November 2008

VVOOLLUUMMEE 1133 IISSSSUUEE 1111 NNOOVVEEMMBBEERR 22000088 APublication by the European Society of Cataract & Refractive Surgeons

1 HOWdo we define evidence-based ophthalmology? In my opinion evidence-based ophthalmology is ophthalmology practised according to knowledge and not belief.The difference between knowing and believing can be striking and we need to follow protocols with proper controls and long- term follow up.This is the hallmark of good science. As well as our traditional methods of sharing and disseminating knowledge in scientific journals,the World Wide Web can help us share our knowledge with other colleagues and the Internet offers a wealth of information to anyone who has a computer and reasonable knowledge of information technology.We also need to be able to separate good quality information from poor information and there is such a large amount of information on the Internet that the challenge is to know where to start looking. The ESCRS EUREQUO project will offer a unique opportunity for ophthalmologists,not only in Europe but all over the world,to learn the importance of collecting data. That is the key behind knowing what you are doing. Collecting data can be time-consuming and challenging but EUREQUO will make the process as simple as it can be and give us the opportunity to compare our data over time with our fellow surgeons. It is important for us to point out that data collection is not the same as evidence-based medicine but by knowing what we are doing and knowing our results we have been able to initiate a lot of serious,well-controlled studies and research.It should be noted that well-performed,multicentre studies based on high-quality databases receive increasing attention as a base for evidence-based medicine. With the development of new techniques,we also see new complications that were unheard of previously so it is as important today as it was 10 years ago to follow your patients and monitor your results. It is not a question of “if” but a question of “when” you apply the standards of evidence- based ophthalmology and one way of doing this is to enlist in the ESCRS EUREQUO project.The project will also encourage ophthalmologists to re-assess and to improve what they are doing today. I think it is also important that while we support evidence- based ophthalmology that we do not forget the importance of encouraging innovation and experimentation. At the XXVI ESCRS Congress in Berlin we had a lot of Free Papers.Some people consider the content of Free Papers as being second-grade information compared to the presentations in the symposia where very few speakers will stand up if they do not have solid ground for what they are presenting. That,to my mind,is not the right approach.Free Papers allow us to consider and discuss new ideas and innovations. They may not be proven or evidence-based and some of the ideas in these papers will fade away quietly,never to be talked about again.Others will mature and be scrutinised and will result in proper studies being carried out. This is one of the strengths of the ESCRS and our congress and I hope it remains so for many years to come. Guest Editorial Ulf Stenevi FRCS, FRCOphth Noel Alpins AUSTRALIA Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN Joseph Colin FRANCE Jose Cunha-Vaz PORTUGAL Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA José GüellIoannis Pallikaris Clive PeckarPaul Rosen Emanuel Rosen Chairman ESCRS Publication Committee MMeeddiiccaall EEddiittoorrss IInntteerrnnaattiioonnaall EEddiittoorriiaall BBooaarrdd European Registry of Quality Outcomes for Cataract & Refractive SurgeryEUREQUO ESCRS EUREQUO project will help us to develop evidence-based ophthalmology Editorial November Ulf Stenevi is a past President of the ESCRS

2 12 Cataract 12Surgeons very positive about new Signature system 13Important to treat dropped lens material with due attention and diligence Cataract Update 7Explantation of multifocal IOLs on the increase 8Nearly 70 per cent of Dutch surgeons use electronic databases for tracking surgeries 9New short-form survey measures patient-reported outcomes of cataract surgery Special Focus – Evidence-based Ophthalmology Refractive Laser 16 Excellent patient satisfaction with ICL implant Refractive Lens > 16 Refractive Lens> 24 Retina> 28 Ocular> Contents 14IntraCOR has multiple advantages relating to its simplicity and safety 15Combination of femtosecond and wavefront-guided better alternative to LASIK More Contents21Anti-VEGF agents appear to inhibit growth of corneal blood vessels Cornea Update Cover Image: GDxTM (Carl Zeiss Meditec) showing progressive retinal nerve fibre loss

4 Contents 35 Feature 24Prone positioning after macular hole surgery reduced with vertical OCT 26Patients must be told how to care for lenses to prevent infectious outbreaks 28New treatment for amblyopia explored 30German survey shows LASIK still the most popular refractive surgical procedure Retina Update Ocular Update 22The importance of new diagnostic technologies in managing glaucoma Glaucoma Update 37 Letter from America 38 Practice Management 40 Outlook on Industry 42 EU Matters 44 In Your Good Books 46 Bio-Ophthalmology 48 Eye on History Features 6 Newsmaker Interview 10EuroTimes Interview 47 Journal Watch 50 Industry News 51 JCRS Highlights 52 Calendar Regulars >37 Feature> Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Assistant Editor Angela Sweetman Graphic Designer Paddy Dunne Circulation Manager Angela Morrissey Contributors Devon Schuyler Eisele Nick Lane Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Stefanie Petrou-Binder Maryalicia Post Seamus Sweeney Gearóid Tuohy Colour and Print Times Printers Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org 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. Editorial Staff EUROTIMES ESCRS ™ Published by The European Society of Cataract and Refractive Surgeons The Total Average NET Circulation for the 12 issues of EuroTimes distributed between 1 July 2006 and 30 June 2007 is 26,104. Winner of the PPAI Business-to-Business Specialist Magazine of the Year 2007 With this issue...

Supported by a three-year grant from the EU,this year the ESCRS and 12 national ophthalmic societies began developing the European Registry of Quality Outcomes for Cataract & Refractive Surgery,or EUREQUO.As a prime mover behind both the Swedish National Cataract Registry,perhaps the most comprehensive and longest running ophthalmic registry in the world,and the long-running European Cataract Outcomes Study sponsored by ESCRS,Mats Lundström,MD,will play an important role.Prof Lundström recently shared his thoughts with EuroTimeson EUREQUO’s potential to increase understanding of cataract and refractive surgery and the prospects for its success. ET:What are the potential research benefits of building an international cataract and refractive surgery outcomes registry? Aren’t randomised clinical trials enough to evaluate new procedures and technologies? Prof Lundström:The really important thing about registries is they are supposed to collect data on all cases so they show you the results of treatments in the real world.You don’t get this with randomised trials.To have the highest predictive power with randomised trials you need strict exclusion criteria.But when you keep out a lot of different patients this also means the trial results are not generalisable.In the registries we can see what really happens when we apply a technique to all kinds of patients.We can also see it over a much longer time,which can be very important. The orthopaedics registries have found that certain implants that worked well at first started to give problems after three or four years.You can’t have a clinical trial go on for so long. ET:Clinical trial data are collected under controlled circumstances,which is a major factor contributing to the reliability of their findings.How do registry data compare in terms of the strength of evidence they produce? Prof Lundström:The strength of evidence in a registry depends on many factors.There must be reasonably large amounts of data,and you have to make sure that it is not just selected cases – you have to be sure that critical parameters like complications are represented in the data.If the registries have a high coverage of cases,if they have systems for validating data, and if they are multicentre or national registries the strength of the evidence they produce becomes stronger and stronger.In a general discussion about different levels of evidence,with prospective randomised trials at the top and expert opinion at the bottom, registry evidence is getting closer in reputation to the clinical trial. ET:All over the world purchasers of healthcare services,whether they are national health plans,insurance companies or individuals,are looking for quality data to guide their buying decisions.Are you concerned at all that registry data might be used to rank providers for this purpose? Prof Lundström:Registry data are not very suitable for this kind of use.If you use registry data in aggregate for calculating risk or complication rates,they are very robust.But if you want to rank units or rank surgeons and there is a certain percentage of missing data,the confidence intervals become so large the data are almost meaningless.If there is just a three per cent loss of data and we calculate based on my hospital number being 45 out of 70,that is misleading because the actual result could be anywhere between number five and number 70.Therefore,it is extremely dangerous to rank if you don’t have almost 100 per cent data.Registries also may not take into account patient mix. If you have complicated cases,you give them to the most skilled,senior surgeons, so your best surgeon may end up with your highest vitreous loss rate because he takes all the hardest cases.I think they may bring forward the possibility of using the data to rank us,but I do not think they will force us because they are well aware of the difficulties.The data may be good enough to assign centres to categories,but they are not good enough to precisely rank units or individuals.In Sweden,the authorities are not interested in going below the clinic level,or at least that is what they are saying now. ET:It sounds like much of the success of the EUREQUO project will depend on getting a high level of cooperation from the participating countries and surgeons.What are the prospects of gaining such cooperation? Prof Lundström:It seems there is a movement under way;it is coming more and more.In some countries it is the initiative of professionals,in others it is the health authorities that are pushing for it, but everyone wants this data.There are registries in Holland and Slovenia and Malaysia and Perth in Western Australia. They do not yet have the same coverage that we do in Sweden,but they are working toward it.There is a lot of enthusiasm for it in southern Europe and in the east.They have incentive to show that they have the same standards in place and produce the same outcomes as other countries.The support of national health authorities does help.In Sweden every private cataract surgeon must participate to get paid.But the national board of health in Denmark set up a registry that failed to reach sufficiently high coverage,so the authorities stepped in and cut the funding.Some countries will be quicker than others,but as more participate that will stimulate the others to join. ET:When the ESCRS European Cataract Outcomes Survey (ECOS) moved from a paper system to on online entry system, participation dropped because clinics could not export data directly from their systems to the ECOS database.Do you anticipate similar issues with EUREQUO,and if so, how will they be addressed? Prof Lundström:There will be a number of improvements to make the system more user-friendly.One of the goals of the three- year development grant from the EU is to develop data export tools that will integrate directly into electronic medical record systems so that centres will not have to double-enter data.The software will reside in the computers so participants will not even have to be connected to the Internet.We will most likely pick up coverage quicker in areas where electronic record systems are the standard. ET:Past attempts to keep registries current also have encountered difficulties keeping up with rapidly changing technology.How do you see EUREQUO addressing this challenge? Prof Lundström:It is difficult to decide what should be in the database given the speed technology changes.Cataract surgery still is to correct a medical disability,but it is increasingly for refractive purposes as well.If you focus on one indication for surgery but not the other you can miss important data.We try to include all that we think is important,but it is not entirely scientific;you cannot include all parameters.The important thing is that important indicators of quality of care are identified and collected.I hope that this European registry will somehow stimulate a discussion about how an audit should be conducted,what data are needed and what it should look like.One drawback of previous refractive registry systems is that when surgeons were asked to give data for a national audit,the data being collected was not enough.Individual countries must decide what should be in an audit,but if EUREQUO could set a standard for what ought to be included in the audit this would increase the value of the system for surgeons.My hope is that this project is moving us in the right direction.It will take time,of course. mats.lundstrom@ltblekinge.se 6 Mats Lundström Newsmaker Interview…Mats Lundström EUREQUO cataract and refractive registry could boost ophthalmic outcomes research Newsmaker Interview Evidence-based Ophthalmology European Registry of Quality Outcomes for Cataract & Refractive SurgeryEUREQUO

Howard Larkin in Berlin AS MULTIFOCAL intraocular lenses grab a growing share of the cataract and refractive surgery market,the number being removed from patients’ eyes also has increased significantly,says Nick Mamalis MD. But unlike monofocal lenses,which are most often explanted due to dislocation or decentration of the lens within the eye, patient complaints of glare and other optical aberrations are the leading reasons multifocal lenses are being removed,according to surveys from ASCRS and ESCRS members compiled by Dr Mamalis at the Intermountain Ocular Research Centre at the University of Utah,Salt Lake City,US. “When we look at data for the 10-year length of the study we see some interesting trends,” Dr Mamalis told a symposium of the XXVI Congress of the ESCRS in Berlin. “There were an increasing number of explanted multifocal lenses seen in the survey compared with previous years.The vast majority were removed because of glare, visual aberrations and similar type problems.” About 70 per cent of multifocal lenses reported removed in 2007 were for glare and related problems,a far higher percentage than in any other lens category.Multifocal lenses also appeared to be explanted at a higher rate compared with their overall market share, which by most accounts is less than 10 per cent,although the small number of lenses in the survey requires caution in making any firm conclusions.For 2007,23 per cent of explanted lenses reported in the study were multifocal acrylic lenses,and another one per cent were multifocal silicone lenses. Monofocal one-piece acrylic lenses made up 24 per cent of explanted lenses and three- piece acrylics made up another 19 per cent, with three-piece silicones accounting for 19 per cent and one-piece plate-type silicone lenses six per cent. “The purpose of the study is not to say one type of lens is better than another,or that complications occur more often with one lens,but to look at what types of complications occur in what types of lenses,” Dr Mamalis stressed. Nonetheless,the 2007 study may give pause to surgeons considering implanting multifocal lenses.While many studies suggest that most patients adjust to haloes,glare and other dysphotopsias inherent in the design of light-splitting multifocal lenses,and are satisfied with multifocal lenses,some patients do not adjust.As a result,methods for distinguishing before surgery which patients are most likely to have difficulty adjusting to multifocal lenses have become hot topics at cataract and refractive education conferences worldwide. Dr Mamalis based his report on an ongoing survey of explanted lenses submitted by ASCRS and ESCRS members from 1998 through 2007.The survey instrument,which is available online and by fax from both organisations,asks surgeons to detail information about complications leading to the explantation or exchange of foldable IOLs.These include the design and material of the lens removed, presenting patient complaint,pre- and postoperative visual acuity,the reason for explantation and complications arising from the surgery. “It takes less than a minute to fill out,” said Dr Mamalis,urging surgeons to submit a survey questionnaire each time they explant a foldable IOL.“We will be presenting the data every year and it will help us keep looking at trends in explantation of IOLs.” While dislocation and decentration of lenses was the most common reason for explantation,with incorrect lens power second and visual aberrations third,the reasons varied somewhat by lens design and material, Dr Mamalis noted. The study breaks out monofocal one-piece lenses with plate designs, one-piece lenses with haptics,and three-piece lenses,though one-piece and three-piece multifocals are reported as a single category. Materials studied include silicone, hydrophobic acrylic,hydrophilic acrylic or hydrogel,and a small number of Collamer lenses. For hydrophobic acrylic lenses – by far the most popular material – dislocation and decentration were the top reasons for removal overall. However,incorrect lens power was number one among three-piece lenses of this material,followed by decentration.Over the 10 years of the study,the rate of three-piece acrylic lenses removed for glare and optical aberrations has been slowly decreasing,but the rate for dislocation and decentration has increased,Dr Mamalis said. Calcification and opacification due to calcification was the number one reason for removal of hydrophilic acrylic lenses,which included both one-piece and three-piece designs. In three-piece silicone lenses,the most frequent cause for removal was dislocation or decentration,a finding that has been stable for 10 years,Dr Mamalis noted.However,the rate of three-piece silicone lenses removed for incorrect power has decreased,he noted. In plate haptic silicon lenses,Dr Mamalis reported some cases of secondary calcification leading to explantation.“However,it is important to discern this calcification from that seen in hydrophilic acrylic lenses.This was not intrinsic to the IOLs,but deposition of calcium on the lens itself in the setting of asteroid hyalosis with a capsulotomy.” For preventing complications necessitating explantation,Dr Mamalis stressed careful surgical technique.A good capsulorhexis keeping the bag intact and placing the lens in the bag is key. nick.mamalis@hsc.utah.edu 7 Glare, optical aberrations are most common reasons for explantation of multifocal IOLs Special Focus Nick Mamalis Evidence-based Ophthalmology

Howard Larkin in Berlin IN THE wake of health insurance requirements that ophthalmic surgeons in The Netherlands report outcomes to get paid,69 per cent are now regularly using electronic databases to track cataract surgeries,says Ype Henry MD.More than half are using a Web-based database developed by the Dutch Ophthalmological Society,he told a symposium of the XXVI Congress of the ESCRS in Berlin. The society’s outcomes database program went online in April 2007.By August 2008 it had amassed detailed operative and outcomes data on more than 50,000 cataract procedures, reported Dr Henry,an ophthalmologist and researcher at the Academic Hospital of Vrije University who surveys Dutch cataract surgeons annually on their practice preferences.About 150,000 cataract procedures are performed in The Netherlands each year, he said. “You may not think this sounds like too much,but for the first year we are very happy to have the 50,000 cases,” said Dr Henry. Convincing surgeons to participate in a data collection program can be challenging,and has often failed in other settings,he pointed out.For example, participation in the ESCRS- sponsored European Cataract Outcomes Study,or ECOS, initially dropped after the survey instrument migrated to the Web,apparently in part due to resistance to manually entering data online. “It’s not easy to keep it simple,fast and still have the right parameters in there.” Dr Henry allows that reimbursement policies requiring surgeons to participate in outcomes databases have spurred participation in the society- sponsored project.“It is an external hospital quality indicator,so 100 per cent of surgeons should be using a database.” But he also believes that the program’s easy-to-use data input design and performance benchmarking features are also major factors in its widespread acceptance. Previously,about half of Dutch surgeons were using a program known as Cataract Post Op,or CPO,a stand- alone program that allowed surgeons to enter data,but only one patient at a time,and without the ability to compare outcomes with others.By contrast,the new system is Web-based, enabling doctors to access it from any computer with a user name and password.It also allows instant benchmarking against the entire database. The new system features a one-page entry system that requires very little typing.Critical data elements such as patient ID number,age,the operated eye, date of the operation,IOL type,refractive target,pre- and postoperative refractions and even many complications and co- morbidities can be entered using menus. The entire input process takes two to three minutes per operation,he says. The system also features a page comparing your own operations,or all the operations from your centre,on one side and all the operations in the database on the other. “You immediately have your own operations side by side with every operation in Holland,” Dr Henry pointed out. The benchmarking page allows surgeons to compare their own complication rates with others for all age groups,co- morbidities and other factors.“The results are right next door.It is an internal audit,” Dr Henry said. For now,the information is kept inside the society,which has the right to determine what information is released to external agencies. Dr Henry personally finds the data useful.“You can see my capsule break is a bit higher than the overall group,and I have to think ‘why is it higher?’ You can easily compare and find out how I am doing.” The user-friendly nature of the program drew several questions from interested observers as to whether it is or would be available in other languages.Dr Henry said the program had been developed by and is owned by the Dutch society,but it may be made available to others. Session moderator Mats Lundström MD,professor at Blekinge Hospital, Karlskrona,Sweden,and principal investigator of the ESCRS ECOS study, noted that development of similar database entry programs will be part of the EUREQUO outcomes project to be developed over the next three years by the ESCRS under a grant from the European Union. y.henry@vumc.nl 8 Ype Henry One year later, more than half of Dutch surgeons using online database Special Focus Evidence-based Ophthalmology

Howard Larkin in Berlin IMPROVING the functional vision of patients in everyday life is a key goal of cataract surgery.Yet relying on lengthy surveys to assess patient-reported visual outcomes can be cumbersome and time-consuming.Now a new survey known as Catquest-9SF has been shown to reliably quantify patients’ level of visual disability before and after surgery using only nine questions. “With just nine questions it should be ideal for measuring patient-reported outcomes without too much burden on the patient or the healthcare personnel.We have tested it on a new group of patients and found it formed a valid measure,” Mats Lundström MD told a symposium at the XXVI Congress of the ESCRS in Berlin. Catquest-9SF,for “short form,” was derived in 2008 from the 33-item Catquest survey instrument,which has been used to evaluate thousands of patients in the Swedish National Cataract Register since 1995. Administered before and after surgery,the longer Catquest questionnaire was designed to comprehensively assess visual disabilities in terms of their impact on patients’ activities of daily life,activity level,cataract symptoms and degree of independence.Many published studies have established the validity of the Catquest survey instrument.However,some have noted response rates that were lower than optimal,in part due to difficulties with patients completing and returning the post- surgery surveys that were mailed to them. Dr Lundström and his colleagues Anders Behndig MD,Per Montan MD and Ulf Stenevi MD of the Swedish National Cataract Register steering committee sought to create a reliable linear measure of patient-reported visual disability that could be more easily used in daily practice.With statistical help from Konrad Pesudovs PhD of Flinders University,Adelaide,Australia,they subjected a sample of more than 21,000 responses to the long-form Catquest survey to Rasch analysis. Using this technique,which is designed to assess how well survey questions measure a unilateral underlying construct,they were able to isolate nine questions from the long- form Catquest that correlated strongly with visual disability defined objectively as measured visual acuity in the better eye. The new short-form survey asks patients to assess their visual performance on a four- point scale in seven areas.These include recognising people’s faces,walking on uneven surfaces,reading the newspaper and performing close work such as knitting.It also includes one question on how much difficulty vision gives the patient in everyday life overall,and one on how satisfied the patient is with their overall visual ability. Not only did these nine subjective questions individually correlate with visual disability,summing their values produced patient scores along a linear scale that correlated to their objectively measured visual acuity.In other words,the answers to these nine questions alone were enough to reliably assess the degree of functional visual disability of individual patients and separate them into clinically meaningful categories – at least among patients who completed the entire 33-question Catquest survey. The next step was to validate the Catquest-9SF survey with a set of new patients who did not receive the long-form survey.It was the positive results of this study that Dr Lundström reported at the ESCRS Berlin congress. The validity and psychometric properties of the Catquest-9SF were tested using classic theory and Rasch analysis for surveys filled out by 1,326 patients at six Swedish cataract surgical clinics before and three months after cataract surgery.The internal consistency of the survey questions was high,with a Cronbach’s alpha score of 0.834. Content validity tested with visual acuity of the better eye was also high with a coefficient of 0.43 (p<0.001),said Dr Lundström, professor at Blekinge Hospital, Karlskrona,Sweden. The Catquest- 9SF had ordered response thresholds.The person separation which tells how effectively a study instrument separates patients was high at 2.65,as was separation reliability at 0.88.All items on the survey fit well into a single overall construct with an infit range 0.84 to 1.40 and an outfit range 0.82 to 1.40,indicating that the questions closely match the underlying quality being tested.The mean score of all patients in the study group also closely matched the distribution of difficulty of the questions, suggesting that the nine questions of the Catquest-9SF match up well in terms of the range of ability they measure relative to the range of disability of the study group. This means that the survey is highly appropriate for typical cataract patient populations, Dr Lundström noted. “If the patients were too disabled or not disabled enough they would be bunched up at one end or the other of the scale.By combining two sections of the longer questionnaire we were able to create a valid short form,the Catquest-9SF,” said Dr Lundström. mats.lundstrom@ltblekinge.se 9 Nine-question survey shown effective in evaluating outcomes of cataract surgery Special Focus Mats Lundström Evidence-based Ophthalmology CChheecckk iitt oouutt oonn hhttttpp::////mmyyeeuurroottiimmeess..bbllooggssppoott..ccoomm ffoorr aa uunniiqquuee oonnlliinnee vviieeww oonn tthhee wwoorrlldd ooff oopphhtthhaallmmoollooggyy EEuurrooTTiimmeessnnooww hhaass iittss oowwnn wweebblloogg!!

