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Special Focus: Education and Training 4 Cover story: EsCRs members have a lot to gain from e-learning platform8 Practice and repetition may be the key to becoming a competent surgeon9 EUREQUO database has a lot to offer trainees10 Patient questionnaires can be a good indicator for cataract surgery success11 Experts discuss measures for ensuring patients have successful outcome13 Trainees advised to avoid high-risk cases14 Training and practice crucial to enable trainees to perform cataract procedures

Cataract & Refractive 15 Measuring iOP after LAsiK16 Alternatives to sutured iOLs examined17 Treating presbyopia with intracorneal inlays18 Latest advances in ophthalmic technology discussed

Cornea 20 Care must be taken when treating patients with advanced corneal pathology21 Cataract surgery in the keratoconic eye23 Results can be unpredictable in corneal collagen crosslinking procedures

Glaucoma 24 study looks at patient outcomes after deep sclerectomy

Retina 26 hiV can still threaten sight despite anti-retroviral drugs28 Effective drug delivery systems under development

Ocular 29 some diagnostic tools for ocular infections can be very sensitive

Paediatric Ophthalmology 30 some guidelines for operating on paediatric cataracts

News 32 EsCRs funds have helped to enable hands-on training in Ethiopian hospital

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may 2013Volume 18 | Issue 05

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Features 34 Eye on Travel35 JCRs highlights37 Book Review39 Ophthalmologica

Publisher Carol FitzpatrickExecutive Editor Colin KerrEditors sean henahan Paul McGinn

Managing Editor Caroline BrickProduction Editor Angela sweetmanSenior Designer Janice Robb

Circulation Manager Angela Morrissey Contributing Editors howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon schuyler Eisele stefanie Petrou-Binder Maryalicia Post Leigh spielberg

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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.

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes.ISSN 1393-8983

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Published byThe European Society of Cataract and Refractive Surgeons

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2012 and 31 December 2012 is 37,563.

40 industry News41 EU Matters44 Calendar

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by Ioannis Pallikaris

it is a genuine pleasure to be associated with this month’s issue of EuroTimes which is devoted to the theme of education and training.

This is a subject in which i have retained an enduring interest all my professional life and which should interest every ophthalmologist dedicated to delivering better outcomes for our patients.

Education and training are lifelong pursuits. There is still a perception that education and training stop as soon as one leaves medical school, whereas in fact the voyage of discovery is only just beginning. There is always something new to learn – in medicine, in ophthalmology, in life – and we continually need to look afresh at age-old problems. That is the dynamo that underpins scientific enquiry and which drives progress in our rapidly evolving field of medicine.

The EsCRs recognises the importance of education and training for its members – and this is true whether those members are young ophthalmologists or seasoned professionals. As this month’s Cover story makes clear, the drive to put education and training at the heart of the society is spurring new developments and initiatives to empower our members and put them in control of the learning process. in allowing EsCRs members free access to CME-accredited learning material in a flexible manner to suit their own schedule and pace of learning, iLearn liberates learning from the traditional classroom environment and puts the learner in the driving seat.

This is how it should be. At the European level, we have seen the importance of enhanced cross-border cooperation in education and training for many of our members from eastern Europe. We definitely need to encourage such partnerships and foster greater international cooperation between European medical institutions in order to harmonise training standards across the region. We could also perhaps take this idea further in the future by establishing a PhD-MD degree on the European level that would be recognised by all participating countries, with the EsCRs and the European Board of Ophthalmology playing an enabling role in the accreditation process.

Looking at the current standards of training and education in our universities, i think there is definitely a need not to overlook the fundamentals in our rush to embrace the wonders of all the technology we now have at our disposal. With so much “on-screen” technology available, we must never lose sight of the benefits that a thorough grasp of visual optics and a firm grounding in mathematics and physics bring to understanding the wonderful complexity of the human eye.

EUROTIMES | Volume 18 | Issue 5

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from the eDItor Volume 18 | Issue 5

Editorial

A VOYAGE OF DISCOVERYThere is always something new to learn and we continually need to look afresh at age-old problems

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

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

Rudy Nuijts tHE NEtHErlaNDs

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* Ioannis Pallikaris MD, PhD is professor of ophthalmology, School of Medicine, University of Crete and founder and director of the Vardinoyannion Eye Institute of Crete

“The ESCRS recognises the importance of education and training for its members – and this is true whether those members are young ophthalmologists or seasoned professionals”

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“Education is not the filling of a pail, but the lighting of a fire," – William Butler Yeats.

The explosion of information technology in the past decade has created new opportunities and tools to assist trainees in the learning process. With the advent of widespread high-speed internet access, sophisticated multimedia content and a generation of “always connected” end users, today’s medical educators have the technical means to try exciting new approaches to educating the physicians of tomorrow.

in crafting its own e-learning platform, iLearn, over the past three years, the EsCRs has sought to meet head on the challenge of creating interactive and engaging learning programmes for its members. By allowing EsCRs members free access to learning material in a flexible manner to suit their own schedule and pace of learning, iLearn seeks to meet the growing demand for learner-driven education that liberates learning from the traditional classroom environment.

“The idea behind iLearn was essentially to provide an online space where EsCRs members could learn, share and develop their knowledge of cataract and refractive surgery from fundamental concepts to advanced skills using assessed, accredited and self-reflective activities and resources,” said Paul Rosen FRCs, FRCOphth, past-president of the EsCRs and member of the Education Committee.

in order to attain that goal, the EsCRs hired a team of instructional designers led by Brendan strong who have worked intensely over the past three years to bring that vision to fruition.

“The development of EsCRs iLearn has been the greatest challenge of my career, and the project of which i am most proud. Working with society opinion leaders and learners has been very rewarding,” Mr strong told EuroTimes.

he noted that the original goal was to provide learners with highly interactive, assessed and accredited content that they could use in their own time to complement their own learning.

“We wanted to create something more than simple recorded presentations and surgical videos, although surgical videos are included. The purpose was – and still is – to get learners involved and engaged,” he added.

Active engagement it is this process of active engagement which goes to the heart of the e-learning process and is one of the undoubted strengths of the iLearn approach compared to traditional instructor-driven learning.

“if you are passively reading or watching, you don’t know how much you are learning as you go along and you don’t really know whether you have fully understood everything,” explained Mr strong. “We wanted to fix that by encouraging a more active mode of learning, by asking questions to help learners construct the knowledge in their own minds. This helps them to better understand and master the information they are learning. We also provide plenty of assessment opportunities and feedback. Not only does this help learning for understanding, but learners can reflect on what they learned and how much they have understood. Then they know whether they need to go back over a course – which they are free to do,” he said.

Mr strong paid tribute to the EsCRs Education Committee and leading ophthalmic surgeons who devoted considerable time and energy to ensuring that the iLearn content is accurate and complete.

“EsCRs iLearn would not be what it is today without the interest and great efforts of the Education Committee and all the subject matter experts. Everyone involved has played an important part in developing

content that provides the best learning experience for members. Of particular note, Drs Oliver Findl and Paul Rosen helped us to develop the approach, while the leaders of the courses currently available – Drs Jose Guell, Dan Epstein, Paul Rosen, Richard Packard, Marie-Jose Tassignon and Khiun Tjia – have been tireless in their support and advice both with developing content to suit EsCRs members and to ensure that we achieve the best outcomes for learners. Their input has also been invaluable in ensuring we achieve accreditation for the content we have created,” he said.

Sharing expertise "If you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning for a lifetime, educate people," – Chinese proverb.

For the surgeons who volunteered to share their expertise for the benefit of their colleagues, getting involved in iLearn was, for many, a natural evolution both from their longstanding involvement with the EsCRs and their personal and longstanding interest in ophthalmic education.

“i was enthusiastic to get involved from the beginning because ophthalmic education is a topic that is very close to my heart,” said Jose Güell MD, past-president of the EsCRs and current chair of the society’s Education Committee.

“When we discussed the proposal some years ago, my immediate answer was 'yes' because i felt that it was the way to go, even though at that time it was not so clear-cut that the internet was going to be a platform that would be suited to teaching in ophthalmology. But when we saw what could be created in terms of interactivity, high-quality video of surgery and so forth, then we realised that we had indeed the potential to develop a really good platform that would be a very useful asset to our members,” he said.

Dr Güell said that the real challenge was to tailor the content and courses to an online audience.

by Dermot McGrath

POWER TO THE PUPIL

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eDucatIon & traInIngCover Story

Launched officially in 2011, the iLearn e-learning platform is pushing ophthalmic education into new territory, with ESCRS members the direct beneficiaries

EUROTIMES | Volume 18 | Issue 5

I believe iLearn is a tremendous adjunct for surgeons in the learning process of improving insight and skills

Khiun Tjia MD

“

With the technology and bandwidth now available we were able to move beyond static presentations and present content in a lively, dynamic and interesting way

“

Jose Güell MD

“Thanks to Brendan strong and his team we realised quite early on in the project that we were able to achieve things that we originally had not thought possible. For instance, the ability to make small segmented video clips with clear explanations, followed by questions and then moving onto another segment. With the technology and bandwidth now available we were able to move beyond static presentations and present content in a lively, dynamic and interesting way. That was very gratifying to see in action,” he said.

indeed, it is this ability to actively engage the learner from the moment they log on to an iLearn course which really takes the educational process to a whole new level, believes Khiun Tjia MD, who was responsible for the Basic Phacoemulsification instructional Course.

“i believe iLearn is a tremendous adjunct for surgeons in the learning process of improving insight and skills. it adds an entire new dimension to teaching. in the 'live' instructional course, information for the attendee is passive. iLearn, by contrast, is highly interactive and assesses understanding of newly acquired knowledge at every step. The two formats complement each other in a very efficient way. The addition of the iLearn tool has created a superior level of teaching,” he said.

For Daniel Epstein MD, PhD who put together the surface Ablation Techniques Course and also the Refractive surgery Didactic Course in conjunction with Jose Guell, iLearn represented the perfect opportunity to extend a long association of ophthalmic education with the EsCRs.

“i had been involved in the design and implementation of the very first EsCRs didactic course, which was a traditional lecture course, so taking that onto an e-learning platform seemed to be the next logical step. Potentially this is a very important development for EsCRs members because the society is a service organisation, and one of its key functions is to provide teaching. iLearn expands on this role with an innovative approach,” he said.

Ease of access “Education is the most powerful weapon which you can use to change the world,” – Nelson Mandela.

Prof Epstein noted that moving a traditional didactic course from a lecture-hall environment to an online setting requires a lot more than simply re-purposing the material for a new presentation format.

“it is more time-consuming than one imagines it will be. You need to look at the material in a completely new light. in a traditional classroom environment there is direct interaction from the students and topics can be explained in greater detail or repeated if necessary. Naturally this is not possible in the online environment so we have to anticipate in the didactic format if things are not clear or what potential problems the learners might experience. This is not obvious, so you have to make sure everything is as simple and clear as possible to avoid any possibility of ambiguity or misunderstanding,” he said.

Ease of access also makes iLearn a particularly attractive service for younger members who may not have the time or the means to travel to the society’s meetings twice a year, points out Oliver Findl MD.

“iLearn is obviously a useful way to reach out to some of the younger ophthalmologists who cannot afford to attend the meetings because of the cost of travel and hotels. But even for those who attended a particular meeting or took part in a course, iLearn is an excellent way of recapping what they have learnt. We all forget details and nuances after one or two years so it is a very good tool to keep reviving your knowledge, even if you have gone through all the live didactic courses,” he said.

While younger ophthalmologists are prone to be more tech-savvy than older colleagues, and thus more at ease with the e-learning concept, experienced surgeons will also derive benefit from using iLearn, said Dr Findl.

“While the first courses that were put on iLearn such as the Refractive surgery Didactic Course, the Cataract surgery Didactic Course and the Workshop on Visual Optics were perhaps more suited to the younger ophthalmologist, that trend is changing as the platform matures and more content is added. i believe that there is great potential in the near future to develop iLearn into more specialised areas which are of interest to more experienced surgeons,” he said.

While acknowledging that residents and younger ophthalmologists are probably most likely to use iLearn in the initial stages, Dr Tjia said that ophthalmologists of all experience levels could benefit from the iLearn methodology.

“While not all instructional courses will appeal to everybody, the beauty of iLearn is that every member can pick the time, topic and location for taking a course. Even after one has completed the iLearn course, users may find the traditional course even more interesting to attend,” he said.

Adapting the content to different target audiences holds the key to broadening the appeal of iLearn, believes Marie-Jose

Tassignon MD, PhD, FEBO, past-president of the EsCRs, who runs the Visual Optics course along with ioannis Pallikaris MD.

“The level of education of e-learning should be organised for different levels of difficulty: the basic level for the trainees, more difficult level for the fellowship ophthalmologists who would like to become subspecialists and the level necessary for continuous medical education. This would cover a large part of the EsCRs attendees at the major meetings. in future also ophthalmic nurses and technician programmes can be taken into consideration,” she said.

Another key challenge facing any e-learning platform is ensuring the content keeps pace with changing developments in surgical techniques, therapies and technologies, said Dr Findl. “Updating the information on a regular basis is obviously important because we are working in a rapidly changing field of medicine. iLearn has been designed to take account of changes in practice and the content will be updated regularly,” he said.

Updating content “Anyone who stops learning is old, whether at 20 or 80. Anyone who keeps learning stays young,” – henry Ford.

Dr Güell agreed that being able to update content on a regular basis is one of the advantages of an e-learning system.

“This is not like an academic book series where the content is changed only every six or eight years. The capacity to update the platform and content really quickly is a large part of its appeal because it makes the platform adaptable to real changes that are occurring in ophthalmic practices,” he said.

With more content and courses now coming on stream, one of the key tasks is to take stock of how iLearn has been received by the very EsCRs members it was designed to serve, believes Prof Epstein.

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EUROTIMES | Volume 18 | Issue 5

Brendan Strong, e-learning co-ordinator, demonstrating the new ESCRS iLearn project to Dr Paul Rosen at the 16th ESCRS Winter Meeting in Prague

Potentially this is a very important development for ESCRS members because the society is a service organisation, and one of its key functions is to provide teaching

“

Daniel Epstein MD, PhD

We all forget details and nuances after one or two years so it is a very good tool to keep reviving your knowledge, even if you have gone through all the live didactic courses

“

Oliver Findl MD

A well-designed office pays dividends in improved productivity and patient experience for years to come. An experienced architect can help ophthalmologists create a workspace that saves time, increases patient throughput and is convenient and relaxing for patients and staff alike.

Our June Cover Story will focus on what ophthalmologists should consider and prepare before designing a new office space, such as type of work, volume, physician and staff efficiency, and finishes and design appropriate to target patient populations.

It will also discuss how doctors and staff can work with architects and space designers to determine their own needs and come up with spaces that meet them efficiently.

How office layout can improve staff efficiency by reducing unnecessary steps between tasks, and how matching building design and materials to function can improve return on facility investments, will also be presented.

Tips for identifying and choosing an architect or design firm with appropriate experience and expertise in medical offices and facilities will be included as a sidebar.

Dessislava Stateva MD, PhD, associate professor, University Hospital in Pleven, Bulgaria. Research interests include phacoemulsification, keratoplasty, epidemiology of low vision and blindness. Subspecialty area – anterior segment surgery.

My reasons for using iLearn were to learn more about different aspects of cataract and refractive surgery. i took courses in Clinical Cornea - Diagnostic Methods, Advanced Phaco Techniques, Fundamentals of Cataract surgery and Premium Lenses. The content of the courses was very informative. iLearn was very easy to use and working with it was an entirely positive experience.

Tanja Petrovic MD, Department of Ophthalmology, Doboj General Hospital, Republic of Srpska in Bosnia and Herzegovina. Currently in the second year of a

four-year programme of specialisation in ophthalmology and completing a master’s thesis on amblyopia in preschool children.

i decided to use iLearn out of curiosity and a desire to acquire new knowledge. it is also a good way to validate existing knowledge. i took the Cornea Didactic Course and i am very pleased with what i learned. While projects such as iLearn can improve my knowledge and experience, i believe that it takes constant work and hands-on experience for me to be a better ophthalmologist.

El hadi Mahfoudi MD, ophthalmologist in private practice, currently head of the unit of refractive surgery in Al Farabi Clinic in Annaba, Algeria.

i used iLearn to complement and enhance my knowledge in refractive surgery, as i started this subspecialty following the acquisition of an iLAsiK platform. i studied all the refractive surgery courses offered and found the content fairly consistent with some elements needing to be updated.

This tool is very important for all EsCRs members, with access on demand and interesting content. Overall it is a rewarding experience. A possible improvement in the future might be more interactivity. i would have liked the possibility of online discussion with trainers, and the possibility of asking direct questions or to discuss a particular case in more detail.

