October 2008 13-10

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1 THErecent XXVI ESCRS Congress in Berlin was one of the most successful in the Society’s history and provided a stimulating and informative forum for the record attendance of 5,300 delegates. The debates that emerged from the Congress will give us plenty of food for thought in the months ahead as we strive to bring some of the lessons we have learned into our practices. In the coming months,EuroTimeswill follow up the very interesting debates on a number of hot topics including multifocal IOLs,current trends in laser refractive surgery,femtosecond laser and therapeutic corneal surgery and smaller incision cataract surgery. One of the most exciting projects to emerge from this year’s Congress is the new Strategic Plan which is being developed by the ESCRS Board which will include new support for a training programme in cataract and refractive surgery. The commitment to this programme is the result of an ongoing strategic review process designed to identify and address future needs of European cataract and refractive surgeons. Over the coming months the Board will formalise a Strategic Plan for the next three to five years which will include a significant investment to educate and support the training of younger doctors, the future lifeblood of the Society,especially from emerging European markets.It is my hope the process will enable the Society to continue to grow and meet the expectations of its members. In recent years the Society has been tremendously successful,but the Board has agreed that there is a need to review structure and strategy to ensure we can continue to grow.We want to create a plan to ensure the Society addresses the requirements of a changing and expanding membership base,and establishes clear policies on issues such as education and engagement of the emerging and developing markets.” The strategic review has been conducted in consultation with the Board,ESCRS Committee Members,industry,world opinion leaders and Society members.I would encourage all ESCRS members to give us their views. The ESCRS has also received a substantial grant from the EU to develop the European Registry of Quality Outcomes for Cataract & Refractive Surgery (EUREQUO).In addition to the ESCRS,the project involves 12 European national societies.Funding is for three years and data collection begins in April 2009. ESCRS firmly believes that a continuing audit of surgical outcomes is needed to ensure the best care for our patients and the EUREQUO project will play a significant part in developing this process.Make sure to visit the website at www.eurequo.org I would also encourage members to become involved in the EuroTimes Practice Management Resource Centre which was launched in Berlin.Cataract and refractive surgeons need to develop their business skills as well as their surgical skills.At the XXVI Congress,we held a series of lectures on business topics such as marketing risk management and reimbursement,topics which are a vitally important adjunct to our meeting.It is important for ophthalmologists today to enable them to thrive and remain independent.It is our intention to build on this programme in future meetings including the 13th ESCRS Winter Refractive Surgery Meeting which will be held in Rome. Finally,I would like to thank all the ESCRS members who worked tirelessly behind the scenes to ensure that the Berlin Congress was a success.Their meticulous preparation and planning has ensured that our Congress is widely recognised as the leading ophthalmological meeting in Europe. We will continue to strive to match the high standards we attained in Berlin and I look forward to seeing you all again at the Winter meeting in Rome next year and at our XXVII Congress in Barcelona. Paul Rosen Paul Rosen is President of the ESCRS From the Editor Paul Rosen 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 New Strategic Plan will build on the success of XXVI ESCRS Congress Editorial October

2 14 Cover Story 19Fewer accidents for cataract patients with shorter waits 20Combined PPV and cataract surgery good option for over-60s 21Study shows PCO greater with microlens 22Very satisfactory performance with pre-loaded IOL delivery system Cataract Update 14MRSA is now the single most common infection occurring after LASIK Cover story 16Hyperopic LASIK outcomes stable at five years 17RLE may be good choice for primary hyperopes Special Focus – Hyperopia Refractive Laser 23NPReading test shows Bilateral ReSTOR has best results 26Inlay procedure promising for treating presbyopia in emmetropes Refractive Lens > 22 Cataract> 28 Refractive Laser> 30 Glaucoma> Contents 28Laser refractive surgery in children More Contents

4 Contents 33 Retina 31Using pegaptanib sodium may have better visual outcomes than those reported 32Refractive surgeons should be aware of contraindications for LASIK surgery 33Triple therapy and AMD 34New treatment approach for RB may transform clinical practice 35Ophthalmology a major beneficiary of boom in genetics research Retina Update Ocular Update 30Low-target IOP called into question Glaucoma Update 36 Special Report 37 Letter from Berlin 38 Out & About 42 EU Matters 43 In Your Good Books 44 Practice Management 45 Bio-Ophthalmology 52 Eye on Travel Features 18 News in Brief 47 JCRS Highlights 48 Industry News 50 Journal Watch 54 Calendar Regulars >35 Ocular> 38 Out & About>54 Eye on Travel> Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Assistant Editor Angela Sweetman Senior 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

Dermot McGrath OVER5,000 ophthalmologists from across the globe gathered in Berlin in September for the XXVI Congress of the ESCRS. Following on from the success of last year’s meeting in Stockholm,the 2008 Congress in Germany’s rejuvenated capital city provided delegates from more than 80 countries with a packed programme of symposia,live surgery,surgical skills courses,free papers,posters and a wide variety of social events. The Congress also coincided with the annual meeting of the European Society of Ophthalmic Nurses and Technicians (ESONT) in which a record number of nurses and technicians attended three days of courses,didactic presentations and special events. This year’s industry events and numerous product launches from a record number of exhibitors also served to illustrate why the ESCRS Congress has become one of the landmark dates in the international ophthalmic calendar. Paul Rosen FRCOphth,the current ESCRS President,thanked all the surgeons,delegates and exhibitors who had helped to make the Berlin Congress such a success.He expressed particular thanks to German colleagues such as Thomas Neuhann MD,Thomas Kohnen MD,Manfred Tetz MD and Michael Knorz MD for their contributions to the society over the years and for their efforts in the organisation of this year’s meeting. Dr Rosen also announced the election by the ESCRS Board of President Elect José Guell MD,who will take over the role of President in January 2010. Promising results for femtosecond intrastromal presbyopia correction One of the stand-out presentations at this year’s symposia,if the reaction of delegates was anything to go by,was Dr Luis Ruiz’s preliminary results for an intrastromal correction (intraCOR) of presbyopia using the Femtec (20/10 Perfect Vision) femtosecond laser system. The non-invasive technique,which takes account of each patient’s refractive properties as well as individual biomechanical and geometrical properties of the cornea,generates a customised pattern for each eye using the Femtec laser with treatment times of between 18 and 30 seconds. Of 200 presbyopic eyes treated with this new modality,an average gain of 6.2 ±2.8 Jaeger lines was achieved in near uncorrected vision with only minimal effects on the distance UCVA. Dr Ruiz said that procedure avoids complications related to flap creation and surface ablation,does not induce dry eye or weaken the corneal integrity and offers faster recovery time than traditional refractive laser techniques. Femtosecond laser and corneal transplantation In other femtosecond laser news,IntraLase-enabled keratoplasty (IEK) represents probably the biggest advance in corneal transplantation in the last 30 years,said Yaron Rabinowitz MD. Using the femtosecond laser to perform corneal grafts leads to quicker visual rehabilitation,faster wound healing and safer surgery,said Dr Rabinowitz.“It represents an excellent and safer new treatment option for keratoconus patients who are contact lens intolerant and is the only viable option when combined with LASIK or ICL implants for patients who want to become completely independent of contact lenses,” he said. A similar view was expressed by Dutch surgeon Rudy Nuijts MD,who noted that the rate of penetrating keratoplasty in The Netherlands has dropped from 90 per cent to 60 per cent in just a few years thanks to the adoption of femtosecond laser cuts for lamellar procedures. Dr Nuijts said he was one of the original advocates of femtosecond laser-assisted posterior lamellar keratoplasty because of the benefits it offered in terms of accuracy, reproducibility and endothelial preservation. Multifocal IOLs Despite fluctuating fortunes over the years,multifocal IOLs are finally starting to deliver on their promise and are now a viable option for many presbyopic patients,according to Manfred Tetz MD.“Multifocal IOLs seemed to be a dead concept some years ago,but improvements in materials and design have brought them back as a genuine option for our patients.Over the past 50 years we had grown accustomed to IOLs as being foldable, monofocal,UV-filtering lenses.Since the year 2000,we have been focusing on the optical qualities of the IOL much more,” he said. Dr Tezt noted that while multifocal IOLs necessarily involved some element of visual compromise for the patient,the technology would continue to improve in the future. “This evolution is taking place.The third-generation multifocal IOLs are already delivering good results for our patients.We need to figure out as a society and throughout clinical research what the best lens or lens combinations are for our patients.I do think our patients are ready for multifocal IOLs in terms of cataract and refractive lens exchange,but we still have to work out the clinical details,” he said. An alternative view of the utility of multifocal IOLs was presented by Graham Barrett MD,who said that surgeons should look at the full range of options available to them before considering adopting multifocal IOLs in their practice. Dr Barrett noted that all multifocal IOLs entail some element of compromise for the patient. “All multifocals,whether refractive or diffractive,are based on the same principle of providing multiple focal planes and create simultaneous focus for near and distance vision.The literature confirms reduced contrast sensitivity as well as associated dysphotopsia such as haloes particularly when driving at night in patients implanted with these lenses,” he said. Dr Barrett said that pseudophakic monovision,which offers better safety and efficacy,is his treatment of choice for these patients. Phakic IOLs Angle-supported phakic IOLs still have a viable future so long as surgeons adhere to careful selection criteria and respect the anatomical dimensions of the anterior chamber,Roberto Bellucci MD told delegates. “The distance between the corneal endothelium and the lens material seems to be the most critical factor for IOL safety,” said Dr Bellucci,who presented the results of a study of 22 eyes of 11 patients who received the new AcrySof Phakic IOL (Alcon) in one eye and the I-Care (Corneal) lens in the fellow eye. Dr Bellucci noted that there were no significant differences between the IOLs in the early postoperative period. Complications over the longer term,however,included pupil ovalisation in two I-Care eyes.Yearly rates of endothelial loss were also greater in the I-Care implanted eyes. When the distance between the IOL and the endothelium was greater than 2.0mm,there was a mean yearly endothelial loss of 1.1 per cent for the AcrySof lens and 2.0 per cent for the I-Care.If the corneal clearance was less than 2.0mm between optic and endothelium,however,the endothelial loss in the I-Care eyes went as high as 20 per cent,said Dr Bellucci and ultimately resulted in two explantations. No AcrySof lens was affected in this way because the design of the lens ensures that there is typically more than 2.0mm between the IOL and the endothelium,he said. MICS continues to push the boundaries Microincisional cataract surgery will continue to push the boundaries in terms of techniques and technology as the trend towards ever-smaller incisions continues apace,noted Rupert Menapace MD in an overview of developments in the field of MICS in recent years. Dr Menapace said that there is now a good selection of IOLs such as the AcriSmart (AcriTec) and Akreos (Bausch & Lomb) that are capable of being inserted through sub-2.0mm incisions or even smaller. In-depth reports on these and other studies presented at the XXVI Congress of the ESCRS will appear in future editions of EuroTimes. Highest attendance to date at annual Congress in Berlin BERLIN 2008HIGHLIGHTS