THEPresident-elect of the ESCRS Dr José Güell believes that the biggest challenge facing the society is to have a real and proper involvement with the “new” countries of Europe. The map of Europe has been redrawn during the last few years with the emergence of new independent states across Eastern Europe and Dr Güell believes that the ESCRS must develop strategies to engage with the ophthalmologists working in these states. “We need to involve them,not just by encouraging them to join the society and attend our meetings,but by going out to their countries to see what they are doing and to invite them onto our committees and study groups.EuroTimes, which is doing a very good job,can also help us in this process by encouraging ophthalmologists from the new countries to write and contribute to the magazine.” Dr Güell,speaking to EuroTimesexecutive editor Colin Kerr,after his election as incoming President at the XXVI ESCRS Congress in Berlin,said one of his main priorities as President will be to re-enforce the quality of education provided by the society and to re-enforce what he describes as the “independence of science” in ophthalmology. “We must continue,both as individuals and as a society,to be closely involved with industry,but we also need to assert our independence as doctors and ophthalmologists.Our relationship with industry is critical and extremely important but we need to renew our principles to ensure our independence.I think this will be good for both ESCRS and the industry.” Dr Güell also believes that the ESCRS must have a stronger role in supporting humanitarian projects not only in ophthalmology in developing countries but in supporting wider humanitarian projects such as famine relief.Hopefully,this might encourage other professional societies to do the same. The membership of the society is continuing to increase and Dr Güell believes that if it supports some of the initiatives he has suggested,more doctors will want to join ESCRS.He is also very keen to stress that these initiatives are not his “personal” initiatives but also those of many of his colleagues who have worked on the Board of ESCRS throughout the last 10 years and before that. The congress remains the focal point for the society every year and Dr Güell says that while the choice of venue can play a part in attracting delegates,the biggest attraction for ophthalmologists is the strength of the society’s educational programme. “If we can improve the already outstanding programme by building on the scientific independence I have proposed,we can improve the quality of our meetings and also attract new members.” There has been some debate in recent years about the need to create a new identity for the ESCRS Winter Refractive Surgery Meeting and Dr Guell says he will work with his colleagues on the Board and with other ESCRS members to improve the present format. “The Winter Meeting needs to be focused on basic training and we must also look at ways of including connected activities through working with other societies,” he says. One of the goals of any professional society is the ability to exchange knowledge about techniques and complications and Dr Güell believes that this has been one of the key strengths of ESCRS. “I personally think that what ESCRS has been doing for the last eight to 10 years must continue,” he says.“We must keep up to date with the newest advances in technology,but our goal must be to train ophthalmologists in basic and well- established procedures.We can show them the new and cutting-edge procedures,but that is not our main goal. It is only a small part of what we do.” The appointment of a new president is a major milestone in the ESCRS and individual presidents put their own definitive stamp on the society.So what qualities will Dr Güell bring to his presidency? “That is a very difficult question as my focus is on the ESCRS as an organisation and not on any one individual,” he says.“I have a strong commitment to the society and this commitment will increase during my period as president.I also think I have an open mind and I think this is important for someone who is involved in helping to direct and lead the society.I also hope I have a good relationship with my colleagues and I think this is important as we strive to strengthen the society in the future.” 10 José Güell EuroTimes Interview – José Güell President-elect Dr José Güell says ESCRS must embrace ‘new’ Europe and scientific independence EuroTimes Interview

Cheryl Guttman in Chicago THE WHITESTAR Signature system with Fusion Fluidics (AMO) offers surgeons state-of-the art phaco technology for enhanced surgical safety and efficiency, according to users who discussed their experiences at the annual conference of the ASCRS. The Signature system is equipped with dual-pump technology so that surgeons can enjoy the responsiveness and holding power of a Venturi pump plus the control of a peristaltic flow-based pump and with the opportunity to switch pump technology on-the-fly using a single cassette,explained Burkhard Dick MD,Ruhr University Eye Clinic,Bochum,Germany. The Signature’s features include an intuitive touch screen interface,wireless Bluetooth accessories,an onscreen animated help system,multilingual user interface,one-step,auto-loading tubing pack,single-step surgeon programming,and a faster prime cycle to minimise wait time. The Fusion Fluidics system also enhances safety through its ability to recognise occlusion and proactively adjust vacuum before occlusion break,he said. “When the vacuum level increases and reaches a preset up-threshold,the Signature fluidics system reverses the pump with a reaction time of as little as 20 milliseconds,actively stepping down the vacuum before the occlusion breaks,” said Dr Dick. To illustrate its performance in maintaining anterior chamber stability,Dr Dick presented a video of a surgical case where capsular rupture was avoided even when the phaco tip approached the posterior capsule after penetrating through a hard,thick nucleus concealing a thin cortex. He also presented outcomes for the first 50 eyes he operated on using the Signature system.The procedures were all performed under topical anaesthesia using the same equipment and settings. One day postoperatively the eyes achieved clear corneas and excellent visual outcomes with a mean BCVA of better than 0.8.At six weeks after surgery,there was minimal endothelial cell loss with a mean change from baseline of about 100 cells/mm2. “In a comparator group of eyes operated on with the Sovereign system using the same pulsed ultrasound technique,similar outcomes were achieved with respect to midterm visual rehabilitation and mean endothelial cell loss.However,vision recovered faster in the Signature group and the range of endothelial cell loss was less, perhaps because the Signature procedures were associated with less total phaco power and time,especially in eyes with hard nuclei,” said Dr Dick. Ekkehard Fabian MD concurred with Dr Dick regarding the benefits of the new pump system on the Signature. “The rapidly responding vacuum pump of this platform permits surgeons to use higher fluidics parameters for increased efficiency without compromising chamber stability and safety.The Signature offers users an advance over the entire range of surgical cases,but the ability to operate safely with a higher vacuum is especially valuable for improving efficient and complete cortex removal,” said Dr Fabian, Rosenheim,Germany. Archiving and teaching tools Researchers also delivered enthusiastic reviews for the new Surgical Media Center (SMC),praising its learning,teaching,and documentation capabilities. In their talks,Dr Fabian and Ann Haustermans MD,AZ Klina,Brasschaat, Belgium,also showcased the SMC,an advanced video overlay system that utilises specialised media software for intraoperative video capture and to allow customisable playback.With its high storage capacity,the ability to create DVD quality recordings,and extensive playback and editing options,the SMC is a valuable tool that surgeons can use for quality assurance documentation purposes and teaching. The SMC performs continuous taping of cataract surgery procedures and blends real-time operating data from the phaco system with the video image from the surgical microscope.It consists of a video control module that represents a simple user interface for manual control of the recording plus a Windows-based laptop computer for offline viewing and editing. Videos are recorded in a DVD quality format (MPEG-2),and the system has a high storage capacity with a minimum recording time of 25 hours.The laptop computer is used for video playback in a customisable format and with the option for frame-by- frame review.Since the overlay graphics on the SMC are maintained in a separate file from the video rather than embedded in it, surgeons can tailor the data appearing as an overlay in the playback to their own preference.The custom-designed layout can then be stored for future use. Options for displaying aspiration,vacuum, and ultrasound power data include bar graphs and speedometers.However,a data plot format that displays a simultaneous, colour-coded,real-time tracking of changes in each parameter throughout the procedure is particularly useful in allowing surgeons to appreciate interactions between their settings and the performance of the phaco system,Dr Haustermans said. She illustrated her point with a video that showed the performance of the Signature Fusion Fluidics system for anticipating vacuum breaks to prevent surge and maintain anterior chamber stability. Dr Fabian agreed that the time curves of the phaco parameters represent a valuable tool for surgeons. “Until now,intraoperative video systems only displayed a single point in time.With the SMC,the data are displayed as a sequence that allows much greater insight as to what is happening during the procedure,” he explained. The SMC can also be used with AMO’s Sovereign and Sovereign Compact phacoemulsification units.However, considering the enhanced capabilities and options available on the Signature,the SMC is a particularly welcome aid for surgeons wishing to optimise their use of this sophisticated new platform,observed Kenneth Rosenthal,MD,FACS,associate professor of ophthalmology,The John A Moran Eye Center,University of Utah Medical Center and in private practice in New York. Dr Rosenthal moderated the session and noted he has been using the Signature system with the SMC since November 2007.He observed that compared with the Sovereign,the Signature system has about three times as many potential settings.While its increased sophistication provides opportunities to improve surgical safety and efficiency,the SMC facilitates the surgeon’s ability to harness the potential of the Signature by allowing careful monitoring and analysis of each procedure in real-time. “The SMC is wonderful technology for surgeons in the learning curve and those who are highly experienced,and I believe that with the ability to view intraoperative video in sync with their surgical settings and as a time sequence,surgeons will find they can revolutionise their performance in the OR,” Dr Rosenthal said. Dr Rosenthal noted that when the Signature system was first installed at his centre,the manufacturer’s representative had programmed it with parameters that were slightly modified compared with the settings that were being used on the Sovereign.Relative to prior outcomes,Dr Rosenthal noted an increase in total phaco time per case,even when operating on softer lenses.Using the SMC,he was able to identify that the phaco power was now coming on earlier at the bottom of foot pedal position 2. “While we might have intuited this to be the reason for the increase in our phaco time,using the SMC we could quickly document it as the cause,and this is just one of many situations where it has proven helpful,” Dr Rosenthal said. burkhard.dick@kk-bochum.de kr@eyesurgery.org dr.fabian@augencentrum.de annhaustermans@skynet.be Data plots Speedometers Laptop & VCM Bar Graphs Courtesy of Ann Haustermans MD 12 Burkhard DickAnn HaustermansKenneth Rosenthal Latest AMO phaco platform garners favourable reviews Cataract Update

Dermot McGrath in Vienna CAREFUL preoperative and intraoperative care allied to rigorous surgical technique can help reduce the risk of visual loss and other complications associated with a dropped nucleus during cataract surgery,according to Oliver Zeitz MD. “A dropped nucleus is a feared complication of cataract surgery but the prognosis of dropped lens material is good if treated with the appropriate surgical approach,” he said. Addressing the annual meeting of the European Society of Retina Specialists (EURETINA),Dr Zeitz of the University Clinic of Hamburg,Germany,said that the incidence of dropped nucleus has decreased in recent years. “Dropped lens material occurs in about 1.6 per 1,000 cases according to a recent large survey of more than 40,000 cataract surgeries.Nevertheless,the incidence may vary between surgeons and there is a clear trend towards lower incidences. Less experienced surgeons having a greater risk of experiencing a dropped nucleus.The incidence is also dropping due to improvements in cataract surgery techniques and technology.In addition, there has been a change in the surgical management of this complication as the average lens that undergoes cataract surgery these days is much softer than the cataract lenses of 10 or 15 years ago,” he said. In terms of predisposing risk factors, Dr Zeitz cited patients with hard nuclei and pseudoexfoliation syndrome as being at greater risk of experiencing a dropped nucleus.Surgery-related risks include a too-small capsulorhexis,capsular tears, insufficient hydrodissection and incomplete cracking of a hard nucleus. “Another important issue is the psychology of the surgeon.He or she must remain fully focused and concentrated on the surgery in order to avoid some of these complications,” he said. Dr Zeitz said that it was important to treat dropped lens material with due attention and diligence. “Dropped fragments of lens material or cortex can cause swelling and inflammation and lead to secondary glaucoma.Small fragments may also be transported via the aqueous humour into the anterior chamber where they can lead to a blockage of the trabecular meshwork with the potential for ocular hypertension and secondary glaucoma,” he said. The surgical approaches to deal with dropped lens material can be broadly divided into two categories:anterior segment and pars plana vitrectomy approaches,said Dr Zeitz. As well as anterior vitrectomy, surgeons also have the option of using the Visco-trap technique,where the anterior chamber is filled with viscoelastics.The viscoelastic will suspend and trap the nuclear fragments as vitreous is subsequently excised,he said. Another approach,first described by Charles Kelman MD,is the posterior assisted levitation (PAL) technique,in which a metal spatula or hook-like instrument is inserted through a pars plana sclerectomy and used to mechanically lift up the dropped nucleus into the anterior chamber.A variation on this approach using viscoelastics instead of a spatula to lift up the fragments has also been described by Richard Packard MD. Dr Zeitz said that while such anterior segment approaches are viable,there is a high risk of uncontrolled vitreous traction with subsequent retinal tears and retinal detachment using these techniques. “Retinal detachment has been reported to occur in between 10 per cent to 26 per cent of cases with an anterior segment approach,compared to about nine per cent for pars plana vitrectomy. This is the reason why we feel that a pars plana vitrectomy approach is safer and more efficient because it allows a controlled release of traction while thoroughly removing any vitreous anterior to the posterior capsule,” he said. While pars plana vitrectomy carries less risk of retinal detachment than anterior segment approaches,there are some steps that the surgeon can take to reduce the risk even more,said Dr Zeitz. “A particularly high risk of retinal detachment has been observed after posterior segment phaco fragmentation techniques,so it is important to perform the removal of the lens at a safe distance from the retina and away from the posterior pole,” he said. While this can be done mechanically,a better option is to insert a bubble of perfluorcarbon liquid (PFCL) to protect the macula and isolate the lens fragments, advised Dr Zeitz. “The retained lens fragments will swim on this PFCL bubble and facilitate the removal of the lens fragments anteriorally.The softer lens material may be removed using a vitrectomy and the harder lens material may be emulsified by phaco.In phaco cases,it is also possible to use PFCL to lift the dropped lens completely up into the pupil.We can then use the anterior segment to access the tunnel that was created for the initial cataract surgery in order to remove the lens fragments anteriorally,almost like a standard phaco technique,” he said. Dr Zeitz emphasised the importance of having a tight tunnel for a safe and efficient vitrectomy. “If there is a doubt that the initial tunnel from the cataract surgery may leak,it might be advisable to suture the tunnel and prepare a new sclerocorneal incision of at least 3.0mm long,” he said. Other factors to reduce the risk of retinal detachment after PPV surgery is to perform a complete removal of the vitreous and to induce a posterior vitreous detachment if it has not already occurred spontaneously,said Dr Zeitz.It is also important to ensure complete removal of any PFCL fluids,which are toxic to the retina if they remain in the eye for too long. Question of timing In terms of the optimal timing for IOL implantation,Dr Zeitz noted that there are conflicting views on this topic in the scientific literature. He stressed that the decision should be taken on a patient-by- patient basis and that the most important prerequisite for the implantation of an IOL is the complete removal of all lens fragments. As the removal of retained nuclear fragments may cause problems under pseudo phakic conditions,Dr Zeitz said his own preference for such cases is to leave the patient aphakic and refer him or her to a retinal specialist for a secondary vitrectomy. “Aphakia is essential from the point of view of the retinal surgeon because this allows them to perform certain techniques of lens removal that are not possible with an implanted IOL.There is no need to worry if the patient is aphakic for a couple of weeks or even a couple of months as there are very easy options to restore refraction using contact lenses and the final IOL can be implanted later,” he said. Dr Zeitz added that IOL implantation can be performed immediately after the vitrectomy if the eye is quiet and not inflamed.Otherwise,a safety-first approach might be the wisest strategy to adopt,he said. “If the eye has suffered loss of vision from a secondary glaucoma or there is not much capsule left and you need to suture the lens,then it might make sense to postpone this and do the implantation in a second operation,” he said. Sulcus-fixated IOLs as well as retropupillary iris-claw lenses may be used depending on the capsular bag status,concluded Dr Zeitz. zeitz@uke.uni-hamburg.de 13 New strategies help surgeons effectively tackle dropped nucleus problems Cataract Update Oliver Zeitz

Cheryl Guttman in Berlin EARLY outcomes with the intraCOR suggest this novel intracorneal refractive surgery may satisfy the quest to find a simple,safe,and effective treatment for presbyopia according to its innovator,Luis Antonio Ruiz MD. IntraCOR is performed using a proprietary femtosecond laser (Femtec,20/10 Perfect Vision) to ablate the stroma without creating a flap.The ablation involves new geometric patterns and leads to corneal reshaping by inducing a redistribution of biomechanical forces.The intraCOR procedure is being investigated for the treatment of myopia,hyperopia,and astigmatism, all without touching Bowman’s membrane,Descemet’s membrane, endothelium,or epithelium. “In 14 years of performing LASIK for presbyopia,I have never seen such amazing safety and quality of vision outcomes as have been achieved in our experience with intraCOR.I believe it would be difficult to find a procedure for presbyopia correction that is easier or more effective.However,further evaluation of intraCOR is needed with expansion to other centres as well as to refine the technique and determine its long-term stability,” Dr Ruiz said. Based on considerations of wavelength and speed of the laser- tissue interaction,only a femtosecond laser can be used for the intrastromal ablation,not an excimer laser.Among the commercially available femtosecond lasers,the Femtec device was identified as being particularly well-suited for the intrastromal treatment because it has a curved interface,which enables more precise positioning of the beam,and it achieves fixation with minimal biomechanical impact on the eye. “Modeling conducted to predict the impact of the intrastromal ablation patterns on the biomechanical response of the cornea revealed that the cornea must be as stress-free as possible during treatment to allow precise, three-dimensional placement of the laser pulses,” noted Dr Ruiz. Dr Ruiz has performed intraCOR for the treatment of presbyopia,myopia,hyperopia,and astigmatism in more than 700 eyes. At the World Ophthalmology Congress 2008,he reported vision and safety results for presbyopia correction based on a series of 45 eyes that were treated using an identical ablation protocol.Follow- up of one month was available for 44 eyes,30 eyes were seen at three months,and six eyes reached the six-month visit. While further refinements in technique are anticipated,the initial results are very favourable.Mean distance UCVA preoperatively was 0.93 and remained at that level throughout follow-up,beginning at one week.Near UCVA improved from a mean of 0.32 to 0.91 on the first day after surgery.At month three, all eyes achieved J2 or better near UCVA while 62 per cent were reading J1 or better. Intermediate vision results have also been excellent,Dr Ruiz added. By the first day after surgery,any effect of the surgery could barely be seen at the slit- lamp and by three months there was no visible evidence of the treatment.There were a few eyes with an early one-line loss of distance BSCVA.However,these eyes still maintained a BSCVA of 20/20.Among the 30 eyes that were seen at three months,none had lost any BSCVA compared with preoperatively.The only adverse symptoms reported were haloes,but they disappeared quickly. Contrast sensitivity was improved in both photopic and mesopic conditions and assessments for corneal biomechanics using the Ocular Response Analyzer (Reichert) showed hysteresis was increased slightly and the corneal resistance factor unchanged.In addition,there were no changes in endothelial cell density or corneal thickness. Pentacam (Oculus) analysis showed there was a similar change in the asphericity of the anterior and posterior corneal surfaces. “That is why near vision is already improved on the first day and remains stable,” Dr Ruiz said. Analyses of the wavefront data at different optical zone sizes show the treatment results in a true multifocal cornea,and this phenomenon explains the excellent vision outcomes across the full range of distances. Within the central 3mm zone there is a decrease of defocus that corresponds with a myopic shift.At 6mm,the refraction is plano or hyperopic,while spherical aberration changes from positive to negative when measured at zone sizes of 3mm and larger. The change in the spherical aberration compensates for the change in defocus and yields increased depth of field so that patients can see better from near to far, Dr Ruiz explained. Compared with existing refractive surgery techniques,intraCOR has multiple advantages relating to its simplicity,speed and safety.The procedure avoids complications associated with flap creation and surface ablation,can be performed in thin corneas after ruling out keratoconus,does not weaken corneal biomechanics or induce dry eye,has a reduced risk of infection,and involves simple postoperative management that involves only the use of artificial tears.In addition,it could be an option to treat presbyopia in the large population of patients with a pseudophakic monofocal IOL. luisantonio.ruiz@gmail.com 14 Antonio Ruiz No-flap ablation procedure envisioned as Holy Grail for presbyopia treatment Refractive Laser The European Board of Ophthalmology is a permanent working group of the Ophthalmology sub-specialty section of the European Union of Medical Specialists (UEMS). The European Board of Ophthalmology Diploma (EBOD) Examination is a test of excellence in ophthalmology. It is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmologic care both in hospitals and in independent clinical practices. The successful candidate may add the title Fellow of the European Board of Ophthalmology (FEBO) after his or her name. eeuurrooppeeaann bbooaarrdd ooff oopphhtthhaallmmoollooggyy European Board of Ophthalmology Diploma Examination20092009 For more information and to apply online www.ebo-online.org Closing date for applications January 31st, 2009 May 8th and 9th , 2009 Le Palais des Congrès de Paris 2, Place Porte Maillot Niveau 3, côté Paris F-75017 Paris France