Sonal Kalia MBBS, currently doing an MS Masters in Ophthalmology at The Department of Ophthalmology, SMS Medical College, Jaipur, Rajasthan, India.

i tried iLearn to see the difference between a European teaching approach and that in my own country. i started with phacoemulsification and found that iLearn had a very lucid approach. My overall experience has been positive and i am looking forward to using it more often. i found iLearn to be a very powerful tool for trainee/young budding eye surgeons as it helps clear misconceptions also and tests your knowledge.

in terms of improving iLearn, i would prefer to have all questions at the end of each section instead of from the beginning. iLearn could also include sample patterns/questions/reading material for various exams for young trainee ophthalmologists and perhaps create discussion groups for them.

Caroline Storimans MD, PhD, an ophthalmologist at Meander Medical Centre, Amersfoort/Baarn, The Netherlands, with a special interest in the

anterior segment, especially cataract surgery and strabismus.

My main reason for trying iLearn was that one doesn’t know what one doesn’t know... i was simply curious. The courses i took were on measuring and understanding corneal refraction and fundamentals of cataract surgery. My impression of the first course was that it was very physics-based, but i learned a lot. The second course was more basic but still interesting, especially as i also work as a cataract surgery instructor. While i did not agree with everything, it was absolutely of value.

it would be good if more “day-to-day” subjects were dealt with such as corneal pathologies, uveitis, glaucoma and retinal disorders (not only the ones rarely encountered). it has been nearly 20 years now since i first studied the books of the American Academy of Ophthalmology course and, as in life, a lot has changed since then. iLearn offers a good opportunity to follow the latest insights in all kind of subjects that are interesting for both younger and more experienced ophthalmologists.

EUROTIMES | Volume 18 | Issue 5

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eDucatIon & traInIng

Cover StoryBrendan Strong – Brendan.Strong@escrs.orgJose Güell – guell@imo.esKhiun Tjia – kftjia@gmail.comDaniel Epstein – Beatrice.Frueh@insel.chOliver Findl – oliver@findl.atMarie-Jose Tassignon – Jose.Tassignon@uza.beco

ntac

ts

“This is the ideal time to evaluate, to see how many hits the site is getting and how well the learners have done on the inbuilt tests. We can then look at the results and see if the enormous work that has been done is having the impact that we hoped it would. We need feedback and evaluation for this and this is an important part of any new development,” he said.

For Mr strong and his team, there is no question of allowing the momentum behind iLearn to slacken in the months ahead.

“We have many exciting plans for the future, and hope to see courses available on iPad later this year, as well as greater use of forums, which will help to bring iLearn to the next level where discussion helps to further develop understanding. in the meantime, we will be working with the subject matter experts to revise the existing courses to bring them up to date with the latest advancements in cataract and refractive surgery, as well as working on some new courses,” he said.

Mr strong also insists that the team should never lose sight of the original goal of the iLearn project – empowering the learner.

“The key to our success is the learner. We hope everyone finds the EsCRs iLearn platform useful – and if they don't, we hope they tell us why. so far, the feedback has been positive. We want to ensure everything we do is driven by our learners, so that what we create is relevant and useful to them. so feedback and contact is vital, and we welcome it.”

Accreditation informationPlease see the EsCRs iLearn site (elearning.escrs.org) for exact information on the courses currently accredited. Application has been made to the UEMs-EACCME for accreditation of two courses currently available on the site (surface Ablation Techniques and Endophthalmitis). All other courses on the site are accredited, with a total of 32 CME credits between them. Full CME details are available on EsCRs iLearn or by emailing elearning@escrs.org.

The learners’ viewpointAdapting the content to different target audiences holds the key to broadening the appeal of iLearn

“Marie-Jose Tassignon MD, PhD, FEBO

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EUROTIMES | Volume 18 | Issue 5

Following a few simple rules and helping to build confidence in the trainee cataract surgeon goes a long way in helping young ophthalmologists become competent in basic phacoemulsification

techniques, according to Paul Ursell MBBs, MD, FRCOphth.

“in terms of teaching and learning a skill such as cataract surgery, you want to achieve two things: you want to avoid errors and when you do it right, you want to be able to repeat that over and over again so that the success rate improves. Repetition helps to build confidence in the trainee surgeon and prepares them for moving on to the next stage of their training and tackling more complicated steps in cataract surgery,” he said.

Dr Ursell, a consultant ophthalmic surgeon at Epsom and st helier University hospitals Trust in the UK, said that it was important to remember that surgical skills are not an innate gift but are rather the fruit of countless hours of practice and repetition.

“This is something that we have seen in the United Kingdom with the scandal involving the high mortality rate of babies who underwent heart surgery at the Bristol Royal infirmary and is now coming out in cataract surgery as well. Basically, the recommendation is now made that children’s heart surgery be carried out only in highly specialist centres which perform lots of cases, because the more cases you do, the better the surgery will be. This holds true for cataract surgery as well. We see that surgeons who are doing a lot of cataracts every year will have a lower posterior capsule rupture rate than a surgeon who is only doing a few,” he said.

Mastering the skill Dr Ursell stressed that repetition is essential in mastering any physical skill, whether it is football, golf or cataract surgery.

“Repetition brings confidence because you learn to repeat the same manoeuvre over and over again. David Beckham had probably kicked more footballs by the time he was 15 than most of us have kicked by the time we are 90 years old, which goes some way to explaining why he is such a good footballer. The common denominator about the world’s best sportspeople is that usually they are mentally very strong and they just do nothing else but practise their particular sport. And in some respects that is what you need to be as a cataract surgeon – it is repetition and doing it at a high level repeatedly,” he said.

Dr Ursell said that every trainee surgeon will traverse four key stages in the learning process.

“This is true whether you are learning how to hit a golf ball or perform a correct capsulorhexis. You start off being incompetent, you can’t do it, and you end up being competent and you can do it. At the start you have unconscious incompetence – you think you can do it and you do not realise how bad you are. Then you start doing it and you go from unconscious incompetence to conscious incompetence as you realise how bad you are at doing

something. That is a good thing, because self-awareness is a big part of this evolution,” he said.

As the surgeon starts practising the manoeuvre he may become good at the task but still has to think about it, said Dr Ursell.

“This is the conscious competence phase. After the task has been performed a few hundred times, the surgeon progresses to the unconscious competence stage where they don’t even need to think about it,” he added.

Build trust and confidence Nurturing confidence in the trainee surgeon by creating a positive environment in which to learn is a vital component of successful training, emphasises Dr Ursell.

“in the old days, medical school training could be very intimidating, with the resident pretty much inconspicuous and scared. intimidation is not really a very good way of learning and it is certainly a very poor way of learning a stressful, physical skill like cataract surgery. so we have got to try to get away from that. We need to build trust and confidence without making the trainee over confident,” he said.

By using modular training, building slowly, and applying Pendleton’s rules for positive feedback and encouragement for the learner, the teacher is helping to create the right environment for the resident to make progress, concluded Dr Ursell.

“We need to take the concepts of repetition, training, complexity of the patient and self-confidence and put all these things together in order to correctly teach cataract surgery. Trainees need to practise the basic skills, and only perform surgery on cases that are within their skill set – so no patients with small pupils, pseudoexfoliation syndrome or weak zonules. We need to titrate the ability of the surgeon against the complexity of the case. Although we tend to focus on the surgeon and the trainee, we must never forget that it is really all about the patients and protecting them. Never forget that the most important person in the operating room is the patient,” he concluded.

n A related EuroTimes podcast interview with Dr Ursell is available at: http://www.eurotimes.org/podcast.asp

CATARACT SURGERYBuilding confidence holds key to successful cataract surgery trainingby Dermot McGrath

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Repetition helps to build confidence in the trainee surgeon and prepares them for moving on to the next stage of their training and tackling more complicated steps in cataract surgery

“Paul Ursell MBBS, MD, FRCOphth

9

EUROTIMES | Volume 18 | Issue 5

The European Registry of Quality Outcomes for Cataract and Refractive surgery (EUREQUO), which is designed to improve

standards of care as well as develop evidence-based guidelines for cataract and refractive surgery across Europe, has much to offer young ophthalmologists.

Training in cataract surgery can be an exciting and daunting experience. it is difficult to think about outcomes when you cannot even complete all the steps without a supportive tutor scrubbed by your side, steering you away from trouble and towards the safe completion of the case.

Ophthalmology trainees need to keep an up-to-date logbook of all the operations they carry out as a record of their surgical training. Most surgical logbooks are a record of the surgical work carried out but not of the outcomes of surgery. however, it is worth starting to think about your cataract surgery outcomes early. Your outcomes will tell you which steps of the surgery you need to work on and where you need to improve. in fact, self-audit is something you will have to do all the time when you qualify as an independent surgeon, so it is worth getting into the habit early.

EUREQUO is an internet-based application that allows you to do just that and makes it easy. it keeps a record of the cataract operations you carry out, including the visual and refractive outcomes and both intraoperative and postoperative complications. it allows you to print reports and compare your results from year to year or from rotation to rotation even if you move hospitals. A report can be produced with ease and speed for your six-monthly or yearly appraisal. in addition, EUREQUO allows you to compare yourself with other EUREQUO users in your own country and the rest of the world. The fact that

benchmark standards based on EUREQUO data are now available gives the trainee surgeon a standard to aim for.

As EUREQUO is web-based, it can be accessed on any computer with an internet connection. i personally find that the easiest way to enter my cases is on my smartphone as i always have it with me. i enter the preoperative and intraoperative data on the day of the surgery and the postoperative data at the two- to three-week postoperative visit. As not all fields are compulsory, the surgeon can choose to enter just a small number of compulsory fields if pressed for time, and still log the case. however, you get a lot more information on your surgery if you make the effort to fill in as many fields as possible. The compulsory fields take three minutes to fill in, while if you wanted to fill in all the fields, it would take about six minutes.

i always try to see my postoperative patients myself and i would advise all trainees to do the same, both in cataract and any other eye surgery. it is the only way to know how well or not you are doing and where you need to improve. in cases where i cannot see the patients myself, i leave clear postoperative instructions for unaided and best-corrected visual acuity, as well as for refraction to be checked so that no postoperative data is missed.

Auditing your surgical results should be as essential as writing the operative note. EUREQUO is a great way for trainees to audit their cataract surgery, helping them to focus on areas to improve on and goals to achieve, preparing them for a lifetime of audit as qualified surgeons.

* Sonia Manning is a higher surgical trainee at The Royal Victoria Eye and Ear Hospital, Dublin, Ireland.

HELPING TRAINEESEUREQUO is a great way for trainees to audit their cataract surgeryby Sonia Manning

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eDucatIon & traInIng

I personally find that the easiest way to enter my cases is on my smartphone as I always have it with me

“Sonia Manning

An example of the capsule complication rate of a trainee in percentage (red) compared with the capsule complication rate of

other surgeons across Europe (green) [taken from EUREQUO]

EUROTIMES | Volume 18 | Issue 5

Although there are many evidence-based strategies for preventing dissatisfaction in patients who undergo surgery for cataracts, there may remain some causes of dissatisfaction that are as yet not

possible to predict or prevent, according to participants in a debate at the 17th EsCRs Winter Meeting.

Visual acuity alone is not a complete outcome measure for patients undergoing cataract surgery, since many who have a visual acuity of 20/20 are still unhappy with their vision, said Mats Lundström MD, PhD, EyeNet sweden, Blekinge hospital, Karlskrona, sweden.

“snellen visual acuity is not the whole picture. We are not operating on eyes that are walking on two legs, we are operating on human beings. They are not only seeking our help to achieve visual acuity, they seek our help so they can see to read, watch TV, recognise faces and so forth. so why not use the patient reported outcome as a measure of success in cataract surgery?” he asked.

he noted that the task of the swedish cataract registry has been the development of the Catquest-9sF questionnaire. it asks patients about their activity limitations in daily life that may be related to vision. “This sort of second-generation questionnaire is a valid measure of visual function. so we have to forget the talk about soft data and hard data. This is really hard data. This questionnaire has been evaluated and compared with 15 other cataract surgery outcome questionnaires and in fact it has been found to be highly responsive and easy to use,” Dr Lundström said.

he noted that he and his associates have used the CATQUEsT-9sF questionnaire to identify risk factors for poor patient-reported outcomes.

The risk factors they identified include ocular co-morbidities, surgical and postoperative complications. Another risk factor they identified for postoperative visual dissatisfaction was having satisfactory vision before surgery.

Most recently, Dr Lundström and his associates conducted a study in which they looked at 10,979 patients operated between 2008 and 2011 who completed the Catquest-9sF questionnaire before and after surgery.

They found that 857 patients (7.8 per cent) had no benefit meaning they had more problems after surgery than before. Among those patients, 245 had a final distance corrected vision of 20/20 and yet were still unhappy. Or, to look at it another way, among those patients with 20/20 vision, 4,947 had benefit but 245 were without benefit.

A comparison of the 20/20 and unhappy patients with the 20/20 and happy patients showed the unhappy patients were more satisfied with their vision and have fewer symptoms and had better near vision before surgery.

One of the major causes of unhappiness after uncomplicated cataract surgery is the presence of dysphotopsias, said ian Dooley MRCOphth, Msc, Royal Eye and Ear hospital, Dublin, ireland.

“Dysphotopsias cause significant distress to patients, both physically and mentally. There are no diagnostic signs

or tests. They are diagnosed clinically based on patients’ symptoms,” he said.

Dysphotopsias, which are present in about three per cent of patients at one year postoperatively, include any light-related visual phenomenon which produces unwanted patterns on the retina of phakic or pseudophakic patients. There are positive dysphotopsias, which are bright artifacts of arc, streaks and halo and negative dysphotopsias, which have the appearance of a dark shadow, typically arc-shaped in the temporal field.

There are devices which detect the amount of stray light hitting the retina. They include C-Quant Nykotest 300. however, in one recently published study (Kinard et al. J Cataract Refract Surg 2013, DOI: 10.1016/j.jcrs.2012.11.023) straylight scatter did not correlate with levels or visual satisfaction measured by the VF 11R questionnaire developed by Dr Konrad Pesudovs' team. (Measuring outcomes of cataract surgery using the Visual Function Index-14. Gothwal VK, Wright TA, Lamoureux EL, Pesudovs K. J Cataract Refract Surg. 2010 Jul;36(7):1181-8. doi: 10.1016/j.jcrs.2010.01.029. PMID: 20610098 [PubMed - indexed for MEDLINE].)

in the absence of objective measurements, questionnaires like the NEi VF 11R are the best way of detecting patients’ dysphotopsias, he said.

Causes and remedies Positive dysphotopsia appear to result from the square edge of an iOL, which reflects peripheral light rays toward the retinal periphery. They are more common with hydrophobic acrylic iOLs with higher refractive index. Raytracing studies suggest that rounding the corners should reduce glare by around 90 per cent. A frosted or textured edge should also reduce the internal light scatter.

Negative dysphotopsias may result from a reflection of the anterior capsulorhexis edge projected onto nasal peripheral retina or from a discontinuity of nasal retinal illumination related to a square-edged optic. Anatomic factors associated with chronic negative dysphotopsia are a small pupil, more anterior extension of the functional nasal retina and increased distance between the iris and iOL plane.

The spontaneous improvement that occurs in most cases may result from opacification of the nasal anterior capsule, which reduces the intensity of chronic negative dysphotopsia. Neuroadaptation may also play a role, Dr Dooley said.

Using a textured edge optic for iOL exchange or as the primary iOL in the second eye lowers the incidence of both positive and negative dysphotopsia. “Patients should be counselled regarding these possible symptoms preoperatively. Patients appreciate knowing that their problem is understood and that remedial options are available,” Dr Dooley concluded.

SURGERY OUTCOMESRisk factors for visual dissatisfaction after cataract extend beyond acuity and refractionby Roibeard O’hEineachain in Warsaw

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Mats Lundström – mats.lundstrom@karlskrona.mail.telia.comIan Dooley – iandooley55@hotmail.com

contacts

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EUROTIMES | Volume 18 | Issue 5

For many years snellen visual acuity has been the principal yardstick of success in cataract surgery, but the past decade has seen the introduction of new psychophysical tests and visual quality and

quality of life questionnaires that may provide further insight into patients’ visual experience. The question of whether these new measurements have any bearing on patient satisfaction was the topic of a debate held at the 17th EsCRs Winter Meeting.

David spalton FRCs, st. Thomas' hospital, London, UK argued that visual acuity remains the most important yardstick, although different patients may prefer different refractive outcomes. “What matters most for the patient is uncorrected visual acuity. Quality has to be at the heart of everything we do but it must be understood from the perspective of the patient. Clinical measures do not always relate to how the patient feels,” Dr spalton commented.