ESCRS / Alcon Video Competition 2008 Winning video provides new insight into dropped nuclei Roibeard O’hEineachain Robert Osher MD,US is the overall winner of this year's ESCRS/Alcon Video Competition for his presentation “Understanding the Dropped Nucleus”.In his video he describes an investigation that came to some surprising conclusions regarding the aetiology of the dropped nucleus during cataract surgery.He also suggests some novel means for preventing the complication in patients at risk.The results of his research indicate that the risk of a nucleus dropping following a tear in the posterior capsule may depend less on the surgeon's performance than on the condition of the vitreous. Dr Osher's presentation included demonstrations of a series of pig and human cadaver eye experiments which tested the various theories regarding the cause of dropped nuclei.Their experiments suggested that gravity on its own is an unlikely cause,since the nucleus was consistently well-supported by the anterior hyaloid face following capsular tears.Moreover,the nucleus did not drop even when the investigators nudged them against the vitreous,suggesting accidental pushing by the surgeon is also an unlikely cause of the complication.The investigators also found that even extremely high infusion rates,with the infusion bottle raised to the ceiling,did not make the nucleus drop. On the other hand,the nucleus did drop during sudden increases in aspiration,as occur with high vacuum at the breaking of occlusion.A remedy for this may be the reduction of pressure, as in slow-motion phaco,which enabled emulsification of the nucleus on the hyaloid face in the experimental setting,Dr Osher suggests.The higher turbulence produced by longitudinal ultrasound also rendered the nucleus more likely to drop than was the case with torsional ultrasound,he adds. Most striking of all,however,was the degree to which pars plana vitrectomy caused the nucleus to drop.Dr Osher pointed out that as people age their vitreous becomes increasingly more aqueous.His experiments showed that an OVD can take the place of the vitreous and support the nucleus throughout phaco emulsification.Dr Osher remarked in his presentation that his findings illustrate the importance of being prepared to question conventional wisdom when seeking to answer unresolved problems in medical science. Educational Category First prize in the Educational Category of the competition went to Athiya Agarwal MD India for “Coloboma”.The presentation commences with a description of the embryonic origins of lens and iris colobomas and illustrates how the irregularly shaped anatomical structures can be treated when they cause functional and/or cosmetic problems. Dr Agarwal's presentation provides quick demonstrations of removing colobomatous lenses and the subsequent implantation of IOLs,with scleral suture support.The video also includes examples of surgery to correct iris coloboma and leave the pupil with a more aesthetically pleasing circular shape with reduced glare.Dr Agarwal also describes the various ocular pathologies with which colobomatous eyes may be additionally affected,such as giant retinal tears and glaucoma,and highlighted the special considerations necessary when performing surgery in such cases. Second prize in the Educational Category went to Hong Kyun Kim MD,South Korea,for “Various illumination methods in eyes with corneal opacification”.Third prize went to Hiroyuki Matsushima Japan for “The Road to Phaco Mastery:The Phaco Technique Grading System”. Innovative Category Donald Tan MD,Singapore received first prize in the Innovative Category for “Endothelial Keratoplasty - Please Don't Fold”.His video provides a demonstration of a new,less traumatic technique for inserting graft tissue into the anterior chamber during Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK).The technique involves using a specially designed micro-forceps to pull a previously dissected graft into the anterior chamber over a viscoelastic-coated intraocular lens glide.Unlike conventional DSAEK,the donor posterior lamella is not folded. The video also describes how in-vitro wet lab studies showed that mean endothelial cell damage could be reduced to nine per cent with the glide technique,compared to 38 per cent with the folding technique.In addition,the presentation shows how in a trial involving 70 eyes,the rate of primary graft failure was 25 per cent with the folding techniques,compared to only two per cent with the glide technique.In addition,the mean endothelial cell count decreased by 63 per cent with the folding technique compared to only 26 per cent with the glide technique. Second prize in the Innovative Category went to Takayuki Akahoshi MD,Japan,for “Square Tip” and third prize went to Boris Malyugin MD,Russia,for “New Technique of Phaco Surgery in Small Pupil”. Scientific Category First Prize in the Scientific Category was awarded to Shigeo Yaguchi MD Japan for “Yaguchi imaging eye camera evaluation of next-generation multifocal IOLs”.His video provides a fascinating and objective simulation of how images are projected on the retina in eyes with some of the newer refractive and diffractive IOLs.The Yaguchi imaging eye camera has an optical system similar to that of the human eye,consisting of a main lens with a 4.0mm aperture,to simulate the cornea and pupil,and a CCD camera which serves as the retina.Its design allows for insertion of an IOL,and in this way the model eye can provide a simulation of the quality of the image produced by the different IOLs in real patients. The video includes side-by-side comparisons,in high resolution,of images obtained with the model eye with a monofocal lens (AF-1,HOYA),the ReSTOR diffractive multifocal IOL,and the ReZoom (AMO) and MultiVision refractive multifocal IOLs (HOYA).The comparison shows that the far images obtained with the multifocal lenses were basically as sharp and clear as those obtained with monofocal lenses at target distances of six metres to one metre.However,the best near images were obtained with target distances of 30cm,for the ReSTOR,35cm,for the ReZoom,and 45cm,for the MultiVision lenses.In night-time conditions,there was slightly more glare from lower beam headlights with the multifocal lenses than with the monofocal lens.There was also more night-time glare from higher beam headlights with the ReSTOR,while night-time haloes were apparent with the ReZoom and the MultiVision. Second prize in the scientific category went to Athiya Agarwal MD,India,for “Aberropia:a new refractive entity” and third prize went to Chul Young Choi MD,South Korea,for “Comparison of actual vacuum pressure:ABS (Aspiration Bypass System) vs non ABS”. Special Cases Category Fernando Trindade MD,Brazil received First Prize in the Special Cases Category for “Watch the Haptic!”.In his presentation he calls attention to the complications that may arise from asymmetrical bag-sulcus fixation of single-piece AcrySof intraocular lens,such as recurrent vitreous haemorrhage,ocular hypertension and anterior inflammation.Dr Trindade presented individual case studies of eyes with the misplaced or displaced lenses and explained the techniques used to arrive at a diagnosis. He also showed how haptic amputation with a MST Amhed- Hoffman scissors alone is often all that is required to solve the problem. Second prize in the Special Cases Category went to Amar Agarwal MD,India,for “Untouchables” and third prize went to Samar K Basak MD,India,for “Late Secondary Angle Closure Glaucoma following Descemet's Stripping Endothelial Keratoplasty and its Management. Young Ophthalmologists Category Viraj Vasavada MD,US received first prize in the Young Ophthalmologists Category for his video “Visco-dissection during phacoemulsification:A Space Story”.Using the Miyake- Apple video/photographic analysis Dr Vasavada and his associates compared hydrodissection and visco-dissection in terms of space created between the posterior lens capsule and cortex during different phases of phacoemulsification. Their investigation,which involved 14 cadaver eyes,showed that greater space was created and maintained between capsule and cortex until the last stages of phacoemulsification in the visco- dissection group as compared to the conventional hydrodissection group.The Miyake-Apple video imaging shows how during conventional hydrodissection a fluid wave spreads across the posterior capsule,confirming the creation of a plane of cleavage between the capsule and the cortex.Eyes that underwent visco- dissection also received an injection of a dispersive OVD into the cleavage plane created by hydrodissection.The surgeon's impressions confirmed the greater space between the capsule and cortex in eyes with visco-dissection at all stages of phacoemulsification and a greater mechanical cushion effect in comparison with hydrodissection alone. Paul Rosen and Pierre Morival, Alcon, present Robert Osher with the Michael Blumenthal Prize While in previous years attendees at the Opening Ceremony of the Annual ESCRS meeting have received a DVD of the winning videos,all of the videos are now available for viewing,free of charge,at the ESCRS on Demand website,which may be accessed through the ESCRS home page www.escrs.org.