Dermot McGrath in Paris ENHANCED safety and better visual outcomes are among the clear benefits of combining a femtosecond laser for flap creation with wavefront-guided,iris- recognition technology for the actual ablation,according to a study presented here by Michael Assouline MD,PhD. “In comparing the different techniques in over 1,000 eyes over a period of five years, there is no doubt that the customised approach using a wavefront-guided system and femtosecond laser (UltraLASIK) delivered better outcomes with less complications than traditional LASIK with a mechanical microkeratome,” he said. Addressing the annual meeting of the French Implant and Refractive Surgery Association (SAFIR),Dr Assouline,in private practice in Paris,said that evaluations of his own patient outcomes as well as other reports in the published literature suggest that the mechanical microkeratome may find itself increasingly supplanted by the femtosecond laser for the creation of the flap in LASIK procedures. “If we look at the safety data,Dr Karl Stonecipher already reported at the ESCRS meeting in Stockholm last year that using a femtosecond laser to create the LASIK flap significantly reduced complications by a factor of four to 10 times,depending on the type of complication involved.In my own series of patients,I found an average of between two to five times less complications. So whatever safety criteria we look at – whether epithelial abrasion,incomplete flap, epithelial ingrowth,retreatments,ectasia,and so forth – the femtosecond flap offers enhanced safety and better visual outcomes for our patients,” he said. Dr Assouline’s retrospective study included a total of 1186 eyes,divided into four separate groups:group 1 included 280 eyes treated with standard LASIK (Planoscan and Hansatome microkeratomes,Bausch & Lomb);group 2 included 192 eyes treated with mechanical microkeratome and wavefront-guided ablation (Zyoptix,Bausch & Lomb,and Hansatome);group 3 included 342 eyes treated with femtosecond laser and customised wavefront-guided ablation with iris recognition (IntraLase FS30,Zyoptix Z100).The final group included 372 eyes which were also treated with femtosecond laser and customised wavefront-guided ablation with iris recognition but without any dilation. All eyes underwent complete postoperative evaluation of best-corrected visual acuity,uncorrected visual acuity,higher order aberrations,optical zone,residual stromal bed,and complications,with a follow- up ranging from one to five years,said Dr Assouline. In terms of refractive outcomes,Dr Assouline said that there was a slight advantage for the eyes treated with the femtosecond and wavefront-guided combination. “The results are impressive as we can see that between 91 per cent and 93 per cent of these eyes are less than 0.50 D from emmetropia in the 0 to -6.0 D myopic treatment range,” he said. Low astigmatism rates with femto laser Dr Assouline said that an important factor in the better quality of vision in the femtosecond laser wavefront-guided ablation group was related to the significant amount of astigmatism correction. “About 70 per cent of UltraLASIK eyes in the low myopic treatment range have less than 0.25 D of residual astigmatism compared to between 30 per cent and 40 per cent for those treated using the traditional method.There was also a significant difference for the -6.0 to -10.0 D treatment group,” he added. The results for higher-order aberrations and visual acuity in low contrast conditions also showed a statistically significant difference in favour of femtosecond and wavefront-guided LASIK compared to traditional LASIK. Dr Assouline noted that one of the clear advantages of the customised wavefront-guided approach is the fact that it spares about 20 per cent more corneal tissue thanks to the Zyoptix system’s advanced treatment algorithm.He added that the system also allows an optical zone enlargement using the same tissue depth to treat eyes with very large pupils (over 7.0mm) and to treat eyes with high refractive defects. This enlargement allows a lesser spherical aberration induction (lower asphericity coefficient modification) and a better quality of vision for the patient. Putting the overall results into context,Dr Assouline said that the femtosecond and wavefront-guided customised ablation represents a clear advance over traditional LASIK. “The femtosecond cut offers enhanced safety with fewer complications than mechanical keratomes.Customised wavefront- guided treatments also add an extra layer of security because the entire process is automated from the initial aberrometry measurements through to the actual ablation with less opportunity for human error.Finally,the advanced algorithm of the Zyoptix platform enables us to save tissue, work with larger optical zones,reduce induced optical aberrations and correct pre- existing optical aberrations to a high degree of precision,” he said. ma@inclo.com 15 Femtosecond, wavefront-guided combination offers superior results, study finds Refractive Laser Michael Assouline

Dermot McGrath in Berlin LONG-TERM clinical experience with the Visian Implantable Collamer Lens (ICL, Staar Surgical) demonstrates consistently high rates of refractive success,good safety and excellent patient satisfaction, according to Carlo F Lovisolo MD. “This lens has proved its viability and safety over the long term with over 100,000 ICLs now implanted worldwide. From this experience and my own clinical experience of over 1,000 implantations,it is clear that chronic IOP rise is not an issue with this lens,nor has there been any problem with chronic uveal inflammation.Once the proper sizing indications are respected,the ICL is safe for the corneal endothelium,” he told delegates attending a special session on phakic IOLs held during the XXVI Congress of the ESCRS in Berlin. Dr Lovisolo,medical director, Quattroelle Eye Centre in Milan,Italy,said that four generations of the sulcus-fixated posterior chamber phakic IOL were implanted over the course of the 15-year study,the majority of which were the latest model,the V4,with improved vaulting to reduce the possibility of contact with the crystalline lens. He noted that there were some known problems with earlier iterations of the implant,including undersizing and decentration with the first-generation lens,and anterior subcapsular cataract with the V2 and V3 models implanted between 1996 and 1998 (Figure 1). The main difference between the V3 and V4 models was a steeper radius of curvature,which provided about 170 microns more clearance between the non- compressed IOL and the crystalline lens, thereby reducing the incidence of anterior subcapsular cataract. Dr Lovisolo said that long-term concerns with all phakic IOLs include complications such as chronic IOP rise, pigment dispersion,corneal endothelial loss,damage to zonules,uveal inflammation and cataract. Looking at these complications in more detail,he said that with follow-up of up to 15 years in some patients,there appears to be no problems of sustained chronic IOP rise in patients implanted with the ICL.Nor is there any issue with the biocompatibility of the implant over the long term,he added. “I have seen no problem of inflammation in patients up to 15 years after implantation,so the material appears to be well tolerated by the ocular structures,” he said. The data on endothelial cell loss is also similarly positive,he said.In a study of 211 eyes after eight years and 64 eyes after 10 years,endothelial cell counts showed a cumulative cell loss over the first year of 2.99 per cent,followed by a mean annual loss of 0.61 per cent,which is similar to normal physiology. Dr Lovisolo said that such data strengthens the case for widening the indications for ICL implantation beyond their original scope. “The studies show that the iris barrier of the lens prevents mechanical chafing, there is no metabolic interference and no ongoing cell loss.As a result,the current guidelines on minimum endothelial cell count should not be the same as for anterior chamber phakic IOLs. So we can perhaps consider implanting this lens in situations that were previously contraindicated such as post penetrating keratoplasty or for patients with stable keratoconus after ring segment implantation or corneal cross linking,or for chronic contact lens wearers with low endothelial cell counts,” he said. Dr Lovisolo noted that one of the major concerns with the ICL implant is the possibility of anterior subcapsular opacities, which in some instances become clinically significant and require cataract surgery. “This particular problem may be due to the lack of an adequate vault in certain patients,but other factors such as sub- clinical inflammation,blockage of aqueous circulation,metabolic disturbances or lack of nutrient flow to the crystalline lens might also play a role,” he said. This type of opacity should also be differentiated from non-progressive surgery-related opacities,which can remain unchanged over many years,he said. Dr Lovisolo noted that most late postoperative complications associated with ICL implantation,such as after- cataract and iridopathy,are size-related and can be thus avoided with proper anatomical measurements. “The key to a successful outcome is to have the correct vault,remembering that the vault depends on lens design,lens behaviour under compression and anterior segment dimensions.We now know that sizing cannot be based on external anatomy,as white-to-white measurements correlate poorly with internal dimensions (Figure 2).To correctly predict implant-to-tissue clearances,the ICL must be customised to the individual size and shape of the whole anterior segment as obtained with VHF ultrasonography,” he said. In terms of anterior segment shape,Dr Lovisolo said that surgeons should remember the mantra that “the only rule is that there is no rule”.He cited a recently published study by Werner, Lovisolo et al in the Journal of Cataract and Refractive Surgerythat evaluated meridional differences in angle-to-angle and sulcus-to-sulcus dimensions in human cadaver eyes using very high frequency ultrasound (VHF US) and anterior segment optical coherence tomography (AS-OCT). The study found that the internal geometry of the anterior segment of human eyes does not constitute a circle,a fact that may have significant relevance for the accurate sizing of phakic intraocular lenses. Dr Lovisolo said that latest generation devices such as the VuMax Ultrasound Biomicroscope (Sonomed) combined with the Lovisolo Custom Phakic IOL Sizer software (Figure 3),now enable surgeons to obtain precise anatomical measurements and predict factors such as IOL compression (Figure 4) and vault height for more accurate sizing of the implant in the eye.He added that implanted eyes should be monitored yearly after implantation to take account of the progressive anterior displacement and thickening of the crystalline lens. carlo.lovisolo@quattroelle.org 16 Carlo F Lovisolo ICL implant is viable and safe over the long term Refractive Lens Figure 1: Typical iatrogenic anterior subcapsular opacities of the crystalline lens caused by the lack of vaulting of an undersized ICL Figure 3:Snapshot of the Lovisolo Phakic IOL Sizer®Figure 4: Finite element analysis (Ansys™) predicts the intraocular deformation of the lens implant under compression Figure 2: VHF echography (Artemis 2, Ultralink) image of an angle closure glaucoma induced by an oversized ICL, emphasised in red. The overall length was correctly chosen on the basis of the horizontal white-to-white distance

14–17 May 2009 Nice Acropolis Centre, Nice, France 99TTHHEEUURREETTIINNAA CCOONNGGRREESSSS EEUURREETTIINNAA 22000099 European Society of Retina Specialists NNiiccee,, FFrraannccee

Devon Schuyler RANIBIZUMAB (Lucentis,Genentech) and pegaptanib (Macugen,Pfizer) appear to inhibit the growth of corneal blood vessels, according to preliminary research. Ranibizumab also appears to inhibit the growth of lymphatic cells in the cornea. “This was the first study to analyse the effects of Macugen and Lucentis on hemangiogenesis and lymphangiogenesis both in the in vivo and in vitro models,” said Anand Parthasarathy MD,in an interview with EuroTimes.He said he hoped that the agents might be used to prevent or treat pathological corneal neovascularisation and corneal graft rejection. Agents that inhibit vascular endothelial growth factor (VEGF) are widely used to treat macular degeneration and diabetic retinopathy.Dr Parthasarathy said he got the idea to use anti-VEGF agents in the cornea after research showed that levels of corneal VEGF mRNA increase after removal of the limbal epithelium. Because overgrowth of blood and lymph vessels “are part of the immune arc for corneal transplantation rejection,” he wanted to see if he could use anti-VEGF agents to suppress hemangiogenesis and lymphangiogenesis. “Though the original use for anti-VEGF agents was for retinal diseases,anterior segment surgeons from both cornea and glaucoma specialties have rapidly adopted them and the indications are expanding to include diseases with limbal stem cell deficiency like chemical injuries or any diseases where VEGF is involved in the pathogenesis,” he said. Dr Parthasarathy,who did his work under the guidance of Claus Cursiefen MD and colleagues at the University of Erlanger- Nürnberg in Erlangen,Germany,presented his data at the annual meeting of ARVO in Fort Lauderdale,Florida.Dr Parthasarathy practises at the TN Shukla Eye Hospital in Jabalpur and the Vasan Eye Care Hospital in Chennai,India. For the in vitro study,the researchers analysed the effects of ranibizumab and pegaptanib on cell cultures of human blood endothelium and lymph endothelium.They found a “significant antiproliferative effect” of ranibizumab and pegaptanib on both types of cells. For the in vivo study,the researchers used a mouse model to simulate inflammatory corneal neovascularisation.Three interrupted 11-0 nylon sutures were placed in the stroma of 30 six-week-old BALB/c mice,and the central 2mm of the corneal epithelium was debrided.Ten mice received ranibizumab drops (5 mg/mL) and 10 received pegaptanib drops (1 mg/mL) four times a day for four days.The 10 control mice received saline drops according to the same schedule. After one week,the mice were euthanised. The corneal flat mounts were stained with CD31 as a panendothelial marker,and image analysis software was used to conduct morphometry of the blood vessels. The researchers found that both ranibizumab and pegaptanib significantly inhibited the growth of blood vessels.In addition,ranibizumab inhibited the growth of lymphatic vessels.Dr Parthasarathy said this made sense because ranibizumab binds to all forms of VEGF-A,whereas pegaptanib blocks only specific forms of VEGF-A. “Lucentis and Macugen have different methods of action;Lucentis inhibits all isoforms of VEGF,while Macugen is specific for the VEGF 165,” he said. Because the growth of lymphatic vessels contributes to graft failure,ranibizumab might be able to increase the survival of both high- and low-risk grafts.Dr Parthasarathy proposed that pegaptanib might be useful for pathologies that are unrelated to grafts,with the potential advantage of fewer side effects. Based on their results,Dr Parthasarathy has used the agents in three patients with corneal vascularisation who were at high risk for penetrating keratoplasty.One patient had corneal leukoma following trauma,and the other two had longstanding pseudophakic bullous keratopathy with vascularisation that was four quadrants deep.He noted that there are also published reports on the use of anti- VEGF agents in humans for chemical burns. Dr Parthasarathy said that he and his colleagues are conducting further studies to arrive at an optimal concentration by looking at varying concentrations of topical ranibizumab and pegaptanib,and whether intact epithelium or epithelial debridement would have an effect on the in vivo model. He added that the researchers are also conducting further analysis of the variation in lymphangiogenesis between the drugs. 21 Anti-VEGF agents used to inhibit corneal neovascularisation Cornea Update

Roibeard O’hEineachain GLAUCOMA is the leading cause of irreversible blindness worldwide but several landmark studies over the past decade have demonstrated that it may be possible in a high proportion of cases to prevent early disease from becoming symptomatic and to prevent symptomatic cases from progressing to total blindness. There is,therefore,now an urgent effort under way to find ways of detecting the disease at its earliest stages,when there are structural changes to the optic nerve but no detectable loss of vision,and to track the progression of disease in order to assess the effectiveness of a given treatment in a given patient and determine whether further intervention may be required. Among the means under investigation include new imaging technologies for visualising the optic nerve head and new types of perimetry that detect subtle changes in the functioning of a patient’s retinal ganglion cells not detectable with standard automated perimetry (SAP). But these new technologies raise many questions.For example,do the new imaging technologies genuinely represent what is physically occurring in the optic nerve head and retinal nerve fibre layer? And are the new perimetry technologies more sensitive than standard automated perimetry? And in lieu of long follow-ups of large numbers of patients,how is it possible to prove that either type of new technology is superior to the current gold standards for structural and functional testing? Moreover,given that,according to most epidemiological studies,half of glaucoma patients are undiagnosed,what role may these new technologies have in screening for glaucoma? Do they have enough sensitivity and specificity to provide a cost- effective means of population screening,or will they miss some cases or will they lead to false diagnoses and extensive unnecessary investigations? The need for objective measurements Stereo optic disc photographs are the current gold standard for detecting glaucomatous structural changes.They are ideal in the sense that ‘the camera does not lie’.The difficulty arises in their interpretation,which can vary not only between different glaucoma specialists,but between different viewings by the same glaucoma specialist,noted Ananth C Viswanathan FRCOphth MD Moorfields Eye Hospital,London UK. Speaking at a special session of the 20th Anniversary Congress of the Royal College of Ophthalmology in Liverpool,Dr Viswanathan cited a study carried out by the AGIS investigators where 14 glaucoma specialists viewed a series of 26 optic nerve stereophotographs with varying degrees of glaucomatous disease.The specialists were asked to determine the degree of notching of the optic disc.The researchers found that the specialists disagreed substantially in 58 per cent of cases. Furthermore,when 10 of the glaucoma specialists were asked to view the same disc stereophotographs again,all classified some of the cases differently than they had previously and over half reclassified at least four cases. Disagreement between specialists may also prevail with regards to the use of stereophotographs for determining glaucoma progression,Dr Viswanathan noted.In a study carried out at the Wilmer Eye Institute (Jampel et al.Am J Ophthalmol.2008 Sep 12;:18790472), three glaucoma specialists were presented with two stereophotographs from 164 glaucoma patients taken a median of 26 months apart and asked to judge whether the eyes were getting worse. The proportion deemed to have progressed by the three observers ranged from seven per cent to 38 per cent.All three expert observers reached a consensus that just two of the discs were definitely getting worse,while two out of three agreed that 10 were getting worse. However,the specialists were masked regarding the actual sequence of the stereophotographs and,in fact,50 per cent of those discs for which a consensus had been reached by two or three specialists as having progressed were actually taken at the beginning of the study. “So I think we need some help here from the machines.We need to try and reduce observer variation.” Diagnosis dependent on normative databases The three main diagnostic imaging devices in use today are the Heidelberg Retinal Tomographer (HRT,Heidelberg Engineering),the GDx,and the Stratus OCT (Carl Zeiss Meditec).All three are designed to provide objective measurements of the optic nerve and or the peripapillary region and all have accompanying software for comparing their measurements with normative databases. “The current machines do work in different ways but produce similar results and single test diagnostics with these devices are really dependent on good quality normal database,” said Stephen A Vernon DM FRCS FRCOphth,Department of Ophthalmology,University Hospital, Nottingham,UK,who also spoke at the Liverpool congress. The HRT is a confocal scanning laser ophthalmoscope.Using a rapid scanning 670 nm diode laser,the computer creates,point by point and layer by layer,a three- dimensional image of the optic disc region. The HRT also provides reflectance images from the light reflected from the surface of the optic disc,and converts the image into a topographic map. In early models of the HRT,the computer software required the operator to manually determine the outline of the disc so that it could calculate whether or not the disc was abnormal,using the Moorfields regression analysis algorithm. To reduce inter-operator variability in defining the disc margins,the HRT III has software that can automatically analyse the profile of the disc and define its outline.The software also compares the disc profile with a normative database specific to three ethnic groups (Caucasian,African and Asian) and arrives at a glaucoma probability score. “But all of these things depend on a normal database.As a result the glaucoma probability score and Moorfields regression analysis seems to suffer from the same problem.They’re not very accurate in small and large discs.That is because if you do a large study of normal people as we did in the Bridlington study of over 3500 elderly people,the norm spreads out as the optic disc gets bigger,” Dr Vernon noted. The GDx VCC uses confocal laser scanning in a different way,based on the principle of birefringence.The microtubules of the retinal nerve fibre layer (RNFL) have birefringent properties because they are thinner than some wavelengths of light and have a polar structure. The GDx VCC exploits this by polarising a laser’s light into two components perpendicular to each other so that they proceed at different velocities through the birefringent RNFL.The difference in velocity between the two components of the polarised light is directly proportional to the thickness of the RNFL. The GDx uses its measurements to produce reflectance and retardation maps of the optic disc and the peripapillary and macular regions.The reflectance image comes from the light reflected directly back from the surface of the retina,and appears as the fundus image on the monitor and printouts.The retardation image is a map of the retardation values converted to RNFL thickness. The GDx also facilitates interpretation of the images by comparing them with a normative database and uses neural network analysis to calculate a score that indicates the likelihood of the optic disc being abnormal. “Like every other machine using a normal database there will be normal people outside the normal range,” Dr Vernon noted. Optical Coherence Tomography,or ‘OCT’,is often described as ‘optical ultrasound’,because like ultrasound it depends on interface “echoes” for its functioning.But instead of ultrasonic vibrations it uses an infrared laser.As with ultrasound,the delay of the reflected light correlates with the thickness of the structure being measured. The Stratus OCT obtains RNFL measurement of the peripapillary region and its software compares it with a normative database,graphed in a TSNIT (temporal,superior,Nasal Inferior and temporal) orientation.The Stratus OCT now also has glaucoma progression analysis that plots RNFL thickness over time and reports any statistically significant change and the rate of change. “You can use it as a quantitative and qualitative scan but although the analysis does correct for age,it does not correct for the normal variations of RNFL thickness that occur with increased axial length and optic disc size.So what we need are individual databases for these various types of eyes,” Dr Vernon added. Practical considerations of diagnostic imaging Achieving the best results with diagnostic imaging technology requires a considerable investment of money and time,said Prof Peter Shah MD,Birmingham & Midland Eye Centre,Birmingham UK. “I have an HRT in my practice and a GDx in my research practice and I can tell you that without good technical back-up they have the potential to produce poor quality data.Are you going to invest in that technical back-up if you have many competing needs in your department? That’s a decision you need to make if you are clinical director,” he added In addition,with currently available diagnostic imaging technology it is difficult and time consuming,and sometimes impossible,to produce useful results in a significant proportion of glaucoma patients, including those with small pupils,any media opacity,or any difficulty keeping still.In some of the more difficult patients a good scan can take the most experienced operator up to 20 minutes,Prof Shah said. “In my practice,I have a lot of elderly patients who are unwell,on multiple systemic and topical medications,they may be wheelchair bound,they may have a tremor,they may not be able to get their neck into the machine because they have cervical spondylosis.In the real world it can be very difficult to get good pictures,” he added. No gold standard for glaucoma progression One of the difficulties in assessing the accuracy of a diagnostic imaging technology and the various forms of visual field testing 22 Ananth C Viswanathan New diagnostic technologies have an evolving role in the clinical management of glaucoma Glaucoma Update