There are a few golden rules in planning surgery that will result in patients having a satisfactory visual acuity for their lifestyle, he said. The first rule is never leave a patient hyperopic. The second rule is to never leave the patient with anisometropia for too long, by planning for the surgery for the second eye. The third rule is to talk to the patients to discover their visual needs. Many patients are entirely happy with emmetropia and readers, while some might prefer a small amount of residual myopia, and yet others might prefer monovision or multifocals.

The problem with monovision is that it increases depth of focus at the expense of stereopsis. Patients need to know what to expect from monovision before surgery. Therefore, the best candidates are those who have undergone a contact lens trial. it is important to generally leave the non-dominant eye with no more than 1.5 D of myopia.

in patients who undergo monovision surgery only to find that the resulting anisometropia is less satisfactory than they expected, piggy-back iOLs are a useful option and are preferable to iOL exchange. The lenses, available from Rayner, are easy to implant and sit in the sulcus. The main difficulty with the lenses is that they are very thin and fragile and therefore are easily torn on insertion.

Dr spalton noted that about 20 per cent of patients can read without glasses after ‘routine’ cataract surgery with monofocal iOLs.

in a study that assessed the ocular and optical characteristics of 30 patients implanted with monofocal iOLs who had a visual acuity better than 6/12 for distance and N12 for near, the only significant correlation was with the high level of against-the-rule astigmatism, which had a mean value of 0.76 D, (Nanavaty et al J Cataract Refract Surg 2006 ; 32 : 1091-1097).

“That may be because snellen charts are easiest to read when the vertical axis is in focus. small amounts of astigmatism increase depth of focus for ‘emmetropic’ patients. in an eye with a monofocal iOL, 0.75 D of astigmatism would increase the depth of focus for distant

vision if it was with-the-rule, and increase depth of focus for near if it was against-the-rule,” Dr spalton said.

in a similar way, spherical iOLs afford patients greater depth of focus than aspheric lenses, because of associated higher order aberrations.

Subtler aspects of vision also important Taking the opposing view, Konrad Pesudovs MD, Flinders University, Bedford Park, south Australia, Australia, maintained that although visual acuity is important, it may not be the aspect of vision in which cataract surgery produces the greatest improvements.

Vision is very complex and involves more than the ability to read snellen acuity charts, Prof Pesudovs said. it also involves contrast sensitivity, colour vision, visual fields and binocularity and depth perception. in addition, there are other measures of visual function that are important such as ability to see under different lighting conditions.

Ultimately, the debate must therefore hinge on the question of whether testing these properties of vision measure the loss that occurs with cataracts and the improvement that cataract surgery can provide that are not predictable from visual acuity testing.

“There are a number of high-quality studies, randomised controlled trials and a Cochrane Review that demonstrate this point. however, what is interesting is that the impact of cataract on visual acuity is fairly small therefore the improvement that we see with cataract surgery is small.”

Visual quality questionnaires are another way of assessing visual outcomes that numerous studies have validated. Many will measure activity limitation and visual disability and there are some that also measure visual symptoms.

One of the most researched is the Catquest-9sF, which asks questions pertaining to specific aspects of vision. For example, it asks patients about their ability to read the paper, a near vision task. Another question concerns the patient’s ability to recognise faces, a contrast sensitivity task.

“Questionnaires can tap into these different realms of visual performance without actually having to measure and that makes them a strong tool for your practice,” Prof Pesudovs added.

ACUITY VS QUALITYSeeing cataract surgery from the patient’s point of view by Roibeard O’hEineachain in Warsaw

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David Spalton – profspalton@gmail.comKonrad Pesudovs – Konrad.Pesudovs@flinders.edu.au

contacts

However, what is interesting is that the impact of cataract on visual acuity is fairly small therefore the improvement that we see with cataract surgery is small

“Konrad Pesudovs MD

Ams t e r d a mAm s t e r d a m20 1 3

5 -9 OCTOBER

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Main SymposiaSaturday 5 October Refractive Surgery in Risky Corneas: Is it Really Safe for the Patient?

Sunday 6 October Femtosecond-assisted Cataract Surgery: Euphoria Amid Skepticism and Financial Restraints

Monday 7 October Unravelling the Mysteries of Myopia

Tuesday 8 October The Management of High Hyperopia

Wednesday 9 October Treating Astigmatism with Cataract Surgery

Binkhorst Medal LectureDouglas Koch USA

The Ablated Cornea: What Have We Done?

Sunday 6 October

Clinical Research Symposia Saturday 5 October

• Treatment of Macular Edema

• Basic Research on Crystalline Lens and IOL Restoring Accommodation

• Effects of Phakic IOLs

• Corneal Stem Cells: A Future for Therapy of Corneal Disease

Other Highlights Saturday 5 October

• Refractive Surgery Didactic Course

• Young Ophthalmologists Programme

• Video Symposium on Challenging Cases

Sunday 6 October

• Workshop on Visual Optics

• Journal of Cataract & Refractive Surgery Symposium

• Young Ophthalmologists Session

www.escrs.org

This year’s programme not to be missed!

13

EUROTIMES | Volume 18 | Issue 5

Capsule rupture during cataract surgery can have dire consequences, including cystoid macular oedema,

rhegmatogenous retinal detachment and a higher risk for endophthalmitis. Beginning surgeons should therefore avoid high-risk cases, said Oliver Findl MD, at the 17th EsCRs Winter Meeting.

“Posterior capsule rupture is actually the most common intraoperative complication. it is usually associated with the need for additional surgery, a greater number of follow-up visits and an increased frequency of postoperative complications,” said Dr Findl, hanusch hospital, Vienna, Austria and Moorfields Eye hospital, London, UK, at a special symposium organised by the EsCRs Young Ophthalmologists' Forum.

he noted that the posterior capsule is only four microns in thickness, and although it is elastic and can withstand some stretching, it can be fairly easily penetrated with a sharp instrument or a vibrating phaco tip. Broken vitreolenticular barriers can cause the vitreous to move anteriorly, exposing the vitreous to traction, which can in turn lead to retinal breaks. There can also be an increased transfer of inflammatory substances from the anterior segment into the posterior segment potentially causing cystoid macular oedema.

in cases where posterior capsule rupture (PCR) actually leads to vitreous loss there is a 10 per cent incidence of cystoid macular oedema. The risk of rhegmatogenous retinal detachment is also high in such cases with reported incidences of five per cent to 15 per cent. The risk is highest in myopic eyes but is also quite significant even in non-myopic eyes.

The risk factors for capsule rupture include posterior polar cataracts, and white cataracts. in the literature, white cataracts have a tear incidence of 10 per cent and an incidence of vitreous loss of three per cent. The capsules of such eyes are wrinkled and less elastic, they also have a weaker zonular apparatus. Traumatic cataracts and eyes with pseudo-exfoliation are also at an increased risk of the complications, usually for reasons of zonular instability, and eyes that have undergone previous vitreoretinal surgery sometimes because of actual capsule trauma during the surgery.

The skill of the surgeon is also a critical factor. For example, the third-year resident in the Us has a capsule rupture incidence of 3.1 per cent to 14.7 per cent, whereas among registrars in the UK the incidence is around 4.4 per cent. The incidence decreases with the increasing number of cases a surgeon has performed and is higher in developing countries, presumably because of the higher percentage of white cataracts.

Dr Findl recommended a grading system for cataracts that would divide them into groups according to their potential risk for PCR. Beginning surgeons should only perform cataract procedures in patients in the low-risk category.

“Posterior capsular rupture is widely regarded as the benchmark complication by which to judge the quality of cataract surgery. ideally you want to audit your cataract results. This is true not only for those who are experienced, but also and especially for those who are just starting surgery. EUREQUO is a very valuable registry where you can enter your data and also benchmark yourself with your centre or your country,” Dr Findl added.

AUDIT RESULTSBenchmark complication among chief perils for beginning surgeonsby Roibeard O’hEineachain in Warsaw

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Special Focus

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Capsule complication in percentage. Each bar = one clinic, requesting clinic in red

Ideally you want to audit your cataract results

“Oliver Findl MD

EUROTIMES | Volume 18 | Issue 5

There is no royal road to learning the skills involved in cataract surgery. instead, expertise can only be gained through the

assiduous practice of techniques learned from highly experienced surgeons, according to Larry Benjamin FRCs, stoke Mandeville hospital, Aylesbury, UK.

“if you want to become an expert in virtually anything it takes 10,000 hours of practice. That's been shown for a number of activities, from music, to sport and to surgery. That’s about five hours a day for 10 years, taking weekends off, before you’re an expert,” Dr Benjamin told the attendees at the Young Ophthalmologists symposium at the 17th EsCRs Winter Meeting.

he noted that prior to participating in surgery; trainee ophthalmic surgeons must first become familiar with the basic principles of cataract surgery. in the UK that begins with a mandatory three-day microsurgical skills course. For the first two days of their course trainees learn how to perform basic incisions, sutures and suture knots. On the third day, trainees learn about phacoemulsification, how to use the

machine and the basic phacoemulsification techniques. They then progress to the wet lab for further training and practice.

Wet labs and simulation A good wet lab has fairly simple requirements and, with a little ingenuity, trainee surgeons can enhance their practice with inexpensive and easily acquired materials, Dr Benjamin noted. in the microsurgical course, trainees also learn simpler things like draping the eye for surgery, using a pig’s eyelid and a pig’s eyeball on a plastic head.

“Even learning to drape correctly takes practice and it’s one of those simple basic things that if you don't get right you can spoil the whole operation,” he said.

The college skills board enables trainees to practise suturing and capsulorhexis techniques. it also enables them to practise more advanced techniques like suturing muscles onto eyeballs. The basic setup of the skills board is very inexpensive, costing only about ₤200.00 (€230.00).

“it’s a good investment. if you have one of these, you can practise forever. Even practising simple suturing techniques

for an hour once a week will make you much better at suturing than most trainee surgeons in the country.

There are many types of devices available for practising surgery in simulation. They include artificial heads that can be fitted with pigs’ eyes or with artificial eyes containing artificial cataracts. The types of simulation vary in terms of their similarity to real surgical conditions, however, all can provide trainees with an enhancement of their surgical skills.

he added that he and his associates designed a plastic head that trainees can use to practise their surgical technique from a superior or temporal position. The model has replaceable plastic eyes, including one type designed for suturing and wound construction and another type that has a synthetic cataract and is designed for practising capsulorhexis and phacoemulsification, and costs around ₤400.00 (€460.00). “They are a really good investment, the eyes are not cheap but there are alternatives around, but if you can get the use of one of these heads, one of these skills boards with each unit in the country you're set up for the next 20 years,” Dr Benjamin noted.

There are also more technologically advanced systems like the Eyesi® simulator (VRmagic Gmbh), which enables surgeons to perform every part of surgery in a kind of virtual environment. Another option is the Kitaro artificial eye system, which can be used for practising capsulorhexis, and phacoemulsification,” he said.

“i think it's very important to use not only the high-tech simulator but also an

ordinary microscope with the suture pad, using plastic or pigs’ eyes. having access to both of these is going to be an advantage to the trainee surgeon,” he added.

Moving on to patients Dr Benjamin said that bringing trainee surgeons to the point where they can complete a cataract procedure on their own takes several stages. in the first stage, the teaching surgeon must determine their students’ knowledge of the surgical process and have them agree to a contract as to what they will achieve in their three months of training.

Following that, the teaching surgeon should have the trainee perform parts of the surgery in his first actual cases. For example, the trainee could begin the procedure but after a pre-agreed length of time hand the case over to the teaching surgeon. similarly, the teaching surgeon might perform the beginning of the procedure and let the trainee finish the operation. The trainee’s first cases should be fairly straightforward, involving cooperative patients with grade ii cataracts and well-dilated pupils.

Also, because procedures are often performed under local anaesthesia trainees and trainers should agree to a code so if something untoward should occur, the patient will not become overly alarmed when the teaching surgeon needs to take over. “in summary, you need to structure the training, to supervise it carefully, it’s hard work. Practice needs to be regular and frequent, simulation is very useful and should be undertaken to prepare you for your first supervised cataract procedures in actual patients,” Dr Benjamin concluded.

Larry Benjamin – larry.benjamin@btopenworld.com

cont

act

PRACTICE IS kEYThree keys to surgical competence: training, practice and more practiceby Roibeard O’hEineachain in Warsaw

14 Special Focus

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15

EUROTIMES | Volume 18 | Issue 5

While the Goldmann applanation tonometer is still considered the current gold standard method in

measuring intraocular pressure (iOP), its measurements are significantly affected by the changes of corneal properties after LAsiK and should ideally be supplemented with additional measurements using a device such as the Ocular Response Analyzer (ORA; Reichert Ophthalmic instruments), according to a study presented at the French implant and Refractive surgery Association (sAFiR) annual meeting.

“Corneal refractive surgery is becoming more popular all the time, with LAsiK still the most popular technique. LAsiK photoablation results in a reduction of the corneal thickness, changes the corneal curvature and also alters the biomechanical characteristics of the cornea, with a reduction of the corneal hysteresis. These three parameters come into play and have an impact on the iOP measurements carried out using the standard Goldmann tonometry method, meaning that these measurements are not completely reliable,” Alice Grise-Dulac MD told delegates.

Dr Grise-Dulac, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France, said that this knowledge prompted her to compare iOP measurements obtained using either Goldmann or ORA, and to compare the biomechanical parameters – corneal hysteresis, corneal resistance and corneal curvature – on three groups of patients before LAsiK, one month after LAsiK and several years after LAsiK.

The three groups were comprised of 86 eyes of 43 patients in the pre-LAsiK group, 86 eyes of 43 patients for the one-month post-LAsiK group and 34 eyes of 18 patients who were examined several years after LAsiK (average 4.56 years).

“The reduced numbers in the latter group underscores one of the key problems of refractive surgery where the patients are usually very happy with their vision and it can be difficult to get them back for follow-up visits,” said Dr Grise-Dulac.

Only myopic LAsiK patients were included in the study and patients who had undergone previous LAsiK or corneal surgery were also excluded.

All patients underwent iOP measurement with Goldmann tonometry and central

corneal thickness was measured using Orbscan (Bausch + Lomb). The ORA exam measured iOP using a non-contact air puff system, and allowed for in vivo measurement of the iOP and biomechanical properties of the cornea.

These included corneal hysteresis (Ch) values, corneal resistance factor (CRF) and two subsequent measures: the iOPg, which is the Goldmann Correlated iOP, and the iOPcc (Corneal Compensated iOP), which takes account of certain biomechanical properties of the cornea. Corneal curvature measurements, based on parameters developed by David Luce, were also taken by Dr Grise-Dulac’s group.

Dr Grise-Dulac said that the measurements taken by Goldmann tonometry confirmed the findings of several other studies in the scientific literature.

“The ORA corneal compensated iOP measurements seemed to provide the most stable and viable measurement of the iOP. The GAT iOP was found to be significantly reduced after LAsiK by an average of 2.0 mmhg. The measurement of iOP with ORA seemed closer to the reality, at least for the iOPcc. interestingly, we found no statistically significant difference between the preoperative iOP values and the values four years after LAsiK using corneal compensated iOP measurements,” she said.

MEASURING IOPCorneal biomechanics show long-term stability after LASIkby Dermot McGrath in Paris

Alice Grise-Dulac – agrisedulac@fo-rothschild.fr

contact

Update

cataract & refractIve

“LASIk photoablation results in a reduction of the corneal thickness, changes the corneal curvature and also alters the biomechanical characteristics of the cornea, with a reduction of the corneal hysteresis”Alice Grise-Dulac MD

Larry Benjamin – larry.benjamin@btopenworld.com

Update

cataract & refractIve

EUROTIMES | Volume 18 | Issue 5

Fibrin glue-fixated posterior chamber lenses and, in limited cases, anterior chamber iOLs, may be viable alternatives for treatment of conditions such as pseudoexfoliation and Marfan’s syndrome that leave

the lens capsule so unstable it will not support an intraocular lens (iOL), presenters told the American Academy of Ophthalmology refractive surgery subspecialty day.

Three-piece foldable iOLs with haptics fixated to the sclera by fibrin glue maintain the natural posterior positioning of the lens, away from the corneal endothelium and trabecular meshwork, noted sadeer B hannush MD of Wills Eye institute, Philadelphia, Us.

“The procedure nicely compartmentalises the eye into anterior and posterior segments, and avoids complications related to sutures and large incisions.”

With the advent of flexible, open-loop designs, angle-supported anterior chamber lenses are regaining popularity, especially for elderly patients, said Camille Budo MD of the University Eye Clinic, Maastricht, The Netherlands.

The procedure reduces complications associated with previous closed-loop designs, such as secondary glaucoma, elevated intraocular pressure, pupil distortion, endothelial cell loss, cystoid macular oedema, pain and worse best corrected vision. And with the earliest examples implanted more than 30 years ago, iris-fixated anterior chamber lenses remain a viable choice, Dr Budo added. still, anterior chamber lenses are riskier and are not suitable for many patients.