Dermot McGrath A capsular bag refilling procedure may offer a novel approach to the age-old problem of restoring ocular accommodation, according to Okihiro Nishi MD,who delivered this year’s Ridley Medal lecture. “Our studies show that refilling the lens capsule with an injectable malleable material while preserving capsule integrity, including zonules and ciliary muscles,offers the potential to restore ocular accommodation,” he said. Explaining the background to his research,Dr Nishi said that many experimental studies over the past 30 years highlight two recurring problems in capsular bag refilling – firstly,leakage of the injectable material from the capsular opening and secondly, the formation of anterior and posterior capsule opacification. To try to overcome these difficulties,Dr Nishi has developed an intraocular lens system comprising a membrane-type intraocular lens placed within the capsular bag and silicone polymers injected behind the lens to provide accommodation. The lens is placed at the anterior portion of the capsular bag in such a way that it seals the anterior capsulorhexis. “The anterior foldable silicone accommodating IOL serves as both an optical device and as a mechanical device to prevent leakage of the injected silicone polymers,” said Dr Nishi. He noted that the lens is fabricated in such a way that it is capable of changes in curvature as well as movement during accommodation.This is accomplished by using a lens that has a variable thickness,stiffness or modulus.A second IOL can then be implanted close to the posterior surface of the capsular bag to prevent posterior capsule opacification (PCO). Describing the technique in more detail,Dr Nishi said that a 3.5 to 4.0mm continuous curvilinear capsulorhexis is created and phacoemulsification and aspiration are performed in the usual manner. A posteriorly placed accommodating IOL with sharp edges is implanted in the capsular bag to prevent posterior capsule opacification and leakage of the injected silicone polymer.In the next step,an anterior IOL is piggybacked over the existing IOL and silicone polymers are injected between the two lenses. In an overview of research in this field,Dr Nishi cited a selection of previous attempts to prevent leakage of injectable IOLs including pre-cured silicone gel,endocapsular polymerisation by ultraviolet light,expansible HEMA-IOL and collagen gel with high concentration.Other approaches, pioneered by Dr Nishi,included the use of endocapsular balloon and the sealing of mini curvilinear capsulorhexis by a plug method. Turning to theories of accommodation,Dr Nishi said that accommodation and disaccommodation can be understood as a balance of elasticity between the lens matrix and capsule. “The artificial lens matrix should be restored in the shape of the disaccommodated state,” said Dr Nishi. In terms of posterior capsule opacification,Dr Nishi noted that while numerous mechanical and pharmaceutical means have been developed to try to combat PCO,none has proven to be easy,safe and effective as a routine clinical procedure. Dr Nishi said that recent tests of the accommodating membrane IOL in young Macaca monkeys underscored the great potential offered by this approach. In these trials,six monkeys were injected with an overfill of 0.125ml of silicone polymers (125 per cent bag volume) and another six monkeys with an underfill of 0.08ml of silicone polymers (80 per cent bag volume). In the 125 per cent bag volume group,one eye failed to be refilled due to an excentrical CCC,while four out of five eyes refilled with one anterior accommodating membrane IOL.One eye refilled with both anterior and posterior membrane IOLs and PCCC,said Dr Nishi. “The new procedure required 20 to 30 minutes surgical time and was found to be highly reproducible.The procedure prevents leakage of the injectable silicone polymer from ACCC and PCCC.The approach solves two of the persistent problems in lens refilling – leakage of the injectable silicone and capsular opacification,at least in the visual axis,” he said. Summing up,Dr Nishi noted that the accommodation obtained was a consequence of the anterior curvature change of the membrane optic and provided a solid platform to continue further research in this area. “Achieving emmetropia remains an issue to be resolved.This approach definitely warrants further pursuit and should be viewed as a legacy to the pioneering efforts of Harold Ridley,” he said. A new approach to age-old problem of restoring accommodation Howard Larkin LIVELYdebates among ophthalmic surgeons and practice management consultants marked each session of the inaugural EuroTimesPractice Management Resource Centre. The sessions,which drew presenters and attendees from throughout the world,offered practical advice for ophthalmologists on every rung of the career ladder. London-based communications consultant Kris Morrill opened the three-day event with a workshop on how to make effective presentations at major national and international meetings. Mark Schaller of the London Business School provided step-by- step suggestions for developing websites for ophthalmic practices. In addition to discussing how to obtain reimbursement for new technologies and procedures,Dr Thomas Seeger,managing director of Medalliance,Germany,provided tips on taking advantage of internet search engines and working with hospital administrators and insurers. Dr Jean-Pierre Benoit,professor of economics at the London Business School,kicked off the second day of the sessions with an engaging talk on “Overcoming Rational Failure.” “Good news can be bad,” Prof Benoit told attendees.“The longer your operating centre goes without an accident or medical error,the greater the tendency to minimise the risk that it can happen.It’s just human nature to pay attention to your own positive experience.Every day you go error-free,the nuisance,time,and expense of going through a complicated checklist seems less important.” Eckhard Weingäertner,MD,medical director of the EuroEyes Clinic,Stuttgart,Germany,leaned on his experience in providing a workshop on “Building your Refractive Practice”. Dr Weingäertner focused on the practical questions that more and more refractive surgeons find themselves facing as patients become more informed and sophisticated about surgery outcomes. “The difference between cataract and refractive surgery is disappearing.Almost everyone knows about multifocal lenses and they expect excellent refractive outcomes,” said Dr Weingäertner.“To meet those rising outcome expectations, surgeons will have to both master the technical skills of refractive surgery and invest in equipment such as advanced biometry devices and excimer lasers needed to produce them.” Dr Weingäertner also noted that service expectations are rising.“When patients are paying hundreds or even thousands of euro extra for multifocal lenses and other advanced refractive technologies,they won’t tolerate long waits for appointments or indifferent attitudes from practice employees,” he said. A number of other leading ophthalmologists and practice management experts – including ophthalmic surgeon Karl Brasse,MD,of Eyeland Design Network,the Netherlands; Walter Pfeifer,of Colana Consulting,Germany;Robert Watson, of Patient Education Concepts,US;Mike Mallie of the Centre for Refractive Marketing,US – also presented a range of strategies for enhancing the patient experience. Such strategies included internal steps practices can take to involve patients earlier in decisions about multifocal lenses and other refractive options.The speakers included a number of suggestions for using technology,art,illustration,and animation to not only educate patients but also to persuade patients to choose their practice for their refractive and cataract surgery. The Practice Management Resource Centre workshop concluded with a presentation on risk management by ophthalmic surgeon Emanuel Rosen,MD,Manchester,UK; medical-legal expert Wolfgang Radner,MD,of Vienna,Austria; and barrister Paul McGinn,of Dublin Ireland.The trio emphasised the importance of patient communication,informed consent,and good record-keeping. “Poor records don’t mean you are a poor technician but they do indicate you are a poor ophthalmologist.As a professional, you have a duty not only to do what is right but to document it as well,” Mr McGinn told the final session. EuroTimeswill sponsor its next Practice Management Resource Centre at the 13th ESCRS Winter Refractive Surgery Meeting in Rome,Italy.Further details of the centre’s planned workshops and an in-depth study of the Berlin sessions will appear in a special supplement with the December issue of EuroTimes.Information on the centre is also available on our website at www.eurotimes.organd on our weblog at http://eurotimespracticemanagement.blogspot.com Practice Management Resource Centre launched in Berlin Okihiro Nishi, who delivered this year’s Ridley Medal Lecture, receives his medal from Paul Rosen Kris Morrill introduces Thomas Seegar at the opening of the Practice Management Resource Centre Jean-Pierre Benoit speaking at the Practice Management Resource Centre