is the absence of a defensible criterion for glaucoma progression that they can be measured against,said Balwantray Chauhan PhD,Dalhousie University,Halifax,Canada. “There isn’t an external gold standard for progression,so progression is therefore necessarily criterion dependent.I suppose at the most fundamental level if you could image and test the function of the individual retinal ganglion cell you would find parity in the relationship between the structural and functional change.But what we measure clinically are surrogates for what we really want to measure,” he said at the Eighth Congress of the European Glaucoma Society in Berlin. As a result of the indirect nature of the measurements,there is generally a poor concordance between findings of structural and functional change in most studies where glaucoma patients have been monitored over several years,Dr Chauhan noted. Furthermore,in large randomised studies like the Ocular Hypertension Treatment Study (OHTS) and the Early Manifest Glaucoma Trial (EMGT),visual field and optic disc change have variously been shown to occur first.But those studies each had their own criteria for disease progression and findings from different studies may not be comparable. “I think from a clinical perspective it is better to talk about a disc change or field change rather than glaucoma progression. Glaucoma progression is really a complex issue to define so we should probably stick with simpler definitions that have a more solid basis,” Dr Chauhan added. Newer perimetry may be more sensitive Several new types of perimetry have become available over the past decade that are designed to more closely reflect visual field changes more sensitively than does SAP,currently the gold standard for visual field testing.However,validation of those technologies will require long follow-up, said Augusto Azuara-Blanco MD PhD,who also spoke at the Berlin EGS congress. ‘I think that standard automated perimetry will be with us for many years to come,” he commented. However,SAP uses a white background and white stimuli and provides a measure of overall visual performance and may therefore conceal the loss of certain types of retinal ganglion cells.Newer types of perimetry such as short wave automated perimetry (SWAP) and frequency-doubling technology (FDT) appear to detect loss of more specific classes of retinal ganglion cells.They may therefore,in theory,detect structural damage to the optic nerve earlier than SAP. Shortwave automated perimetry (SWAP) is similar to SAP except that it uses a yellow background and blue stimuli.It tests the activity of the blue-yellow ganglion cells and the konicellular layers of the lateral geniculate nucleus.In numerous hospital- based studies SWAP has shown greater sensitivity in detecting glaucomatous damage than SAP. However,SWAP requires a longer test time,has more variability,lower specificity and does not work well in patients with lens opacities,Dr Azuara-Blanco said. “I think that the original high expectations for SWAP have not been fulfilled,” he added. Frequency doubling perimetry appears to be showing more promise.Based on the frequency doubling illusion,FDT tests the activity of large parasol ganglion cells.The results of both hospital-based and population studies indicate that FDT can detect visual field loss with greater sensitivity and specificity than standard white-on-white perimetry. On that basis,FDT could have advantages over SAP for monitoring progression of visual field loss.However,long-term studies will be necessary to prove whether or not that is true. There are also a range of other new technologies under investigation for visual field testing such as flicker perimetry and motion perimetry,which measure the activity of the same set of retinal ganglion cells as FDT,and high-pass resolution perimetry,which measures the activity of the parvocellular ganglion cells.But research with those devices is still in the pilot stages,Dr Azuara-Blanco added. "SAP has evolved,and current fast strategies such as SITA and TOP are more accurate than the older ones." Consensus meeting finds population screening unjustified Despite the enormous costs of glaucoma to patients and society,there is insufficient evidence to justify population screening for glaucoma with currently available diagnostic technologies.That was the conclusion of a consensus meeting about screening for glaucoma organised by the World Glaucoma Association in April 2008,said Thierry Zeyen MD PhD who was a participant at the meeting. “When we want to screen for open- angle glaucoma we have four questions to ask.First,is open-angle glaucoma an important health problem? Second,is there an effective treatment? Third,is there an accurate screening test? And lastly,is the cost of screening economically balanced?” said Dr Zeyen,Leuven University Hospital, Leuven,Belgium. That glaucoma is an important health problem seems pretty clear,he noted.The prevalence of glaucoma is roughly one per cent among people aged 40 years,four per cent among people aged 80 years.Roughly 70 million are affected by glaucoma worldwide and according to most epidemiological studies,50 per cent are undiagnosed. Furthermore,according to the World Health Organization,glaucoma is the leading cause of preventable irreversible blindness worldwide.Population studies like Olmsted study and the St Lucia Eye Study indicate that around 10 per cent of patients diagnosed with glaucoma will go blind bilaterally and 20 per cent will go blind unilaterally after 20 years.Glaucoma also has an impact on the quality of life.It can contribute to falls and traffic accidents. Healthcare costs increase with the severity of the disease. Moreover,there is effective treatment for glaucoma;numerous randomised clinical trials have shown that IOP lowering medication can delay the onset and progression of primary open-angle glaucoma. On the other hand,it is much less clear whether there is an accurate screening test for glaucoma, since the sensitivity and specificity for population- based tests are unknown.Most studies have involved selected groups mostly hospital patients with a disproportio- nately higher rate of severe disease and involving clinicians with a lot of experience in identifying patients with the disease. As a result, mass population screening for the disease might yield a high proportion of false positives,which would in turn make it not very cost effective. A better approach might be to use opportunistic screening,taking IOP measurements, performing visual field tests and diagnostic imaging in patients aged 40-45 years who are at risk for developing glaucoma,during routine eye exams when they seek consultation regarding reading glasses,Dr Zeyen suggested.Another opportunistic screening strategy is to incorporate glaucoma case findings into already existing programmes (e.g.eye examination related to the driver licence). “Glaucoma screening may be more cost effective when the initial assessment is supervised by known medical technicians screening for multiple diseases.For example if you set up a programme screening for diabetes with fundus photographs you can take that opportunity to also look at the optic disc,” he said. a.viswanathan@ucl.ac.uk stephen.vernon@nuh.nhs.uk Shah.Peter@swbh.nhs.uk bal@dal.ca aazblanco@aol.com thierry.zeyen@uz.kuleuven.ac.be 23 Glaucoma Update

Dermot McGrath in Vienna A SPECIALLY adapted vertical OCT system can help shorten the duration of face-down positioning after macular hole surgery,according to Claus Eckardt MD. “We would all be happy if we could spare our patients the discomfort of face- down positioning after macular hole surgery or at least shorten its duration. No matter what resources one uses,it remains a torture for the patient.Using the vertical OCT allows us to determine within 24 hours if the macular hole has been closed and helps us to avoid prescribing unnecessarily long face-down positioning,” said Dr Eckardt,Augenklinik Staedtische Kliniken in Frankfurt, Germany. Addressing the annual meeting of the European Society of Retina Specialists (EURETINA),Dr Eckardt said that patients are usually required to remain in a face-down position for one to three days or even longer following macular hole surgery. This prone position allows the air or gas bubble that has been inserted by the surgeon to press against the macula and be gradually reabsorbed by the eye, thereby sealing the hole.As the bubble is reabsorbed,the vitreous cavity refills with natural eye fluids. In order to examine the patient in the prone position,Dr Eckardt said that he uses a remodelled Topcon OCT with a mobile armature. “We had the OCT remodelled so that the angle of the optical beam is rotated by 90 degrees,thus the beam no longer strikes the eye horizontally but vertically. It makes a major difference.My colleagues and I can no longer imagine performing macular hole surgery without the vertical OCT.This new technique is extremely helpful for us and it motivates patients to remain in the face-down position as they await their next OCT examination,” he said. In order to assess the efficacy of the new system,Dr Eckardt and colleagues recently completed a study of 33 patients treated for macular holes with air tamponade and OCT-based duration of facedown positioning. After 24 hours,OCT analysis showed that the hole was definitely closed in 54 per cent of patients and questionably closed in nine per cent. Patients whose macular holes were definitely closed 24 hours postoperatively did not need to remain in a face- down position, whereas those whose macular holes were questionably closed had to remain in a face- down position for a further 24 hours. The macular hole was still open in 12 per cent of patients and OCT was not possible in 24 per cent due to clouding of the optical medium.Both of these groups of patients were also required to remain in a face- down position until the closure of the macular hole had been confirmed by OCT. After three days, the macular holes were closed in 91 per cent of eyes,and were still open in the remaining three eyes (nine per cent). Dr Eckardt noted that of the four eyes (12 per cent) of patients whose macular holes were still open after the first day,only one hole closed during the following three days despite the patient remaining in the face- down position. “We can conclude from this that if a macular hole has not closed within 24 hours,there is only a slight chance that it will close during continued face-down positioning,” he said. For the three eyes whose macular holes had not closed after three days,the patients were reoperated on three to five days later using the same procedure.After three days in the prone position,two of the three holes had closed,reported Dr Eckardt. Excellent results with experience Dr Eckardt said that since the study was concluded,his team has continued using the same approach on almost 100 eyes with excellent results. “Our experience has been that even very large macular holes usually close within one day postoperatively and air tamponade has led to a successful closure of the macular hole in more than 90 per cent of our cases.In my opinion,this success rate makes longer-lasting gases unnecessary.And air also has the great advantage that OCT images of the macula can be obtained at the third day postoperatively or even sooner if a vertical OCT system is used,” he said. Even without a vertical OCT system,Dr Eckardt said that the use of air tamponade allows early re-operation should the hole fail to close after the first attempt. “This is a major advantage compared to perfluoropropane (C3F8) which allows OCT examination using conventional techniques only after about four weeks. Our results suggest that tamponade of the macula for longer than two days is of no tangible benefit to the patient,” he said. Dr Eckardt noted that while several previous studies have reported using a long-lasting gas without postoperative facedown positioning,this technique presented its own inherent problems. “While this is positive from the point of view of it requiring no face-down positioning,the major drawback to this approach is that the patients experience great irritation due to the gas bubble,” he said. In terms of the use of air tamponade, Dr Eckardt said that he was aware of only two previous studies where this approach had been tried.In 1999,Park and co- workers reported macular hole closure in 91 per cent of patients after four-day face- down positioning,while in 2003,Sato and Isomae achieved a macular hole closure rate of 91 per cent after only one day of prone positioning.The latter study, however,only included macular holes up to 400 microns in diameter,added Dr Eckardt. C.Eckardt@em.uni-frankfurt.de 24 Claus Eckardt Vertical OCT reduces the need for prone positioning after macular hole surgery Retina Update Figure 1b: Same eye one day after surgery (ILM peeling and air tamponade). The macular hole is closed. OCT imaging was obtained by a vertical Topcon-OCT Figure 1a:Preoperative photograph of a macular hole (size: 530 microns) Courtesy of Claus Eckardt MD

Howard Larkin IN THE wake of recent outbreaks of infectious keratitis among contact lens wearers due to Acanthamoebaparasites in the US and Fusariumfungi in the US and elsewhere,an expert panel convened by the US Food and Drug Administration (FDA) has recommended that ophthalmologists and other eye care professionals counsel patients to take more care in cleaning and wearing lenses. The FDA’s Medical Devices Advisory Committee Ophthalmic Devices Panel also recommended improvements in preclinical testing of multipurpose contact lens solutions to ensure efficacy against a wider range of infectious agents.In both the Acanthamoebaand Fusariumoutbreaks the use of specific multipurpose contact lens solutions were found to be primary contributing factors,according to research conducted by the US Centers for Disease Control and Prevention.The products implicated have been withdrawn from the market. The FDA panel recommendations are based on input from the American Society of Cataract and Refractive Surgery (ASCRS),the American Academy of Ophthalmology (AAO),the US National Eye Institute,the CDC and other interested parties.They likely will form the basis for new regulation of multipurpose contact lens solutions by the FDA. Lens care practices highlighted On the lens care side,the FDA panel recommended that patients be instructed to “rub and rinse” contact lenses daily,and avoid “no-rub” care regimens.Rubbing and rinsing lenses in contact lens solution – not water – has been shown to better remove biofilms,debris and adhesions thought to contribute to infections better than soaking in multipurpose solutions alone. While the panel stopped short of suggesting that “no-rub” solutions be banned,they recommended that “no-rub” products be required to meet the same standard of efficacy currently achievable with “rub and rinse” lens care regimens. Until such “no-rub” products are developed and their efficacy proven,patients should be encouraged to “rub and rinse,” the panel said.Several multipurpose contact lens solutions currently are marketed as “no-rub” products. Patients also should be counselled not to top off lens care solutions in lens cases, avoid rinsing lenses in water or saliva,and avoid swimming or going in hot tubs with contact lenses in place. “All the water we get in recreationally is contaminated,” William Ehlers,MD,of the University of Connecticut Health Center, told the panel. Contact lens and storage cases also should be replaced on a regular schedule as prescribed by a doctor,added Dr Ehlers, who represented the AAO,ASCRS,the Contact Lens Association of Ophthalmologists and the Cornea Society before the panel. “This is the first time in at least a decade that four large ophthalmic organisations have come together to develop recommendation with regard to lens care.” Counselling patients on lens care is particularly important because non- compliance with lens care regimens is thought to be a contributing factor in most contact lens-related eye infections, according to Malvina Eydelman,MD, director of the FDA’s ophthalmic device division. “This is a very unique medical device in that patients have enormous control over the rate of infection,” she said. However,relying on patients to properly care for contact lenses is problematic.Dr Ehlers cited research suggesting that nearly four out of five patients are not compliant with lens care or replacement schedules. He emphasised the need for eye care professionals to maintain a close relationship with patients to help ensure that they are following safe lens use practices. Better testing sought On the manufacturing side,the panel called for testing of multipurpose contact lens solutions for efficacy against a wider range of infectious agents before approval for sale.Currently,Acanthamoebais not one of the five challenge organisms used in preclinical testing of multipurpose solutions. In laboratory tests,most multipurpose solutions were found to be ineffective against at least one strain of Acanthamoeba, according to research presented to the panel by a CDC researcher.Not only should Acanthamoebabe added to the list, resistant strains isolated from infected patients should be used for testing when possible,the panel recommended. In addition,the panel recommended that solutions be tested on a wide range of lens materials,including silicon hydrogel lens,to ensure their effectiveness with each. Different lens materials respond differently to solutions,research presented to the panel shows.For example,some types of lenses absorb preservatives in lens care solutions,possibly weakening the solutions’ efficacy against some microorganisms. Multipurpose solutions also should be tested in conditions simulating the “real world”,including use of a solution at the lower end of the active ingredient specifications,the panel said.In addition, tests also should be conducted with no- rub,no-rinse soaking,and with rub and rinse times as short as five seconds and shorter than recommended soak times. This is particularly important as the lens care solution associated with the international Fusariumoutbreak,Bausch & Lomb’s ReNu with Moistureloc,was found to be very effective against Fusariumunder optimal conditions,but less so when used under common noncompliant consumer conditions,said Elmer Tu MD,of the University of Illinois at Chicago,who briefed the panel on the history of the two outbreaks on behalf of the four ophthalmology professional groups. Dr Tu also noted that a non-disinfectant ingredient in the ReNu solution may have interfered with its efficacy.This prompted a recommendation that any change in lens care solution,no matter how slight,be subjected to full preclinical testing.The panel also recommended that manufacturers establish and verify safe lens and solution storage timeframes,and mark products with disposal dates. But Dr Tu stressed that testing and improved patient hygiene will not be enough to completely eliminate microbial keratitis.He pointed out that the root causes of the outbreaks have not all been determined.In particular,while the Acanthamoebaoutbreak was statistically tied to AMO’s Complete MoisturePlus solution, withdrawal of the product from the market did not end the outbreak,and about half of the cases reported did not involve the solution. “This suggests that the underlying factors for the persistence of the Acanthamoeba keratitis remain unknown,” Dr Tu said. In addition to increased testing,a mechanism for monitoring contact lens infections and the organisms causing them could prove beneficial both in validating testing regimens,and protecting the public from infections,he added. 26 FDArecommends better lens hygiene to eliminate infections Ocular Update RECENToutbreaks of infectious eye disease associated with various lens care products have put the spotlight on contact lens health issues.The CLEER Project (Contact Lens European Evidence Reporting) is off to a good start,allowing ophthalmologists, opticians and optometrists to report incidents on an online database (www.cleer-project.eu). Since June 1 of this year,more than 70 eye care professionals from 10 countries have participated. The CLEER Project is being conducted under the auspices of the European Contact Lens Forum.The primary goal is to provide factual data about significant incidents in Europe induced by,or related to contact lenses, including non-corrective or cosmetic lenses.The data will be used to support efforts to regulate the supply of contact lenses in Europe in order to ensure the protection of the public.Such regulative legislation already exists in the UK and the US.Japan is considering introducing similar legislation. “The strong start and building momentum is very encouraging and shows that the European eye care professionals understand the importance of the CLEER Project. Recent regulation of non-corrective coloured contact lenses in Japan show that this is not an isolated effort in Europe alone,” said Helmer Schweizer, president of the EUROMCONTACT trade group. CLEER view of CL problems in Europe Wash hands and dry with lint-free towel before handling contact lenses. Avoid contact with water.Lenses should not be stored or rinsed in tap water or supposedly sterile water.Lenses should be removed for swimming or hot tub use. Never put lenses in the mouth. Do not use rewetting or saline solution as a disinfectant. Follow lens wear and replacement schedules specified by eye care professionals. Rub lenses and rinse with lens cleaning solution before soaking them. Regularly clean lens cases.Cases should be rinsed and allowed to air dry before reusing. Rinse lens cases with lens care solution, not water. Never reuse lens care solutions or top off solution in a case. Never allow the tip of the lens care solution bottle to touch any surface. Follow lens manufacturer guidelines for safe extended storage of lenses.In no case should lenses be stored for more than 30 days. Re-disinfect stored lenses before reuse. Understand that single-use disposable lenses are safest,and rigid gas-permeable lenses are safer than soft lenses. Understand that extended wear lenses increase infection risk.Only lenses specifically designed for extended wear should be used for extended wear. Contact lens care recommendations Developed jointly by AAO, ASCRS, Cornea Society and Contact Lens Association of Ophthalmologists, 2008

Pippa Wysong in Toronto CANADIAN research suggests the brains of older children (and possibly even adults) may be more neuroplastic than previously believed,opening the door to new treatments for amblyopia. In a paper published in the Canadian Journal of Ophthalmology,researchers found that older children with anisometropic amblyopia who had failed other treatments, achieved an improvement in best corrected visual acuity (BCVA) after daily use of spectacles that had a monocular telescopic device added on. Over a 24-week period,the subjects, some who were as old as 16 years of age, wore the glasses for half an hour daily over the amblyopic eye when watching television.During this time,the “good eye” was covered with a patch.According to Samuel Markowitz MD,associate professor of ophthalmology and director of the Low Vision program at the University of Toronto,use of the telescopic device over the amblyopic eye is exercising the part of the brain responsible for vision in the amblyopic eye. Unlike the effect one gets with spectacles where magnification is used,the telescopic device uses improved distance vision for training,eliminating the impact from accommodation,Dr Markowitz told EuroTimesin an interview.Telescopic low- magnification was used to help provide a larger field of vision as well as enhance the quality and clarity of the image sent to the brain,and provide a larger field of vision. Both aspects promote brain plasticity, he said. In general,young patients with amblyopia have poor compliance because they dislike not being able to see clearly when their good eye is patched.Methods such as patching “promote non-compliance,while compliance in our study was excellent,” Dr Markowitz said.He attributes this to the fact that kids could actually see a fairly clear image with the amblyopic eye with the telescopic device. Historically,treatments have been most effective when children are less than nine years of age,said Dr Markowitz.This has to do with the brain having greater plasticity during youth and better compliance,since amblyopia is largely a problem of vision interpretation by the brain. Eighteen patients (11 males and seven females) participated in this prospective, non-randomised efficacy trial.Patients with strabismic or deprivation amblyopia were excluded.Subjects were each prescribed a new pair of eyeglasses to give them BCVA and told to wear the glasses all day.They were also provided with a X2.2 Galilean telescopic device that could be attached to the glasses in front of the amblyopic eye, and told to use it for half an hour a day while watching television. Prior to use of the intervention,mean BCVA in the amblyopic eyes was 20/63.At a six-month follow-up visit,it had improved to a mean of 20/35.In 10 patients,BCVA improved to 20/25 or better. “Regardless of age,the brain can reorganise neural pathways,perhaps as effectively as it does in young children, meaning treatments may be as effective later in life as they are at a younger age,” he said. The fact that this group had an improvement in BCVA suggests that age may not be such a limiting factor in terms of restoring sight in patients,he said. In a second Canadian study,Robert Hess, PhD,professor of ophthalmology at McGill University in Montreal,used repetitive transcranial magnetic stimulation (rTMS) of the visual cortex in nine amblyopic adults. Findings were recently published in Current Biology. Transcranial magnetic stimulation (TMS) is a non-invasive method for stimulating parts of the brain by use of weak electric current that are induced into the tissue by use of rapidly changing magnetic currents. rTMS produces effects that last slightly longer than the actual time of stimulation.It is generally being used to study brain activity,with some clinical studies being done investigating its use for conditions such as stroke,migraine,dysphagia and other conditions. According to Dr Hess,there is reason to believe that when it comes to amblyopia, the cells in the part of the brain that are supposed to process vision in the ‘bad eye’ are actually still healthy and active.But amblyopes can’t get good vision because “those cells are actively being suppressed by the cells that are driven by the normal eye,” he said.“When amblyopes look through both eyes they see through only one eye because the other eye is suppressed.” rTMS affects the most excitable cells. “We reason that the most excitable cells will be those driven by the good eye.And if we can reduce their sensitivity a little bit, they might release the bad eye from the suppression,” he said. A total of nine adult patients with strabismic amblyopia were included in this exploratory efficacy trial.Amblyopia ranged from being fairly moderate to severe.All of the patients underwent testing with 1 Hz rTMS stimulation,and six also underwent testing with 10 Hz stimulation.In addition, five healthy controls with normal vision also underwent rTMS stimulation. “What we found is when we did 10 minutes of rTMS,we improved the vision in the amblyopic eye ...It didn’t change the normal eye but it did change the amblyopic eye,” he said. Only contrast sensitivity was measured before and after stimulation.Overall,all the six patients who underwent both the 1Hz and 10 Hz stimulation had a short-term improvement in contrast sensitivity. “They improved their contrast sensitivity by a factor of two.That didn’t mean their contrast sensitivity was normal,” just that it improved in relation to their good eye, he said. “The fact that it does work in adults means it could form part of a new treatment for adults.But even if [rTMS] doesn’t,it still means something scientifically.It means that a significant fraction of visual loss is recoverable.Even if we don’t use TMS in the future there may be other things we can use.It’s still worth trying to recover vision in these people,” Dr Hess said. Neuroscience research In recent years neuroscience studies have shown that there is still some degree of plasticity in the brain in adults too,said Cheryl Grady,PhD,a neuroscience researcher at Toronto’s Rotman Research Institute at Baycrest.She was not a part of the study,but spoke to EuroTimesabout plasticity in general. Neuroscience research has also shown that in depression,specific patterns of brain activity are seen through fMRI during depressive episodes.However,some research demonstrated that cognitive behaviour therapy and antidepressants lead to a different pattern of brain activity – patterns that are not depressive;another indicator of plasticity.This sort of brain exercise can affect and improve mood. In more recent years,it was discovered that a part of the brain,the hippocampus, actually has a region that contains a type of neural stem cells.Triggering the growth of new cells could,one day,be a way to enhance brain plasticity too. snm@on.aibn.com cgrady@rotman-baycrest.on.ca robert.hess@mcgill.ca 28 Samuel MarkowitzRobert Hess New advances in amblyopia treatment Ocular Update Telescopic training deviceTMS stimulation of the visual cortex Courtesy of Samuel Markowitz MDCourtesy of Robert Hess PhD

