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The wonderfully complex and dynamic nature of the human optical system is the result of a long process of evolution that deserves to be fully respected in the quest to generate so-called ‘super vision’ for patients, according to Ioannis Pallikaris MD, PhD, who delivered this year’s Binkhorst Medal Lecture. “As we continue to learn more about the best possible functional vision that can be achieved for our patients, we have come to realise that the human optical system is a dynamic site with constantly changing optics in a continuously accommodated process,” he said. In a wide-ranging lecture, Dr Pallikaris questioned the desirability of trying to deliver aberration-free 20/10 visual acuity, the so-called ‘eagle vision’ which has been championed in some quarters. “This trend to transform all frogs to eagles ignores the significance of the existence of frogs in our ecological system. The survival of eagles, after all, relies on a frog-eating diet,” he said. Dr Pallikaris paid tribute to Darwin’s evolutionary theory and the important role it has played in granting humans “perfection in their imperfect optical systems.” “I am not certain whether, during the process of human evolution, it is our vision and what we see that shapes our soul, or whether it is actually our soul, wishing to see through its own eyes, that shapes our vision,” he said. Dr Pallikaris noted that technology has itself evolved to an extraordinary extent in the 30 years since he first started his career as an ophthalmologist. “Back then, I was hand-drawing on the Placido and a small, almost primitive computer was recording the moves my hand was making so as to outline the shape of the cornea. That was the first stage of topography and 15 years later we developed Tracey technology. Nowadays, one touch of a button can provide us all with the relevant information about the optics and the shape of the cornea and the total optics of the eye,” he said. Since the first microkeratome was used to cut a corneal flap for LASIK about 20 years ago, Dr Pallikaris said that today’s femtosecond lasers are capable of creating any desirable shape of the graft or flap. Likewise, modern MRI imaging and other technologies now allow researchers to know so much more about the biodynamics and hydrodynamics of the eye and their role not only in refractive surgery, but also in the ageing of the eye, he said. As well as the successes and the breakthroughs, the road to progress has been inevitably paved with a number of false starts and wrong turns, including thermal lasers and CK for presbyopia, said Dr Pallikaris. “It has taken us 30 years of consistent and persistent effort to come up with new inventions. While in this agony and struggle, and the more our knowledge was enriched, and the deeper our thoughts were reaching, and the acuter our judgment got, we came to realise that many of our initial objectives and our newly-formed perceptions did not really mean that much after all, or worse, they were heading in the wrong direction,” he said. Reflecting on the role of the true inventor and researcher in an increasingly fast-paced consumerist society with its allure of wealth and constant pressure to perform, Dr Pallikaris said that it was important to stay focused on the key values that spur genuine innovation. “In ancient times, when thought was faster than time, we had enough time to reflect on our initial reasoning and actions. Nowadays, it seems that time runs faster than our thoughts. It seems that before we think of something, it has already been realised. In effect, the advantage to reflect on things is lost,” he said. Dr Pallikaris said that all true researchers who aim to last in time should embrace Ashbery’s philosophy of the “invisible avant-garde”. “By resisting recognition, their ticket to short-lived fame and the death of their creative life, they can turn the curse of Midas to an actual blessing and mingle myth and reality so as to break through to what deserves to be distinguished, even if it takes the vision of an eagle or a gifted frog to see it,” he said. In conclusion, Dr Pallikaris said that if delegates could take away just one overriding message from his lecture, he hoped that they would bear in mind the axiom of the Greek philosopher Socrates: “I know that I know nothing”. XXVII Congress of the ESCRS 2009 Tuesday 15 September Binkhorst lecture explores the myth and reality of super vision Dr Ioannis Pallikaris was presented with the Binkhorst Medal by ESCRS president Dr Paul Rosen INSIDE: ESCRS DESIGNATES 2010 AS EUROPEAN YEAR OF LASIK