CHINESEophthalmologist Shiu Ting Mak MRCS (Ed) was the recipient of the inaugural EuroTimes John Henahan Prize,set up to honour John Henahan,the late visionary editor and guiding light of EuroTimesfrom 1996 to 2001. Dr Mak received the first prize of E1,000 and a specially commissioned trophy which was presented to her by Dr Emanuel Rosen,chairman of the ESCRS Publications Committee,at the XXVI Congress of the ESCRS in Berlin. The prize,which was open to ophthalmologists under the age of 40 who are members of the ESCRS,was awarded for the best essay written on the theme of “Why I became an ophthalmologist”. Two other young ophthalmologists,Soosan Jacob MD,India, and Maryia Morkhat MD,Belarus,were also commended by the jury for the high quality of their entries.A selection of the entries will also be published on the EuroTimesweblog at http://myeurotimes.blogspot.com/. BERLIN 2008HIGHLIGHTS The EuroTimes John Henahan Prize Why I became an ophthalmologist... Shiu Ting Mak, MRCS(Ed) My beloved grandmother lost her left eye because of neovascular glaucoma.Her right eye is also legally blind because of advanced proliferative diabetic retinopathy.Since I was a child,I accompanied her to hospitals and clinics,spending hours in long queues,waiting to be seen by ophthalmologists.I love my grandmother because she is a very capable person. Widowed at a young age,she did three jobs to strive a living for her seven children.Unfortunately,since her vision started to deteriorate,she was unable even to go out for a walk on her own.The only time she could leave home was when someone accompanied her to see a doctor.I understand how she feels, and sometimes I do feel upset by the fact that she is so much troubled by her poor vision.Is there anything worse than when one can only recognise her family members by listening to their voices? At the same time,I truly realise how difficult and inconvenient it can be for families with visually disabled members. Because of this,I longed to become an ophthalmologist to relieve the pain,both physical and psychological,of patients and families with eye diseases.During my final year of study in medical school,I was attached to the Ophthalmology Department.This was the first time I got a taste of what exactly ophthalmology was like.I had the opportunity of talking to Prof Dennis Lam,chairman of the department.He shared with us his pathway of a young college boy evolving into a world-class ophthalmologist.When he knew I was planning to enter ophthalmology training,he even wrote me a little note to give me encouragement and support.Prof Lam is a very famous figure in Hong Kong because of the many voluntary eye services he offers for the underprivileged in China.I respect him very much,therefore,I was really excited by my encounter with him. This further boosted my ambition in pursuing ophthalmology as my lifelong career so that I can take part in his meaningful blindness eradication projects. I find ophthalmology one of the most gratifying specialties in medicine.In some branches of medicine,treatment is offered in a trial-and-error manner with no guarantee.Yet in ophthalmology,we tend to cure people.Once a cataract operation has been successfully completed,the patient will never require such a procedure again.And more importantly, the improvement in vision can be instantaneous.What could be more gratifying than after a 30-minute cataract operation,the patient smiles at you and says he can see the world clearly again? “Vision 2020:The Right to Sight” is a worldwide collaboration to eradicate blindness by 2020.China,being the most populous country in the world,unfortunately still has a large population suffering from blindness,and the number is expected to continue rising because of the ageing population.It is estimated that China has as many as 6.9 million blind people with cataract being the leading cause of blindness,1and among them more than 60 per cent live in rural area2with lack of expertise and resources.While there are approximately 24,000 practising ophthalmologists in China,1only 20 per cent work in rural areas.As the majority of blind people living in rural areas are farmers with low incomes,they cannot afford expensive fees and transportation to seek medical help in the better equipped cities.The cost of cataract surgery in hospitals ranges from 2500 to 8000 RMB per eye3(approximately 230 to 740 Euros), which can be a year’s or even a few years’ income for an ordinary farming family. Among the 17 ophthalmologists per million population,1only half perform surgery.4Even for those who are fortunate enough to receive cataract surgery in rural areas,it has been reported that around 50 per cent are still legally blind afterwards.3This is attributable to poor surgical technique of ophthalmologists,and use of intracapsular cataract extraction leaving patients aphakic without provision of glasses.In a population-based study conducted in Shunyi County,more than 60 per cent of patients were left aphakic after cataract surgery. Uncorrectable aphakia attributable to surgical complications were common.5Data from a national survey showed that only 28 per cent of Chinese ophthalmologists graduated from a recognised university and only half had the expertise to perform cataract operations.6,7The same survey also revealed that county hospitals suffered from a significant lack of resources and equipment.Only 39 to 42 per cent of the hospitals has an ophthalmoscope,57 to 63 per cent a slit lamp, and 19 to 36 per cent an operating microscope.6,7 “Project Vision” is a blindness eradication programme launched by Prof Dennis Lam a few years ago.While many organisations arrange experienced ophthalmologists to visit China and perform numerous operations for the needy within their period of visit,Prof Lam thought of something different. He believes that emphasis should be given to training Chinese ophthalmologists,particularly rural practitioners,to perform cataract surgery in a safe and effective manner.Only by achieving this can more patients be treated persistently and blindness in China could be successfully eradicated.In order to reduce the cost of surgery,Prof Lam invented the SLIMCE technique,which stands for sutureless,large-incision,manual cataract extraction.Using this technique,phacoemulsification machines and sutures are not required,thus lowering the cost of surgery to only 700 RMB (approximately 65 Euro).Prof Lam and his team have been offering intensive training to help Chinese ophthalmologists acquire this technique,and it is hoped that with successful skill transfer,more and more poor rural people can receive sustainable,cheap,and effective cataract surgery to combat blindness. China is the world’s most populous country,yet she also has one of the highest blindness rates worldwide.The estimated one million new cataract cases each year has outgrown the 600,000 cataract operations performed annually.This poses a challenge not only to public health officers,but also to all ophthalmologists.Prof Lam’s “Project Vision” may be a possible solution as it offers sustainable,cheap yet high-quality cataract surgery which can be afforded by most rural dwellers in China. It is my dream that one day blindness will be eliminated from our world.I want to play a role and contribute;this is why I chose to become an ophthalmologist. References 1. ORBIS. “Blindness in China – Fact File”. http://www.orbis.org/Default.aspx?cid=5711 . Accessed 6 July 2008. 2. World Health Organization, Human Development Report 2006, Country Sheet: China (2004). 3. Lin Y. Comparative study on preventing avoidable blindness in China and in Nepal. Chin Med J 2007; 120(4): 280-3. 4. Congdon N. Project Vision: A Program for Sustainable Eye Care in China. Medscape Ophthalmology 2007. http://www.medscape.com/viewarticle/550417_1. Accessed 6 July 2008. 5. Zhao JL, Sui RF, Jia LJ, Fletcher AE, Ellwein LB. Visual acuity and quality of life outcomes in patients with cataract in Shunyi County, China. Am J Ophthalmol 1998; 126: 515-23. 6. Lin Y. Prevention of blindness: Priorities in China. Med Progress 2000; 27: 12-18. 7. Lin Y. Analysis on the status of department of ophthalmology in general hospital. The yearbook of Chinese health. Beijing, 2000: 150-151. Emanuel Rosen presents the EuroTimes John Henahan Prize to Shiu Ting Mak

THE winning presentations in this year’s Poster Competition at the XXVI Congress of the ESCRS featured a broad range of new ways of assessing eyes both before and after cataract and refractive surgery. First prize in the Cataract Category went to Georgia Cleary FRCS,UK,for her presentation “Visante OCT versus AC Master:Comparison of anterior chamber depth measurements in eyes implanted with an accommodating intraocular lens”.Her poster described an investigation which demonstrated a poor correlation between the measurements of the two devices and showed that the Visante OCT overestimates the forward movement of the optic of a prototype accommodating IOL. The study involved 22 patients who underwent implantation of the accommodating IOL in one eye.Six months postoperatively,Dr Cleary and her associates measured the anterior chamber depth (ACD) of the patients’ IOL-implanted eyes using the Visante OCT (Zeiss) and the AC Master (Zeiss) instruments.They took the measurements as the patients viewed the internal fixation target at distance,and at accommodative positions of -1.0 D and -2.0 D.They also measured the ACD after administration of pilocarpine 4.0 per cent. The investigators found that Visante OCT’s ACD measurements were significantly lower than the AC master’s under all conditions and that the difference increased under accommodative stimulus and pilocarpine administration.The mean ACD measurement with a distance target was 4.360mm with the Visante OCT compared to 4.387mm for the AC Master (p=0.001).With the -1.0D fixation target the ACD measurements were 4.347mm vs 4.371mm, respectively(p=0.019),and with the 2.0D fixation target the ACD measurements were 4.332mm vs.4.364mm,respectively (p=0.017). Under pilocarpine stimulation,ACD measurements of the Visante OCT and AC Master were 4.057mm and 4.116mm, respectively (p<0.0001),and the change in ACD was significantly greater with the Visante OCT than with the AC Master (0.308mm vs 0.270mm,p=0.011). Dr Cleary noted that the Visante OCT measurements are semi-subjective in that they require the operator to manually delineate the ACD onto the anterior segment image provided. The AC master,on the other hand,obtains its axial length and ACD measurements objectively on the line of sight. “The Visante overestimates the forward IOL movement and thus accommodative performance.Measurements obtained by these two instruments are therefore not comparable,” she added. Abhay Vasavada FRCS,India,received second prize in the Cataract Category for his presentation “Software based assessment of postoperative rotation of the toric IOL:A new technique”.The technique involves the use of digital retroillumination images,which are superimposed on a specially designed grid,and special software,which determines the centre of the IOL,based on the locations of the innermost toric marks of the IOL.A major episcleral vessel serves as an anatomical landmark. In the poster,Dr Vasavada describes the results obtained with the technique in an eye of a patient who had undergone implantation of an AcrySof toric IOL (Alcon).The results showed that the maximum median rotation,0.8 degrees, occurred between one week and one month postoperatively, and that the lens became increasingly rotationally stable thereafter. Third prize in the Cataract Category went to Yutaro Nishi, UK,for “Reproducibility of measurement of IOL decentration and tilt using a clinical Purkinjemeter system”. The new Purkinjemeter described in the poster measures the position and orientation of implanted IOLs by the alignment or misalignment of Purkinje images reflected from an array of LEDs projected into the eye and captured by a digital camera. Dr Nishi’s study showed that the same examiner obtained almost exactly the same decentration measurements from images thus obtained at separate times from 12 pseudophakic eyes,with a mean variation of only 0.07mm.In addition,the measurements obtained by two separate examiners in another 12 pseudophakic eyes were also small,with a mean difference of 0.098mm. Refractive Category First prize in the Refractive Category went to William Bourne MD,US,for his poster “Endothelial cell loss nine years after LASIK and its importance for eye banks”.His presentation provides the details of a study which showed that corneas donated by LASIK patients may be acceptable after all for patients undergoing posterior lamellar keratoplasty,since their endothelium’s appear to be unaffected by the refractive procedure. The study involved 20 eyes of 10 patients who underwent LASIK to correct refractive errors ranging from -4.0 D to - 9.25D.Dr Bourne and his associates took central endothelial photographs of all eyes prior to surgery and at nine years’ follow-up.They analysed the endothelial cells with the centre method after appropriate calibration for magnification. They found that the patients’ endothelial cell density appeared to decrease by a mean of 0.8 per cent per year,with cell counts falling from 3,002/mm2 at baseline to 2,800/mm2 at nine years’ follow-up.The rate of cell loss was very similar to the 0.6 per cent rate Dr Bourne and associates found in a previous study involving 42 normal unoperated corneas of control patients during a 10-year period. Moreover,the coefficient of variation of cell area and hexagonality did not change at nine years after LASIK compared to preoperative values.Furthermore,the rate of endothelial cell loss was no greater among the eight eyes which had undergone repeat LASIK than it was among those which had undergone only a single procedure. “Some eye banks refuse all donated eyes that have had LASIK,this is appropriate for eyes to be used for penetrating keratoplasty.For posterior lamellar or endothelial keratoplasty, post-LASIK eyes should be appropriate if the endothelium is normal,” Dr Bourne said. Second prize in the Refractive Category went to Renato Ambrosio MD,Brazil,for “Enhanced screening for refractive candidates based on corneal tomography and biomechanics”.Dr Ambrosio’s presentation describes a technique for excluding corneal ectasia suspects from corneal surgery,using corneal tomography obtained with the Pentacam Scheimpflug camera (Oculus) and biomechanical measurements obtained with the Ocular Response Analyser (Reichert). In a study involving 50 eyes of 25 patients with seemingly unilateral keratoconus,Dr Ambrosio and his team were able to show that although,based on topography and CCT,nine (36 per cent) of the non-keratoconus eyes would have been considered as good candidates for LASIK,in fact,all contralateral eyes had at least one 'red flag' for keratoconus based on the enhanced screening criteria. Third prize in the Refractive Category went to Vasilios Diakonis MD,Greece,for “Effect of intraoperative corneal hydration in post PRK refractive outcomes”.The poster provides details from a study involving 190 eyes of 103 patients who underwent PRK with mitomycin C for myopia that was less than -5.0 D or greater than -5.0 D with or without intraoperative stromal hydration applied directly before the ablation. The study showed that among those undergoing PRK for less than 5.0 D the mean predictability was 0.29 D with hydration compared to 0.44 D without hydration.However,there was no significant difference between the hydration and non-hydration groups undergoing corrections of more than 5.0 D. BERLIN 2008HIGHLIGHTS Poster competition winners show new ways of looking at eyes before and after surgery Georgia Cleary Live Surgery

