills they need to achieve their practice goals. “Doctors

sometimes think they should be catered to more than people are willing to do,” he says. “But that is life. You have to do some things for yourself and you can’t escape that.”

Registration for both workshops is free but each day's workshop is limited to 65 participants.

The programme concludes on Monday September 19 when the third masterclass for ophthalmologists will be delivered by Prof Keith Willey, London Business School.

At previous congresses, the masterclass has been held on a Friday but this year it will be held on a Monday to allow those attending the meeting with busy schedules a better chance of taking part.

The topic of this year’s masterclass is “Developing High Performance Practices".

Prof Willey will share the profiles of participants following a pre-course survey and make comparisons to businesses in other sectors. “Transformation requires a leader, and a leader requires a vision to guide the plan and enroll colleagues,” Prof Willey says.

We also hope to present for the first time a special Case Study focusing on a European ophthalmological practice. Further details will be available presently.

This course is limited to 50 participants and the course fee is €200.

For more details on the Practice Development Programme, visit: www.escrs.org.

new Challengestransformation requires a leader, and a leader requires a visionby Colin Kerr

42 Feature

pRACtiCE dEvElOpmENt

Journal watchVaricella vaccination cuts zoster by more than halfOlder patients who receive the varicella vaccine (Zostavax, MSD) are significantly less likely to develop zoster complications, including zoster ophthalmicus, a large-scale population study reveals.

H Tseng and colleagues compared the incidence of zoster in 75,761 vaccinated patients 60 years and older and 227,283 unvaccinated controls during a three-year period. The vaccinated patients showed a 55 per cent lower incidence in herpes zoster infection compared with controls. The protective effect was found regardless of age at vaccination, gender, race, or concomitant chronic disease.

Vaccinated patients were also less likely to be hospitalised for zoster-related problems. This included a statistically significant reduction in cases of zoster ophthalmicus. Patients who did not develop complete immunity following vaccination had fewer and milder symptoms than unvaccinated people.

The clinical studies leading up to approval of the varicella vaccine showed a 51 per cent reduction in shingles and a 67 per cent reduction in post-herpetic neuralgia. The current study is

important because it confirms these findings in less idealised, real-world conditions. The original US FDA study did not assess ophthalmic zoster, which makes this study particularly important, the researchers note.

The current study supports recommendations by health authorities for wider use of the herpes zoster vaccine. This could benefit patients of all ages, but might particularly help the older patient groups who are most at risk of developing herpes zoster and post-herpetic neuralgia.

The herpes zoster vaccine has been available for children in Japan and Korea since 1988. It was approved for chicken pox prophylaxis by the US FDA in 1995. Approval of the vaccine for prevention of herpes zoster in individuals 60 years of age and older came in Europe and the US in 2006. The adult vaccine is given as a single dose by injection and is the only product on the market that can prevent post-herpetic neuralgia. H Tseng, JAMA, “Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease,” 2011;305(2):160-166.

Doctors sometimes think they should be catered to more than people are willing to do. But that is life. You have to do some things for yourself and you can’t escape that

“

Tom Harbin MDProf Keith Willey speaking at a previous masterclass during the XXVII Congress of the ESCRS in Barcelona in 2009

EUROTIMES | Volume 16 | Issue 4

Toric IOLs, new standard of care?Even modest amounts of astigmatism can have major effects on vision, a new study confirms. Moreover, uncorrected astigmatism can significantly affect patients’ independence, quality of life, and well-being, UK researchers note. They reached this conclusion after conducting an unusual protocol in which healthy presbyopes with minimal astigmatism were asked to wear test spectacles simulating various amounts of cylinder, and then to perform various tasks with mobile phones, computers and driving simulators. Distance acuity decreased as the amount of simulated cylinder increased, as did near visual acuity and reading speed. Simulated driving did not appear to suffer, but patients complained of diminished clarity of vision. Uncorrected astigmatism at the 45-degree or 180-degree orientation resulted in worse distance and near visual acuity and subjective clarity than at the 90-degree orientation. These findings suggest that moderate uncorrected astigmatism can lead to restricted independence, reduced quality of life, and higher risk of falls. The researchers note that astigmatism is very common, particularly among older patients, yet most public healthcare systems do not cover the use of toric IOLs in cataract patients with significant amounts of astigmatism. They propose that correction of corneal astigmatism in cataract patients by using toric IOLs should become the standard of care.n JSWolffsohnetal.,JCRS,“Effectof

uncorrectedastigmatismonvision”,Volume37,Issue3,pages454-460.