Only the proprietary§ OZil® Torsional handpiece delivers controlled side-to-side ultrasonic shearing. With virtually no repulsion, INFINITI® Vision System with OZil® delivers a level of followability that will dramatically alter the way you perform phaco. Forever. www.infinitivision.com $OFRQ,QF,1)(8 Welcome to the world of true custom *OZil® Torsional handpiece. § Patents pending. is a registered trademark of Alcon, Inc. EuroTimes ET T oday OZil®*HAS TURNED THE TIDE IN PHACO, CHANGING THE LANDSCAPE. FOREVER. ,1)(8(77RGD\LQGG 30
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FOREVER. ,1)(8(77RGD\LQGG 30 Launch of EuCornea dedicated to cornea and ocular surface disease A new subspecialty organisation, EuCornea, dedicated to scientific exchange and enhanced collaboration for specialists interested in cornea and ocular surface disease was launched this weekend in Barcelona. In this interview, Vincenzo Sarnicola MD, one of the founders of this new society, explains the purpose, structure and goals of EuCornea. Why have you and your colleagues decided to establish EuCornea? As subspecialisation within ophthalmology increases, the demand and pressure on individuals to keep up to date with their skills and knowledge also increases. A lot of new knowledge is generated in europe and many specialist societies have consequently emerged. We felt the need to establish a society dedicated to the speciality of cornea and ocular surface disease that would promote personal relationships and exchange of scientific knowledge and practical skills among cornea specialists in europe and also encourage and support scientific research in the field of cornea and ocular surface disease. As there was no overarching society within europe for this specialty, we felt that was a niche that needed to be filled. Who will be eligible for membership? All ophthalmologists and related specialists in general and those specialising in cornea and ocular surface disease in particular will be eligible. The bye-laws make it possible to have a wide membership. Full membership is open to cornea and ocular surface disease specialists and associate membership to those not focused exclusively on this speciality. These categories are largely for individuals practising in europe. The international membership category opens membership to the rest of the world and there is a special trainee membership category for junior doctors in training. What will be the major activities over the next 12 months? Following on from its launch on Saturday, September 12, we will now focus on establishing a founding Board and executive. Our immediate goal will be to promote the society to a global audience and encourage as wide a representation from within europe and across the world as possible. We aim to hold the first euCornea conference from 17 to 19 June 2010 in Venice, Italy. How will the organisation be administered? The society is officially registered in Dublin, and is a legal entity in accordance with and governed by the laws of Ireland. The Memorandum and Articles of Association and the bye-laws have already been formulated in accordance with european Union law and legally endorsed. The general management of euCornea will be vested in an elected Board consisting of a president, vice-president/president elect, secretary, treasurer, eight ordinary Board members, euCornea founding directors and co-opted members. Explain the importance of the contribution of Jose Guell, Francois Malecaze and Harminder Singh Dua to the new organisation? All three of them are leaders in their fields in their respective countries. They have all contributed to the advancement of knowledge in the subspecialty and have an international stature. They have organisational and management skills and have a wealth of experience in teaching, training, research and the clinical and surgical aspects of the speciality. In the spirit of euCornea each of them is from a different european nation. We have all worked together as a team to convert an idea into reality. We share the same vision and enthusiasm about euCornea and want it to succeed for the benefit of the specialty and for all our colleagues working in the area. As founding directors we are committed to ensuring the passage of the new society through its formative years. euCornea will be managed by Agenda Communications in Dublin, Ireland. How do you see your relationship with other European and international ophthalmic organisations? euCornea will be an all-inclusive society. There are several smaller national societies devoted to cornea and some also to the ocular surface in europe. euCornea expects them to continue to function and flourish as they are but hopes that their members will also join euCornea to extend their objectives to the european stage. As many of our academic and clinical interests overlap with those of other societies we feel that we will complement other societies and also eventually become the major organisation that will inform governments on policy related to this subspecialty. We hope that eye banking within europe will find euCornea as a natural home