Stefanie Petrou Binder MD in Berlin THE 2008 German survey of cataract and refractive surgery revealed a marked rise in new diagnostic platforms and customised treatment approaches.The investigators predicted these numbers would continue to rise. The survey also showed that LASIK was still the most popular and commonly performed refractive surgical procedure, and that femtosecond laser systems became more widely used for flap creation.New laser and microkeratome systems gained widely in popularity. “The 2007 and 2008 surveys of cataract and refractive surgery in Germany reflect the current trends and practice styles of cataract and refractive surgery. Femtosecond laser systems were prominent as were wavefront-guided or optimised LASIK treatments,” said Mike Holzer MD, at the DGII (German Society for Intraocular lens Implantation, Interventional, and Refractive Surgery) session of the XXVI Congress of the ESCRS in Berlin, in which he reported the results of the 2008 refractive and 2007 cataract surgical surveys of the DGII. The investigators surveyed 274 refractive surgeons who were members of the DGII, the KRC (Commission of Refractive Surgery),or were found by means of an internet-based search,which located surgeons performing, refractive and laser surgeries. They compared the 2008 results to previous DGII survey data obtained in 2005.The number of refractive surgeons surveyed in 2005 was 267. The survey consisted of a two-page questionnaire with multiple choice questions.The investigators hoped that keeping it simple would help get a higher response rate.The evaluation was anonymous,and the tabulation and analysis was done using Microsoft Access and Excel programmes.The overall response rate was 43.2 per cent. The majority,62 per cent,of German refractive surgeons operated in laser centres or private practices,compared with 77 per cent in 2005.Up to 25 per cent operate out of general hospitals, nearly twice as many as in 2005,and 13 per cent operated out of university hospitals,about the same as in 2005. The most commonly performed refractive procedures were:LASIK (64.2 per cent) followed by refractive lens exchange (11.5 per cent),phakic IOLs (6.9 per cent),PRK (5.5 per cent),EpiLASIK (3.1 per cent),LASEK (4.0 per cent),and Intacs (0.4 per cent).Superficial treatments like LASEK,PRK and EpiLASIK, combined,made up about 12 per cent of refractive surgeries,Dr Holzer observed. Similarly,refractive options such as refractive lens exchange and phakic IOLs comprised another 12 per cent and seven per cent,respectively. The number of LASIK procedures performed per month in the 2008 survey showed that almost 35 per cent performed between 1-10 LASIK surgeries per month (40 per cent in 2005),17 per cent performed between 11-20/month (25 per cent in 2005);about five per cent did 21-30/month (17 per cent in 2005),six per cent did 31-40/month (seven per cent in 2005),five per cent did 41-50/month (five per cent in 2005),two per cent did 51-60/ month (six per cent in 2005),four per cent did 61-70/month (one per cent in 2005),and about one per cent did over 100/month in 2008 (similar to 2005). Overall,the numbers did not change dramatically between 2005 and 2008,Dr Holzer said. The popularity of excimer laser systems showed some firm favourites:29 per cent of surgeons used the Allegretto Wavelight system,25 per cent used Kerakor 217/217Z (Bausch & Lomb),21 per cent used ESIRIS (Schwind),nine per cent used the MEL 80 (three per cent the MEL 70) (Carl Zeiss Meditec),nine per cent the VISX S4 (AMO),three per cent the Amaris (Schwind) although it had only just been introduced,and one per cent used the Nidek EC. The survey showed that excimer laser systems were installed in different types of centres,including laser centres,private practices,university hospitals and general hospitals.While Dr Holzer noted no real trend toward any specific system,laser centres tended to have the highest number of Wavelight (Allegretto) systems and university hospitals had the highest number of Kerakor systems. Mechanical microkeratomes were used in all types of surgical centres,without preference.Interestingly,the Hansatome was used only half as much in 2008 (26 per cent) as in 2005 (59 per cent).The Zyoptix XP was used in 20 per cent of surgeries implementing mechanical microkeratomes,and the use of the Pendular (Schwind) almost doubled since 2005,to 17 per cent.Surgeons used the Amadeus less than in 2005,showing a decline from 15 per cent to eight per cent,in 2008.The Amadeus II was used by 12 per cent. Among femtosecond laser systems,the vast majority (72 per cent) used the IntraLase FS (AMO),14 per cent used the VisuMax (Carl Zeiss Meditec),seven per cent used Femtec (20/10 Perfect Vision), and seven per cent used Femto LDV (Ziemer) The implementation of diagnostic devices largely corresponded to the laser systems that were used.Interestingly,the Pentacam (15 per cent) and the Pentacam HR (13 per cent) (Oculus) were used in almost 30 per cent of refractive surgeries. This revealed a definite preference on the part of surgeons,as the Pentacam is not part of any specific excimer laser system. There was no trend with respect to what types of centres installed these diagnostic devices. The 2007 cataract survey was given to members of the DGII,BVA (German ophthalmologists) and BDOC (German ophthalmic surgeons),totalling 701 eye surgeons at 327 surgical sites.The overall response rate was approximately 40 per cent. Cataract surgeries in Germany in 2007 totalled 388,107,of which 76 per cent were performed in private practices and 24 per cent in clinics. The most commonly implanted IOL (58 per cent) was hydrophobic acrylic,then hydrophilic acrylic (33 per cent),and silicone (nine per cent),with PMMA not playing any role at all. German surgeons continued to prefer peribulbar or retrobulbar injections in 63 per cent of cataract surgeries.They used topical anaesthesia in 25 per cent and general anaesthesia in 12 per cent of cataract surgeries. mike.holzer@med.uni-heidelberg.de 30 Mike Holzer German survey shows marked trend toward customised LASIK treatments in refractive surgery Ocular Update

31 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 Cornea Daye-Posterse-Posters e-Posters Basic Optics Course FRIDAY Symposium “Endothelial Keratoplasty” Cataract Course (Part 1) Refractive Course (Part 1) Wetlabs Wetlabs SATURDAY Symposium & Live Surgery “Refractive Cataract Surgery” Cataract Course (Part 2) Refractive Course (Part 2) SUNDAY Symposium “Stretching the Limits of Excimer Laser Surgery” Free Papers Practice Management Programme BREAK Free Papers BREAK Wetlabs PRELIMINARY PROGRAMME OVERVIEW New this year to the scientific programme: For experienced surgeons and those in private practice – Practice Management Programme Presentation Skills Risk Management Marketing Your Practice For Residents and those in training – Integrated Didactic Programme Basic Optics Course Cataract Surgery Didactic Course Refractive Surgery Didactic Course 13th ESCRS Winter Meeting in conjunction with SOI (Italian Society of Ophthalmology) Cavalieri Hilton Hotel, Rome, Italy 6–8 February 2009 Online registration now available New extended didactic programme For more details see www.escrs.org

13th ESCRS Winter Meeting Part I. Visual Optics 08.00Speaker to be confirmed Corneal topography and IOL power calculation 08.20F. Van de Velde BELGIUM Light propagation in the eye 08.40Speaker to be confirmed Aberrations of the optical system 09.00A. Glasser USA Optics of crystalline lens 09.20M.J. Tassignon BELGIUM IOL designs 09.40R. Applegate USA Retinal image quality 10.00Discussion 10.15Break Part II. Visual Behaviour (Psychophysics) 10.35S. Plainis GREECE Visual psychophysics: Evaluating quality of vision 11.05T. Van den Berg NETHERLANDS Contrast sensitivity/glare. Importance of different domains of the point spread function 11.25H. Ginis GREECE Modelling the optics of the human eye 11.45A. Glasser USA Accommodative response: Binocular vision, visual electrodiagnosis 12.05Discussion 12.20Break Part III. Imaging the Human Eye 13.20Speaker to be confirmed Imaging the cornea 13.40Speaker to be confirmed Imaging of the anterior segment of the eye: Scheimpflug/OCT 14.00F. Van de Velde BELGIUM OCT - SLO of the retina 14.20A. Pallikaris GREECE Adaptive optics of the retina 14.40Discussion 15.00End of session CATARACT SURGERY DIDACTIC COURSE Part 1 Friday 6 February 15.00 – 17.00 15.00P. Ursell UK Learning how to learn cataract surgery Ergonomic Surgery 15.10M. Ward UK, D. Allen UK - Patient flow- Theatre nurses - Setting up microscope- Principles of surgery - Draping and anaesthesia Incisions 15.40J. Alio SPAIN -Temporal vs superior - Corneal vs scleral -Knife technology Capsulorhexis 16.00Speaker to be confirmed - Basic ergonomics - Use of needle and forceps - Staining - Tear out recovery 16.30Discussion 17.00End of session Part 2 Saturday 7 February 08.00 – 13.00 08.00D. Smerdon UK Teaching the teachers of cataract surgery 21st Century Phaco Dynamics 08.20R. Packard UK, E. Fabian GERMANY - Physics - Pump mechanisms - Tip technology - Power and delivery - BMICS vs CMICS Advanced Phaco Techniques 09.20A. Vasavada INDIA, A. Franchini ITALY, S. Morselli ITALY, R. Packard UK -For soft, medium hard cataracts -Phaco chop -BMICS vs CMICS 10.20Break 10.40Z. Biro HUNGARY Viscoelastics Premium Lenses 11.00Speaker to be confirmed Aspheric lenses 11.10M. Piovella ITALY Multifocals 11.20S. Daya UK Accommodating lenses 11.30T. Rabsilber GERMANY Toric IOLs 11.40B. Moriarty UK IOL-VIP 11.50G. Auffarth GERMANY New technologies - synchrony Video Symposium 12.00Complications and Complex Cases Video Judging Panel R. Packard UK, V. Piccardo ITALY, L. Benjamin UK, E. Dahan ISRAEL, P. Rosen UK 13.00End of session BASIC OPTICS COURSE Friday 6 February 08.00 – 15.00 Chairpersons: I. Pallikaris GREECE M.J. Tassignon BELGIUM Part 1 Friday 6 February 15.00 – 17.00 15.00C. Roberts USA Corneal topography and IOL power calculation 15.25D.S. Siganos GREECE Patient selection and preoperative preparation 15.40G. Kymionis GREECE Lasers in refractive surgery 15.55R. Bellucci ITALY LASIK - surgical technique 16.15T. Seiler SWITZERLAND Surface Ablation Techniques (SATs): Surgical technique 16.35D. Epstein SWITZERLAND Results of corneal refractive surgery 16.55Questions and answers 17.00End of session Part 2 Saturday 7 February 08.00 – 13.00 08.00T. Kohnen GERMANY Incisional and coagulative corneal procedures: Principles, technique and results 08.10J. Krumeich GERMANY Overview of microkeratomes 08.30J. Colin FRANCE Intrastromal corneal implants 08.40A. Marinho PORTUGAL Overview of phakic IOLs 09.00Speaker to be confirmed Refractive Lens Exchange 09.20O. Findl UK Multifocal IOLs 09.30G. Grabner AUSTRIA Presbyopia 09.50R. Applegate USA Quality of vision evaluation 10.10C. Roberts USA Biomechanics of the cornea 10.30Break 11.00J.L. Güell SPAIN Refractive reoperations and enhancements 11.20J.L. Alió SPAIN Customised ablational procedures 11.35V. Katsanevaki GREECE Non-optical complications of LASIK and corneal surgery 12.00V. Katsanevaki GREECE Optical complications of refractive surgery 12.15R. Nuijts NETHERLANDS Complications of phakic IOLs 12.35Questions and answers 13.00End of session REFRACTIVE SURGERY DIDACTIC COURSE 32

6–8 February 2009, Rome Friday 6 February 17.00 – 19.00 Endothelial Keratoplasty Chairpersons: L. Fontana ITALY R. Nuijts NETHERLANDS 17.00D. Ponzin ITALY Is the use of organ cultured precut tissue safe for endothelial keratoplasty? 17.15B. Allan UK Graft adhesion after Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) 17.30M. Holzer GERMANY Endothelial keratoplasty with the femtosecond laser 17.45Y.Y.Y. Cheng NETHERLANDS Quality of vision after femtosecond-assisted Descemet Stripping Endothelial Keratoplasty, DSAEK and PK 18.00M. Busin ITALY How to minimise endothelial cell loss and manage complications in DSAEK 18.15M. Muraine FRANCE Descemet membrane endothelial keratoplasty 18.30Discussion 19.00End of session MAIN SYMPOSIA Sunday 8 February 11.00 – 13.00 Stretching the Limits of Excimer Laser Surgery Chairpersons: J. Alio SPAIN F. Carones ITALY 11.00R. Lindstrom USA Is LASIK Safe? Global outcomes and patient satisfaction 11.12A. Marinho PORTUGAL LASIK and high myopia: What are the limits? 11.24R. Krueger USA LASIK without a flap 11.32Speaker to be confirmed When LASIK and when surface ablation? 11.44D. de Ortueta GERMANY Limits of hyperopic LASIK 11.52M.A. Arbelaez OMAN Wavefront: Myths and reality 12.00M. Jankow SERBIA Abnormal corneas, cross-linking and laser ablation. Can we make it? 12.08A. Artola SPAIN Presbyopia as the last frontier: Corneal multifocal LASIK 12.20Discussion 13.00End of session 14.59Live refractive cataract surgery (Two cases) Refractive lens surgery: Part III 15.27Accommodating IOL technology 15.35Accommodating IOLs: Pro 15.40Accommodating IOLs: Con 15.45Discussion 15.49Live refractive cataract surgery (Two cases) Refractive lens surgery: Part IV 16.17Toric IOL technology 16.24Toric IOLs: Pro 16.29Toric IOLs: Con 16.34Discussion 16.39Live refractive cataract surgery (Two cases) 17.06Enhancement with the aid of femtosecond LASIK 17.16Obtaining optimal LASIK outcomes: Microkeratomes or femtosecond lasers? 17.23Discussion 17.28Live refractive surgery (Two cases) 17.55Closing Keynote Lecture The European refractive cataract surgery market 18.07Conclusions 18.15End of session Saturday 7 February 13.00 – 18.15 Refractive CataractSurgery Conference Room Chairpersons: T. Akingbehin UK, R. Bellucci ITALY Surgical Theatre Chairpersons: M. Piovella ITALY, S. Rossi ITALY Conference Room Coordinator: F.I. Camesasca ITALY Live Surgery from the San Carlo IDI Hospital Eye Department,Rome Chairperson: S. RossiITALY 13.00Opening remarks 13.05Opening Keynote Lecture Refractive cataract surgery: The state of the art 13.20Live refractive cataract surgery (Two cases) Refractive lens surgery: Part I 13.47Aspheric IOL technology 13.55Aspheric IOLs: Pro 14.00Aspheric IOLs: Con 14.05Discussion 14.09Live refractive cataract surgery (Two cases) Refractive lens surgery: Part II 14.37Multifocal IOL technology 14.45Multifocal IOLs: Pro 14.50Multifocal IOLs: Con 14.55Discussion 33

ESCRS ANNUAL CORNEA DAY iinn ccoonnjjuunnccttiioonn wwiitthh SICSSO (Società Italiana Cellule Staminali e Superficie Oculare)aanndd SITRAC (Società Italiana Trapianto di Cornea) Friday 6 February 09.00 – 16.30 Chairpersons:E. Balestrazzi ITALY, J.L. Güell SPAIN, V. Sarnicola ITALY Penetrating Keratoplasty Today: New Technology and New Perspectives Moderators: J. Colin FRANCE, S. Fruscella ITALY 09.00E. BalestrazziITALY Femtosecond laser technology for penetrating keratoplasty 09.12B. SeitzGERMANY Excimer laser-assisted penetrating keratoplasty 09.248 single case presentations 10.04Discussion 10.30Break Ocular Surface Reconstruction Moderators: G. Grabner AUSTRIA, A. Montericcio ITALY 11.00M. RolandoITALY Semiology and diagnosis in ocular surface disease 11.12S. TuftUK Ocular surface reconstruction: An overview 11.248 single case presentations 12.04Discussion 12.30Break Deep Anterior Lamellar Keratoplasty Moderators: G. CaprioglioITALY, J. Krumeich GERMANY 13.30V. Sarnicola ITALY DALK surgery and results 13.42L. Mastropasqua ITALY Femtosecond laser-assisted corneal lamellar transplant 13.548 single case presentations 14.34Discussion Lamellar Corneal Surgery for the Treatment of Posterior Corneal Dystrophies Moderators: A. CaporossiITALY, R. NuijtsNETHERLANDS 15.00C. MacalusoITALY DSAEK surgery for Fuch's dystrophy 15.12M. BusinITALY Beyond DSAEK: The quest for perfect surgery 15.248 single case presentations 16.04Discussion 16.30End of session 13th ESCRS Winter Meeting 34

Maryalicia Post ORVIETO,sitting high above the Umbrian landscape like an island on a rock,is a mediaeval city about 100km north of Rome.Unlike other historic hill towns such as Frascati and Viterbo, it came through World War II intact,spared because of a discrete “gentlemen’s agreement” initiated by Orvieto’s surrendering German commander. On June 14,1944,he sent a message to the approaching Allied forces:“In consideration of the historic beauty of Orvieto,the German commander proposes that the city of Orvieto be declared open.” The Allied commander agreed,and the battle raged 20km away;in three days of heavy shelling,many died and suffered,but the town of Orvieto was not among them.So this hilltop city with its awe- inspiring cathedral,its palaces,towers,its panoramic views of the Umbrian countryside – and its famous white wine – remains a place of historic beauty. Recently,I took the Rome-Florence train to Orvieto from Rome’s Termini.In about an hour, the train arrives at the foot of the plug of volcanic rock on which Orvieto stands;a funicular directly opposite the train station glides up to the city – or very nearly up to it – in a few minutes.A small orange shuttle bus travels the rest of the way,motoring up the narrow and twisting high-walled roadway. Abruptly,the view opens out and you are in front of the cathedral,a joyous fantasy of carved marble and glittering mosaic,one of the most magnificent in Italy. Built at the end of the 13th century,Orvieto’s cathedral was designed to house the miraculous altar cloth that gave rise to the solemn church feast of Corpus Christi.The cloth itself is housed in an exquisite silver and enamel reliquary that stands over a metre high.The display of the cloth dominates the chapel to the left of the main altar.To turn on the lights in the chapel,insert a coin in the device to the left as you enter. Even more famous than the altar cloth is the San Brizio Chapel,to the right of the altar.Its glimmering walls are entirely covered with frescoes by Fra Angelico,Gozzoli,and Luca Signorelli.Art historians suggest that Signorelli’s “Apocalypse”,with its entwined nude figures,inspired Michelangelo’s “Last Judgment” in the Sistine Chapel.On the way in to the chapel there is a bank of audio guides to explain the frescoes in detail,but it’s better to buy a guidebook in one of the shops near the duomo before going in. The Piazza in front of the cathedral is broad and pleasant; the buildings surrounding it sit back at a respectful distance from the duomo.There are a few restaurants among them, and I had lunch at a table with a view of the cathedral while I waited for the tour of Underground Orvieto. Though the brochure I picked up at the Tourist office listed daily tours at 11,12:15,16:00,and 17.15,I learned that my tour would start at 14:45 – and it did.A guide led our group of about a dozen English-speaking tourists to a gateway on a hillside path.From there,we descended a ramp-like walkway to the opening of the caves.Just inside,a map showed us where we were in relation to the town.We were nearly under the duomo,as it turned out.Caves extend under every part of Orvieto,more than a thousand cavities tunneled over three millennia in the soft tufa with which and on which the town was built.Many of the caves are in private ownership,serving as cellars for the buildings above them. The Etruscans began this labyrinth of caves and tunnels;the Romans and their successors carried on for thousands of years,forming a bewildering succession of rooms,tunnels, stairs,and passageways that intersect and superimpose on each other.The traces of all these civilisations,from Etruscan to the present day,remain in these caves,from the early millstones for crushing olives hundreds of years before Christ to the cave used as a bomb shelter in World War II.But most of all,these dimly lit caves speak of the people who dug them.The walls and ceilings bear the chip-marks of quarrying workmen;the wall of a narrow well shaft is carved with the footholds of Etruscans who dug deep down into the volcanic stone to reach precious water. Throughout history,Orvieto’s inhabitants were fixated on ensuring access to water.From the time of the Etruscans – between the seventh and third centuries BC – rulers of Orvieto dug wells. When Pope Clement VII fled Rome during its sacking in 1527 and established his seat in Orvieto,he prepared for any eventual siege by having two wells dug,one of them,St Patrick’s Well,to provide water to the Albinos fortress.St Patrick’s Well is 62 metres deep and encircled by two flights of steps:one for the men and beasts going down,the other for those coming up with their heavy burdens of water. If water were a problem,it seems wine never was.Orvieto Classico,the straw-coloured white wine produced in the fields below the rock,was part of the payment made to the artist Signorelli for painting the cathedral’s “Apocalypse” fresco. After Oriento became a papal city in 1450,the wine was regularly provided to the tables of the prelates and noblemen of Rome. The Underground Tour had taken an hour,and it was almost time for the train back to Rome;an afternoon had been too short to do justice to the city.There’s enough to see in Orvieto to make it a good weekend away.There were museums of Etruscan finds I hadn’t visited,dozens of shops selling pottery,lace and leather that I’d just walked by,and an Etruscan necropolis lower on the hillside that I might have explored.Nor had I sampled the famous white wine. In the undistinguished town of Orvieto Scale,I discovered the train was delayed and I had 45 minutes in hand;only a few steps away from the train station,I found “Il Resto,” a bright and cheerful small bar where I could rectify at least one omission.I had that glass of Orvieto Classico – and it was worth the detour. Escape to an island on a rock with a visit to Orvieto 6–8 February 2009, Rome By train,use Rome’s Termini station and take the express Rome/Florence train to Orvieto.Return ticket about ?30.At the funicular desk you can buy a ticket that includes the bus up to town for 90 cent. By car,take the A1 autostrada between Florence and Rome and exit at Orvieto Scalo,the town at the foot of the cliff.Leave your car at the free parking place outside the train station and take the funicular up to Orvieto.If you’re looking for a car and driver to take you to Orvieto or anywhere else in or around Rome, you can contact MLM Limousine Service at +39-328- 317-2346 and ask for Elié. Staying there:Orvieto has a few comfortable hotels and the tourist office lists them.I didn’t stay in town, but was attracted to the Hotel Maitani (named in honour of the designer of the cathedral’s facade) for its convenient location only steps from his masterpiece.www.hotelmaitani.com. While you’re there:If you visit Orvieto in February, note that the Orvieto Underground tour runs only Saturday and Sunday that month.Tours at 11,12:15, 16:00 and 17.15.The rest of the year,the tours go daily at these same times. Getting there: Orvieto Cathedral 35