The European Society of Ophthalmic Nurses and Technicians (ESONT) held their annual meeting during the XXVI Congress of the ESCRS in Berlin.369 delegates attended three days of courses,wetlabs,free papers and symposium sessions.Stephanie Binder MD reports on some of the highlights. Taking glaucoma personally Have you ever taken the problem of patient compliance so seriously that you tried the medications out on yourself,to see what patients go through? Almost the entire staff at Hara Eye Hospital,Utsunomiya,Japan,did just that in a recent glaucoma medicine compliance trial. “The best way to understand how our patients feel is to instill the drops into our own eyes.Some of the causes of poor compliance include eye irritation,the need for frequent applications,multiple medicines,and difficulty using the bottles. Patients need to know what to expect and it is the job of the medical staff to make sure they do,” reported Aki Kaneda,an ophthalmic nurse and trial participant. Some 47 doctors,nurses,and other staff members evaluated the sensation and package handiness of 10 different,commonly prescribed anti-glaucoma eye drops.After removing the labels and numbering the bottles one to 10,each participant applied one drop of a medicine to his/her eye and another medicine into the opposite eye,a half-day later. Participants rated each medicine and bottle using a score system from zero to two,with zero indicating good,one neutral, and two poor.The scores of the 47 participants were averaged for each factor.Scores over one for any particular medicine were judged to be unacceptable,Mrs Kaneda noted. The average scores for eye irritation and blurred vision each exceeded a score of one for three medicines.The scores for hyperaemia differed greatly among the study participants,with symptoms lasting a long time,in some cases.Two medicines scored between zero and one for all disturbing sensation factors.All drugs were within the acceptable range for hyperaemia and aftertaste.The scores for the softness of the container varied widely. Mrs Kaneda observed that 10 per cent of the deterioration of the visual field in glaucoma patients is related to non- compliance with the use of eye drops.No matter how good the eye drop is,it cannot be effective if it is not used as directed by the doctor,she said. “We do not want to judge the medicines as good or bad.We want to be able to prepare the patients regarding sensation and package usefulness.We obtained first-hand information that will help us to explain the medications to patients.This may increase patient compliance.” Nurses’ know-how extends to ICR patient needs Portuguese ophthalmic nurses are helping keratoconus patients prepare both mentally and physically for intra-corneal ring (ICR) implantation,with much emphasis on patient education,reducing patient anxiety and preparing them psychologically for surgery. Since 2003,ophthalmic nurse Paulo Marques has cared for 30 patients receiving INTACS ICR at the Coimbra University Hospital,Coimbra,Portugal.Patient numbers are increasing due to expanding ICR indications,and as these numbers increase,so does the significance of the nurse’s role in these patients. “The nurse takes the responsibility of putting the keratoconus patient at his ease and educating him about post-op care.We have our patients’ needs to attend to pre- and postoperatively,” said Mr Marques. Mr Marques meets the patient and family in the surgical unit, prior to the operation,where it is his job to promote a calm, noise-free,and safe environment.After some initial paperwork in which he verifies the illness,prescribed medications,existence of allergies,etc,the ophthalmic nurse prepares the patient psychologically for the upcoming surgery,explaining again in detail the pre- intra- and postoperative steps. An informative explanation is important to reduce anxiety, prior to surgery.Once the patient is informed and calm,the nurse begins the physical preparation,including intravenous access,evaluation of vital functions,ensuring the patient did not eat or drink preoperatively,etc. Postoperative care involves much time and patience on the part of the nurse to reduce patient anxiety.The nurse teaches the patient about vital hygienic procedures to avoid post-op infection.If necessary,the nurse will wash the patient’s eye with sodium chloride 0.9 per cent.He then applies a topical antibiotic,anti-inflammatories,and corticosteroids. ICR surgery allows patents to be discharged on the same day of surgery.After explaining home care to the patient and his family members,the nurse provides written guidelines detailing post-op care before discharge.Patients also have 24/7 access to the emergency department by phone,postoperatively. Building up eye cancer patients According to Finnish ophthalmic nurse,Irmeli Österman,the feeling of having control over one’s own life and receiving experienced support from healthcare professionals in patients with malignant choroidal melanoma are the key factors influencing how they overcome the harsh reality of getting cancer. “A cancer diagnosis is a major crisis for a patient,and the stress reaction lowers the quality of life,requiring that the patient maintain strong life control and social support.Nurses can help patients adapt and fit into their new role as cancer patients,” Mrs Österman said. In a study involving 20 patients diagnosed with malignant choroidal melanoma within a year,Mrs Österman interviewed patients to evaluate coping tactics and the level of patients’ orientation to life,focus on problem solving in their lives,and capacity to deal with stress factors. She used the Antonovsky salutogenic theory of sense of coherence (SOC),which describes the way in which people can achieve positive health results.According to the sociologist’s theory,a sense of coherence is given by three factors: comprehensibility,manageability,and meaningfulness. Her study revealed that the patients’ own resources and positive personal attitudes helped them to cope with the crisis. Leading a positive life in spite of cancer,maintaining hobbies, playing sports,meeting with friends and continuing to work, were a source of sustenance. Keeping up good relationships and having an active social life is also important.Peer groups and religion give support to cope with stress,as do the acceptance of the notion that illness belongs to life,she said. Control of everyday life had physical and mental aspects. Maintaining normal activities,and adjusting to physical changes, required physical and mental adaptation.The patients had to have faith and see hope for the future.They felt they had the power to affect their own lives. Experienced support for eye melanoma patients come from different sources,she explained.Physicians and nurses offer informational support.Mental support came from partners,family members,and friends. Nurses can help cancer patients to hone their ability to function and achieve positive health results,in spite of serious illness.By developing preventive nursing care interactions and methods,we can support life control among eye cancer patients, she emphasised. Portuguese nurses put patient safety first Patient safety is essential and requires achieving three major objectives:identifying safe and effective diagnostic and treatment procedures,ensuring they are used where needed,and performing them correctly. Coimbra University Hospital has streamlined its ophthalmic outpatient procedures to ensure utmost patient safety.These procedures are three-fold:pre-,intra-,and postoperative, reported Patricia Antunes. “We promote communication among the surgical team and implement consensual standardised protocols,but with enough flexibility to meet specific patient needs.Wrong site,wrong procedure,wrong person surgery must be prevented.Our department has developed patient care processes over the years to prevent adverse events in outpatient surgery,” she said. Preoperatively,a verification process first acknowledges the patient’s problem,and the nurse orders the relevant documentation,images,implants and special equipment. On the day of surgery,the patient is admitted after a correct patient identification,the operative site is unambiguously marked, and the patient is prepared according to established protocols. In the OR,the nurses re-establish patient identification,confirm the operation site,implants,and required equipment,and administer drugs according to established protocols. Finally,at the recovery centre,the nurse prepares the patient for discharge and transfers the responsibility of care to family.The hospital provides 24-hour phone and emergency centre support. “Little research has been done and many argue that not enough is known about the prevalence of adverse events of patients undergoing out-patient surgery.Several studies estimate that adverse events in hospitals range from four to 17 per cent, half of which are avoidable.Reactions to medication comprise the most frequent of these,followed by surgical nosocomial wound infections,and technical complications,” she observed. Mrs Antunes reported that cataract outpatient surgery represents 86 per cent of all ophthalmic surgery at her department.By contrast,ophthalmic outpatient surgery in Portugal is 30 per cent of all surgeries.Given the increasing trend toward outpatient surgery,further comparisons of data collection methods would enhance our knowledge and further improve patient safety. While the numbers of ambulatory surgeries rose at Coimbra, the number of adverse events declined,owing to the implementation of care strategies,she said. ESONT meeting featured leading experts in comprehensive programme