and already some directors of eye banks have expressed their desire to join euCornea. We are honoured and privileged by this interest and would welcome all such requests. What is the significance of launching the new organisation at the ESCRS Congress in Barcelona? eSCRS is a well organised, globally popular organisation which attracts thousands of european and international delegates to its meetings. Although euCornea is not part of eSCRS and is an independent organisation, it acknowledges that the pull of eSCRS would allow us to spread the euCornea message to a wider audience and enable a number of ophthalmologists and cornea and ocular surface disease specialists, who attend the eSCRS congress, to attend the launch and learn first hand what euCornea is about. From left: Harminder Singh Dua, José Güell, Francois Malecaze, Vincenzo Sarnicola
Annual surveys show European and American practice differences persist WhILe european and American ophthalmic surgeons have almost universally adopted phacoemulsification and about two-thirds of both groups now use topical antibiotics for cataract surgery, the two groups continued to display divergent preferences in many areas including equipment, lenses, pharmaceuticals and surgical approaches to specific problems, according to two surveys conducted in 2008. Training, local regulation, market history and general economic conditions all appear to play a role in the variation, said David V Leaming, MD, of Palm Springs, California, US, author of the parallel studies. For example, 60 per cent of the 634 members of the American Society of Cataract and Refractive Surgery (ASCRS) responding to the survey use presbyopia-correcting lenses in their practices compared with only 33 per cent of the 731 respondents from the european Society of Cataract and Refractive Surgeons (eSCRS). This may be because US law allows surgeons to bill public insurance for the cost of a standard cataract procedure with the patient picking up only the added cost of the premium lens and fitting services, while in most european countries public insurance will not cover any part of a premium lens procedure, leaving the patient to pay the entire cost of both the procedure and the lens out of their own pocket, Dr Leaming said. US surgeons also appeared more likely to take steps to correct astigmatism in cataract surgery, with 60 per cent using toric lenses compared with 44 per cent of european respondents; and 52 per cent of US surgeons using limbal relaxing incisions compared with 36 per cent in europe. “LRIs have been advocated for years as the trend toward refractive cataract surgery progresses. I think toric IOLs are an improvement in predictability with positive financial incentives as well. I’m sure toric IOLs will increase in use in the eU but will be limited if the physician has to pay extra for that technology and cannot balance, bill the patient.” however, european respondents were more likely to report offering refractive lens exchange, with 44 per cent doing so compared with 24 per cent in the US. europeans were also more likely to use phakic lenses, with 36 per cent compared with 12 per cent in the US. The greater availability of approved phakic lenses in europe may account for this, Dr Leaming noted, though 37 per cent of US surgeons reported they plan to start using phakic lenses. Liability concerns may also inhibit RLe in the US, he added. european surgeons were also more likely to embrace microincision cataract surgery, with 4.2 per cent routinely using a sub-2mm incision compared with 1.5 per cent in the US; 27 per cent using coaxial microincision equipment versus 19 per cent in the US; and nine per cent using bimanual microincision equipment compared with five per cent in the US. here again, more thin lenses that can be used with sub-2mm incisions are available in europe. Alcon Infiniti with OZil, Bausch & Lomb’s Millennium and Abbott Medical Optics’ WhiteStar phaco machines finished 1-2-3 in both surveys. In the wake of the landmark eSCRS study demonstrating that intracameral cefuroxime reduces the risk of endophthalmitis, 57 per cent of european respondents reported using intracameral antibiotics, up from 52 per cent in 2007 and more than double the rate reported in 2004. Meanwhile, US use of intracameral antibiotics held steady at 10 per cent last year amid safety concerns about the lack of an ophthalmic preparation of cefuroxime and continued faith in the superior efficacy of the fourth generation flouroquinolones that are available for topical use in the US but not in europe. however, 26 per cent of US surgeons did report using antibiotics in irrigant solutions, compared with 20 per cent in europe, though the evidence of the efficacy of this practice is not as strong as that for intracameral injections. US surgeons were also more likely to use non-steroidal anti- inflammatory