“We use these lenses only if in-the-bag or sulcus fixation is not possible.”

since 1988, Dr hannush has implanted 470 posterior chamber lenses fixated to the sclera with sutures. so why change now? “Amar Agarwal has been trying to convince me that scleral fixation can be made better and i am buying into it,” he said. The typical patient presents with a subluxated implant in the capsular bag years after routine cataract surgery, Dr hannush said. Pseudophacodonesis is often seen with eye movement. his current procedure involves two scleral flaps, pars plana infusion or an anterior chamber maintainer, anterior vitrectomy, a three-piece foldable iOL, scleral grooves and fibrin glue to fix the haptics to the sclera.

Dr hannush cuts two scleral flaps on opposite sides of the eye, usually 12 and 6 o’clock, and carves grooves in their bases to accommodate insertion of the lens haptic ends. he performs a 25-gauge pars plana vitrectomy, entering 3.5mm posterior to the limbus, prolapses the implant into the anterior chamber where it is cut and extracted, and follows with a more complete anterior vitrectomy.

The folded lens is inserted using a bimanual “handshake,” held by forceps on either side. Dr hannush feeds the haptics through the sclerotomies into the pre-cut grooves. Air pumped into the anterior chamber keeps the lens stable while fibrin glue is applied externally to hold the haptics in the scleral grooves. The flaps are closed and conjunctiva pulled over. Complications are few, but include occasional iris optic capture, hyphaema, decentration, haptic disinsertion and hypotony, Dr hannush noted.

“Advantages are small self-sealing incisions when using a foldable iOL, a well-formed globe throughout the procedure with less risk of iris prolapse. it also avoids suture-related complications.”

The technique also avoids complications associated with the large surgical wounds needed for rigid PMMA lenses, such as leakage, shallow anterior chamber and induced astigmatism, Dr hannush added. And it can be combined with other procedures, such as endothelial keratoplasty.

Anterior chamber lenses in cases where posterior lens placement is not possible, anterior chamber iOLs may be viable. But careful patient selection and preparation are essential, Dr Budo said. For all lenses, the anterior chamber must be deep enough to ensure adequate clearance from the corneal endothelium. however, this problem is less likely in aphakic patients than phakic patients. The anterior chamber also must be completely free of vitreous, and a meticulous vitrectomy should be performed if necessary, Dr Budo said.

For angle-supported lenses, the entire angle must be completely intact, Dr Budo added. iris-fixated types require only two opposite points of stable iris tissue.

Advantages of iris-fixated lenses include one-size-fits-all for adults, and the option to orient the lens at any angle, unless a toric model is being used to correct astigmatism, Dr Budo said. A smaller version is available for paediatric use. The lenses can be explanted easily at any time and have remained in place with no iris atrophy for more than 30 years in some patients. in aphakic eyes, the lens surface is also usually far enough from the endothelium that long-term cell loss is minimal.

A disadvantage of iris-fixated iOLs is that an incision of 5.0mm or so is needed to insert a rigid PMMA lens, Dr Budo noted. however, a flexible model is coming onto the market. inserting an iris-fixated lens also requires skill. success with the lens is almost entirely surgeon-dependent, he said. Angle-supported lenses are easier and quicker to insert. But complication risks are much higher, and long-term monitoring is required, Dr Budo said.

On the upside, long-term results are good, particularly with iris-fixated lenses, and monitoring is easy because the entire lens is visible, he noted.

Sadeer B Hannush – sbhannush@gmail.comCamille Budo – camille.budo@skynet.be

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UNSTABLE CAPSULEGlued posterior chamber IOLs and anterior chamber IOLs emerge as alternatives to sutured IOLsby Howard Larkin in Chicago

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Aphakic iris fixation lens post iris suture

Aphakic iris fixation lens post trauma

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Patient JB suffered penetrating trauma and underwent pars plana vitrectomy/lensectomy leaving him aphakic

Same patient (JB) post placement of a sclerally fixated/glued 3-piece silicone IOL. The lens is well centred, and the traumatic iris damage demonstrates the lens contour

Update

cataract & refractIve

EUROTIMES | Volume 18 | Issue 5

intracorneal inlays implanted in the non-dominant eye, including bifocal refractive and pinhole aperture designs, are effective for treating

presbyopia, presenters at an EsCRs symposium told the refractive surgery subspecialty day of the American Academy of Ophthalmology annual meeting. Though some are still in the early stages of development, they are generally well-tolerated and stable refractively, and longer follow-up is required to demonstrate their long-term viability.

in a 12-month study of the second generation of the iCOLENs (Neoptics, hunenberg, switzerland), 60 per cent of patients gained two or more lines of near visual acuity and 34 per cent gained three or more lines, said Thomas Kohnen FEBO, Goethe University, Frankfurt, Germany.

The 3.0mm iCOLENs is composed of a copolymer with hydrogel properties. A 0.15mm hole in the centre facilitates nutrient flow, and the lens is curved to minimise changes in corneal curvature. A central distance zone is surrounded by a positive refractive zone for near. it is implanted about 300 microns deep into a tunnel cut by femtosecond laser using a special preloaded injector.

Of the 52 patients implanted in 2011, 47 retained the lens for 12 months, Prof

Kohnen noted. Of those, all were generally satisfied, though 70 per cent still used reading glasses “sometimes” and 24 per cent “often”. Before surgery, all used reading glasses full-time, with uncorrected near VA of 20/50 or worse.

however, 30 per cent lost one or two lines of uncorrected distance acuity. Even so, 86 per cent reported their distance vision was not impaired, with the remaining 14 per cent finding it impaired “sometimes”, Prof Kohnen reported. Mean change in corneal curvature was +0.20 +/-0.78 D. There were no complications and no reports of pain or discomfort, though six patients reported mild or intermittent glare not serious enough to interfere with driving.

These results were an improvement over the first design, which Prof Kohnen

implanted in four patients in 2010. Of those, one saw uncorrected near vision improve from 20/50 before surgery to 20/25 at 24 months, while uncorrected distance dropped from 20/20 to 20/32. The other three patients saw large decreases in distance vision with little improvement in near. Their lenses were explanted, restoring vision and demonstrating the reversibility of the procedure. Based on this experience, the lens edge was thinned, from 20 microns to 15, and its curvature changed based on observed anterior corneal changes, resulting in a more-predictable effect.

iCOLENs patients recover quickly without lost work time and no corneal complications have been observed, Prof Kohnen said. however, the technical procedure has a learning curve, and patients sometimes do not achieve optimal results despite excellent surgical outcome and lens selection. Further refinements are in progress, he said.

ioannis Pallikaris MD, PhD, University of Crete, Greece, also reported good results with another hydrogel intracorneal implant for presbyopia, the Flexivue Micro-Lens (Presbia). Also implanted in a pocket created by a femtosecond laser in the non-dominant eye, the 3.0mm lens has a peripheral add of +1.25 to +3.0 D. it improved uncorrected near vision from a mean of 20/100 to 20/25, with uncorrected distance declining from 20/20 to 20/40 in the operated eye. however, binocular distance vision was unaffected in the 40 patients studied, Dr Pallikaris said.

After surgery 92 per cent reported no need for reading glasses, and no intra- or postoperative complications were seen, Dr Pallikaris said. intracorneal lenses are safe and effective for treating presbyopia in patients aged 45 to 65, he concluded.

Gunther Grabner MD, salzburg, Austria, reported excellent long-term results with the KAMRA pinhole inlay (AcuFocus, California, Us). The 3.8mm-diameter inlay has a 1.6mm aperture in the centre. Dr Grabner began implanting an early model six years ago. since then, thickness has been reduced to 5.0 microns from the original 25, it is now made of polyvinylidene fluoride instead of Dacron or polymide, and it now contains 8,400 pores of variable size distributed pseudo-randomly rather than uniformly as in the earliest versions.

At 36 months, 32 emmetropic patients gained a mean of 4.6 Jaeger lines near vision, achieving J2 from J7-J8 preoperatively, as well as 20/25 intermediate vision from 20/40. Distance vision in the operated eye fell from a mean of 20/16 to 20/20.

“What i like most about this technique is that basically they lose very little distance visual acuity,” Dr Grabner said. in addition, reading acuity and speed increase. All patients reported they could drive at night without glasses, and would have the surgery again, he added.

For 17 cases that have reached 60 months follow-up, mean near vision has remained stable at J2, while mean near vision in the non-implanted eye has dropped from J8 to J9.

Complications include one case of epithelial ingrowth requiring two flap lifts, and two decentred implants that were re-centred at seven months. One implant inserted at a shallow 140 microns was removed due to a hyperopic shift. “it seems to be stable, it doesn’t show inflammation or changes over time,” Dr Grabner said.

Dr Grabner has implanted the KAMRA in post-LAsiK, patients, ametropes up to -5.0 D and +3.0 D, as well as patients with monofocal iOLs. “This will be a very nice group to target.” in 20 pseudophakic cases, near vision improved from J6 to J2 over one year, he noted.

Dr Grabner pointed out that with up to 60 months follow-up and more than 18,000 implants, including 12 ophthalmologists and four optometrist, the KAMRA is stable and well tolerated causing minimal loss of distance visual acuity, and allows for complete ocular exam and treatment postoperatively.

Thomas Kohnen – Kohnen@emi.uni-frankfurt.deIoannis Pallikaris – pallikar@med.uoc.grGunther Grabner – G.Grabner@salk.at

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PRESBYOPIA INLAYSNon-dominant eye corneal implants promising for wide range of patientsby Howard Larkin in Chicago

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S/L Photos: the Lens is “invisible” and does not influence the S/L and fundus examination

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Thomas Kohnen FEBO

Update

cataract & refractIve

EUROTIMES | Volume 18 | Issue 5

European ophthalmologists will need to overcome a combination of economic, organisational and regulatory hurdles to ensure

that their patients fully benefit from the latest advances in ophthalmic technology, according to a panel of experts at the XXXth Congress of the EsCRs.

“While high-volume and low-cost cataract surgery is now standard, we have seen that product selection of some newer technologies is being limited due to increased costs in public healthcare systems,” Dr Matteo Piovella told delegates attending a joint EsCRs/italian society of Ophthalmology symposium on the future of healthcare in Europe.

Dr Piovella argued that doctors in italy and some other European countries no longer have the freedom to choose the best technology for their patients. One possible solution, he said, might be to introduce a system of co-payments, with the government paying for a “standard” cataract procedure with implantation of a monofocal iOL and the patient picking up the tab for any “extras”, such as a toric or multifocal iOL.

Panellists agreed that advances in technology have resulted in improved outcomes for patients and spurred manufacturers to continually upgrade their product lines.

“i think there is no doubt that we have improved our results when we consider the evolution from intracapsular and extracapsular extraction through to phaco, microincision cataract surgery and now femto cataract,” said Ulf stenevi MD.

“When the results are better and when patients request these technologies and the doctor sees that they actually do improve outcomes, then they are usually incorporated into our practices. But the cost factor is also important. if we accept that certain technologies are very good then the taxpayers and the clinics will buy them. if they are not accepted by the patients, however, and it is just the doctors who think they are good, then it will take more time,” he added.

The improvements in technology have also helped to reduce costs for cataract surgery, pointed out Richard Lindstrom MD. “Back in the late 1970s i was doing

intracapsular cataract extraction, which took one hour per procedure with a five per cent complication rate, at a cost of just over $5,000 dollars an eye. Today we are doing three to four procedures an hour and the cost is around $1,600 dollars an eye and the outcomes are extraordinarily better,” he said.

Moderator Peter Barry FRCs asked the panel why so-called “premium” iOLs – accommodating, multifocal and toric lenses – represented less than one per cent of the market in Europe compared to 14 per cent in the Us.

“We welcome many American colleagues to our European meeting and many of them tell us that they come here in order to develop what is new in terms of innovation and technology because the FDA system won't allow them to even try out what is being developed in Europe. Now we have the paradox that our American counterparts are performing more premium iOL implantations over there than we are in Europe. is this because European citizens don’t have the money to spend on these lenses?” said Dr Barry.

For Paul Rosen FRCs, FRCOphth, the main problem resides in the absence of a co-payment system for many European countries.

“in the United states co-payments are an accepted part of the healthcare system, whereas in countries such as italy and the UK they are not allowed and therefore the

premium iOL technology has not migrated into the public system as expected,” he said.

Roberto Bellucci MD noted that technology is often developed for specific cases and only becomes more widely used if its efficacy and safety are proven over time.

“We are forced to some degree to use new technology, because in cases involving complications legal problems may arise if the surgeon has been shown not to have used the best available technology for every patient,” he said.

Dr Bellucci also voiced doubts about whether a voucher or co-payments system could be successfully introduced in italy.

“i can see potential problems with a voucher system where the patient is able to choose the centre where he or she wants to have surgery. With this approach, public hospitals will see a reduction in the number of procedures and there will be an impact on employment for nurses and medical staff, leading to protests from trade unions, so there are potential political problems as well,” he added.

Dr Barry also took issue with the term “premium iOLs” which he said implied that some intraocular lenses were somehow sub-premium.

“The term is essentially based on the premise that multifocal or toric iOLs are the perfect iOL for everybody. And i would suggest that that idea is an absolute nonsense. There are a lot of patients out there for whom the premium iOL is in fact the monofocal lens. We would have a far better chance of convincing health providers, insurance companies and patients if we did not suggest that we are selling these lenses for everybody and creating an artificial two-tier system,” he said.

Thomas Kohnen FEBO said it was important for each country to define the standard of care in order to avoid confusion surrounding the issue of premium iOLs.

“We have to be careful of these ‘premium’ lenses because they are not good for everybody and not everybody should have a multifocal lens – if the patient has an endothelial problem for example. We have to define the standard of care either nationally or internationally. it is something that is evolving all the time as technology progresses. so we need a standard and then we need to have an ‘extra’ situation as well that takes account of additional services that the patient might want to pay for,” he said.

Given the emphasis on reducing costs for national healthcare systems, Dr Barry asked whether a case might be made for moving cataract procedures from the hospital environment into dedicated cataract centres.

Dr Rosen pointed out that the concept of “cataract factories” had already been tried in the UK with mixed results. “The government introduced 'independent sector treatment centres' in the UK over a decade ago and they were a political move to break what the government saw as the doctors’ stranglehold on the system. They spent £3bn on developing these centres and to some extent they worked because they dealt with waiting lists. The other good thing that came out of it was the fact that it introduced competition so a lot of departments raised their game,” he said.

On the debit side, however, the new centres threatened the viability of existing health facilities rather than complementing them, said Dr Rosen.

“What tended to happen is that things drifted towards the lowest common denominator with a lot of potential for disruption in the healthcare system. For example, in the UK if you do a cataract procedure there is small profit made and that money goes to cross-subsidise a lot of other services like psychiatry. That principle is lost if the work is farmed out to a private contractor,” he said.

The result in Oxford was that the government sought to transfer a large number of cataract operations from the Oxford Eye hospital to the private centre, undermining the financial viability of the hospital and compromising the training of ophthalmic surgeons, explained Dr Rosen.

“in the end, Oxford Eye hospital successfully competed against the private centre and performed the majority of the scheduled cataract operations. it ended up costing the government a fortune, reported to be £12,000/cataract treated due to the nature of the contract, and was deemed a total disaster in Oxford,” he said.

Matteo Piovella – piovella@piovella.comUlf Stenevi – ulf.stenevi@oft.gu.seRichard Lindstrom – rllindstrom@mneye.comPeter Barry – peterbarryfrcs@theeyeclinic.iePaul Rosen – phrosen@rocketmail.comRoberto Bellucci – roberto.bellucci@azosp.vr.itThomas Kohnen – Kohnen@em.uni-frankfurt.de

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OPHTHALMOLOGY TRENDSPhysicians losing freedom to choose best technologies for their patients by Dermot McGrath in Milan

18

While high-volume and low-cost cataract surgery is now standard, we have seen that product selection of some newer technologies is being limited due to increased costs in public healthcare systems

“

Matteo Piovella

There are a lot of patients out there for whom the premium IOL is in fact the monofocal lens

“Peter Barry FRCS

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Update

cornea

EUROTIMES | Volume 18 | Issue 5

Combining cataract surgery with endothelial keratoplasty may have a role in treating patients with advanced corneal pathology, but so long as the cornea is clear, cataract surgery is enough

on its own. This was the consensus arrived at by the two participants in a debate on the issue at the 17th EsCRs Winter Meeting.