37 AS NATIONS across Europe search for ways to trim growing healthcare costs,a look at how US patients are responding to the current economic slow-down might be instructive. In recent years,US health policy has moved aggressively toward treating healthcare as just another consumer product.Government programmes and private employers have pushed patients to spend more and more out of their own pockets for medical care while health insurance covers less and less.The theory – very popular in the Land of the Free (Market) – is that exposing patients directly to the financial pain of higher healthcare costs gives them a strong incentive to become better informed and more careful healthcare consumers.The result will be less wasteful spending on unneeded services,and lower costs for needed services thanks to price competition among providers. It’s working,too.For example,in response to co-payments on prescription drugs that have jumped tenfold or better in many cases,major drug retailers across America, led by Wal-Mart,now offer a month’s supply of many generic prescription drugs for $4, or about ?2.80.Walk-in clinics at local pharmacies staffed by nurse practitioners and physicians’ assistants also are beginning to give physicians in general practice and hospital emergency rooms a run for their money diagnosing and treating minor injuries and illnesses,including sprains, allergies,ear infections and flu.It turns out that the average American patient/consumer not only likes to save money.They also like to save time.A trip to a doctor’s office for an unexpected minor problem can easily eat up a half-day’s work. But as the US economy slips,evidence is mounting that directly exposing patients to rising medical costs also forces them into decisions that may save money in the short term,but could lead to catastrophic health problems – not to mention much exponentially higher treatment costs – in the long term.Indeed,the number of drug prescriptions filled in the US fell by 0.5 per cent in the first quarter of 2008,and by nearly two per cent in the second quarter – the first such declines in more than a decade,according to market researcher IMS Health.During the same period,physician office visits also fell,as did laboratory tests by some of America’s largest commercial labs. These declines come as out-of-pocket costs for US patients are skyrocketing.In 2008,the annual cost of an average health plan rose to nearly ?9,000 per family,more than double the ?4,000 it cost in 1999, according to an annual survey of nearly 2,000 businesses by the Kaiser Family Foundation,a nonprofit health-policy research organisation based in California,and the Health Research & Educational Trust. Workers’ annual contributions to those premiums also more than doubled – to about ?3,400 in 2008 from about ?1,600 in 1999.Workers also have taken on more costs beyond premiums, mostly in the form of higher deductibles. About 18 per cent of all workers with some kind of health coverage face deductibles of at least $1,000,or about ?680,up from 12 per cent of workers in 2007. The trend is particularly pronounced among employers of less than 200 workers.One- third of these employers now offer only plans with deductibles of $1,000 deductibles or higher,up from 21 per cent in 2007.Smaller businesses also are significantly less likely than larger ones to offer health insurance. While virtually all firms with 200 or more employees offer health benefits to their workers,only 62 per cent of smaller firms do so.Just under half of the smallest firms, employing three to nine workers,offer health benefits.Among all small firms not offering health benefits,nearly half (48 per cent) cite high premiums as the most important reason for not doing so. Overall,about 60 per cent of US workers receive health insurance benefits through employers, down from about 69 per cent in 2001. The situation is only likely to get worse. When asked about their plans for next year,14 per cent of all firms say they are “very likely” to raise workers’ premium contribution next year,and 12 per cent say they are “very likely” to raise deductibles. Very few firms say they are “very likely” to restrict eligibility for coverage or drop health coverage altogether. Some argue that the service volume declines now being observed are exactly what was intended,and show that such patient cost-sharing measures lead to better-informed and more-constrained healthcare spending.However,a great deal of evidence suggests that in fact these measures are leading many patients to avoid preventive and maintenance therapies for chronic conditions.The result could well be an overall increase in spending. For example,a survey by the National Association of Insurance Commissioners found that 22 of 686 consumers said that finances have led them to go to doctors less often while 11 per cent said they had cut back prescription drugs to save money. Speaking at an investors’ conference in September,the head of Walgreen Co.,which operates more than 6,200 drug stores in the US,said the prescription drug sales market is the tightest he had seen in 27 years in the industry,and that his company is working with local pharmacists to help them convince customers of the need to fill their prescriptions.A survey done for the Wall Street Journalfound that pap smears and routine visits to OB-GYNs are also down significantly,suggesting that many cuts in healthcare spending are in preventive services. “With rising deductibles,more and more people face a substantial amount out of pocket for their healthcare before their insurance fully kicks in,” Kaiser President and CEO Drew Altman,PhD,said in a statement.“Health insurance is steadily becoming less comprehensive,and it’s no wonder that in today’s tough economic climate many families count healthcare costs as one of their top pocketbook issues.” One consequence of the consumerisation of healthcare in the US is that medical care is no longer recession-proof.This may be something for doctors to keep in mind as they add services that must be paid for out of patients’ pockets.Demand can take a sharp dive with the economy,as many a refractive surgeon knows. But the more serious consequence appears to be the risk to patients’ health presented by excessively high costs for medical services.When it comes down to paying the rent or going for an annual check-up – or even taking a daily drug for a non-symptomatic disorder such as high blood pressure – the rent often wins.This truly is the choice that many Americans now face. Feature Letter from America ‘Consumer-directed’ insurance plans undercut US healthcare spending Growing out-of-pocket medical costs lead patients to skimp on needed care bbyy HHoowwaarrdd LLaarrkkiinn When it comes down to paying the rent or going for an annual check-up... the rent often wins. This truly is the choice that many Americans now face DDoonn’’tt MMiissss OOuuttllooookk oonn IInndduussttrryy Page 40

Feature A s medical director of the EuroEyes Clinic in Stuttgart,Germany – one of the largest providers of refractive surgery in Europe – Eckhard Weingärtner, MD,knows what it takes to get patients in the door.That’s why he has some of his most highly trained and experienced employees doing a job that many practices hand over to the lowest-paid new hire – answering the phone. “A refractive practice lives by new patients. There are two sources of information patients have for your practice,the internet and the person who answers your telephone when the new patient calls,” Dr Weingärtner says.“By the time patients call your clinic they have already surfed your website and looked at all the options.They have made the decision to spend ?3,000 or ?5,000 to get refractive surgery. The only question is,‘Will they get it from you or from somebody down the street?’” With traditional ophthalmic services,such as cataracts,patients come in mostly through referrals from other doctors.As a result,a surgeon’s reputation in the medical community can be enough to ensure a steady stream of patients. But with elective procedures it’s different.Potential patients aren’t as likely to depend on the recommendation of their general practitioner or a general ophthalmologist. They may not even have a regular doctor. They are much more likely to inform themselves with research on the internet or base their decision on the recommendation of a friend or colleague. These patients will instantly judge your practice by how well – or poorly – you answer the phone,many practice management experts say.And they are looking for more than just evidence that you are clinically competent. They are also gauging how well they will be treated as customers – whether you’ll make them wait,whether you’ll give them personalised service,and whether you’ll treat them with kindness and concern.It takes training and practice to convey all of that in a phone call that might last less than two minutes. That’s why having informed,highly trained employees answer the phone is critical.“The phone call is usually the first personal contact you have with the patient,and the first impression on the phone will often determine if the patient will decide to have surgery at your centre,” Dr Weingärtner says.“That is why the person who answers the phone should be able to do more than just make an appointment;they need to be able to talk in a direct and open manner about LASIK and refractive IOLs and the different conditions and refractive errors and how to proceed with treatment at your centre.If the person who answers the phone can’t do that,or if you don’t answer the phone,the patient will just call the next clinic.” Four rings,maximum The first step in answering the phone is to answer it promptly.“If you want to have a big refractive practice,you have to answer the phone after no more than three or four rings,” Dr Weingärtner says.Many patients will hang up rather than wait for 10 or 12 rings, and many will not leave a message if voice mail picks up. Once the receptionist answers the phone, attitude and tone of the voice are extremely important.All staff should be trained to use a script to answer calls.It can be as simple as “Hello,this is Dr Ryan’s clinic.How may I help you today?” Staff also should be instructed to smile when they answer,and should be coached on conveying caring in their voices. At Dr Weingärtner’s clinic,if calls can’t be picked up at the reception area,they ring through directly to other staff.In all cases, new patients speak to highly trained nurses and refractive surgery coordinators.These senior staff members also are well versed in all aspects of the clinic’s products and services as well as those of competitors so they can answer the detailed questions that many refractive patients have.EuroEyes has a one-year training programme to prepare staff to become refractive surgery coordinators. “This is our calling card – the phone and our website.You can’t spend enough money on this to make a good impression.” Dr Weingärtner points out that answering the phone in a professional manner is an important follow-up to having a good website.“Today’s patients are very well informed and you want them to be talking to people who know what they are asking about.They don’t need to talk to the doctor directly,but they should talk to someone who can answer questions.If you can’t answer their questions at your centre they will find somebody who can.” Driving consultations Just as an effective website drives phone calls to your refractive practice,effectively answering the phone drives patients to your clinic for in-person consultations,says Mark Walsh,global manager for business development for Advanced Medical Optics. He recommends keeping records of all incoming calls and setting a specific goal for converting new patient calls to consults. Based on consulting he does around the world,he says that about 60 per cent of patient calls should result in scheduling a consultation. Walsh points out that as important as it is to create a good impression on the phone, and to respond to patient questions knowledgably,the patient cannot be scheduled for treatment until he or she has an in-person consult.“You don’t close the deal until the consultation,” he says. Walsh agrees that staff should be carefully trained to answer phones,and that they should be well-informed about all aspects of refractive surgery,financing and other questions patients might have.However,he recommends that staff not give out too much information on the phone.Questions should be handled in a way that encourages the patient to come in for a consult.For example, a question about services and fees might be answered like this: “Our fees start at ?1,500 per eye.When you come in for your iLASIK consultation,we will review with you all of the services we provide,and we can better assess your needs. Let’s look at some consultation dates and times…” To track the effectiveness of your practice’s phone operations,Mr Walsh recommends tracking all incoming calls,and having “mystery shoppers” make regular calls to see whether and how your phones are being answered. Such calls can reveal not only issues with staff training – they may even uncover phone lines that are not working properly or other obstacles to patients getting the service they need,he notes. “How you respond on the phone matters. If you give the patient too much information on the phone they may not come in,” Mr Walsh says.This is particularly true of patients who may have some fear about the procedure.“You want to drive the patient to the consultation for answers.” 38 Practice Management Winning refractive patients on the phone How you answer the first call often determines if the patient comes to you – or moves on bbyy HHoowwaarrdd LLaarrkkiinn

BARCELONA 2009 XXVIICongress of the ESCRS 12 – 16 September 2009 CCIB Congress Centre Barcelona Spain Abstract submission deadline: 15 April 2009 EUROPEANSOCIETYOFCATARACT& REFRACTIVESURGEONS SYMPOSIA TOPICS: Cataract and Macular Disease Cross-Linking Paediatric Cataract and Refractive Surgery Managing Subluxated Lenses Surgical Solutions for high refractive errors Please note that the Symposia titles are provisional and may be subject to revision. ANNOUNCING First World Congress of Paediatric Ophthalmology and Strabismus Saturday 12 and Sunday 13 September 2009

I n February,Jim Mazzo,the chairman and CEO of Advanced Medical Optics,was concerned about a looming recession in the US. Weak sales of excimer laser procedures in the first six weeks of the year led him to predict an overall decline in 2008 US volume of 15 per cent,down from previous projections of six per cent growth. Six months later,AMO again revised its estimate.After a nearly 40 per cent slump in June and a 20 per cent decline for the second quarter overall,the firm announced in August that it expected full- year 2008 US excimer procedure sales to drop 25 per cent below 2007 levels.As a result,AMO also reduced its 2008 earnings per share estimate to $1.00 to $1.15,or about ?0.68 to ?0.80,from the prior guidance of $1.25 to $1.45,or about ?0.87 to ?1.00. AMO wasn’t alone.Major US LASIK provider chains also reported sharp drops in volume.In October,LCA-Vision Inc – which operates about 70 vision centres in the US – projected a 52 per cent decrease in volume for the third quarter based on falling appointment bookings. TLC Vision Corp.,based in Canada,also projected a drop in laser refractive surgery volume at its centres throughout the US,though the firm says the reduction will be “significantly less than the market declines of mid-40 per cent range guided by the leading manufacturer in this space,” according to news reports. But dark as this cloud was,there was something of a silver lining,at least for AMO.Despite the decline in US procedure revenues,the firm’s overall refractive sales increased 1.5 per cent in the second quarter,mostly on the strength of sales of new systems, particularly IntraLase femtosecond lasers, and growth in procedure fees outside the US.In addition,cataract sales rose almost 15 per cent based on strong sales of phacoemulsification systems,intraocular lenses,and viscoelastics.The reintroduction of multipurpose lens solutions and new artificial tear products increased eye care sales by 202 per cent. AMO’s international procedure,implant, and related sales hit a new high in the second quarter,at ?22m,up 45.1 per cent.Overall,sales rose 22.6 per cent to about ?220m. “AMO’s second-quarter results showed the strength and resiliency of our global business, despite the declines in domestic refractive volumes brought on by the weakening US economy,” Mr Mazzo said. “The value and benefit of expanding our refractive business internationally came into focus as strong refractive sales outside the US helped to partially offset domestic challenges.Our cataract business took advantage of powerful new technologies and delivered solid performance domestically and internationally.” Instability in the US market also affected Carl Zeiss Meditec,Jena, Germany,though they,too, showed strong growth through the first three quarters of financial year 2007/2008.Led by strong sales in its Europe,Middle East,and Africa region, overall revenues were up nearly seven per cent and net income after minority interest up 17.3 per cent. The percentage of revenues flowing from the Americas region dropped about 17 per cent,in part due to a decline in value of the US dollar. “The continuing economic uncertainty in the US also led to a reluctance to invest,” according to a company statement. That’s something of a reversal as the US has been Carl Zeiss Meditec’s largest revenue source,and a major focus for growth in years past.In the first nine months of this year,though,revenues from the Americas,mostly the US,dropped to 32.8 per cent of Zeiss’ total,down from 42.3 per cent in the same period a year before.By contrast, revenues from Europe,the Middle East, and Asia jumped 24.5 per cent,to make up 35.7 per cent of total revenues, Feature 40 Outlook on Industry US economic problems take toll on global ophthalmic manufacturers Europe, Middle East, and Asia drive growth as firms consolidate to broaden offerings bbyy HHoowwaarrdd LLaarrkkiinn Jim Mazzo, AMO

41 displacing the US as the firm’s largest market region.Asia/Pacific sales were also up 19.6 per cent,making up 22.9 per cent of the firm’s sales.Acquisition of the Acri.Tec line of intraocular lenses helped increase surgical sales. “Thanks to the stable demand for our products,Carl Zeiss Meditec’s development in the first nine months was satisfactory,despite the uncertainties in the overall economic environment,” said Michael Kaschke,the firm’s president and CEO.“In future, our aim will be to exploit the growth potential on the market that remains untapped.” Likewise,second quarter sales outside the US grew much quicker for Alcon Inc, Huenenberg,Switzerland. International sales rose 28.9 per cent to about ?660m,or 15.4 per cent excluding foreign exchange,with emerging markets sales increasing 29.5 per cent,or 18.9 per cent excluding foreign exchange.Sales in the US increased 7.0 per cent to about ?545m.Surgical sales were up 21.6 per cent,or 13.1 per cent on a constant currency basis,while pharmaceutical sales rose 17.6 per cent,and consumer eye care 2.2 per cent. Sales of high-technology lenses,including toric and aspheric lenses,as well as continued popularity of the Infiniti phaco system and OZil hand piece,helped drive surgical sales.Refractive sales were also up 215 per cent due to sales of the WaveLight Allegretto refractive laser, which is making inroads into the US market as well as Europe,though this increase was offset somewhat by declining procedure revenues from the installed base of LADARVision excimer lasers. “The results for the second quarter demonstrate the benefits of our global operations that experienced strong growth in our core product lines and solid sales performance around the world,” said Cary Rayment, Alcon’s chairman,president and CEO.“Revenues in both developed and emerging markets outside the US were particularly robust,while our advanced technology intraocular lenses and glaucoma franchise continued to deliver excellent sales growth.” Alcon is far less exposed to the volatile refractive market than is AMO.As a result, its stock price has held up well,trading at the beginning of October in the $160 range after a 52-week high of $178.AMO, on the other hand,was trading at about half its 52-week high of about $32. In addition,companies worldwide appear to be doing better outside the US market than within it.Indeed,several exhibitors on the floor at the XXVI Congress of the ESCRS indicated that they are now booking more sales and making more contacts through the European show than its American counterparts.Could it be that the centre of gravity of the ophthalmic industry worldwide is shifting to Europe? The more diversified ophthalmic companies – both geographically- and clinically-wise – may be better positioned to ride out what looks like rough times ahead. Feature Online Registration Available now 6–8 February 2009 See www.escrs.org for more information 13th ESCRS Winter Meeting in conjunction with SOI (Italian Society of Ophthalmology) Cavalieri Hilton Hotel, Rome, Italy