drugs (NSAIDs) before surgery, with 79 per cent doing so compared with 36 per cent in europe. Of those using NSAIDs, 66 per cent of US surgeons started treatment three days before surgery compared with 28 per cent in europe. hydrophobic acrylic lenses remained the overwhelming favourite on both sides of the Atlantic, with 80 per cent of US surgeons and 77 per cent of european surgeons preferring them. Alcon’s AcrySof Aspheric was the top hydrophobic acrylic lens choice in both surveys. Alcon’s ReSTOR was the top presbyopia-correcting choice in both surveys, followed by Bausch & Lomb’s Crystalens in the US, and Carl Zeiss Meditec’s AcriLisa and AcriLisa Toric in europe. european surgeons were more likely than their US counterparts to do LASIK, LASeK and PRK, but US surgeons who do laser refractive surgery were more likely to use wavefront-guided procedures, with 81 per cent doing so compared with 61 per cent in europe. Femtosecond laser flap cutters continue to gain popularity, with 33 per cent using them in the US and 59 per cent wanting to acquire the technology. The ASCRS survey was sent to 4,993 recipients for a 13 per cent response rate while the eSCRS survey went to 3,350 members and generated a 22 per cent response. Alcon, AMO and Bausch & Lomb were major sponsors of both surveys; Ophtec was a minor sponsor of the eSCRS study. 4
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EYE ON TRAVEL See another side of Barcelona 6 T he ‘eixample’ or ‘extension’, is that bit of Barcelona that stretches in an orderly grid of wide streets on the far side of the Plaça Catalunya. It’s the first place the people of Barcelona come to shop and do business; and though most tourists visit its most iconic landmark – the Sagrada Familia – it’s the last place most tourists explore. But when you’ve had enough of the labyrinth of medieval streets in Barcelona’s picturesque old town, this is an area worth investigating. At the end of the 19th century when Barcelona’s city walls at last came down, the city’s head civil engineer Lldefons Cerdà made his proposal for the extension of Barcelona into the surrounding countryside. Cerdà believed that a well-ventilated, sunlit environment could help to eliminate the disease and civil unrest that beset Barcelona’s cramped old city. So, the blocks of housing he proposed for the eixample were oriented NW by SW to ensure sunlight at some time of day to every apartment. each block (manzana) had only two sides and in the middle was a miniature park where the building’s residents could enjoy light and air. The avenues were broad and straight. Corner buildings were sheared off at 45 degrees to allow steam trams to turn in the street. The Madrid government, which equated the wide streets with more efficient crowd control, enthusiastically supported the plan. But as urban planning, the scheme was not a success. To maximise profits builders added extra stories and in-filled the interior parks with shops and warehouses. Where Cerdà had anticipated 259 inhabitants per hectare, by1925 there were eight times that number. (As the opportunity arises the courtyards are being restored in a joint venture between the city of Barcelona and Catalan banks.) Though today transformed for the most part into multi-family and office buildings, these self-confidently bourgeois structures, decorated in the Catalan version of Art Nouveau, still charm with their turrets and balconies and fanciful ironwork. The extension’s two principal avenues are Passeig de Gràcia and Rambla de Catalunya. Lined with cafes and top-flight restaurants they have become the centre of the city’s upmarket shopping area. All the big name boutiques, foreign and Spanish, are represented here, catering to Barcelona’s super chic residents. An alleyway off Passeig de Gràcia 53-55 leads to Bulevard Rosa housing more than 100 fashionable small shops. Up a stairway at no. 55 Passeig de Gràcia is the Bulevard dels Antiquaris, a vast arcade with over 70 shops selling antiques, old musical instruments and vintage toys. The extension is also where you’ll find some of Gaudi’s most splendid achievements. his expiatory Chapel of the holy Family (the Sagrada Familia) has - as Gaudi himself predicted – become the icon of Barcelona. Under construction since 1926 the stained glass windows are currently being installed; there are decades more to go before completion. The exhibition of ‘Gaudi and Nature’ inside the main entrance of the church sheds light on how the great architect incorporated the natural forms of flowers and trees into his designs. You will see the same motifs repeated in each Gaudi building you visit. his Casa Batlló is part of the ‘Block of Discord’ - a series of three extraordinarily flamboyant yet dissimilar examples of modernism on the Passeig de Gràcia. The other two structures are Casa Lleó- Morera by Lluis Domènach