“Performing cataract and keratoplasty is the way to go if the endothelium is close to decompensation and you are well trained in Descemet’s-stripping automated endothelial keratoplasty (DsAEK),” said Beatrice Cochener MD, PhD, professor and chair, Department of Ophthalmology, Brest University hospital, France.

she noted that Fuchs’ corneal dystrophy is the most common indication for endothelial keratoplasty, and patients with the condition frequently suffer from coexisting cataract. in those cases where corneal dystrophy has advanced to the point where decompensation is likely, combining the cataract and endothelial keratoplasty procedures can reduce the time required for visual rehabilitation, without compromising the safety or efficacy of either procedure.

The corneal criteria for a combined procedure should not be the endothelial cell density, since corneas with cell counts below 500/mm2 do not always decompensate. instead, surgeons should base their decision on the effect of the disease on corneal clarity, Prof Cochener said.

PKP vs DSAEK The classic triple procedure, which combines penetrating keratoplasty (PKP), phacoemulsification and iOL implantation, provides faster rehabilitation than performing the two procedures separately. it also reduces the chance of further endothelial trauma, such as might occur if the keratoplasty had been performed first and cataract procedure had been performed later.

however, the predictability of the postoperative refraction is limited with this combination, because it results in a cornea with an anterior and posterior corneal curvature different from that which was measured preoperatively.

in contrast, DsAEK produces no significant changes in corneal topography, and so changes the corneal refraction

significantly less than PKP. As a result, the refractive outcome of combined cataract and DsAEK procedures is much more predictable.

in a series of 315 eyes of 233 patients who underwent the combined cataract /DsAEK procedure, the mean BCVA was 20/31 and 93 per cent of patients had visual acuity better than 20/40 at six months' postoperative (Terry et al. Ophthalmology. 2009; 116(4):631-639).

however, DsAEK does induce mild postoperative hyperopic shift because of increased concavity of the posterior surface. The amount of the hyperopic shift ranges from zero to three dioptres, and is dependent on the difference between the peripheral and central thickness of the corneal button.

The more recently introduced technique of Descemet’s membrane endothelial keratoplasty (DMEK) may eliminate the hyperopic shift, since the donor button consists entirely of the endothelium and Descemet’s membrane. in addition, Friedrich E Kruse MD, in Erlangen, Bavaria, Germany, has reported that procedures combining DMEK with phacoemulsification result in visual acuity outcomes equivalent to those of DMEK alone.

Keratoplasty not to be undertaken lightly Combined procedures should only be performed in Fuchs’ dystrophy cases where the patient who would have required the cornea procedure anyway, stressed Jesper hjortdal MD, PhD, Aarhus University hospital, Denmark.

“Combining phacoemulsification plus iOL implantation with DsAEK is attractive in patients with Fuchs' endothelial dystrophy. however, endothelial keratoplasty has a number of associated risks. Besides which, DsAEK can be performed three to six months after phacoemulsification if the cornea deteriorates," he said.

Dr hjortdal noted that Fuchs’ dystrophy progresses in a gradual way going through several distinct stages before vision is seriously compromised. Moreover, corneal guttata such as are seen in the early stages of Fuchs’ corneal dystrophy do not always progress Fuchs’ corneal dystrophy. it would therefore be a waste of corneal donor tissue to perform keratoplasty in eyes that still only have the early signs of disease.

Complications occurring during phacoemulsification may necessitate postponement of keratoplasty, leading to the waste of the lamellar button. in addition, the unclear intraocular media after keratoplasty can make cystoid macular oedema difficult to diagnose and treat.

Furthermore, unlike patients who undergo cataract surgery alone, patients who undergo DsAEK rarely have a postoperative visual acuity of 20/20 or better. in a study involving 548 eyes the median visual acuity was 20/28 (Terry et al, Ophthalmology. 2012;119(10):1988-96).

in addition, primary failures are not uncommon with DsAEK, especially in a surgeon’s first procedures. in fact, 10 per cent of DsAEK grafts fail within three years (Ang et al (Ophthalmology 2012; 119: 2239-2244).

DsAEK is also still a fairly new procedure and the literature published to date provides no information as to what will happen to DsAEK grafts in the long-term. in particular, the long-term safety in terms of endothelial cell loss compared to PKP has yet to be determined.

Moreover, in common with those who undergo PKP, patients who undergo DsAEK often receive topical steroid for six to 12 months postoperatively. Given that 15 per cent of people are steroid responders, patients must be closely monitored for increased iOP in order to avoid glaucomatous damage to the optic nerve.

And finally, despite its non-invasive and topography-preserving nature, there are as yet no prospective randomised studies demonstrating that DsAEK is superior to PKP for Fuchs’ endothelial dystrophy. Dr hjortdal nonetheless maintained that in his own experience DsAEK is clearly better. he also concurred with Prof Cochener regarding endothelial keratoplasty’s future promise.

“We will have better techniques available in a few years. DMEK and ultra-thin DsAEK may result in better visual acuity compared to conventional DsAEK. Further down the pipeline we may also be using autologous endothelial cells that are cultivated ex vivo, which could greatly reduce the risk of rejection,” he said.

Beatrice Cochener – beatrice.cochenerlamard@chu-brest.frJesper Hjortdal – jesper.hjortdal@dadlnet.dk

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COMBINED PROCEDURETreating cataracts and corneal dystrophy in one procedure best reserved for eyes with more advanced corneal diseaseby Roibeard O’hEineachain in Warsaw

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DSAEK (OCT and slit lamp)

Performing cataract and keratoplasty is the way to go if the endothelium is close to decompensation and you are well trained in Descemet’s-stripping automated endothelial stripping keratoplasty (DSAEK)

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Beatrice Cochener MD, PhD

“ Combining phacoemulsification plus IOL implantation with DSAEk is attractive in patients with Fuchs’ endothelial dystrophy. However, endothelial keratoplasty has a number of associated risks”Jesper Hjortdal MD

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EUROTIMES | Volume 18 | Issue 5

iOL calculation for patients with cataract and keratoconus can be challenging, but modern diagnostic technology, broadly customisable toric iOLs and the

availability of new ways to adjust refraction postoperatively mean that patients have a good chance of a satisfactory visual outcome, said Tobias Neuhann MD, Marienplatz Eye Clinic, Munich, Germany. (see Figure 1.)

“Cataract surgery in the keratoconic eye must be customised in every case because every patient is different,” Dr Neuhann told the 17th EsCRs Winter Meeting.

he noted that his own approach to keratoconic eyes first involves performing standard topography but also using a Pentacam scheimpflug camera to create a Belin-Ambrosio map to identify the grade of ectasia. he and his associates also use the Pentacam and corneal OCT to determine whether the eye has undergone previous refractive surgery because patients sometimes forget. They also perform standard biometry and keratometry and endothelial cell counts because eyes with keratoconus are prone to Fuchs’ dystrophy. And last but not least, they perform a retinal OCT so that they can give patients a better idea of what sort of visual outcome they can expect.

Dr Neuhann noted that in cataract patients with keratoconus he performs phacoemulsification in his standard way, except that he uses a capsular tension ring in all cases. There is no increased risk of lens subluxation in such cases, but the capsular tension ring is useful because it makes the lens easier to replace if necessary. he added that it has yet to be determined how useful femtosecond laser-assisted cataract surgery will be in cataract patients with keratoconus.

Customisable refraction Toric iOLs are suitable in most eyes with cataract and keratoconus, Dr Neuhann said. in Europe

there are toric iOLs available which provide up to 20 D of toric correction. There are also add-on lenses available which, unlike the piggy-back lenses of old, sit in the sulcus, well-separated from the principal lens in the capsular bag. “The add-on lenses are very helpful and they are not calculated by biometry, they are calculated by the refraction. That means the patient tells you after the surgery what the power of supplementary iOL needs to be,” he said. (see Figure 2.)

he added that results with the Light Adjustable Lens (LAL®, Calhoun vision) have shown it to be very effective in the correction of up to 2.0 D of sphere and up to 3.0 D of cylinder postoperatively. in a series of 65 astigmatic eyes in which he and his associates implanted the lens, postoperative refractive adjustment reduced the cylinder from about 2.0 D to about 0.5 D in all cases.

“i think the Light Adjustable Lens is the best device to correct astigmatism up to two or three dioptres. No other current method is as precise and it has demonstrated great safety, efficacy and stability. You can also make very predictable spherical correction with it, so you can get the refraction you really want,” Dr Neuhann said.

GOOD OUTCOMEPostoperative refraction now more predictable and correctable by Roibeard O’hEineachain in Warsaw

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Update

cornea

Figure 1: Intracorneal ring segment for keratoconus treatment, now challenging IOL calculation

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Figure 2: Add-on IOL: calculation via refraction and not biometry

The add-on lenses are very helpful and they are not calculated by biometry...

“ Tobias Neuhann MD

4TH EUCORNEACONGRESS

AMSTERDAM 2013

4-5 OCTOBER

2 Days. 12 Symposia. 6 Courses. 12 Free Paper Sessions.

www.eucornea.org

Friday Symposian Infections

n New Contact Lenses in Irregular Astigmatism

n What I do differently this year than last year

n Cicatrizing Ocular Surface Disease

n Laser Assisted Lamellar Keratoplasty

n Ocular Surface Reconstruction & Keratoprosthesis

Coursesn Stem Cell Therapy for Ocular Surface Reconstruction

n What Can Go Wrong in Lamellar Surgery

n Current State of CXL (Corneal Collagen Cross-linking)Controversies and hot topics

EuCornea Medal LectureFriday 4 October17.00 – 18.00

At the Opening Ceremony

The Cornea: How Many Endothelial Cells Are Necessary?Gabriel van Rij THE NETHERLANDS

Saturday Symposian Iatrogenic Corneal Disease

n Ocular Tumours

n Posterior Lamellar Keratoplasty

n Cornea Infections and Infl ammatory Disease: An Asian Perspective

n Ocular Traumas

n New Research in Cornea

Coursesn Techniques for Evaluating Dry Eye

n Corneal Imaging Update

n Eye Banking and Corneal Transplantation

EUROTIMES | Volume 18 | Issue 5

Corneal Collagen Crosslinking (CXL) can have several potential complications most of which are avoidable, but even with the best technique the results are not 100 per cent predictable, said

Farhad Hafezi MD, PhD, chairman of the Department of Ophthalmology, University of Geneva, Switzerland.

The complications of CXL can arise from each step of the procedure: from overexposure to the ultraviolet rays, from the wound-healing process after the treatment and from the epithelial removal, Prof Hafezi said, in a keynote lecture he delivered at a Cornea Day session at the 17th ESCRS Winter Meeting.

With regard to ultraviolet exposure, Prof Hafezi noted that adherence to the established treatment protocol will ensure that the treatment does not extend too far into the cornea and damage the endothelium. That means first applying the riboflavin to the eye for at least 25 minutes to ensure an even concentration throughout the cornea, which should be at least 400 microns thick. The eye should be then exposed to no more than a total dose of 5.4 Joule, using fluences of 3 mW, 9 mW and 18 mW, respectively.

“In the past 11 years, I have not seen a decompensation in any case where this rule has been respected,” he said.

In addition, Prof Hafezi’s studies in rabbit eyes (Richoz et al., submitted) indicate that the CXL treatment does not affect the limbus or pose any risk of limbal stem cell insufficiency even when performing decentred treatments in eyes with pellucid marginal degeneration.

Observations of corneal wound healing are raising some very intriguing possibilities. In a small minority of patients there has been an unexpected postoperative dense haze that has been accompanied by a massive postoperative flattening of the cornea (Hafezi et al., Br J Ophthalmology, 2010).

Typically after crosslinking there is an arrest of the progression of the cone in about one-third of patients and a slight regression of the cone, by about two or three dioptres, in about two-thirds of patients. In nearly all eyes there is also a transient haze, like that which occurs after PRK, only deeper.

However, in about one out of every 200 procedures there is haze that does not go away and in these cases there has also been massive remodelling that results in a corneal flattening of up to 11 D. The improvement in refraction is so dramatic in most cases that patients are very happy and do not complain about the pronounced haloes and other photic phenomena induced by the haze, Prof Hafezi noted.

“This massive remodelling might be highly beneficial for the patient, what we have to figure out is how we can induce it and control it,” he said.

In some patients re-epithelialisation is delayed, which can be frustrating for the patient, although it is easily managed in most cases. Topical NSAIDs are very strongly contraindicated in such cases and may lead to infectious

corneal melting via activation of matrix metalloproteinases, Prof Hafezi added.

“Crosslinking is an extremely safe procedure if the surgeon stays within the indication’s limits and has experience with open surfaces,” he concluded.

CXL COMPLICATIONSAdherence to treatment protocols maintains safety but there can be surprisesby Roibeard O’hEineachain in Warsaw

23

What Makes The Perfect Surgeon? Dr Oliver Findl talks to Dr Jack Holladay about the importance of surgical technique

EYE CHAT

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Update

CORNEA

Farhad Hafezi – farhad@hafezi.ch

contact

Figure 1: Epithelium-off CXL performed in a patient with progressive keratoconus

Figure 2: Remodelling process following CXL: topographical changes and assessment of stromal haze. (A) Scheimpflug analysis of the anterior corneal surface (true net power)

before (left) and at 12 months after CXL (middle). The difference image (right) shows a strong reduction of Kmax values readings of up to 9.5 D. (B,C) Slit-lamp images of

the central deep stromal haze (arrows) in the left eye. (D) Corneal confocal microscopic sections of the anterior corneal stroma at 170 µm depth. The stroma shows activated

keratocytes (arrow) and hyperreflective deposits corresponding to subepithelial fibrosis (arrowhead). (D) High-resolution Scheimpflug imaging of the corneal haze (arrows)

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[Reproduced from British Journal of Ophthalmology; authors Farhad Hafezi, Tobias Koller, Paolo Vinciguerra, Theo Seiler; Volume 95, Issue 8; Licence date March 22, 2013;

with permission from BMJ Publishing Group Ltd]

EUROTIMES | Volume 18 | Issue 5

Eight to 10 years after deep sclerectomy, patent decompression chambers in intrascleral space were maintained in most cases, and suprachoroidal aqueous flow was frequently detected on

ultrasound examination, Pierre-Yves Santiago MD, of Clinique Sourdille, Nantes, France, told the XXX Congress of the ESCRS.

But while the consistent finding of suprachoroidal outflow is intriguing, its significance is unclear, Dr Santiago said.

“Subconjunctival filtration has long been considered the main IOP-lowering mechanism, in many cases diffusing posteriorly. Suprachoroidal outflow is often observed, but we are not sure if it is a mechanism or a consequence of IOP lowering.”

The study, which also examined intraocular pressure (IOP), topical treatment requirements and re-operation rates, is thought to be the first 10-year study of filtration architecture following deep sclerectomy. Outcomes of patients with and without implants, and with and without anti-metabolite treatment were compared.

Dr Santiago recommended further studies beyond the select group of patients he imaged, all of whom had successful procedures. Confirmation of suprachoroidal outflow as an IOP-lowering mechanism could lead to new filtration surgery approaches that are long-lasting and less prone to bleb-related failures and complications.

Long-term outcomes Patients for the outcomes study were selected at random between February and June 2012. From these, a subset of patients with favourable outcomes were imaged to investigate the possible role of suprachoroidal outflow in IOP lowering, Dr Santiago said.

In a comparison involving 47 eyes in 31 patients with a mean follow-up of 127 months, outcomes for those that received a hyaluronate implant at surgery were broadly similar to those that did not, though mean IOP was slightly lower while mean topical medications and re-operation rates were higher in the implant group.

The 22 eyes in the implant group fell from mean IOP of 22.0 mmHg and 1.77 topical drugs pre-op to 13.8 mmHg and 0.84 topical drugs with four re-operations, or 18 per cent, at 132 months mean follow-up. The 25 eyes in the non-implant group fell from mean IOP of 22.3 mmHg and 1.12 topical drugs pre-op to 14.7 mmHg and 0.44 topical drugs with three re-operations, or 12 per cent, at 122.7 months follow-up, Dr Santiago reported.

Similarly, in a group of 54 eyes in 40 patients, all with hyaluronate implants operated by the same surgeon, and 14 treated with mitomycin-C and four with 5-flourouracil, outcomes were nearly identical in the anti-metabolites and non-anti-metabolite treated groups, Dr Santiago reported. Mean IOP fell from 24.3 mmHg and 1.6 mean topical treatments pre-op to 14.8 mmHg and 0.9 topical drugs at 101.5 months mean follow-up, with 26 per cent treated for cataracts, 11 per cent re-operated for glaucoma and 3.6 per cent receiving selective laser trabeculoplasty.

“In summary these are satisfactory outcomes at 10 years,” Dr Santiago said. Medical treatments when necessary were about half pre-op levels, with the added advantage of achieving IOP control, with the need for re-operations due to uncontrolled pressure running 11 per cent to 14 per cent.