BERLIN 2008HIGHLIGHTS EESSCCRRSS WWEELLCCOOMMEERREECCEEPPTTIIOONN President’s Dinner Welcome Reception and President’s Dinner sponsored by

Nick Lane PhD Methicillin-resistant Staphylococcus aureus(MRSA) infection is emerging as the leading cause of poor visual outcomes after both cataract and refractive surgery.With recent studies showing growing resistance to fourth- generation fluoroquinolones, EuroTimesasks what ophthalmologists can do about it. A decade ago,MRSA was an arcane threat – worrying,but restricted mainly to intensive care wards.But according to a study published in JAMAlast October,by the Centers for Disease Control and Prevention (CDC),MRSA is now a bigger killer than AIDS,with nearly 20,000 deaths a year attributed to it in the US. And MRSA is no longer restricted to immunocompromised patients.Last year, APIC – the Association for Professionals in Infection Control and Epidemiology – reported that MRSA was eight times more prevalent in US hospitals than had been thought,with an infection rate of about five per cent.Nearly 70 per cent of hospital Staphylococcusinfections are now multiple drug-resistant MRSA. In a follow-up survey of more than 2000 infection specialists reported this June,76 per cent said their hospitals had taken steps to prevent MRSA transmission in the last year,but 54 per cent said that not enough was being done. Worse,MRSA has left hospital and invaded the community.Strains such as USA300 have been linked with outbreaks in sports teams and clubs (the first being a British rugby team in 1998) as well as prisons,families,schools and other locations where people come into close contact. The common denominator seems to be skin abrasions,turf burns or other minor wounds.One outbreak,for example,was traced to a local unlicensed tattoo artist. Skin infections are easily mistaken for spider bites. The carriage rate of MRSA in the population is startling.A 2004 study showed a carriage rate of about 20 per cent.Four years on,that rate is now close to 50 per cent,according to Francis Mah MD,at the University of Pittsburgh and co-medical director of the Charles T Campbell Ophthalmic Microbiology Laboratory. The figures are very similar in Europe. According to a 2006 review in The Lancet from the EARSS (European Antimicrobial Resistance Surveillance System) the prevalence of MRSA in Western Europe and the US is equivalent,with the carriage rate in the UK,Ireland,France,Spain and Italy at 25 to 50 per cent,with only slightly lower rates in Germany and Eastern Europe. Rates are lower in Holland and Scandinavia,but MRSA is on the rise there too. Not surprisingly,ophthalmologists are beginning to reap the whirlwind. The eyes to the wrong At Cornea Day,preceding the ASCRS conference in Chicago this April,Terry Kim, MD,of the Duke Eye Centre,Durham, North Carolina,presented the results of an ASCRS-sponsored survey of infectious keratitis. The first report of MRSA causing keratitis was as recent as 2001,yet according to the survey,in 2007 as many as 61 per cent of cases were caused by Staphylococcusinfections.The incidence of mycobacterial infection,in contrast,has fallen. “MRSA is now the single most common infection occurring after LASIK and surface ablation procedures,” Dr Kim concluded. The risk of infection,he noted,was significantly greater with surface ablation and keratome use than with LASIK and femtosecond lasers. It’s a similar story after cataract surgery. The incidence of endophthalmitis has been rising for more than a decade – a trend that has paralleled the widespread adoption of clear corneal incisions – but as in keratitis,there has been a change in the spectrum of causative organisms. According to a retrospective study published in the AJOthis March by Vincent Deramo MD,and colleagues at Long Island Vitreoretinal Consultants and the Albert Einstein College of Medicine,MRSA infection accounts for around 18 per cent (six of 33 culture-positive cases) of acute endophthalmitis referred to their vitreoretinal practice over three years. Dr Deramo notes that,despite the small size of their study,the incidence of endophthalmitis caused by MRSA appears to have grown substantially since the Endophthalmitis Vitrectomy Study was published in 1996,when MRSA was reported in just six of 323 isolates (1.9 per cent). Even more seriously,visual outcomes with MRSA were poor in four of these patients (67 per cent),with visual acuity at last follow-up being no light perception in two eyes,and hand movement in two eyes. “That’s a much worse outcome than the ‘typical’ patient with coagulase-negative Staphylococcus endophthalmitis – still the most common pathogen – many of whom regain 20/40 or better vision if treated early,” Dr Deramo told EuroTimes.“In addition,most of our MRSA patients had serious corneal involvement as well,which is uncommon in endophthalmitis.” Vahid Feiz MD,of UC Davis Medical Centre,has reported similar experiences. “There is a consensus now that MRSA can be more aggressive and damaging to the eye than some of the other infections.This is especially true of endophthalmitis after ocular surgery,” he told EuroTimes. Courting resistance As recently as 2004,Dr Mah could write in a review (Curr Opin Ophthalmol) of the fourth-generation fluoroquinolones moxifloxacin and gatifloxacin,“Gatifloxacin has equal efficacy when compared with vancomycin against methicillin-resistant and fluoroquinolone-resistant Staphylococcus aureusin a rabbit model.Gatifloxacin actually had superior clinical scores compared with vancomycin.” He also noted that the fourth-generation fluoroquinolones have “a delayed propensity to the development of bacterial antibiotic resistance.” These virtues were instrumental in the widespread adoption of fourth-generation fluoroquinolones by ophthalmologists. Yet by 2006 Dr Deramo and others were already reporting serious resistance to gatifloxacin and moxifloxacin.In a retrospective consecutive series of 42 eyes with acute endophthalmitis,74 per cent (31 eyes) had been treated with perioperative gatifloxacin or moxifloxacin – and 57 per cent (24 eyes) were still taking one of these antibiotics at the time of diagnosis. In his 2008 AJOpaper,Dr Deramo noted that in all six cases of MRSA endophthalmitis,the patients had been started on fluoroquinolone antibiotics two or three days before surgery. And Dr Deramo’s worrying findings have recently been corroborated by the Ocular TRUST Study (Tracking Resistance in US Today),reported in the AJOthis June.While confirming the broad efficacy of fluoroquinolones in general,including gatifloxacin and moxifloxacin against MSSA, S.pneumoniae,and H.influenzae,the TRUST group reported poor efficacy against MRSA. In 197 ocular isolates of Staphylococcus aureus,MRSA susceptibility to fluoroquinolones was just 15.2 per cent, right across the class.An alarming 76 per cent and 82 per cent of ocular MRSA isolates were resistant to moxifloxacin and gatifloxacin,respectively. The authors concluded,“High-level in vitro MRSA resistance suggests the need to consider alternative therapy to fluoroquinolones when MRSA is a likely pathogen.” But it should be noted that ophthalmologists are not the villains here – it’s the scandalously widespread use of fourth-generation fluoroquinolones in animal husbandry that is at fault. The only agent tested in the Ocular TRUST Study that retained high efficacy against MRSA was trimethoprim,which was effective in 94 per cent of cases,although it was less effective against S.pneumoniae,and H.influenzaethan the fluoroquinolones. Ironically,the antibiotic that has long been at the centre of controversies in ophthalmology,vancomycin,has also retained good efficacy against MRSA, according to both Dr Deramo and Dr Feiz, although periodic cases of resistance have been reported.Unfortunately,vancomycin is not being tested in the TRUST Study. In 1995,the CDC recommended against routine prophylaxis with vancomycin,in an effort to halt the spread of resistance,a recommendation habitually ignored by 14 MRSA – the rising menace Cover Story “There is a consensus now that MRSA can be more aggressive and damaging to the eye than some of the other infections. This is especially true of endophthalmitis after ocular surgery” Vahid Feiz MD