i Montaner and Casa Amatller by Josep Puig i Cadafalch; they are privately owned and except for their lobbies are closed to the public. The Casa Batlló may normally be visited from 09.00h to 20.00h daily. It occasionally closes early for private events. Check the website; www.casabatllo.cat. The pride of the eixample is Casa Milà, known as La Pedrera – the stone quarry. The last building Gaudi designed before committing himself to his life’s work, the Sagrada Familia, this building has never ceased to amaze if not always to delight. An early tenant complained to Gaudi that her apartment had no straight wall against which to place her piano. he advised her to take up the violin. La Pedrera’s undulating forms have been compared to a beehive, a cliff dwelling and a sand castle. Salvador Dali said its beauty was ‘edible’. Make up your own mind on a guided tour of an apartment, the attic and the roof. Both it and the Casa Batlló are UNeSCO heritage Sites. Visits daily from 09.00. Last admission is 18.00 in winter, 19:30 in summer. www.lapedreraeducacio.org A special bus for shoppers services the eixample running between Placa Catalunya and Placa Pius XII on the Diagonal. Called the Tomb Bus (Tomb means roundtrip), tickets cost €1.20. If you’re already familiar with Barcelona’s five top tourist sights, what next? 7 Vox Doc ET Today asks doctors what has drawn them to attend the XXVII ESCRS Congress in Barcelona. “eSCRS and Barcelona is a very good combination. I am interested in attending several courses and the exhibition. In terms of ophthalmology, the european way of looking at things is very interesting.” “It is a very good meeting and I am looking forward to hearing about a lot of the new ideas that are being developed at this conference. Barcelona is also a very nice place to come and visit.” “The eSCRS meeting is always a very good meeting for cataract and refractive surgeons. I am also doing a certification course for a new phakic lens implant.” Ken Soon Tah - MALAYSIAJanet Hina - JORDANTess Huynh - AUSTRALIA
Title Subtitle 8 paris2010 XXVIII Congress of the ESCRS 4–8 September 2010 Le Palais des Congrès www.escrs.org EuropEan SociEty of cataract & rEfractivE SurgEonS
Title Subtitle 99 XXVII ESCRS Congress in Barcelona sets new attendance record ESCRS declares 2010 European Year of LASIK The latest registration figures for the XXVII eSCRS Congress in Barcelona show that this year’s congress has attracted a record attendance. Over 5,500 delegates attended the meeting. This year’s meeting also incorporated the first World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) which was attended by over 900 delegates. When exhibitors are added to the attendance, eSCRS brought almost 10,000 people to Barcelona for one of the most successful congresses in the society’s history. IN celebration of the 20th anniversary of the first LASIK surgeries, the european Society of Cataract and Refractive Surgeons (eSCRS) has designated 2010 as the european Year of LASIK. Approximately 3.5 million LASIK surgeries are performed every year for the correction of myopia, hyperopia and astigmatism. eSCRS, the leading professional society for european refractive surgeons, is uniquely placed to lead this celebration, said eSCRS president Paul Rosen. LASIK pioneer Ioannis Pallikaris MD, PhD, past eSCRS president and Binkhorst Medal lecturer at this year’s eSCRS Congress in Barcelona, will highlight european Year of LASIK with an Anniversary Congress in Crete, Greece in July 2010. The ‘father’ of modern LASIK, Greek ophthalmologist Dr Pallikaris, said that the decision of the eSCRS to designate 2010 as the Year of LASIK is an important recognition of the significance of LASIK in the history of ophthalmology. “I am very pleased that the eSCRS has designated 2010 as the Year of LASIK. This was something I have been in favour of for some time now and I fully support this initiative to celebrate what was essentially a european breakthrough,” said Dr Pallikaris. Dr Pallikaris, who was the first surgeon to use the hinged flap technique in 1990, said that 2010 is a particularly opportune time to mark this important event. “In July next year we will be holding the 10th Aegean Cornea Meeting and the celebration of the 20th anniversary of Vardinoyiannion eye Institute of Crete (VeIC), and it is fitting that these events coincide with the 20th anniversary of the first LASIK procedure here in Crete. This will be an opportunity for ophthalmologists and researchers to take stock of the past, present and future of LASIK in particular and developments in anterior segment surgery in general. I think we should see this Year of LASIK as an opportunity to recognise and celebrate what was essentially a european breakthrough and I have no doubt that the eSCRS will play an active role in promoting the year and helping to raise awareness about this achievement,” he said. Missed a session today? www.escrsondemand.org n Symposia n Free Papers n Other Key Sessions n Video Competition Winners n ePosters n Medal Lectures Available to View Now at Iranian delegates attending this year’s conference “I am very pleased that the ESCRS has designated 2010 as the Year of LASIK. This was something I have been in favour of for some time now and I fully support this initiative to celebrate what was essentially a European breakthrough” Ioannis Pallikaris MD, PhD Paul Rosen