Feature A recent ruling by the European Court of Justice may keep down the costs of ophthalmic pharmaceuticals and protect the balance sheets of drug manufacturers. The somewhat convoluted ruling,handed down last September,forbids a pharmaceutical or medical device manufacturer from refusing to fill “ordinary” wholesale orders for their products. However,the ruling does allow a manufacturer to refuse to fill wholesale orders that are larger than ordinary. At the heart of the case is the practice of “parallel exporting”.Parallel exporting consists of buying products in an EU country where they are cheaper – such as Greece – and selling them at a profit to retailers in countries such as Germany and the UK,where the same product costs local retailers more to buy through the national distribution network.The reason for the variance in pharmaceutical and medical device prices is multi-faceted and largely determined by the unique way in which each EU country regulates and runs its own health services. European pharmaceutical manufacturers have long complained about the damaging effects of parallel exporting on their profits – and ability to invest more money for research and development of new drugs. Pharmaceutical companies estimate that parallel exports lose them about ?4bn annually.Despite such complaints,the EU courts have resolutely defended parallel exporting as a means by which competition can keep down prices. This latest EU Court of Justice case, known as Sot.Lélos kai Sia EE and Others –v- GlaxoSmithKline AEVE Farmakeftikon Proïonton,arose after pharmaceutical wholesalers in Greece cried foul about the practices of the Greek subsidiary of the pharmaceutical giant,GlaxoSmithKline plc. The subsidiary,known as GlaxoSmithKline AEVE Farmakeftikon Proionton,imports,warehouses,and distributes pharmaceutical products of the GSK group in Greece.As such,it holds the marketing authorisation in Greece for certain prescription-only medicines. For years,GSK AEVE met the orders of Greek wholesalers,who,in turn distributed the GSK products to Greek hospitals and pharmacies.In addition to supplying Greek institutions,however,the wholesalers also engaged in parallel exporting to the UK and Germany. The roots of the Greek case extend back to November of 2000,when GSK AEVE stopped meeting the orders by the Greek wholesalers who were engaging in parallel exporting.The company withheld three medicines – Lamictal,used to treat epilepsy;Imigran,used to treat migraine;and Serevent,used to treat asthma.At the same time,GSK AEVE itself began to distribute the same medicine directly to Greek hospitals and pharmacies. In February 2001,GSK AEVE started once more to supply the wholesalers with the three drugs,but only in quantities sufficient for the Greek market. The Greek wholesalers ultimately sued GSK AEVE in a civil court in Athens.In that case,they alleged that the company had violated EU competition law.EU law forbids a large company that dominates a particular market from using its market dominance to distort competition in that market.In particular,Article 82 of the EU’s Treaty prohibits a dominant company from limiting production,markets,or technical development if such limits ultimately cost the consumer more money. When the case came up for hearing in the Athens court,the court referred the case to the European Court of Justice to clarify whether GSK AEVE had abused is dominant position and whether the company could restrict its sales of drugs to wholesalers. In its decision,handed down on September 16,the Court of Justice cited a number of previous cases in which it had ruled that any abuse by an undertaking of its dominant position is incompatible with the so-called “common market” between EU countries.Such abuse may,in particular, consist in limiting production,markets,or technical development to the prejudice of consumers. The court also found that by refusing to meet the Greek wholesalers’ orders,GSK AEVE aimed to limit parallel exports by those wholesalers to the markets of other EU countries in which the medicines are more expensive. Having made those preliminary findings, the court then went on to consider whether,in the pharmaceutical sector,there are particular circumstances which might, generally,justify a refusal to meet wholesale orders. The Court of Justice pointed out that parallel exports of medicinal products from an EU country where the prices are low to another EU country in which the prices are higher open up,in principle,an alternative source of supply to buyers of the medicines in many countries at lower prices than those applied on the same market by the pharmaceutical companies.In other words, parallel exports are good because they can reduce the price that the final consumer ultimately pays. The court then analysed the possible effect of national regulation of the prices of medicines on the assessment whether the refusal to supply is an abuse.The court noted that the control exercised by EU countries over the selling prices or the reimbursement of medicines does not entirely remove the prices of those products from the law of supply and demand.The community rules on competition are also incapable of being interpreted in such a way that,in order to defend its own commercial interests,the only choice left for a pharmaceutical company in a dominant position is not to place its medicines on the market at all in an EU country where the prices of those products are set at a relatively low level. Having come to that finding,the court ruled that a pharmaceutical company must be able to take steps that are “reasonable and proportionate” to protect its own commercial interests.In order to assess whether such steps are reasonable and proportionate,a court must ultimately assess whether the order placed by the wholesaler was “ordinary”. The court then examined the impact of national regulation on the supply of medicinal products,and more particularly the argument put forward by GSK AEVE that companies that engage in parallel exports are not subject to the same obligations regarding distribution and warehousing as the pharmaceutical companies and are therefore liable to disrupt the planning of production and distribution of medicines. In that regard,the court ruled that,in cases where parallel trade would effectively lead to a shortage of medicines on a given national market,it was not for companies holding a dominant position but for national authorities to resolve the situation.Having said that,the court added that the law must allow a pharmaceutical manufacturer to protect its own commercial interests when it receives huge orders.“A producer of pharmaceutical products must be in a position to protect its own commercial interests if it is confronted with orders that are out of the ordinary in terms of quantity,” the court ruled.“Such could be the case,in a given Member State,if certain wholesalers order from that producer medicines in quantities which are out of all proportion to those previously sold by the same wholesalers to meet the needs of the market in that Member State.” Having come to that conclusion,the Court of Justice said it was up to a national court to ascertain whether the orders are “ordinary”,based on the previous business relations between the pharmaceutical company and the wholesalers and the size of the orders. If the orders were ordinary,then any pharmaceutical company that occupied a 42 EU Matters bbyy PPaauull MMccGGiinnnn EU court attempts to strike balance between patients and pharma profits Competition law and ‘parallel exporting’ In its submission to the European Court of Justice, the Greek subsidiary of GlaxoSmithKline plc – GlaxoSmithKline AEVE Farmakeftikon Proionton – argued in support of its decision to limit its supply of drugs to Greek wholesalers who were engaged in the practice of so-called “parallel exporting”. Such a practice, which is legal, involves a wholesaler buying drugs in a country where the drugs are cheaper and selling those drugs to retailers in countries where those drugs are more expensive. The practice costs pharmaceutical companies in Europe about ?4bn annually in lost profits. According to GSK AEVE, EU law that prohibits a company from taking steps to resist parallel exporting should not apply to pharmaceutical companies for the reasons below. 1.Pharmaceutical manufacturers do not control the prices of their products; public authorities not only fix those prices but also buy the medicines for their national health systems. Even where those prices are the result of negotiations between the authorities and the pharmaceuticals companies, the fact that those companies accept them does not in itself imply that the prices cover all the fixed costs connected with the development of the pharmaceutical products. Moreover, even if such a system of agreed prices exists, individual EU countries are still in a position to impose cuts in those prices. 2.By law, pharmaceutical manufacturers must deliver their products in all EU countries where they are authorised to do so; by contrast, parallel exporters are free to shift their activities from one product or market to the next if the latter product or market offers a higher profit margin, which can lead to shortages in some exporting EU countries. Thus, parallel trade has negative consequences for the planning of production and distribution of medicines. 3.Parallel trade in medicines reduces the profits that pharmaceutical companies can invest in research and development activities on which they depend in order to remain competitive and attractive to investors. By contrast, distributors that profit from parallel trade make no contribution to pharmaceutical innovation. Furthermore, in the EU countries where the prices of medicines are cheaper, the marketing of new medicines might suffer if it became impossible for pharmaceutical companies to hold back supplies with the aim of limiting parallel trade. In such circumstances, those companies would have an interest in delaying the launch of new products in EU countries where the prices are low. 4. Parallel trade provides no genuine benefit to the ultimate consumers. Since the greater part of the price difference goes into the pockets of intermediaries, parallel trade does not result in genuine pressure on the prices of medicines in the EU countries where those prices are higher. dominant position in the market could not legally refuse to fill such orders. For more details,visit the EU Court of Justice website at www.curia.eu

World Congress of PaediatricOphthalmology and Strabismus 12 & 13 September 2009 www.wcpos.org During the XXVII Congress of the ESCRS CCIB Congress Centre, Barcelona, Spain

Feature Mastering Phaco Chop Techniques Editors:Ashok Garg,Jorge L Alio, Robert J Weinstock,Frank Joseph Goes,Mark Packer,Keiki R Mehta, Jerome Jean Bovet,Boris Malyugin,CS Dhull,Bojan Pajic,Roberto Pinelli, Cyres K Mehta Jaypee Brothers Medical Publishers Ltd.,New Delhi,2008. W hat makes life enjoyable? What makes working life (that factor which dominates so much of our time and yet so few of us seem to actively like or even tolerate) enjoyable? Enthusiasm. Think of any of the teachers or mentors who have made a positive, lasting impression on you.It is unlikely that they were cynical about their subject, or their work. Think of someone whose achievements you admire – whether in public life,the arts,sport, medicine, scientific enquiry,within your own private sphere – and are they cynical, “marking time,” or unenthused about their work? No. Enthusiasm is the great well spring of satisfaction,what enables us to bear the drudgery and distractions inherent in the working world. Better an enthusiastic street sweeper than an embittered,jaded doctor or hedge fund trader or professor or real estate speculator. Or at least,I would argue. “Above all,gentleman,not the slightest zeal” Talleyrand once said.The French statesman and political survivor perhaps meant political zeal rather than zeal in general,but his words reveal a cultural truth. Ironically,in the 18th Century “enthusiast” was a pejorative word,implying religious fanaticism which overtook all other considerations of civilised behaviour. Enthusiasm is now a positive concept,but culturally we are still somewhat suspicious of enthusiasm.The “tall poppy syndrome” is not only a charter to cut down those who achieve more than the norm;it is also a guarantee that many of us will hide our own enthusiasms and delight in aspects of our work. Why do we fear enthusiasm so? It makes us feel slightly guilty at our own attitude, perhaps,or maybe resentful that someone else feels so happy about what we are jaded about.Or perhaps Arthur Balfour,British Prime Minister in the early years of the 20th Century,captured the essence of this suspicion when he wrote that,“it is unfortunate,considering that enthusiasm moves the world,that so few enthusiasts can be trusted to speak the truth.” This book comes bearing an awesome commendation – “I anticipate that all cataract surgeons,and in turn their patients,will benefit from this epic work” – from Samuel Masket MD,of the Jules Stein Institute in California,in his foreword.Dr Masket also writes that “small incision cataract surgery is arguably the most gratifying and efficient procedure currently practised in all medicine.” This,of course,is the perspective of the specialist,but it’s good to read the obvious enthusiasm of Dr Masket. An “epic work” may be something of an overstatement,but the book is testament to the enthusiasm of its editor and contributors. Ashok Garg has assembled a multi-national team to produce this book.After all,a volume of this size and quality dealing with one specific portion of the phacoemulsification procedure,must surely be testament to the enthusiastic devotion of many practitioners,keen to be as perfect as possible in their work. As Garg writes in the first chapter of the book “Phaco Chop in Transition:An Introduction,” cataract surgery overall has undergone a revolution in the years since it was first introduced.As is familiar to practitioners in all branches of medicine, yesterday’s miracle procedure is today’s routine procedure is tomorrow’s out-of-date, less than satisfactory procedure.Side-effects and suboptimal functional outcomes which are accepted in the early years of initial uncritical enthusiasm are soon enough seen as fatal flaws. This book is divided into four parts.The first covers phacodynamics and preliminary considerations in phaco chop.The second discusses the various phaco chop techniques themselves.This,at 118 pages,is the longest individual section.A third section deals with phaco chop in complicated cases and the management of complications that may ensue.Finally,a section covers recent advances and new technologies that can be used,and will be used more and more in future. The authors come from India,Indonesia, Australia,Mexico,Switzerland,the US,the Netherlands,Spain,Taiwan,Switzerland,Cuba, France,Colombia,China,Russia,Sweden, Belgium,and Italy.Truly a league of nations! There is perhaps a slight Indian preponderance,as can be expected from a book edited by Ashok Garg from India and published by Jaypee Brothers of New Delhi. The book is richly illustrated with many figures and diagrams.There is a slightly overpoweringly colour to some of the photos,reminiscent of old Technicolor movies. There is not just one but two DVDs.No text on surgical technique seems complete without at least some audiovisual component.And this is as it should be. Learning any technique from books is extremely difficult.Think of how you learned to drive a car or ride a bicycle.Books which tell you how to do these things are available, but are somewhat beside the point.Driving and cycling are learnt by doing.The same is true of surgical technique.A DVD is an aid, but can only be an aid. The book is extremely practical.It is for the enthusiastic cataract surgeon,or ophthalmic trainee.Of course,one would hope that this would mean every surgeon and trainee.In no field is enthusiasm as vital as a medical career.Lack of enthusiasm compounds the pressures of an already onerous job.If every day is simply a dutiful drudge,the drudgery can overwhelm.Enthusiasm is perhaps impossible to fake,but it can be cultivated.All of us have moments,one would hope,in our professional lives which can be built on to foster this enthusiasm. 44 In Your Good Books Fostering enthusiasm promotes satisfaction for master and learner of phaco chop bbyy SSeeaammuuss SSwweeeenneeyy MMDD Enthusiasm is now a positive concept, but culturally we are still somewhat suspicious of enthusiasm

Feature R esearchers have long known that environmental factors interact with an individual’s genes.The medical literature is replete with case studies of twins and siblings that share either all or half of their genome but often suffer very distinct medical conditions. One of the reasons behind such phenomena is a differential influence of diverse environmental factors – including different microenvironments within the womb,diet,lifestyle,and geography. Recent research within a population of glaucoma patients has revealed a correlation between the extent of visual field loss and a patient’s postcode.As remarkable as it may sound,an analysis of the details shows that such a finding is not only predictable but also expected across the globe. As ophthalmologists well know, glaucoma has been sub-divided in the clinic into a variety of categories which depend on factors such as the iris-cornea angle, whether or not the glaucoma is primary or secondary in nature,and the age of onset of the disease. Traditionally,there are three major categories of glaucoma based on the classification of the disease being open- angle,closed-angle or congenital.“Open- angle” and “closed-angle” refer to the angle at the junction of the iris and cornea.The open-angle variety is the more common and slowly progressive form whereas the closed-angle is generally rarer and often associated with a rapid rise of IOP.Congenital glaucoma,normally diagnosed before the age of three years,is often associated with ocular developmental abnormalities and a membrane obstructing the path of aqueous outflow. Open-angle glaucoma (OAG) is the most common form estimated to affect approximately half of the 70 million people affected worldwide with glaucoma.Primary open-angle glaucoma (POAG),which includes forms of the condition not associated with either other anatomical abnormalities of the eye or an ocular manifestation of a systemic disease,affects approximately two per cent of the population over the age of 45 years. POAG varies in its age of onset and has been classified into the late onset form, generally termed chronic open-angle glaucoma (COAG),and the less frequently observed juvenile onset form,juvenile open-angle glaucoma (JOAG).However, given the painless nature of the disease in its early stages this classification may be somewhat arbitrary,as affected individuals may remain unaware of the disorder for many years before formal diagnosis. One of the steps on the path to devising such clinical care programmes is to understand the factors that influence when a patient first presents with symptoms of POAG. A recent study led by researchers and doctors at the University of Manchester and Manchester Royal Eye Hospital in the UK found that patients presenting with more advanced visual field loss were more likely to come from a background of lower educational attainment.In addition,such patients were less likely to be aware of a family history of glaucoma that,if known, could have resulted in earlier presentation to specialist ophthalmic services.For details of the study,see the advance online publication of Eye of 8 August 2008. Undoubtedly,the earlier that glaucoma is detected the better the prognosis for the patient.In other words,a significant risk factor for future visual impairment from glaucoma is late clinical presentation with advanced visual field loss.Although there have been significant advances in treatment over the past 15 years glaucoma remains the second leading cause of blindness in the UK.One of the major factors in glaucoma progressing through to complete blindness is that by the time the patient reaches special care services, significant atrophy and damage has already occurred. Education and socio-economic status appear to be key determinants on when an individual concludes that medical attention is required.The Manchester researchers investigated the relationship between socio-economic status and the extent of visual field loss in patients with POAG.The research team looked at a range of parameters including intraocular pressure, cup to disc ratio,family history of glaucoma,visual acuity,extent of visual field loss,age,gender,ethnicity,and residential postcode.Using rigorous statistical methodology and linear regression tools,the research group were able to show that “the extent of visual field loss in glaucoma patients at first presentation is related to a combination of clinical and socio-economic factors including the patient’s postcode.” The scientists subsequently suggest that the finding could be a valuable aid to targeting future case-finding resources. While the finding may not surprise front-line clinicians that treat glaucoma patients on a regular basis the methodology used in the study provides an unprecedented level of resolution in mapping the visual field loss onto postal code districts.Such information can provide invaluable guidance to healthcare professionals seeking to more effectively plan and direct scarce medical resources to where they will provide maximal benefit. The research study examined a cohort of 113 glaucoma patients between 1995 and 2005 that were divided into two groups:group 1 – affluent,and group 2 – socio-economically deprived.The researchers estimated the socioeconomic status of the patients from their residential postcode using the ACORN index (http://www.caci.co.uk/brochures.aspx).This index uses a range of different databases to identify social characteristics of a population with a resolution for each postcode of approximately 15 residences and then allows for the classification of individuals into a variety of socioeconomic groups. In an analysis of the data that cross- referenced clinical data with ACORN statistics,the researchers found that 79 per cent of the patients who presented with mild vision loss were categorised as group 1 (affluent). In contrast,60 per cent of the patients presenting with moderate visual field loss and 63 per cent of presenting with severe visual field loss were from group 2 [characterised by poorer economic status]. Furthermore,the researchers were able to correlate knowledge of family history of glaucoma with group 1 at 27 per cent, compared to group 2 at 17 per cent while the ACORN tools were additionally able to demonstrate that the level of educational attainment was again higher in group 1 than in group 2 (18 per cent versus 98 per cent having either none or unknown qualifications). The authors concluded that “the awareness and knowledge of glaucoma (or any other eye disease) improve with the level of education and socioeconomic status.” In summary,the authors present some “insight into the clinical and social risks of late presentation.Poor socioeconomic status,educational level, associated systemic condition,and old age show a strong association with visual impairment in addition to the known clinical factors.Patients presenting with advanced visual field loss due to glaucoma can be identified from area-based measures of socioeconomic status (ACORN index)”. The value of these derived relationships may be their subsequent use in targeting populations at risk of late presentation and of becoming blind due to glaucoma.” Clearly,if the Manchester-led study is to be taken on board,some very simple steps may be adopted to minimise the chance of such tragic outcomes. 46 Bio-Ophthalmology Glaucoma risk extends beyond genes, so check your patient’s postcodebbyy GGeeaarrooiidd TTuuoohhyy EUROTIMES ESCRSPODCAST If you are an ophthalmologist, this is the podcast you should be listening to on www.escrs.org. We discuss the big issues in cataract and refractive surgery with our panel of experts. And if you have any suggestions as to who should be on EuroTimes Podcasts, please let us know. NEW US doctors question ESCRS study results. Why are some in the US hesitating to accept the results of the ESCRS Endophthalmitis Study? Recent research within a population of glaucoma patients has revealed a correlation between the extent of visual field loss and a patient’s postcode Undoubtedly, the earlier that glaucoma is detected the better the prognosis for the patient. In other words, a significant risk factor for future visual impairment from glaucoma is late clinical presentation with advanced visual field loss

Journal Watch More AMD genes British scientists report they have found six variants within the gene called SERPING1 that are associated with age- related macular degeneration (AMD).The investigators conducted genomic screening on 479 patients with AMD and an equal number of controls without the disease.They found that the SNP variant rs2511989,located within intron six of the SERPING1 gene,showed highly significant genotypic association with AMD.SERPING1 encodes the C1 inhibitor,which has a crucial role in inhibition of complement component 1 (C1) and might implicate the classic pathway of complement activation in this disease,they note.The research builds on previous genetic studies that identified mutations in the complement factor H (CFH) gene and a locus on chromosome 10 encompassing the HTRA1/LOC387715/ARMS2 genes. Variants in complement 3 (C3) and an HLA locus containing both factor B and C2 genes are also implicated. S Enni et al.,Lancet,“Association between the SERPING1 gene and age-related macular degeneration:a two-stage case-control study”, Early Online Publication,7 October 2008. Corneal self-repair Swiss researchers report new observations indicating how the cornea uses stem cells to repair itself.Using mouse models they demonstrated that everyday wear and tear on the cornea is repaired from stem cells residing in the corneal epithelium,and that more serious repair jobs require the involvement of other stem cells that migrate from the limbus.The research challenges this prevailing opinion that the limbus is the only place where corneal stem cells reside. Y Barrandon et al.,Nature,“Oligopotent stem cells are distributed throughout the mammalian ocular surface”,Advance Online Edition,Oct 1,2008 Value of a standard vision test for children questioned A review of the Baltimore Paediatric Eye Disease Study,the first large-scale visual acuity assessment of preschool children, suggests that one commonly used vision test was so inaccurate that its usefulness is questionable.The study evaluated 1504 children using a series of vision tests, including the fixation preference test (FPT) and the Amblyopia Treatment Study test (ATS).The study found that the FPT did not accurately identify the presence or absence of visual acuity problems in this study population.The inaccuracies became apparent when ATS and FPT results were compared for children able to perform both tests.If the experience of this study can be generalised,the use of FPT should be reconsidered, they conclude. DS Friedman et al, Ophthalmology,“Prevalence of Decreased Visual Acuity among Preschool-Aged Children in an American Urban Population:The Baltimore Paediatric Eye Disease Study,Methods,and Results”, October 2008,1786-1795.e4. DS Friedman et al, Ophthalmology,“Lack of Concordance between Fixation Preference and HOTV Optotype Visual Acuity in Preschool Children:The Baltimore Paediatric Eye Disease Study”, October 2008,1796-1799. Contact care more important than lens type Recent outbreaks of ocular infection associated with contact lens solutions highlight the risks associated with contact lens wear.The largest combined study of microbial keratitis and contact lens wear to date suggests no particular advantage to using newer types of lenses.The studies concluded that new lens types, including silicone hydrogel “soft” lenses and daily disposables,did not reduce the risk of microbial keratitis. The researchers believe that other factors – such as tear film stagnation,corneal changes beneath the lenses, and slowed turnover of corneal surface cells – may be more important than oxygen permeability in the development of microbial keratitis.Other risk factors in the study included improper hand cleaning,younger wearer age,use beyond recommended time spans,smoking,and male gender. JKG Dart et al.,Ophthalmology,“Risk Factors for Microbial Keratitis with Contemporary Contact Lenses:A Case-Control Study”, October 2008,1647-1654. 47 by Sean Henahan Vision science highlights from the world’s leading journals of medicine and scienceJJoouurrnnaallWatch European Registry of Quality Outcomes for Cataract & Refractive SurgeryEUREQUO What is EUREQUO? Improve treatment and standards of care for cataract and refractive surgery Develop evidence-based guidelines for cataract and refractive surgery across Europe Make significant impact on the exchange ofbest practice between practitioners in relation to patient safety 1 2 3 The project aims to: EUREQUO is a European Quality Registry for visual outcomes ofcataract and refractive surgery Join the network EUREQUO gives a unique opportunity to monitor and compare results Quality registries create a sufficient basis for studying rare diseases, treatments and complications Collecting data will support you to make an audit report The collection ofyour data will facilitate the analysis ofsurgical outcomes and the development of evidence-based European Quality Guidelines See www.eurequo.org for more information