ophthalmologists.Even in 2006,a survey of ASCRS members by Samuel Masket MD, Jules Stein Eye Institute,Los Angeles, indicated that some 18 per cent of cataract surgeons in the US continue to use intracameral vancomycin after cataract surgery. Peter Barry MD,Dublin,chairman of the ESCRS Endophthalmitis Study Group,told EuroTimesthat as many as 60 per cent of Americans who receive an infusion of antibiotics for prophylaxis receive vancomycin. In 1999 and again in 2005,the CDC issued a politely worded joint statement with the AAO,advocating that “prudence, and perhaps even restraint,should be exercised in the selection of appropriate antimicrobial agents” – again recommending against the routine prophylactic use of vancomycin in hospital settings (but not necessarily in outpatient clinics),while conceding there is no evidence that ophthalmologists have encouraged resistance through their less-than- restrained use. The irony deepens.In place of vancomycin, the AAO/CDC joint statement recommends the use of povidone-iodine antisepsis – which is in any case practically universal as the standard of care – and the perioperative use of broad-spectrum topical antimicrobials, with an activity spectrum that includes both Gram-positive and Gram-negative bacteria. Presumably they had in mind something like the fourth-generation fluoroquinolones. But now gatifloxacin and moxifloxacin are losing activity against MRSA,while vancomycin,overused prophylactically by ophthalmologists,has retained its efficacy. Given the inexorable rise in MRSA infections and their poor ophthalmic outcomes,what’s the best policy now? A surprising place to look may be the ESCRS Endophthalmitis Study,which examined precisely none of these questions. There’s been a degree of ambivalence about the ESCRS Study,with a split emerging between the Europeans and the Americans about the use of intracameral cefuroxime. Dr Barry and colleagues have argued that the five-fold reduction in endophthalmitis proves that intracameral cefuroxime should be considered the gold standard.American ophthalmologists like Dr Randall Olson MD, at the University of Utah,have criticised the narrow spectrum of activity of cefuroxime,its potential for allergic reactions,and the lack of unit-dose packaging or FDA or indeed EMEA approval for intracameral injection. The high rate of endophthalmitis in the control groups also troubles many ophthalmologists,including Dr Barry,although Dr Olson suspects that the true incidence of endophthalmitis is likely to be much higher than most ophthalmologists suspect. But whatever the optimal antibiotic regimen may be,an important,if less appreciated,aspect of the study was the rate of MRSA endophthalmitis – zero,according to Dr Barry,despite the large study population of more than 16,000 patients. That’s not because any of the antibiotics were effective against MRSA,because they probably weren’t.Even levofloxacin,a third- generation fluoroquinolone given topically in the study,is broadly inactive against MRSA, with 79 per cent resistance,according to the Ocular TRUST Study,right up there with gatifloxacin and moxifloxacin. And it probably wasn’t because MRSA is less of a threat in Europe.The 24 ESCRS Study centres were in Austria,Belgium, Germany,Italy,Poland,Portugal,Spain,Turkey and the UK – all with MRSA rates broadly comparable to the US. Dr Barry believes the absence of MRSA in the ESCRS Study was attributable to the rigorous exclusion criteria applied in the study,which excluded patients from nursing homes and other settings where MRSA is rife. While this probably artificially lowered the ‘real’ rate of endophthalmitis even further, there is another important take-home lesson here – the risk of MRSA can be identified in advance and dealt with accordingly.Screening works. “We apply the same criteria in my own practice,” Dr Barry told EuroTimes.“We screen all patients at high risk of MRSA and they must have three consecutive negative swabs before we go on to surgery.” Dr Feiz agrees that rigorous screening of high-risk patients is imperative.He cites the highest risk groups as healthcare workers, chronically ill patients,anyone hospitalised recently or in long-term care facilities, patients with poorly controlled diabetes or on renal dialysis,and any patient with a history of MRSA at any site. These patients are likely to be colonised with MRSA”,Dr Feiz told EuroTimes.“The usual site of colonisation is the nose.” In addition to the standard preoperative antisepsis,notably povidone-iodine,Dr Feiz notes that community-acquired MRSA is still usually sensitive to trimethoprim (a view confirmed by the Ocular TRUST Study) and chloramphenicol drops. Timing is also very important.For example,in the ESCRS Study,Dr Barry notes there was a standard preoperative antisepsis regimen – “Povidone-iodine had to be applied for three minutes,” he told EuroTimes.“And I mean three minutes – we timed it.” Other preventive measures include mupirocin ointment, available as a nasal ointment, which eliminates MRSA in 91 per cent of colonised healthcare workers within two to four days. If that fails,a second option is linezolid,an oral medication with excellent MRSA coverage. “It has wonderful penetration into the eye after two oral dosings”,Dr Feiz told EuroTimes,“and there is also some animal work looking at linezolid eye drops.Very promising.” He recommends that preoperative oral linezolid be considered in patients at high risk of MRSA infections. So what about vancomycin? Should it be used prophylactically or reserved for treatment? Drs Barry,Feiz and Deramo are all in broad agreement here:treatment only. “I never recommend prophylactic use of vancomycin.” Dr Deramo told EuroTimes.“I would reserve it for treatment only.We’re in big trouble if resistance develops to vanco....” 15 Cover Story Terry KimPeter Barry “We apply the same criteria in my own practice. We screen all patients at high risk of MRSA and they must have three consecutive negative swabs before we go on to surgery” Peter Barry MD

16 Cheryl Guttman in Chicago HYPEROPIC LASIK performed with the Allegretto Wave (Alcon) excimer laser provides excellent refractive and visual outcomes with good long-term stability during follow-up extending to five years, said Stephan L Kaminski MD. At the 2008 ASCRS Symposium on Cataract,IOL and Refractive Surgery,Dr Kaminski presented analyses of data collected from 29 consecutive eyes of 17 patients that were treated with LASIK for up to +6.0 D of hyperopia using the Allegretto Wave 1006 platform. The data showed good refractive stability in all patients between one month and five years.Mean SE was 2.61 ± 1.38 D preoperatively and 0.35 ±1.20 D at five years. Between the one-month visit and the five- year follow-up, the mean shift in SE was +0.42 D ±0.52 D. Although most eyes demonstrated a slight hyperopic shift over the five years of follow-up, predictability remained excellent at the last follow-up. At one month, SE was within 0.50 D of emmetropia in 92 per cent of all eyes and within 1.0 D in 98 per cent.At five years,the achieved SE was ±0.50 D of emmetropia in 89 per cent of eyes and ±1.0 D in 94 per cent. The UCVA outcomes were also excellent and stable.At one month after surgery, 60 per cent of eyes had 20/20 or better UCVA and 98 per cent could see 20/40 or better without correction.The results at five years were identical, reported Dr Kaminski,Medical University, Department of Ophthalmology,Vienna, Austria. “There are relatively few published studies with up to five years of follow-up after hyperopic LASIK,and there remains a need for ongoing follow-up to further evaluate long-term regression.The results in our series are favourable and even superior compared with data on UCVA outcomes reported by surgeons using other platforms.This latter difference may reflect the fact that our patient population was relatively younger,” he said. Dr Kaminski added that although the series included patients treated for up to +6.0 D of hyperopia,based on the experience accumulated to date,he currently considers +5.0 D as the upper limit for hyperopic LASIK. The LASIK flaps were created using an Amadeus I microkeratome (AMO).The ablations were performed with a 6.5mm optical zone and a 9.5mm ablation zone using a personalised LASIK nomogram. The amount of correction was based on the patient’s manifest refraction with a five per cent upward adjustment rather than the cycloplegic refraction. “We tell our hyperopic LASIK patients that an enhancement may be needed to improve the refractive outcome,” said Dr Kaminski. The postoperative treatment regimen included a topical fluoroquinolone and prednisolone acetate along with hyaluronic acetate. The safety of the surgery was excellent. There were no intraoperative complications.One eye developed grade II diffuse lamellar keratitis after surgery,but was treated successfully with a topical steroid and experienced no adverse sequelae. Preoperatively,BCVA was 20/20 or better in 82 per cent of eyes and 100 per cent of eyes achieved 20/40 or better BCVA.At follow-up visits from one month onwards,no eyes lost more than two lines of BCVA and only a small proportion lost two lines.At five years, BCVA was unchanged from the preoperative level in about 81 per cent of eyes and improved by one or more lines in 11 per cent,while six per cent of eyes had a one-line loss. To put the results from this five-year follow-up into perspective,Dr Kaminski presented UCVA data from three published studies evaluating five-year outcomes after hyperopic LASIK using the STAR S2 (VISX),the Technolas (Bausch & Lomb),and the SVS Apex (Summit) excimer lasers.In these three studies,the proportion of eyes achieving UCVA 20/20 or better ranged from 34 per cent to 50 per cent.UCVA of 20/40 or better was achieved by almost 90 per cent of patients treated with the STAR S2 and SVS Apex lasers,but in only 66 per cent of eyes in the Technolas series. Stephen Kaminski Outcomes stable at five years after hyperopic LASIK Special Focus Hyperopia “The results in our series are favourable and even superior compared with data on UCVA outcomes reported by surgeons using other platforms. This latter difference may reflect the fact that our patient population was relatively younger” 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