Suprachoroidal outflow To illustrate the possible role of suprachoroidal outflow in IOP lowering, Dr Santiago randomly selected 21 eyes of 12 patients from those with favourable outcomes. Of these, 14 eyes had hyaluronate implants and nine were treated with anti-metabolites. Mean pre-op IOP of 20 mmHg and 2.0 topical treatments were reduced to 12.6 mmHg and 0.33 treatments at a mean follow-up of 108 months for the entire group.

These patients were examined using 50 MHz ultrasound biomicroscopy probe. UBM is the only technology currently available capable of imaging deep scleral architecture and function, Dr Santiago said. Because ultrasound is dynamic, it makes static measurements difficult. Nonetheless, bleb and decompression chamber volumes were recorded, with a mean of 86.6 cubic mm for filtration blebs and 14.6 cubic mm for decompression chambers.

Dr Santiago also imaged suprachoroidal outflow channels and aqueous outflow, though it is sometimes difficult to do so. Of the 21 eyes, suprachoroidal outflow was definitely detected in 10, appeared probable in six and was definitely not present in five patients.

But while it might be expected that adding suprachoroidal outflow to subconjunctival blebs and intrascleral channels would further reduce IOP, no correlation was found between IOP and the presence of suprachoroidal outflow, Dr Santiago reported.

Dr Santiago presented ultrasonograms of several cases with and without suprachoroidal flow, all of which had stable IOP for seven years or more, often in the 10 to 12 mmHg range. Indeed, 12 years after surgery, one patient had nearly identical pressure in both eyes with one showing clear suprachoroidal outflow and the other with no detectable flow. These results raise a question as to whether suprachoroidal outflow is a real outflow mechanism, or merely a consequence of surgically induced hypotony, he said.

Dr Santiago noted a similar question arising from studies of circular cyclocoagulation of the ciliary processes in rabbits. As the processes atrophy after treatment, uveo-scleral gaps are created.

“It was noticed on histological analysis, and in vivo we can see suprachoroidal outflow that can participate to lower IOP as a consequence of hypotony.”

Since this is the first long-term investigation of filtration architecture with a 10-year follow-up, and the patient population was narrow, Dr Santiago recommended additional, broader studies.

GLAUCOMA SURGERYStudy examines filtration architecture, suprachoroidal outflow 10+ years after deep sclerectomyby Howard Larkin in Milan

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GLAUCOMA

Pierre-Yves Santiago – pierre-yves.santiago@clinique-sourdille.com

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EUROTIMES | Volume 18 | Issue 5

In the early days of HIV-AIDS, opportunistic ocular infections were common in severely immune-compromised patients.

Cytomegalovirus (CMV) retinitis was the most prevalent, affecting 15 to 40 per cent of patients with advanced HIV disease, with toxoplasmosis also a frequent problem.

The advent of effective anti-retroviral therapy, which allows patients’ natural immune systems to recover, reduced CMV retinitis rates about 75 per cent, William R Freeman MD, director of the Jacobs Retina Center at the University of California – San Diego, La Jolla, US, told the American Academy of Ophthalmology annual meeting.

“Our residents and medical students see these things and have no idea what they are because they have no experience with them.”

Nonetheless, infectious retinitis and choroiditis remain among several ways HIV disease threatens sight and ophthalmologists must be on guard, Dr Freeman said. They can occur alone or in combination, and may result in acute retinal necrosis, which can spread quickly in both eyes. “It really requires clinical acumen to diagnose quickly and choose the right treatment.”

Atypical presentation Infectious retinitis often presents differently in immune-suppressed patients, which can make diagnosis and monitoring progression challenging, Dr Freeman said. In HIV patients with old toxoplasmosis scars, toxo retinitis often becomes confluent and may not look like toxoplasmosis.

CMV retinitis may present with a classic tomato ketchup and cheese appearance, or it may be much subtler, resembling cotton wool spots, and may recur after it appears cured as a slow advance of lesion borders, Dr Freeman said. CMV progresses slowly, so he recommends waiting a week if it’s not clear. Overall, clinical guidelines allow about 95 per cent of cases to be diagnosed by ophthalmoscope and fundus photographs, but sometimes a transvitreal retinal biopsy is needed.

The patient’s CD4 count can help with differential diagnosis – CMV retinitis

occurs almost exclusively in patients with less than 40 cells per ml, Dr Freeman noted. “As ophthalmologists, we have to be cognizant of the patient’s medical condition. We are all physicians and we have to know how to order the tests and interpret them.”

Systemic ganciclovir typically halts initial CMV progression, but the virus becomes resistant, and progression can resume. “We have to realise that if a patient is already on treatment and CD4 is low, we are going to have to supplement with intravitreal ganciclovir implants or other therapies,” Dr Freeman said.

Other infectious agents include syphilis and herpes zoster or simplex, which can rapidly propel progressive outer retinal necrosis. These also must be identified and treated early, Dr Freeman said.

Aggressive management of retinal detachment is also indicated, with vitrectomy and permanent silicone oil tamponade as first line treatment to prevent recurrent detachments due to expanding lesions, Dr Freeman added.

Even without retinitis, HIV patients still lose vision, Dr Freeman said. “Cotton-wool spots add up in time. We see a degeneration of axon profiles at autopsy in patients without retinitis but with a history of cotton-wool spots.”

HIV VISION LOSSCMV, toxoplasmosis still exist despite anti-retroviral drugsby Howard Larkin in Chicago

26 Update

RETINA

William R Freeman – freeman@eyecenter.ucsd.edu

contact

As ophthalmologists, we have to be cognizant of the patient’s medical condition. We are all physicians and we have to know how to order the tests and interpret them

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A key component for developing successful retinal degeneration drug treatments is the availability of efficient drug delivery

systems. A variety of systems under active development include virus vectors, cell-based delivery vehicles and encapsulated devices.

However, new research led by Dr M Dominik Fischer, now at the Nuffield Laboratory of Ophthalmology, Oxford, introduces a novel approach, which he presented to delegates attending the 3rd EURETINA Winter Meeting.

The new system, characterised by the delivery of genetically engineered human mesenchymal stem cells (MSCs) encapsulated within miniaturised alginate spheres or “MicroBeads”, may provide the means to achieve sustained drug release without necessitating repeat administration.

Dr Fischer explained that MicroBeads were “small spherical structures with a core of human mesenchymal stem cells, the core, about 120 μm across in diameter is protected by a biopolymer that shields the cells from the host humoral and cellular immune response but is semi-permeable for small proteins or substances, and biologicals that can be secreted with a size limit of about 300kDa. So it is quite a versatile system in that you can engineer those cells to secrete neuro-protective substances or even anti-angiogenic or anti-inflammatory biologicals”.

Such a delivery system may provide an advantage over alternative approaches if the engineered cells can be designed to deliver a steady and reproducible level of therapeutic biologicals over a sustained period of time.

Dr Fischer told delegates that for “any form of retinal disorder you would think that there is a therapeutic target level of your biological that you would like to achieve; if you do an intravitreal injection you have a quick rise of concentration of your drug and a quick drop again; ideally you would like to achieve consistent dosing at that therapeutic target level and have a physiological feedback between the diseased tissue and your compound. This is why we think MircoBeads might be a good idea; having a cellular system in place that can have a physiological feedback with the target tissue and possibly express the therapeutic biological around the ideal target level”.

The initial objective of Dr Fischer’s studies at the Centre for Ophthalmology in

Tübingen was to monitor the viability of MicroBead encapsulated MSCs in the mouse eye by histologically tracking the impact of the delivery procedure and the subsequent expression of an engineered reporter construct, green fluorescent protein.

Dr Fischer reported that successful expression of the reporter gene was demonstrated for up to four months following implantation. In addition, the research results showed that the MicroBeads remained stationary and functional throughout the four months investigated suggesting the potential of MicroBeads for sustained delivery of biologicals making them a promising candidate for intermediate-term therapeutic use in human hereditary retinal degenerations and other ocular disorders.

While there may be significant further work ahead in optimising the technology, the opportunity to control levels of therapeutic drug delivery will undoubtedly spur continued research on the application of the encapsulated cells. In particular, the use of inducible promoters to control gene expression and thereby ensure constant and safe therapeutic levels of a drug, combined with the added safety feature of a cellular suicide gene, all present a level of control for clinicians to fine tune the next wave of molecular medicine tools.

28 Update

RETINA

M Dominik Fischer – Dominik.Fischer@merton.ox.ac.uk

contact

MICROBEADSOpportunity to control levels of therapeutic drug delivery will spur continued research by Gearoid Tuohy in Rome

The concept of MicroBeads

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EUROTIMES | Volume 18 | Issue 5

Theoretically, polymerase chain reaction (PCR) can amplify a single strand of target DNA a trillion times. Thus, its sensitivity as a diagnostic tool for ocular infections is of a similar magnitude

– theoretically. But in the real world, PCR can be far too sensitive, detecting random, or even dead, microbes that are not responsible for observed disease, Todd P Margolis MD, PhD, of the University of California – San Francisco, US, told the American Academy of Ophthalmology annual meeting. “There’s a big disconnect between sensitivity and clinical relevance.”

Indeed, one PCR study detected bacteria or fungi in 52 per cent of swabs exposed only to air (Kim et al. AJO 146: 714-723, 2008). Another generated 42 per cent false positives when the assay was set to detect one copy of varicella-zoster virus (VZV) DNA (Short et al AJO 123: 157-164, 1997).

“That’s why you don’t set a PCR-based assay to infinite sensitivity,” said Dr Margolis, who is also medical director of a clinical ocular microbiology lab.

Conversely, many factors can sharply reduce actual assay sensitivity, resulting in false negatives, Dr Margolis said. Among them are specimens containing substances that inhibit the PCR reaction, samples from partially treated eyes, diluted samples, inadequate samples and samples that are not adequately frozen or not kept cold enough in shipment.

Also, clinically relevant assay parameters differ for aqueous, vitreous and corneal samples. Worse, there are no standards for sampling corneal tissue, and the amount of host DNA differs enough in epithelial and stromal tissue that they require different assay approaches to yield clinically meaningful results, Dr Margolis said. “If you are going after stromal lesions you are probably not going to pick it up.”

Generally, vitreous samples are more reliable than aqueous for most infectious retinal disease. PCR assays for cytomegalovirus (CMV) iritis/corneal endotheliitis are notoriously inaccurate, yielding false negatives for about 75 per cent of clinically evident cases in his lab, Dr Margolis noted. PCR assays are also extremely sensitive to small process variations from lab to lab, he added.

Because of these variables, PCR assay parameters must be developed specifically by pathogen and sample type at each lab. The repeatability and clinical predictive power of each parameter set must be validated for it to be useful for diagnostic purposes, Dr Margolis said.

“Molecular diagnostics are not magical assays. Results should be interpreted with caution,” he advised.

PCR in practice Nonetheless, PCR represents a new paradigm in ocular infection diagnostics, said Regis P Kowalski MS [M]ASCP, associate professor of ophthalmology at the University of Pittsburgh medical school and executive director of the ophthalmic microbiology lab at the University of Pittsburgh Medical Center (UPMC), Pennsylvania, US.

“Not everything can be cultured, especially for intraocular areas,” Prof Kowalski said. Clinically validated PCR can be highly useful and accurate in these cases.

For example, in his lab, PCR detects 100 per cent of VZV vs about nine per cent for cultures, and 100 per cent of Chlamydia vs about 38 per cent for culture.

However, culturing is more accurate for some pathogens, such as adenoviruses (ADV). Like other lab tests, PCR should be used to supplement other diagnostic methods, including clinical suspicion, culture isolation, microscopy and confocal microscopy.

Prof Kowalski also emphasised the importance of sending clinical samples only to clinical labs that have validated assays for specific infectious suspects, and to avoid using research labs. Clinical labs use both true positive and true negative test samples to validate assays, whereas research labs do not, he explained.

Rigorous clinical validation requirements result in high reliability, Prof Kowalski said. “In more than 10 years testing, no known false positives have been reported with patient samples in our lab.”

UPMC offers PCR in-house for herpes simplex virus (HSV) 1 & 2, VZV, ADV, CMV, Epstein-Barr virus (EBV), Chlamydia, Neisseria gonorrhoea and Acanthamoeba, Prof Kowalski said. The lab is also part of an international network that provides validated tests for toxoplasma, tuberculosis, mycobacterium leprae and rubella, with turnaround times of 24 to 48 hours.

“It’s important to have a network for less common pathogens. No lab tests for everything, not even the CDC.”

Prof Kowalski also stressed the importance of proper sampling, preservation and storage practices. He recommends several steps for surgeons interested in adding molecular diagnostics to their practices.

First, find a molecular test facility and educate yourself on its capabilities and protocols, and how to take and process samples. Second, keep simple supplies on hand, including saline, viral transport, swabs and cold packs.

Third, process samples correctly and arrange appropriate transport by courier. Fourth, be reasonable in your expectations. “Don’t pan sample and expect PCR for everything. It doesn’t work, it’s quite expensive and it’s not going to happen,” Prof Kowalski said.

Send undiluted samples, untreated samples, freeze samples immediately at -80 C if you can, and send samples frozen, Dr Margolis added. He cautioned that PCR results always must be put in context. “The problem is usually not the test, it is the interpretation by the individual receiving the test results.” Clinical correlation is always advised.

MOLECULAR DIAGNOSTICSRigorous clinical validation requirements result in high reliabilityby Howard Larkin in Chicago

29

Enter the John Henahan Writing Competition for Young Ophthalmologists.

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Update

OCULAR

Todd P Margolis – Todd.Margolis@ucsf.edu

contacts

Regis P Kowalski – kowalskirp@upmc.edu

EUROTIMES | Volume 18 | Issue 5

Paediatric cataracts present the ophthalmic surgeon with many compromises and dilemmas, but evidence has accumulated over the years that support certain strategies in the treatment of such

eyes, said Alina Bakunowicz-Łazarczyk MD, at a symposium of the Polish Society of Cataract and Refractive Surgery at the 17th ESCRS Winter Meeting.

“There are questions surrounding anterior and posterior capsule management and there are questions around when we should perform anterior vitrectomy and laser capsulotomy and which intraocular lens we should use, the type of lens and the power of the lens,” said Dr Bakunowicz-Łazarczyk, Medical University of Bialystok, Bialystok, Poland.

In congenital cataracts there is also the important question of when to operate, she noted. Operating too late will result in a lifetime of poor visual acuity, operating too early will increase the risk of glaucoma.

There is a loss of one line of eventual visual acuity for every three weeks of the first 14 weeks of life outside the womb that a child’s congenital cataract is left in the eye. Operating within the first month of life reduces the likelihood of strabismus and will also preserve an eventual extra Snellen line of vision, but there is a greater risk of glaucoma and secondary membrane development. Conversely, children who undergo surgery when they are between 14 and 31 weeks of age will have a lower risk of glaucoma, but will have an unrecoverable loss of eventual vision, Dr Bakunowicz-Łazarczyk said.

Paediatric eyes have several anatomical features that can make the removal of a cataract very difficult. To begin with

they are very small and have small lenses. In addition, their elastic and thick anterior capsules require the application of more force to create the initial tear when performing a capsulorhexis. For that reason, a procedure using a vitrector, called vitrectorhexis, may be useful. Another alternative is endodiathermy.

In addition, children’s pupils can be difficult to dilate and may require the use of retractor hooks and rings. Furthermore, their thin and elastic sclera makes it hard to create a self-sealing incision and generally a 10-0 nylon suture is therefore necessary.

To prevent posterior capsular opacification (PCO), Dr Bakunowicz-Łazarczyk recommended performing a posterior

capsulorhexis plus vitrectomy in patients less than three years of age and posterior capsulorhexis only in patients three-to-six years of age. In patients more than six to seven years of age the posterior capsule should be left intact.

If PCO occurs, a YAG Laser capsulotomy is usually sufficient although anterior vitrectomy may be necessary in some cases where the visual axis becomes opacified.

Intraocular lenses (IOLs) are usually implanted in patients greater than two years of age because at one year of age there is a shift in refraction of 10 D, she said. However, some have reported acceptable results in children as young as seven days old.

She added that single-piece hydrophobic acrylic IOLs seem to be the best implants to use because they have a lower risk of PCO and secondary glaucoma. There have also been good reports with iris-fixated IOLs. Hydrophilic acrylic IOLs, on the other hand, are prone to calcium phosphate deposits and silicone contamination on the IOL surface.

PAEDIATRIC CATARACTSWhen to operate and how to operate for best vision in the long-termby Roibeard O’hEineachain in Warsaw

30 Update

PAEDIATRIC OPHTHALMOLOGY

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Alina Bakunowicz-Łazarczyk– alina.lazarczyk@umb.edu.pl

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Diathermic capsulorhexis

There are questions surrounding anterior and posterior capsule management and there are questions around when we should perform anterior vitrectomy and laser capsulotomy and which intraocular lens we should use...