Feature T he 19th century Italian ophthalmologist,Pietro Gradenigo, descended from a long line of influential Venetians. Half a millennium before his birth the first Pietro Gradenigo became the 49th Doge of Venice.Remembered for many lasting constitutional changes in the Most Serene Venetian Republic it was during his reign – from 1289 to 1311 – that Marco Polo returned to Venice from his Oriental wanderings. As well as his namesake,two other Doges of Venice were among Pietro Gradenigo’s ancestors. Bartolomeo Gradenigo was Doge when a hurricane hit Venice.After this,a fisherman presented the Doge with a ring he claimed to have received from St Mark that night. This led to the ceremonial marriage of Venice to the sea,a ritual which ceremonialised Venice’s maritime mastery and dependence.The Gradenigos also numbered two cardinals,14 procurators and a great number of diplomats and soldiers. Born in 1831,Pietro Gradenigo was educated in Venice and in 1848, took part in a rebellion against Austrian rule.Venice had lost its independent Most Serene Republic status in 1797 with its conquest by Napoleon.The French Emperor’s Kingdom of Italy lasted until 1814, at which point Venice became part of the Austrian-ruled Kingdom of Lombardy-Venetia. The Venetians successfully resisted Austrian forces until August 24th 1849,defying an epic siege. Pietro Gradenigo is recorded as serving with distinction in this rebellion.This was against the wishes of his father,who supported the Austrians.The rebellion also saw his brother Giuseppe killed. Pietro Gradenigo’s medical career was divided between Venice and its near neighbour Padova.At 24,he graduated as a doctor of medicine from Padova.After serving in the Venice hospital for a spell,he became first assistant in the Padova eye clinic,working with Prof Gian Antonio Gioppi,followed three years later by appointment as surgeon to the Venice Hospital,a post he held for 10 years.In 1873, he was appointed to the professorship in ophthalmology back in Padova,succeeding Gioppi, where he remained until his death in 1904. By the time of his appointment as professor,Gradenigo had acquired a considerable reputation.Patients came from as far as the lower Balkans to see him. Gradenigo was one of the first ophthalmologists in Italy to use the ophthalmoscope,recently invented by Helmholtz.Among his particular clinical interests were the treatment of corneal opacity,antisepsis of the eye,and the operative treatment of cataract.He invented a special thermometer and stethoscope for ocular use,and developed a tonometer for measuring intraocular pressure.He also studied the application of electricity to the eye.He was an advocate of digital massage for retinal detachment. A skilled painter and sculptor,he put his many talents to use in producing an atlas of ophthalmology.His ophthalmological publications were collected by some of his former students and published after his death.He wrote popular works on ophthalmology as well as technical ones.He had a particular interest in the blindness of the most famous Italian and most famous scientist of all time,Galileo Galilei. Galileo,who lived from 1564 to 1642,went completely blind in 1638.In the middle of 1636,his sight began to deteriorate and in July 1637,he wrote to his friend Elia Diodati that he had lost the use of his right eye.In his left eye,he reported seeing a “luminous halo” around candle flames,and he was affected by a constant ocular discharge.In January 1638, Galileo wrote again to Diodati that he had lost all vision in his left eye.In the same month,he petitioned the Inquisition,under whose auspices he was under house arrest, asking to be freed.This was declined,though he was allowed to move house to be closer to his physicians.In a poignant twist,one of his most historically prominent visitors in his last years is supposed to have been John Milton in 1638,author of such powerful poems about blindness.Galileo (though not his blindness) is alluded to in Milton’s epic Paradise Lost. In popular accounts it was (and still is) sometimes argued that the strain of observing sunspots,or of astronomical observation in general,affected the great astronomer’s sight.Gradenigo argued that Galileo’s blindness was caused by glaucoma. Certainly solar observation had nothing to do with his loss of sight.However,dispute continues about the likely cause.An online discussion about the issue is located on the UK Royal College of Optometrists page at http://tinyurl.com/3ncjq6 Pietro was the father of Giuseppe Gradenigo (1859-1926),who became a prominent audiologist.Giuseppe lent the family name to Gradenigo’s Syndrome. References: Hirschberg, J. The History of Ophthalmology. Volume 8b – The First Half of the Nineteenth Century (Part Five) Great Britain/Italy Obituary for Count Pietro Gradenigo, MD, British Medical Journal, 1904 December 24; 2(2295): 1732. Stephens, D. Giuseppe Gradenigo and his contributions to audiology, The Journal of Laryngology and Otology May 1997, pages 418-423 48 Eye on History Pietro Gradenigo – from revolution to ophthalmology and the blindness of Galileobbyy SSeeaammuuss SSwweeeenneeyy

Missed the XXVI ESCRS Congress in Berlin? Available online @... Video Competition Winners ePosters Medal Lectures Symposia Free Papers Other Key Sessions www.conference2web.com/escrs

Industry News Healon D®gets PMA The USFDA has granted AMO pre-market approval (PMA) for Healon D® viscoelastic. The clear dispersive ophthalmic viscosurgical device (OVD) is intended for use as a surgical aid in cataract extraction, IOL implantation,corneal transplant,and glaucoma filtration surgery.According to the company,the low molecular weight of the compound allows it to coat the cornea and remain in place throughout the entire surgical process,and its lower viscosity provides ideal lubrication of IOL insertion systems.As with other Healon products, Healon D®OVD is latex free. AMO will introduce two new dual-pack ophthalmic viscosurgical systems featuring Healon D® and Healon GV® OVDs as well as Healon D® and standard Healon® OVDs in combination packs. www.amo-inc.com New trabeculoplasty laser approved Solx received FDA 510(k) clearance for its Solx 790 Titanium:Sapphire laser trabeculoplasty procedure.The clearance followed completion of a multicentre, international clinical trial that established equivalency of TLT to argon laser trabeculoplasty in its ability to reduce IOP in patients who have primary open-angle glaucoma and have poorly controlled IOP on maximally tolerated medications,and/or who have prior failed trabeculoplasty.The trial was conducted in the US,Europe, Canada and Israel.Nearly 200 patients were randomised to one or the other treatment.The 790 laser emits pulses at a near-infrared 790 nm wavelength to loosen particles in the trabecular meshwork without causing significant thermal damage. The energy penetrates deeper into the tissue than other currently used trabeculoplasty lasers and may therefore lead to longer-lasting treatment benefits,the company says. www.solx.com New non-contact tonometer from Reichert Reichert introduced the Reichert 7 Non- Contact Auto Tonometer,the seventh- generation non-contact tonometer from the company.The Reichert 7 offers many of the features of the previous non-contact tonometers,with added bonus features such as a refreshed design,enhanced user- interface,and a triple-measurement mode. The Reichert 7 features the industry's only one-touch measurement system.The company reports that the self-aligning system of the Reichert 7 reduces exam times by allowing the doctor or technician to simply position the patient in front of the instrument,press the touch screen and obtain an automatic measurement.The new "triple-measurement" mode further shortens exam times by taking three successive measurements,eliminating the need to re- position the patient for multiple readings. www.reichert.com Alimera reports DME results Alimera Sciences reported the interim six- month safety and efficacy results from its ongoing open-label,Phase 2 pharmacokinetic study of Iluvien,an intravitreal insert being developed for the treatment of diabetic macular oedema.The six-month interim readout indicated that 18 per cent of the high-dose patients had an improvement in best-corrected visual acuity of 15 letters or greater over baseline. However,the percentage of low-dose patients who had an improvement in BCVA of 15 letters or greater from baseline, decreased by 10 per cent.While patients in the low-dose group had no adverse IOP events,12 per cent of those receiving the high-dose experienced IOP increases. Other adverse events included cataract formation.The study is designed to last for three years. www.alimerasciences.com 50 Recent developments in the vision care industryIInndduussttrryyNews Regulatory UpdatesProduct LaunchesResearch Updates Topcon and Oculentis announce European cooperation Topcon Europe Medical BV,and Oculentis GmbH, subsidiary of Oculentis BV,announced they will start joint activities to market their complete range of ophthalmic surgery products.Oculentis manufactures intraocular lenses,viscoelastics and retinal liquids and Topcon manufactures diagnostic and surgical equipment for retinal and cataract applications.Both companies plan to use the extensive sales network of Topcon Europe Medical in Europe and the specialised sales team of Oculentis in Germany to deliver products to ophthalmic surgeons across Europe.The companies also agreed to collaborate in the development of new products. www.topconmedical.com www.oculentis.com Merck and SurModics end collaboration Merck will pay SurModics Inc.$9m to end the licence and research collaboration agreement the companies signed in June 2007.Merck’s decision to discontinue the collaboration was made following a strategic review of its business and product development portfolio,according to representatives from SurModics.Merck and SurModics were collaborating on a sustained drug-delivery system for treating retinal disease. www.merck.com www.surmodics.com Alcon shares repurchase Alcon announced it would purchase up to one million common shares by December 31 from the public in order to cover employee equity compensation plans. Nestlé SA and Novartis AG said they will not participate in the programme.Alcon has approximately 70 million shares that are publicly traded out of total outstanding shares of approximately 300 million,the company said. Nestlé owns 52 per cent of outstanding common shares and Novartis recently acquired 25 per cent of outstanding shares. www.alcon.com Red Hot Mamas Allergan launched a new national dry eye campaign it will conduct with the help of the “Red Hot Mamas”,a menopause education provider. The campaign will include the Dry Eye Book Club,featuring author Jacquelyn Mitchard,who has experienced the condition herself.The company hopes the new initiative will encourage women to visit the ophthalmologist to learn about dry eye symptoms and treatments.The company cited research indicating that women are disproportionately affected by dry eye associated with hormonal changes caused by ageing and menopause.Allergan markets three dry eye products, RESTASIS (cyclosporine ophthalmic emulsion),OPTIVE Lubricant Eye Drops,and REFRESH artificial tears. www.allergan.com www.dryeyebookclub.com Company News Jacquelyn Mitchard

Dysphotopsia and cataract surgery Dysphotopsia has been called the number one troublesome complaint after uneventful cataract surgery.What are the common factors of patients with negative dysphotopsia following phacoemulsification cataract surgery? Dr Robert Osher evaluated the incidence, course,and possible factors associated with negative dysphotopsia in 250 consecutive patients who underwent phacoemulsification with implantation of a single-piece acrylic intraocular lens during routine cataract procedures.Patients were asked whether they noticed a temporal shadow on the day after surgery and were followed by serial evaluations for three years.The incidence of negative dysphotopsia was 15.2 per cent on the first postoperative day,decreasing to 3.2 per cent after one year,then 2.4 per cent after two and three years.Common findings included a shallow orbit, prominent globe,space greater than 0.45mm between the iris and IOL by ultrasound biomicroscopy,and perimetric comet-shaped light in the area corresponding to the shadow.Slitlamp revealed a transparent peripheral capsule and a shadow sign in which a linear shadow on the iris became curvilinear as the light from the slit beam was projected through the incision toward the pupil. Based on the analysis,it does not appear that IOL design is a principle factor in dysphotopsia. Rather,Dr Osher hypothesises that corneal oedema associated with a bevelled temporal incision could contribute to transient negative dysphotopsia. RH Osher et al.,JCRS, “Negative dysphotopsia:Long- term study and possible explanation for transient symptoms”,October 2008,Vol. 34,Issue 10,1699-1707. Laser or lens for myopic astigmatism? High myopes with significant astigmatism pose a special challenge for refractive surgeons. Japanese researchers conducted a study comparing outcomes in 30 eyes that underwent implantation with a posterior chamber phakic intraocular lens,the Staar toric implantable Collamer lens, and 24 eyes that underwent wavefront-guided LASIK (Technolas).Patients all had up to 6.0 dioptres of myopia and more than 1.0 dioptre of astigmatism.Assessments at one week and one,three,and six months postoperatively suggested better visual outcomes among the lens group,with all eyes within 1.0 dioptre of the intended correction,compared with 71 per cent of eyes in the LASIK group.There were no significant complications in the ICL group,while two eyes in the LASIK group required enhancement ablations. Noting that toric ICL implantation was better than wavefront-guided LASIK in eyes with high myopic astigmatism in almost all measures of safety,efficacy, predictability,and stability,the researchers suggest that toric ICL implantation may become a viable surgical option to treat high myopic astigmatism.They note that some patients with high myopia or thin corneas may not be good candidates for LASIK because of the risk for keratectasia,and could be considered candidates for the ICL.Moreover,they add that the lens has the general advantage of being removable and replaceable with an IOL should the need arise. K Kamiya,JCRS,“Comparison of Collamer toric contact lens implantation and wavefront-guided laser in situ keratomileusis for high myopic astigmatism”, October 2008,Vol.34,Issue 10,1687-1693. 51 JCRS Highlights by Thomas Kohnen Journal of Cataract and Refractive Surgery jointly published by the ESCRS and ASCRSJJCCRRSSHighlights CChheecckk iitt oouutt oonn hhttttpp::////mmyyeeuurroottiimmeess..bbllooggssppoott..ccoomm ffoorr aa uunniiqquuee oonnlliinnee vviieeww oonn tthhee wwoorrlldd ooff oopphhtthhaallmmoollooggyy EEuurrooTTiimmeessnnooww hhaass iittss oowwnn wweebblloogg!!

November 2008 8-11ATLANTA,GA,USA American Academy of Ophthalmology Joint meeting with SOE Tel:+1 415 447 0320 / Fax:+1 415 561 8576 Email:meetings@aao.org Web:www.aao.org/annual_meeting 13-14BRIGHTON,UK UKISCRS Annual Meeting 2008 Tel/Fax:+44 0 1642 651208 Email:ukiscrs@onyxnet.co.uk / Web:www.ukiscrs.org.uk 21LONDON,UK The Medical Contact Lens & Ocular Surface Association (MCLOSA) Contact Lenses,Corneal Infections & Keratoconus Email:mclosa.admin@gmail.com Web:www.mclosa.org.uk 27-29SHARM EL SHEIKH,EGYPT 1st Egyptian International Meeting for Presbyopia Email:congress@presbyopiaegypt.net Web:www.presbyopiaegypt.net 27-30BANGKOK,THAILAND 21st APACRS Annual Meeting in conjunction with the 22nd Congress of the Royal College of Ophthalmologist of Thailand Tel:(65) 6322-7469 / Fax:(65) 6327-8630 Email:apacrs2008@gmail.com / Web:www.apacrs.org 28TOULOUSE,FRANCE Euromyopia 2008 Email:jpcomb@wanadoo.fr Web:www.euromyopia.com December 2008 12AMSTERDAM,NETHERLANDS 3rd Amsterdam Retina Debate Tel:+31 20 566 8585 / Fax:+31 20 696 3228 Email:retinadebate@amc.uva.nl January 2009 15-18HYDERABAD,INDIA Asia ARVO Email:asiaarvo@lvpei.org Web:http://www.asiaarvo2009.org February 2009 6-8ROME,ITALY 13th ESCRS Winter Refractive Surgery Meeting Tel:+353 1 209 1100 / Fax:+353 1 209 1112 Email:escrs@escrs.org Web:www.escrs.org March 2009 5-7ALICANTE,SPAIN Lens,Refractive & Wavefront Summit 2009 & 11th ARI (Alicante Refractiva Internacional) 10th WFC (Wavefront Congress) Web:www.alicanterefractiva.com Email:refractiva@vissum.com 19-21ANTWERP,BELGIUM 10th Antwerp Vitreoretinal Course Fax:+32 3 443 4580 Email:info@avcantwerp.info Web:www.avcantwerp.info 26-30MANAMA,KINGDOM OF BAHRAIN International Congress of Middle East African Council of Ophthalmology Web:www.meaco.org April 2009 4-8SAN FRANCISCO,CA,USA ASCRS/ASOA Symposium and Congress Contact:ASCRS Tel:+1 703 591 2220 / Fax:+1 703 591 0614 Web:www.ascrs.org May 2009 14-17NICE,FRANCE 9th EURETINA Congress Tel:+353 1 209 1100 / Fax:+353 1 209 1112 Email:euretina@euretina.org Web:www.euretina.org 16-19BALI,INDONESIA 24th Congressof the Asia-PacificAcademy of Ophthalmolgy Tel:+(62-21) 319 07282 / Fax:+(62-21) 392 7516 Web:www.apao2009bali.org 30-PRAGUE,CZECH REPUBLIC 2 JuneThe 10th Congress of International Ocular Inflammation Society (IOIS) Tel:+420 284 001 444 / Fax:+420 284 001 448 Email:ioisprague2009@guarant.cz www.ioisprague2009.com June 2009 13-16AMSTERDAM,NETHERLANDS 17th Congress of European Society of Ophthalmology (SOE) Web:www.soe2009.org July 2009 8-11BOSTON,MA,USA WORLD GLAUCOMA CONGRESS 2009 and International Glaucoma Symposium Web:www.worldglaucoma.org September 2009 12-16BARCELONA,SPAIN XXVII Congress of the ESCRS Tel:+353 1 209 1100 / Fax:+353 1 209 1112 Email:escrs@escrs.org Web:www.escrs.org 12-16ISTANBUL,TURKEY 22nd ECNP Congress Tel:+32 2 777 0188 / Fax:+32 2 779 5960 Email:ecnp2009@iceo.be October 2009 24-27SAN FRANCISCO,CA,USA American Academy of Ophthalmology Joint meeting with PAAO Tel:+1 415 447 0320 / Fax:+1 415 561 8576 Email:meetings@aao.org Web:www.aao.org/annual_meeting April 2010 10-14BOSTON,MA,USA ASCRS/ASOA Symposium and Congress Contact:ASCRS Tel:+1 703 591 2220 / Fax:+1 703 591 0614 Web:www.ascrs.org September 2010 4-8PARIS,FRANCE XXVIII Congress of the ESCRS Tel:+353 1 209 1100 / Fax:+353 1 209 1112 Email:escrs@escrs.org Web:www.escrs.org October 2010 14-17HAMBURG,GERMANY 23rd International Congress of German Ophthalmic Surgeons Tel:+49 911 393 1617 / Fax:+49 911 393 1620 Email:doc@mcnag.info Web:www.doc-nuernberg.de 16-19CHICAGO,IL,USA American Academy of Ophthalmology Tel:+1 415 447 0320 / Fax:+1 415 561 8576 Email:meetings@aao.org Web:www.aao.org/annual_meeting April 2011 26-30SAN DIEGO,CA,USA ASCRS/ASOA Symposium and Congress Contact:ASCRS Tel:+1 703 591 2220 / Fax:+1 703 591 0614 Web:www.ascrs.org May 2011 26-30NURENBERG,GERMANY 24th International Congress of German Ophthalmic Surgeons Tel:+ 49 9113931639 / Fax:+ 49 9113931620 Email:doc@mcnag.info Web:www.doc-nuernberg.de September 2011 17-21VIENNA,AUSTRIA XVIX Congress of the ESCRS Tel:+353 1 209 1100 / Fax:+353 1 209 1112 Email:escrs@escrs.org Web:www.escrs.org October 2011 22-25ORLANDO,FL,USA American Academy of Ophthalmology Tel:+1 415 447 0320 / Fax:+1 415 561 8576 Email:meetings@aao.org Web:www.aao.org/annual_meeting Alcon Tel:+1 817 293 0450 Fax:+1 817 551 8968 www.alconlabs.com Pages:25,29,OBC AMO Tel:+49 7243 501 610 Fax:+49 7243 501 100 www.amo-inc.com Pages:IFC,3,17-19 A.R.C. Laser Tel:+49 911 217 790 Fax:+49 9111 217 7999 www.arclaser.de Pages:9,38 ASCRS Tel:+1 703 591 2220 Fax:+1 703 591 0614 www.ascrs.org Pages:36,45 ASICO Tel +1 6309868032 Fax +1 6309860065 Pages:44 Bausch & Lomb Tel + 44 20 8781 5500 Fax + 44 20 8781 2997 www.bausch.com www.micsplatform.com Page:IBC BRD www.benzrd.com Pages:40-41 Canon Email:medical.ophthalmic@canon- europe.com www.canon-europe.com/medical Page:5 Carl Zeiss Meditec Tel:+49 3641 220 333 Fax:+49 3641 220 332 www.meditec.zeiss.com Pages:8 Croma-pharma Tel:+43 2262 / 68468 -0 Fax:+43 2262 / 68468 -165 www.croma.at Page:27 Haag Streit Tel:+49 4103 709 02 www.haag-streit.com Page:7,15,24 NIDEK Tel:+81-3-5844-2641 Fax:+81-3-5844-2642 www.nidek.com Page:11 Oertli Instrumente AG Tel:+ 41 71 7474 200 Fax:+ 41 71 7474 290 www.oertli-instruments.com Page:21,23 Oculus Tel:+ 49 64120050 Fax:+ 49 6412005295 www.oculus.de Page:30 Ocusoft Tel:+1 800 233 5469 www.ocusoft.com Page:6 Reichert Tel:+1 727 5680909 Fax:+1 727 5680919 Page:48 Wavelight Tel:+4991316188-0 Fax:+4991316186-111 Page:10 Zeimer Tel:+41 323327050 Email:innovation@ziemergroup.com www.ziemergroup.com Page:51 Calendar NovemberAdvertising Directory

AcrySof® IQ IOL takes center stage with reduced spherical aberration, increased contrast sensitivity, and signifi cant improvement in functional vision.1 For advanced performance, turn to the classic: AcrySof® IQ IOL. 1. Results of a controlled, randomized, double-masked, multicenter, contralateral implant clinical study of the AcrySof® IQ IOL versus a spherical control lens. CMS Approved. NTIOL Reimbursed. ©2007 Alcon, Inc. 9/07 NIQ164-EU/1/2 For further information concerning this lens and/or the surgical procedure, please refer to the package insert. NIQ164_64496AL.indd110/8/075:04:15PM