Angle-supported phakic IOLs for myopiaAngle-supported phakic IOLs for myopia can provide safe and predictable long-term refractive correction in patients with moderate to high amounts of myopia, pooled data from three international studies concludes. Patients with -6.0 to –16.5 D of myopia all underwent implantation of anterior chamber angle supported phakic IOLs (AcrySof Cachet, Alcon). Interim results on 104 of 360 study participants for whom three-year follow-up data was available showed that UDVA was 20/40 or better in 97.1 per cent and 20/20 or better in 46.2 per cent. The CDVA was 20/32 or better in all but one of the 104 patients and 20/20 or better in 80.8 per cent. The mean MRSE was −0.24 D ± 0.55 (SD) (range −2.00 to 1.63 D). The residual refractive error was within ±0.50 D of target in 78.8 per cent of cases and within ±1.00 D in 91.3 per cent. In terms of endothelial cell density, the

annualised percentage loss in central density and peripheral density from six months to three years was 0.41 per cent and 1.11 per cent, respectively. No pupil ovalisation, pupillary block, or retinal detachment was observed. The researchers comment that these endothelial cell findings suggest that with appropriate patient selection, including adequate anterior chamber depth and appropriate preoperative endothelial cell density, the safety concerns associated with previous angle-supported phakic IOLs may be assuaged.n MCKnorzetal.,JCRS,“Angle-supported

phakicintraocularlensforcorrectionofmoderatetohighmyopia:Three-yearinterimresultsininternationalmulticenterstudies”,Volume37,Issue3,pages469-480.

Focus on KamraThe search continues for a safe and effective treatment for presbyopia. Two-year results from a study of a small-aperture intracorneal inlay known as the Kamra (AcuFocus) have been published. The intracorneal inlay is designed to increase the depth of field based on the principle of small-aperture optics to restore near and intermediate visual acuity without a significant impact on distance vision. Thirty-two emmetropic presbyopes received the implants in their non-dominant eyes and were then evaluated over the study period. Improvements were noted over the two-year period in all tested reading performance parameters. The researchers acknowledge that longer term follow-up is needed, but believe that this corneal inlay has the potential to be a safe, stable, and effective treatment for presbyopia.n AKDexl,JCRS,“Readingperformance

afterimplantationofasmall-aperturecornealinlayforthesurgicalcorrectionofpresbyopia:Two-yearfollow-up”,Volume37,Issue3,pages525-531.

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43Review

JCRS hiGhliGhtSJournal of Cataract and Refractive Surgery

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

Thomas KohnenASSOCIATE EDITOR OF jCRS

Advertising Directory: Abbott Medical Optics: Page: IFC; Alcon Laboratories: Pages: 7, 11, 25, OBC; ASCRS / Eyeworld Pages: 16, 21, 38; Carl Zeiss Page: 33; D.O.R.C International BV Page: 27; Medicel AG Page: 9; Mediphacos Page: 34; Moria Page: 43; NIDEK Page: 31; Oculus Optikgeraete GmbH Page: 35; Oertli Instruments AG Page: 15; Rayner Intraocular Lenses Ltd Page: IBC; VSY Biotechnology Page: 3; Ziemer Page: 17

May

July

2011

2011

26-29london, UK

11th EURETINA Congresswww.euretina.org

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

Reference44

CAlENdAR Of EvENtSDates for your Diary

June

September

2011

2011

3

6-10

16-17

Geneva, Switzerland

Mar del Plata,

arGentina

vienna, aUStria

PRESBYMANIA 2011www.presbymania.com

19th Argentinian Ophthalmology Congresswww.oftalmologia2011.com.ar

2nd EuCornea Congresswww.eucornea.org

April

May

2011

2011

December 2011

1-4International Symposium on Ocular Pharmacology and Therapeuticswww.isopt.net

vienna,aUStria

9-11

4-7

Milan,italy

Geneva,Switzerland

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

Joint Congress of SOE/AAO www.soe2011.org

June2011

29-2 PariS, FranCe

World Glaucoma Congress 2011www.worldglaucoma.org

1-3 leUven, BelGiUMLeuven Retina Meetingwww.leuvenretinameeting.eu

21-23 dead Sea, iSrael

8-10 Crete, GreeCe

September

12th Aegean Retina Meetingwww.aegeanretina.gr

2011

Fifth International Symposium on Refractive Surgery, Cataract and Corneawww.dead-sea2011.co.il/

19-22 iStanBUl, tUrKeyVIII Congress of SEEOSAnd IX Congress of BSOSwww.seeos-bsos2011.org

24-26 BirMinGHaM, UK

19-22 nUrnBerG, GerMany24th Intl. Congress of German Ophthalmic Surgeonswww.mcn-nuernberg.de

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

9th SOI International Congresswww.soiweb.com

18-21roMe,italy

May2011

1-524th Intl. Congress of German Ophthalmic Surgeonswww.mcn-nuernberg.de

Florida,USa

5-8 Porto aleGre, BrazilXXXVI Ophthalmology Brazilian Congresswww.cbo2011.com.br/

23-24 BordeaUx, FranCe

8-9 GotHenBUrG, Sweden1st World Congress on Surgical Trainingwww.surgicon.org

Eurokeratoconus IIwww.jbhsante.fr

23-266-7 22-2513-16

Milan,italy

dUBlin,ireland

orlando,Fl, USa

SeoUl,Korea

91st SOI National Congresswww.soiweb.com

13th International Paediatric Ophthalmology Meeting Dublin

American Academy of Ophthalmology Annual Meetingwww.aao.org

2011 APACRS-KSCRS Annual Meetingwww.apacrs.org

NovemberOctober October20112011 2011

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