“

Alina Bakunowicz-Łazarczyk MD

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EPOS/WSPOSEuropean Paediatric Ophthalmological Society /

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PAEDIATRIC SUB SPECIALTY DAY

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EUROTIMES | Volume 18 | Issue 5

ORBIS has worked in Ethiopia for over 14 years to implement a model for comprehensive rural eye care focussing on

capacity building, healthcare technology development and advocacy to address critical gaps in eye care.

Since 2011 ESCRS has supported ORBIS to develop a Paediatric Eye-Care Centre in Gondar Hospital. ESCRS funds have gone towards training resident ophthalmologists in sub-specialties such as paediatric cataract and glaucoma in order to be able to treat a wide range of paediatric eye conditions.

The latest installment of this training took place in October 2012 when ORBIS conducted a week-long hospital-based programme in Gondar. In a video which was recently posted on the ESCRS website, ORBIS volunteer and paediatric ophthalmologist Dr Donny Suh can be seen giving hands-on training to Dr Mulusew Asferaw, the head of the Paediatric Eye Care Unit at Gondar. This type of training is only possible thanks to the support of ESCRS members who since 2011 have donated over €70,000 to ORBIS and Oxfam.

Hands-on training Dr Suh said that the trainees in Ethiopia would have access to videos and the Internet, but this did not compare with the trainees and their

teachers working together in a close hands-on setting.

“These doctors,” said Dr Suh, “do not have access to a lot of the medical equipment that is available. Also, for the management of complicated cases, they do not know how to address them,” he said.

On the first day of training, Dr Suh screened and selected some of the complicated cases that Dr Asferaw would not be able to manage himself. On the following four days, Dr Asferaw carried out surgeries on the patients under Dr Suh's supervision.

Dr Asferaw said hands-on training was very important. “It is not theoretical, it is a skill transfer and I can observe, assist and carry out some of the steps.”

The video, which is three minutes long, was photographed and produced by Geoff Oliver Bugbee for ORBIS International.

Project updates As part of its support for ORBIS, ESCRS funded Dr Asferaw and his colleague Dr Asamere Tsegaw to attend the XXX ESCRS Congress in Milan, Italy in 2012.

ESCRS is also supporting the Oxfam Wash programme in Uganda in the Kitgum and Lamwo districts. Money donated by ESCRS to the project helps to strengthen the services provided by local government

in a Community Based Water Resource Management programme. This is designed to enable the government and people to take responsibility for their own water and sanitation needs and performance in the future. This year, the ESCRS charitable donation will support a new Oxfam project in The Congo and EuroTimes will feature an update on this programme in our June issue.

There will also be further opportunities to donate to the charities when delegates register for the XXXI ESCRS Congress in Amsterdam, The Netherlands.

* The ORBIS video is available at: http://www.escrs.org/charitable-donations/news-updates.asp

GONDAR PROJECTBuilding eye care capacity in Gondar, Ethiopiaby Colin Kerr

32 News

ORbIs

Hands-on training in theatre Injecting botox into the muscle

Dr Suh screens patients with trainees

In a video which was recently posted on the ESCRS website, ORBIS volunteer and paediatric ophthalmologist Dr Donny Suh can be seen giving hands-on training to Dr Mulusew Asferaw

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EUROTIMES | Volume 18 | Issue 5

The 13th EURETINA Congress in Hamburg this September will provide delegates and guests with the opportunity of enjoying some

of Europe’s most novel tourist attractions.Miniature Wonderland, known as “the

largest model railway in the world,” occupies a floor of a Speicherstadt warehouse. It’s an astonishing layout that boasts more than 12,000 metres of tracks in HO scale, divided into seven sections. Begun in 2000, it won’t be completed until 2020; meanwhile, it gets bigger every day and visitors can watch the model makers at work.

At the moment there are about 900 trains made up of 11,000 carriages. Circumvent the almost perpetual queue by buying your ticket from your hotel concierge or book online at: www.minatur-wunderland.com.

The extent of the installation is the first surprise. It covers 1,500 square metres – the Alps are five to six metres high. Whole cities are reproduced including Hamburg with 200 separate and recognisable buildings. Buttons on the railings surrounding the display allow visitors to instigate a ‘fire alert’. One of the buildings catches fire and fire trucks respond, the number of them depending on a randomly assigned level of conflagration. The newest addition is an airport with regularly arriving and departing flights, tracked on a board just as in a proper airport. From time to time the lights fade over Miniature Wonderland and it becomes night. Some 50,000 electric lights illuminate the cities, the roadways, the tunnels, the airport. It’s a short night and

then it’s dawn again. Kehrwieder 2-4, Block D Speicherstadt. Open Monday to Friday 9:30am - 6pm, Tuesday to 9pm, Saturday 8am - 9pm, Sunday 8:30am - 8pm.

When the lights really do go down in the city, Hamburg’s red-light district, Reeperbahn, switches on. Other cities, notably Amsterdam, have famous red-light districts but nowhere else can claim to be

the place the Beatles found their style, their haircuts and their first public. ‘Beatle tours’ leave the Reeperbahn area at 4pm on Thursday, Friday, Saturday and Sunday. For details, visit: www.beatles-tour.com. A memorial square, Beatles-Platz, containing five stainless steel outline sculptures of the group is at the intersection of Reeperbahn and Grosse Freiheit (Great Freedom) Street.

Grosse Freiheit is where Hamburg’s erotic theatres flourish. Entrance fees are low but drinks come at a price. In the Safari Club, for example, a single beer might cost €25. For details, visit: www.safari-hamburg.de. Back on the Reeperbahn, note the entrance to Herbertstrasse. The sign on the red gate that bars the way warns the street is off limits to female tourists and those under 19. The Reeperbahn Festival, now in its eighth year, runs from Thursday 26th until Saturday 28th September 2013. Some 250 new international bands, solo artists and indie stars will be showcased in and around Hamburg. For details, visit: www.reeperbahnfestival.com.

The classic finale to a Saturday night on the Reeperbahn is breakfast in the St Pauli Fish Market, a five-minute walk away from the S-bahn Landungsbrucken or S-bahn Reeperbahn stops. Stalls are open Sunday morning from 5:30 until 9:30 or 10 selling fish fruit, vegetables and much more. In the old fish auction hall, enjoy a lavish breakfast surrounded by people drinking beer, singing and dancing to live music before the rest of Hamburg is out of bed.

Hamburg’s museum-ship, the Rickmer Rickmers, won the Cutty Sark Tall Ships race in 1958 as the “Sagres.” Then she was a Portuguese cadet training ship. Now restored and under her original name, the three-masted bark is proudly berthed in Hamburg’s harbour. The onboard museum unravels her tangled history. Enjoy a meal – fish is a specialty – in the ship’s handsome mess hall. The museum is open daily from 10:00 to 18:00, the restaurant 11:00 to 18:00. For details, visit: www.rickmer-rickmers.de.

If you prefer your ships on dry land, visit the ten-storey International Maritime Museum in a converted warehouse in the picturesque Speicherstadt area. Opened in 2008, it houses the incredible private collection of Prof Peter Tamm, Sr. Exhibitions range over 3,000 years of maritime history; some 26,000 model ships, numerous uniforms and a wide assortment of naval trappings are on view. You’ll see famous steam engines, marine research exhibitions and the nearly seven metres long Lego model of the Queen Mary 2. Koreastrasse 1. Closed Monday. Open Tuesday-Sunday 10:00 to 18:00. Thursday closing is at 20:00. For details, visit: www.internationales-maritimes-museum.de.

“Dialogue in the Dark” has become a worldwide phenomenon, but only in Hamburg can you experience the original Dialogue; this is where the concept originated in 1988. Blind guides lead groups of visitors through specially constructed rooms in which scent, sound, wind, temperature and texture substitute for information no longer provided by sight. The visitor is led through a park, a city street, a boat cruise, a bar with these unexceptional routines becoming a new and possibly bewildering experience. In the process, accustomed roles are reversed: people who can see are taken out of their familiar environment as blind people provide them with security and a sense of orientation, transmitting to them the sense of a world in which vision plays no part.

“Dinner in the Dark” is a variation of the experience. The evening begins with a champagne reception at 7pm in the light of the foyer. Then diners are brought in small groups into the dark rooms of the exhibition where they learn to employ different senses to understand their surroundings. Finally, blind waiters serve a four-course “surprise” dinner in complete darkness. Visitors must rely on alternate senses to identify the food – and to preserve their table manners. (Dinner is €55). For details, visit: www.dialog-im-dunkeln.de.

ONLY IN HAMBURGExperience six of the city’s unique attractions

34 Update

EYE ON TRAVEL

by Maryalicia Post

The Rickmer Rickmers museum-ship

The world’s largest train set at Miniature Wonderland Control Room at Miniature Wonderland

35

EUROTIMES | Volume 18 | Issue 5

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Sticky topicGlued intrascleral haptic fixation of an intraocular lens (IOL) is a technique for posterior chamber IOL fixation in eyes with absent or insufficient capsule support. First described in 2008, the technique continues to evolve and the method is being applied to an increasing array of scenarios. The intraoperative externalisation of the IOL haptics is the key step in glued-IOL surgery. Amar Agarwal describes a modification of the glued-IOL procedure in which the IOL haptic is bimanually transferred from one glued IOL forceps to another under direct visualisation in the pupillary plane. Called the “handshake” technique”, the modification provides better intraocular manoeuvrability throughout the surgery and extends applicability of the technique to challenging cases that require haptic manipulation, such as IOL drop and haptic slippage. It also provides the intraoperative advantage of a well-formed globe throughout the surgery.

Dr Agarwal notes that one of the significant factors in the technique is the use of a foldable IOL. This provides all the advantages of small-incision surgery. A 3-piece foldable IOL with a C-loop or a modified C-loop configuration is used. Based on the surgeon's preference, an infusion cannula or an anterior chamber maintainer is fixed and the flaps and sclerotomies are made. The corneal incision is fashioned with a 2.8mm keratome, which is slightly enlarged to allow easy insertion of the IOL. A side port is made to provide better manoeuvrability and also serve as a future access point when required.

A video of the complete procedure can be viewed online at http://www.jcrsjournal.org/article/S0886-3350%2813%2900030-8/fulltext.

n A Agarwal et al., JCRS, “Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens”, Volume 39, No. 3, 317-322.

LASIK for low astigmatismThe surgical correction of low astigmatism remains controversial. One recent study found that uncorrected astigmatism, even as low as 1.00 D, can cause significantly decreased vision. However, there are pitfalls when performing LASIK to correct astigmatism because residual or induced astigmatism can lead to patient dissatisfaction. German researchers studied the refractive and visual outcomes of wavefront-optimised laser in situ keratomileusis in 448 myopic eyes with low astigmatism of 0.75 D or less.

Preoperative subjective sphere ranged from −2.75 D to −11.50 D. By four months postoperatively, the mean UDVA was 0.10 ± 0.13 logMAR and the mean manifest refraction spherical equivalent −0.05 ± 0.68 D. There was no statistically significant difference in efficacy or safety between the preoperative cylinder groups. Astigmatic overcorrection for a preoperative cylinder of 0.25 D and 0.50 D was suggested by the correction index, the magnitude of error, the index of success and the flattening index. Considering that preoperative cylinder of 0.50 D or less was significantly overcorrected, the researchers suggest that caution should be used when considering full astigmatic correction for manifest cylinder of 0.50 D or less.

n A Frings et al., JCRS, 366 - Efficacy and predictability of laser in situ keratomileusis for low astigmatism of 0.75 dioptre or less, Volume 39, No. 3, 366-377.

Femto flap accuracy at 200kHzThe femtosecond laser has been widely adopted by surgeons performing LASIK surgery. Advances in femtosecond technology, including higher laser repetition rates, have resulted in a reduction in the time taken to create the cut and in the energy requirements. Cummings and colleagues compared the intended versus the resultant thickness of laser in situ keratomileusis (LASIK) flaps created with a new 200 kHz femtosecond laser in 431 eyes of 258 patients. At three months' follow-up, the mean post-LASIK flap thickness was 120.23 μm ± 13.94, with the intended flap thickness of 120 μm.

n A Cummings et al., JCRS, “Predictability of corneal flap thickness in laser in situ keratomileusis using a 200kHz femtosecond laser”, Volume 39, No. 3, 378-385.

Review

jCRs HIGHLIGHTsJournal of Cataract and Refractive Surgery

Thomas Kohnenassociate editor of jcrs

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37

EUROTIMES | Volume 18 | Issue 5 olixia adv-half page vertical-Eurotimes-ENG care-1301v06jmo.indd 1 01.03.13 13:57

Comprising two volumes and more than 1,500 pages, Copeland and Afshari’s Principles and Practice of Cornea is a serious, comprehensive work that covers every aspect of the cornea – from basic structure and function to autologous ex vivo cultivated limbal epithelial transplantation and everything in-between.

Published by Jaypee Highlights, this monumental work is divided into 19 sections, accompanied by three interactive DVD-ROMs featuring 22 surgical videos.

Sections 1 and 2 cover the basic science and examination techniques of the cornea, including confocal and specular microscopy, and finishing with a chapter on cornea biomechanics. Section 3 discusses the epidemiology of blinding corneal disease, primarily in the Third World.

Moving on to clinical topics, Sections 4 through 8 thoroughly cover infectious, immunologic, ocular surface, metabolic and congenital, and dysplastic and malignant disease, respectively. Each section is organised under broad sub-headings such as “Corneal Microbiology” and “Interstitial Keratitis,” allowing the reader to easily find the correct section based on interest or clinical findings. Once the correct topic has been found, the text is organised logically, progressing from etiology and pathogenesis to clinical findings, diagnosis and treatment.

Particularly useful and interesting is “Trauma,” the subject of Section 9. Practising trauma surgery is difficult because of its great variety and unpredictability. In essence, an ophthalmologist must be lucky to have had several opportunities to practise it during his or her training. And yet, because it can occur at any moment and constitutes a medical emergency requiring rapid care by the first available ophthalmologist, operating a traumatically damaged anterior segment is something each eye doctor needs to be able to do competently. So, preparing for this inevitable occurrence is crucial, and this text gives a good overview of how to get started on trauma repair.

Volume 1 finishes up with sections on corneal dystrophies and degenerations (10); conjunctival and corneal manifestations of dietary deficiencies (11); contact lenses (12); and a section on “Emerging Innovation,” (13). This last section covers “Gene Therapy in the Cornea” and “Biosynthetic Alternatives to Human Donor Tissue.”

Volume 2 is devoted primarily to surgery of the cornea and other ocular surface structures. Starting with a history of corneal

surgery (Section 14) dating back to the Greek physician Galen (130-200 A.D.), who first suggested restoring the clarity of an opaque cornea, the text quickly moves on to in-depth discussions of tissue adhesives, conjunctival flaps, and scleral transplantation in Section 15.

Section 16, “Ocular Surface Rehabilitation,” is the longest section of the text. The term “rehabilitation” is interpreted very broadly: it includes obvious topics such as pterygium surgery, amniotic membrane transplantation and limbal stem cell transplantation, but also the entire domain of keratoplasty.

Section 17 discusses the femtosecond laser while Section 18 is an extensive guide to corneal instrumentation. The final section comprises step-by-step guidelines for 26 surgical procedures.

This large text comprehensively covers the whole spectrum of “Cornea”, and is as such primarily appropriate for those interested in specialising in corneal disease, whether as a treating physician or a clinical researcher. This might include cornea fellows; general ophthalmologists expected to diagnose and treat a wide range of pathology; corneal subspecialists who are looking for an all-in-one update on the current state of the art, as described by their colleagues worldwide; and doctoral candidates conducting research on the cornea who need to be well-versed in all aspects of corneal problems and their treatment.