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ORange cataract study shows improving outcomes 11 The latest-generation femtosecond laser provides for faster flap creation, less inflammation and greater patient comfort, according to Richard Lindstrom MD. “In addition to all these benefits, another advantage is the ability to more fully customise the flap which helps to ensure corneal biomechanical stability,” Dr Lindstrom told delegates attending the XXVII Congress of the eSCRS. Dr Lindstrom said that the fifth-generation femtosecond technology generates a higher repetition rate with tighter spot separation, faster procedure time and less energy being delivered into the eye than previous iterations of the technology. The ability to provide customised flap shapes with an expanded bevel in side cut angles is another advantageous feature of the latest generation lasers, he said. “Fifth generation femtosecond technology provides increased customisation parameters to increase patient comfort, increase flap creation speed, tailor the flap to the patient and improve flap stability,” he said. Fifth-generation femtosecond lasers allow greater customisation 11 INITIAL clinical studies are generating positive results about the value of intraoperative wavefront aberrometry using a proprietary device (ORange Intraoperative Wavefront Aberrometer, Wavetec Vision) for improving the refractive and visual outcomes of patients undergoing cataract surgery, said edward J holland MD, at the XXVII Congress of the eSCRS. ORange provides real-time analysis of cylinder, allowing surgeons to make and enhance limbal relaxing incisions (LRIs) as needed. Results from comparative studies indicate use of this technology reduces the amount of residual cylinder and the rate of refractive surprises while improving vision outcomes. “A study by Warren hill MD, including 6,000 patients undergoing cataract surgery showed that more than half of these subjects had more than 0.75 D of pre-existing astigmatism. Relaxing incisions have been the most common method for managing this astigmatism to improve visual outcomes, but the results for this technique can be unpredictable, in part because surgeons cannot be absolutely certain about the length and depth of their incisions,” said Dr holland, professor of ophthalmology, University of Cincinnati, and director, cornea service, Cincinnati eye Institute, Cincinnati, Ohio, US. “Findings from clinical studies show that by providing real-time refractive assessment, this intraoperative wavefront aberrometer is a great tool for surgeons striving to provide patients with the best visual outcomes.” Dr holland reported data from a manufacturer-sponsored trial conducted at the first 10 sites in the US where the device was commercially available. The study cohort consisted of 94 patients who underwent LRIs with intraoperative ORange evaluation and 189 historical controls operated on by the same surgeons without use of this technology. Mean cylinder preoperatively was the same in the ORange group and controls, 1.45 D and 1.47 D, respectively, but was 35 per cent lower postoperatively in the eyes evaluated with ORange versus the controls, 0.47 D vs. 0.7 D. “Thirty-nine per cent of ORange patients underwent an intraoperative enhancement because of identified undercorrection. Surgical surprises, defined as >1.5 D of residual cylinder at 30 days, occurred at a rate of eight per cent in the control group, but were absent in the ORange group,” reported Dr holland. Preliminary data from an ongoing prospective randomised clinical study currently under way at the Cincinnati eye Institute are corroborating the multicentre trial results. ET Today Special Edition XXVII Congress of the ESCRS 2009 Publisher: Carol Fitzpatrick executive editor: Colin Kerr editors: Sean henahan, Paul McGinn Managing editor: Caroline Brick Production editor: Angela Sweetman Senior Designer: Paddy Dunne Assistant Designer: Janice Robb Contributing editors: howard Larkin, Dermot McGrath, Roibeard O heineachain ORBIS International Medal Larry Benjamin, a member of the ORBIS UK Board of Trustees, presents Noopur Gupta from India with the ORBIS International Medal for her Free Paper entitled “Socio-demographic features and risk factor profile of keratomalacia in early infancy”
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