Review

bOOk REVIEW

Monumental compilation

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

BOOKS EDITORLeigh Spielberg

PUBLICATIONPRINCIPLES AND PRACTICE OF CORNEA

EDITORSRobert A Copeland Jr and Natalie A Afshari

PUBLISHED BY JAYPEE HIGHLIGHTS

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Ranibizumab stabilises AMD Intravitreal ranibizumab can maintain baseline visual acuity for three years in eyes with exudative AMD, although most patients will not have a lasting improvement in their vision, according to the results of a retrospective study involving 84 eyes of 77 patients. The study showed that among 52 eyes who completed three years of follow-up the mean BCVA was 49.33 letters at baseline and 49.52 letters at the 36-month visit. The average number of treatments was 8.6 at three years. In eight eyes (15.4 per cent) BCVA had increased by 15 or more letters compared to baseline and in 32 eyes (61.5 per cent) BCVA had stabilised, but eight eyes lost more than 15 letters of BCVA.

nMarques et al, Ophthalmologica; DOI:10.1159/000343709

Gas tamponade affects corneal biomechanicsGas tamponade with sulphur hexafluoride (SF6) and perfluropropane (C3F8) when combined with pars plana vitrectomy (PPV) may affect biomechanical parameters of the cornea in the early postoperative period, according to the results of a comparative trial. In the study, 19 eyes underwent pars plana vitrectomy with perfluropropane, 14 eyes underwent PPV with sulphur hexafluoride tamponade and 16 eyes underwent PPV without tamponade. During the first postoperative week, the perfluropropane group had significant increases in corneal resistance factor (CRF), corneal compensated intraocular pressure (IOPcc) and Goldmann-correlated intraocular pressure (IOPg). In the sulphur hexafluoride group, CRF increased significantly but the increases in IOPcc and IOPg were not significant. The group without gas tamponade also had increases in CRF, IOPcc and IOPg, but they did not reach statistical significance.

nTeke et al, Ophthalmologica; DOI: 10.1159/000341573

Systemic factors and DMEThe results of a retrospective study indicate that systemic factors have an important bearing on visual outcomes and clinical findings pre- and postoperatively in patients with diabetic macular oedema

(DME) who undergo vitrectomy with internal limiting membrane (ILM) peeling. The study involved 31 eyes of 27 patients. Preoperatively, foveal average retinal thickness was significantly thicker in patients who had cardiovascular disease or cerebral infarction (p = 0.0019), cystoid macular oedema (p = 0.0028), or were not on dialysis (p = 0.012). Six months postoperatively, foveal average retinal thickness was significantly greater among patients with a higher body mass index (p = 0.0088). Preoperatively, BCVA was significantly lower when an epiretinal membrane was present (p = 0.042). Six months postoperatively, BCVA was significantly lower in the group who had no previous history of diabetes treatment (p = 0.023) and those with a higher preoperative glycosylated haemoglobin (p = 0.033).

nYamada et al, Ophthalmologica; DOI: 0.1159/000345494

Ranibizumab speeds recovery Intravitreal Ranibizumab resolves neurosensory detachment more quickly than observation alone in eyes with acute central serous chorioretinopathy (CSC), new research suggests. In a study involving 20 patients who had acute CSC, the mean time to complete resolution of neurosensory retinal detachment was only 4.2 weeks among 10 patients randomly allocated to receive intravitreal ranibizumab. That compared to 13 weeks among 10 patients in the observation group. By six months' follow-up there was no difference between the groups in terms of central foveal thickness or BCVA.

nKim et al Ophthalmologica; DOI: 10.1159/000345495

Review

OPHTHALMOLOGICA

José Cunha-VazEDITOR OF OPHTHALMOLOGICA,The peer-reviewed journal of EURETINA

39

José Cunha-VazEDITOR OF OPHTHALMOLOGICA,The peer-reviewed journal of EURETINA

EUROTIMES | Volume 18 | Issue 5

Human retinal protectionHigh Performance Optics (HPO) of Roanoke, Virginia, a company focused on human retinal protection from blue light, has announced that it has exclusively licensed Essilor globally with its technology, intellectual property, trade secrets, and know-how regarding the selective blue-light filtering of spectacle lenses.

“Essilor and HPO have independently developed ‘selective’ blue-light filtering spectacle lens technology capable of protecting the retina of the human eye from the hazards of high energy blue light. The companies believe the HPO global exclusive license to Essilor will allow for a more rapid exploitation and adoption of the technology globally and in addition speed its availability to the global population. Both companies have agreed to share the technology with the optical/vision care industry worldwide by way of global sublicensing,” said a HPO spokesman.

n www.hpousa.com

Feature

A number of anti-VEGF-A therapies are now being used to treat eye diseases including wet macular degeneration, diabetic macular oedema and retinopathy of prematurity. A recent study raises concerns about the effects of continuous inhibition of intraocular VEGF on the ciliary body. The researchers looked at VEGF-A expression during ciliary body development in a mouse model. This confirmed that VEGF-A plays a key role

at the onset of ciliary process formation. Neutralisation of systemic VEGF-A produced thinning of the non-pigmented epithelium, vacuolization of the pigmented epithelium, loss of capillary fenestrations and thrombosis. These changes were associated with impaired ciliary body function, as evidenced by decreased intraocular pressure. The researchers conclude that VEGF-A has an important role in ciliary

body homeostasis and so the potential for undesired off-target effects should be considered with the chronic use of anti–VEGF-A therapies.

n KM Ford et al., Investigative Ophthalmology & Visual Science, “Expression and Role of VEGF-A in the Ciliary Body,” November 2012 53:7520-7527.

journal Watch

journal Watch

Anti-VEGF side effects

Regulatory approvalRayner Intraocular Lenses, Ltd, has received regulatory approval for sale of its products in Mexico and Thailand, according to a company spokeswoman.

In Mexico, the Mexican Secretaria de Salud granted regulatory approval for the company’s aspheric and spherical models of the monofocal C-flex range, as well as the Superflex range in aspheric and spherical models and the T-flex toric IOL.

In Thailand, Rayner’s complete portfolio of hydrophilic acrylic lenses received regulatory approval including: C-flex® and C-flex® Aspheric, Superflex® and Superflex® Aspheric, T-flex® Aspheric, M-flex®, M-flexT®, Sulcoflex® Aspheric, Sulcoflex® Toric, Sulcoflex® Multifocal and the Sulcoflex® Multifocal Toric. In addition, the Raysert®, Rayner’s small incision injector was cleared for sale in Thailand.

n www.rayner.com

Collaborative research agreementAciex Therapeutics has entered into a collaborative research agreement with Portola Pharmaceuticals that provides Aciex with exclusive rights to develop Portola’s small molecule dual Spleen Tyrosine Kinase (Syk)/Janus Kinase (JAK) inhibitors for ophthalmic indications.

“The Portola library includes both compounds with extensive preclinical systemic data packages as well as earlier stage research compounds. The two companies will target development of drugs to treat topical ophthalmic diseases, including ocular allergy, dry eye and other inflammatory eye conditions, for which there is a strong scientific rationale for Syk and JAK inhibition,” said an Aciex spokeswoman.

Under the terms of the agreement, Aciex will obtain access to Portola’s small molecule dual Syk/JAK inhibitors and will lead clinical development activities for ophthalmic indications. Both companies will fund and participate in development activities related to the programmes. Portola retains the right to develop these compounds for non-ophthalmic indications.

n http://aciexrx.com

A newly identified biomarker detectable in urine could prove useful in developing a portable field test for onchocerciasis or river blindness. Using a painstaking process of metabolomic data mining the researchers were able to identify a metabolite that occurred in the urine from onchocerciasis-infected patients but not in health controls. The metabolite, N-acetyltyramine-O,β-glucuronide, could be traced to O. volvulus as a neurotransmitter molecule that is secreted by young, reproducing worms and then modified by the human body on its way to being excreted in urine. This biomarker appears to be specific for an active infection, suggesting that a field test based on the biomarker would be robustly useful. The next goal would be to create a simple and inexpensive urine dipstick test that is tolerant of extreme temperatures and portable. Current diagnostic methods include biopsies for microscopic analysis, and an ELISA antibody test for microfilariae, which may yield positive results even for non-active infections.

n Globisch et al. Proceedings of the National Academy of Sciences, “Onchocerca volvulus Neurotransmitter Tyramine is a Biomarker for River Blindness,” 2013 110 (11) 4218-4223.

New biomarker for onchocerciasis

Don’t miss Calendar, See page 44

40

INDUsTRY NEWsRecent developments in the vision care industry

Ophthalmic surgery has been severely curtailed in Toronto, Ontario as Canadian health authorities attempt

to deal with the worst outbreak of Severe Acute Respiratory Syndrome (SARS) so far reported outside Asia.

Near the end of March, all hospitals in the greater Toronto area were ordered to suspend non-essential services, including non-urgent ophthalmic procedures.

Shortly afterwards, the World Health Organisation (WHO) took the

unprecedented step of advising the public against travelling to Toronto because of the SARS outbreak, but a week later lifted the travel advisory because the situation there has improved.

The WHO also issued travel advisories for Guangdong Province, Hong Kong Special Administrative Region, Beijing and Shanxi Province – all in China.

EUROTIMES | Volume 18 | Issue 5

National ophthalmology associations could be prohibited from imposing continuing medical education

requirements on their members if such requirements interfere with the free market provision of CME by other ophthalmology groups, under a ruling from the EU's highest court.

In its decision, the European Court of Justice ruled that EU law precludes a professional association from imposing on its members a system of compulsory training that eliminates competition or lays down conditions that discriminate against competing providers of continuing education courses.

Even if a professional association is mandated by national law to provide compulsory continuing education to its members, it is not immune to the effects of competition law, the court also held.

The case arose after the Portuguese Competition Authority investigated that country's Order of Chartered Accountants, known by the Portuguese acronym of “OTOC.” Under Portuguese law, all chartered accountants must belong to the order, which represents their professional interests and oversees all aspects of their practice.

As part of its commitment to continuing education, OTOC adopted a regulation by which all chartered accountants were required to obtain, every two years, an annual average of 35 credits for training. Under the regulation, the training must have been provided or approved by the OTOC.

In particular, the OTOC regulation specified that of the 35 required hours, each accountant must complete 12 so-called “institutional” training hours to keep them abreast of legislative initiatives and amendments and of questions of ethical and professional conduct. That training could be provided only by the OTOC.

Professional training The remaining hours of continuing education were known as “professional” training, which consisted of study sessions on various accountancy topics. Under the regulation, the OTOC provided professional training courses but also held the sole power to register other bodies to provide professional training courses for chartered accountants and to approve

or reject proposed professional training sessions by those registered bodies.

In May of 2010, the Portuguese Competition Authority found that the OTOC's regulation distorted competition for the market of compulsory training for chartered accountants throughout the country, which was in breach of EU law.

OTOC appealed the decision to the Lisbon Court of Appeal. That court, in turn, requested the European Court of Justice to rule whether EU competition law applied to professional associations.

In its judgment, delivered at the end of February, The Court of Justice found that EU competition law does apply to professional associations, and OTOC attracts no immunity from competition law even if it has a legal obligation to provide compulsory continuing education programmes.

The Court of Justice also found that by restricting the provision of one type of continuing education to itself and controlling those bodies that provided the other type of continuing education, the OTOC was imposing discriminatory conditions on any competitors of the association.

The Court of Justice, however, did not decide whether the conduct of OTOC was illegal but rather sent back the case to the Portuguese appeals court to determine whether there was any objective justification for such discrimination after analysing the effects of the OTOC's conduct on the provision of continuing education to accountants in Portugal. In particular, the Portuguese court will

have to determine whether the fact that chartered accountants are required to earn a minimum of 12 institutional training credits per year from OTOC and to obtain professional training credits only from bodies approved by OTOC constitutes an illegal restraint of competition.

RESTRAINT OF TRADE?Discriminatory control of CME courses could violate EU competition lawby Paul McGinn

41Feature

EU MATTERs

From the ArchiveSARS crisis curbs ophthalmic surgery as hospitals shut down

For details of the decision, Ordem dos Técnicos Oficiais de Contas -v- Autoridade da Concorrência (Case C-1/12), visit the European Court of Justice website at www.curia.eu.

“Even if a professional association is mandated by national law to provide compulsory continuing education to its members, it is not immune to the effects of competition law, the court also held.”

n From EuroTimes, Volume 13, Issue 4, April 2008, p10

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Reference

CALENDAR OF EVENTsDates for your Diary

Advertising Directory: Abbott Medical Optics: Page: IBC; Alcon Laboratories: Pages: 7, OBC; Alsanza Medizintechnik und Pharma GmbH: Page: 28; ASCRS/Eyeworld: Pages: 38, 42, 43; Bausch + Lomb: Page: 19; Carl Zeiss Meditec: Page: 35; Croma-Pharma GmbH: Page: 37; D.O.R.C. International BV: Page: 9; Katena Products Inc.: Page: 24; Medicel Ag: Page: 14; Nidek: Page: 15; Oculus Optikgerate GmbH: Page: 13; Oertli Instruments AG: Page: IFC; Rayner Intraocular Lenses Ltd: Page: 11; Technolas Perfect Vision: Page: 3; Ziemer Ophthalmic Systems: Page: 21

2013

44

MAY

ARVO5-9 MaySeattle, Washington, USAwww.arvo.org

11th SOI International Congress15-18 MayMilan, Italywww.congressisoi.com

Black Sea Ophthalmology Society & ESCRS Academy Meeting24-26 MayTbilisi, Georgiawww.bs-os.org

Th e Visions of Gullstrand – 600 year jubilee31 May - 2 JuneLandskrona, Swedenwww.feinpat.hemsida24.se

JUNE

European Society of Ophthalmology (SOE) 20138-11 JuneCopenhagen, Denmarkwww.soe2013.org

JUNE

10th Congress SEEOS and 3rd Congress of Macedonian Ophthalmologists20-23 JuneOhrid, Macedoniawww.zom.mk

International Meeting on Anterior Segment Surgery22-23 JuneVerona, Italywww.femtocongress.com

JULY

Indian Intraocular Implant & Refractive Surgery Convention6-7 JulyChennai, Indiawww.iirsi.com

26th APACRS Annual Meeting11-14 JulySingaporewww.apacrs.org

5th World Glaucoma Congress17-20 JulyVancouver, Canadawww.worldglaucoma.org

SEPTEMBER

XXXVII UKISCRS Annual Meeting5-6 SeptemberManchester, UKwww.ukiscrs.org.uk

14th International Paediatric Ophthalmology Meeting12-13 SeptemberDublin, IrelandEmail: hmurphy@materprivate.ie

13th EURETINA Congress26-29 SeptemberHamburg, Germanywww.euretina.org

OCTOBER

ESCRS Glaucoma Day4 OctoberAmsterdam, Th e Netherlandswww.escrs.org

4th EuCornea Congress4-5 OctoberAmsterdam, Th e Netherlandswww.eucornea.org

XXXI Congress of the ESCRS5-9 OctoberAmsterdam, Th e Netherlandswww.escrs.org

OCTOBER

EPOS/WSPOS Paediatric Sub Speciality Day9 OctoberAmsterdam, Th e Netherlandswww.wspos.org

NOVEMBER

AAO Annual Meeting16-19 NovemberNew Orleans, USAwww.aao.org

93rd SOI National Congress27-30 NovemberRome, Italywww.congressisoi.com

2014 FEBRUARY

NEW ENTRY18th ESCRS Winter Meeting14-16 FebruaryLjubljana, Sloveniawww.escrs.org

F A M I L Y O F I O L S

F A M I L Y O F I O L S

F A M I L Y O F I O L S

Multifocal Toric Multifocal Toric MonofocalPreloaded

The TECNIS® family of IOLs: Proven performance and outcomes. Invaluable peace-of-mind.

You deserve some inner peace. And that’s what you get with the broad portfolio of TECNIS® aspheric IOLs. The proven combination of optics, material, and design associated with TECNIS® IOLs continues to help you provide patients with predictable, high-quality outcomes.

When it comes to peace-of-mind, the choice is clear.

Visit www.tecnisiol.com to learn more.TECNIS is a trademark owned by or licensed to Abbott Laboratories, its subsidiaries or affiliates. ©2012 Abbott Medical Optics Inc.www.AbbottMedicalOptics.com / 2012.11.14-CT81

© 2012 Novartis 2/12 CON11241JAD-EUWelcome to the new possible.

In 1968, Dick Fosbury revolutionized the high jump by developing a technique that elevated him to Olympic gold, raising the bar for athletes the world over.

Game Changer

It’s time to rewrite the rules of vitreoretinal surgery.• Experience the ULTRAVIT® 5000 cpm probe with surgeon-controlled duty cycle to reduce

iatrogenic tears and post-op complications1

• Trust in integrated and stable IOP compensation2

• Enhance patient outcomes and achieve faster visual recovery with ALCON® MIVS platforms3

• Improve your OR turnover by 39% with V-LOCITY® Effi ciency Components4

1. Rizzo S, et al. Comparative Study of the Standard 25-gauge Vitrectomy System and a New Ultra-high-speed 25-gauge system with duty cycle control in the treatment of various vitreoretinal diseases. Retina, 2011; Vol. X; No. X. 2. Riemann C, et al. Prevention of intraoperative hypotony during vitreoretinal surgery: an instrument comparison. ASRS. Poster Presentation, 2010. 3. Nagpal M, Wartikar S, Nagpal K. Comparison of clinical outcomes and wound dynamics of sclerotomy ports of 20, 25, and 23 gauge vitrectomy. Retina. 2009;29(2):225-231. 4. Alcon data on fi le 954-0000-004.

EuroTimes 9/1/12

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