Howard Larkin in Berlin REPLACINGthe crystalline lens with a one-piece foldable intraocular lens is proving to be an attractive option for treating select patients with both primary and refractive surgery-induced hyperopia, Albina Ivashina MD,Ophthalmic Clinic OCOMED,Moscow,Russia told a symposium at the XXVI Congress of the ESCRS. RLE may be particularly useful for patients whose corneas flatten over time after RK surgery,leading to induced hyperopia,because their weakened corneas often make them poor candidates for laser surgery.However,great care must be taken in determining lens power for such patients due to aberrations induced by previous surgery,and the tendency of the RK incisions to swell after surgery leading to temporary fluctuations in refractive outcome. RLE also may be a good choice for primary hyperopes who are not good candidates for LASIK or phakic IOLs due to corneal problems or restricted anterior chamber dimensions. “Refractive clear lens exchange is the fastest growing segment of ophthalmic surgery.Often it is becoming the terminal refractive procedure for all components of refractive error,” Dr Ivashina said. To test the efficacy,safety,predictability and stability of refractive lens exchange across a range of hyperopic conditions, Dr Ivashina studied four series of patients.These included seven eyes in five patients with induced hyperopia after RK, TKK or phakic IOL procedures;eight eyes in five patient with moderate and high primary hyperopia;four eyes in two patients with presbyopia and hyperopia; and two eyes in two patients with hyperopic anisometropia.The patients ranged in age from 22 to 61 years old. Their preoperative hyperopic refractions ranged from +2.5 dioptres to +12.0 dioptres with a mean error of +6.34 dioptres.Axial length ranged from 16.9mm to 25.6mm with a mean of 20.9mm. All patients underwent phacoemulsification procedures using Alcon Legacy or Infiniti machines.The lenses implanted were AcrySof Natural SN60AT and AcrySof IQ aspheric,and the Rayner C-Flex and Superflex in powers ranging from +24 to +46 dioptres. Piggyback IOLs were used in two eyes.All lenses were implanted in the capsular bag. No significant intraoperative or postoperative complications occurred in any of the study patients. The results were quite good,Dr Ivashina reported.In follow-up periods ranging from six months to five years, 76.4 per cent of eyes were within one dioptre of emmetropia,and 88 per cent within two dioptres,and 100 per cent within 1.5 dioptres of the target refraction.Half of the eyes had uncorrected distance visual acuity (UCVA) of 0.8-1.0,75 per cent had UCVA of 0.6-0.7,and all had UCVA of 0.5.Mean UCVA improved from 0.15 preoperative to 0.73 postoperative. Postoperative best-corrected vision was 0.8-1.0 in 65 per cent of eyes,and 0.5 or better in 93.7 per cent.No eyes lost a line of best-corrected Snellen vision,while eight eyes gained one line and seven eyes gained two or more lines.Mean BCVA improved from 0.64 preoperatively to 0.84 postoperatively.The mean uncorrected near vision after surgery was J2,and 78 per cent of patient reported no need for spectacles after surgery. Haloes and glare were not a problem for most patients,with 76 per cent reporting no night vision difficulties. However,two patients did report haloes in night driving and one found them disturbing.Overall satisfaction with the procedures was high,with 95 per cent reporting high satisfaction and four per cent medium satisfaction,Dr Ivashina reported.No retinal detachments or cystoid macular oedema were observed in any patient in the four series. “Refractive lens exchange with single- piece intraocular lenses is efficacious and safe for hyperopia correction after previous refractive surgery,and in moderate and high hyperopes,resulting in good uncorrected visual acuity.Proper patient selection is very important for achieving good results.RLE is the procedure of the future,” Dr Ivashina concluded. 17 Refractive clear lens exchange an option for patients with hyperopia induced by refractive surgery Special Focus Hyperopia SSeeee wwwwww..eessccrrss..oorrggffoorr mmoorree iinnffoorrmmaattiioonn EUROTIMES ESCRS ™ A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY Thanks to everybody who attended the inaugural EuroTimes Practice Management Resource Centre workshops at the XXVI ESCRS Congress in Berlin. The second series of workshops will be held at the 13th Winter Meeting in Rome. See the November issue of EuroTimesfor further details and visit our website at www.eurotimes.organd our weblog at http://eurotimespracticemanagement.blogspot.

News in Brief Aluminium foil offers multiple advantages as alternate draping material STERILEaluminium foil draping is an easy to use,effective,and less expensive alternative to standard cloth draping in patients undergoing oculoplastic surgery, according to researchers from Brown University,Providence,Rhode Island,US. At the 2008 annual meeting of the Association for Research in Vision and Ophthalmology,they presented their experience using the aluminium foil draping to isolate the surgical field in a series of 300 outpatient oculoplastic procedures.All patients received a standard sterile preparation of the periocular skin with 10 per cent povidone-iodine prior to drape placement.There were no cases of wound infection,drape fire,or laser-induced skin burns. “Aluminium foil draping may also have benefits for cataract surgeons and possibly others,but we first became interested in it when reports of drape fire during elective oculoplastic procedures became increasingly common,particularly with the increased use of the CO2 laser.Not only does aluminium foil avoid that hazard,but at our facility,an aluminium foil surgical pack costs just over $4.00,which is half our cost for a standard paper drape pack,” said Mark Heimmel MD. Dr Heimmel noted the sterile aluminium foil draping is also much easier to use than paper drapes because it molds to the patient’s facial contours.As another advantage, the aluminium foil is impermeable to liquid whereas paper drapes become soggy and cumbersome when wet. mark_heimmel@brown.edu Russian rave rattles retinas MOSCOWhospital eye departments were kept busy by a recent wave of retinal problems caused by a powerful laser show held during a huge outdoor rave 50 miles from the capital.At least 29 young people presented with retinal burns to Moscow’s Central Ophthalmological Clinic and other hospitals following a powerful laser light show at the Aquamarine Open Air Festival in Kirzhach.Patients reportedly all had visible retinal scarring and have suffered vision loss of as much as 80 per cent. Anti-VEGF injection decreases corneal vascularisation Nuns and cataracts Dermot McGrath in Paris INTRAVITREALinjections of bevacizumab (Avastin,Genentech) seem to offer a safe and effective treatment for treating vascularisation in corneal diseases,according to a study presented at the 2008 French Society of Ophthalmology (SFO) meeting in Paris. “The initial data after six months’ follow-up indicates that bevacizumab is well tolerated by the majority of patients,and is effective at inhibiting the growth of choroidal neovascularisation and rubeosis iridis in patients with neovascular glaucoma,” concluded the study authors.However,they noted that Avastin seemed less effective in the treatment of diabetic macular oedema. The prospective study carried out by Frédéric Azan MD and colleagues at the Department of Ophthalmology,Hotel-Dieu Hospital,Paris,included 37 patients with a mean age of 66 treated by 1.25mg intravitreal injection of bevacizumab.There were no serious adverse local or systemic side effects noted during the follow-up period. The majority of patients experienced a marked reduction in exudative symptoms and macular thickness as measured by OCT.For all patients presenting with neovascular glaucoma,investigators noted a significant reduction in the rubeosis iridis as early as the eighth day after initial treatment. CChheecckk iitt oouutt oonn hhttttpp::////mmyyeeuurroottiimmeess..bbllooggssppoott..ccoomm ffoorr aa uunniiqquuee oonnlliinnee vviieeww oonn tthhee wwoorrlldd ooff oopphhtthhaallmmoollooggyy EEuurrooTTiimmeessnnooww hhaass iittss oowwnn wweebblloogg!! Cheryl Guttman The prevalence of cataracts among convent-dwelling nuns in Ireland appears to be substantially lower than in an age-matched general population,according to preliminary results from the Irish Nun Eye Study (INES),an epidemiological study being conducted by researchers from Northern Ireland. “These interim findings are consistent with the hypothesis that sunlight exposure is a risk factor for cataract development.The nuns are being recruited from a number of convents that represent a spectrum of light exposure conditions,which should allow a correlation between exposure and risk,” said Giuliana Silvestri MD,consultant ophthalmic surgeon,Queen's University & Royal Hospitals,Belfast. “Currently,we have developed a questionnaire to quantify light exposure,and we will also be investigating other potential confounding factors that may be relevant in this population, including diet and hormonal load.” The analysis was conducted as a substudy in an investigation designed primarily to investigate the prevalence of age-related macular degeneration in a light-protected community.The study aims to recruit 1000 nuns aged 65 years and older.The analysis was based on the first 200 eyes in nuns who had an average age of 70 years. Photographic grading studies revealed cortical opacities of five per cent or greater in 26.3 per cent of eyes.The study also showed posterior subcapsular opacities affecting more than five per cent of the lens in 1.9 per cent. By comparison,in the Beaver Dam Eye Study,the prevalence rates of cortical and subcapsular lens opacities among women aged 75 years and older were 44 per cent and 13 per cent, respectively.Among the nuns,20 per cent of eyes had prior cataract surgery,which the investigators also believed is low considering the cohort’s average age. g.silvestri@qub.ac.ukWhiteStar enables zero ultrasound phaco THE SOVEREIGNsystem with WhiteStar (Advanced Medical Optics) allows safe and effective cataract surgery without ultrasound power,although the “ZEro UltraSound” (ZEUS) technique does not appear to further reduce corneal endothelial loss compared with surgery performed using the same platform and low ultrasound power,according to a prospective study conducted by ophthalmologists from Sant’Antonio Hospital,Padova,Italy. Their trial included 54 eyes operated on with the ZEUS technique and 36 eyes in which some ultrasound was used (mean effective phaco time 0.372).Patients included in the study had senile cataracts with nuclear hardness grade of 2-4 and no risk factors for complications or a poor visual outcome.All procedures were performed by a single surgeon using the same “quick chop” technique to minimise ultrasound use. There were no complications.Endothelial cell loss at one and six months after surgery was lower in the ZEUS group than when ultrasound was used,although the differences were not statistically significant.Endothelial cell loss seemed to correlate with cataract grade.However,in comparing subgroups with the same nuclear hardness grading,there were also no statistically significant differences in endothelial cell loss rates between eyes operated on with and without ultrasound. “The very low amount of ultrasound power that can be used with WhiteStar may explain why we saw no further benefit for minimising endothelial cell loss using the ZEUS technique.However,our endothelial cell loss rates are comparable to other studies using WhiteStar where phaco times were as long as six to eight seconds.Perhaps length of surgery and intraocular liquid fluidics are more important determinants of endothelial injury,” said Marco Tavolato MD. 18

19 Pippa Wysong in Fort Lauderdale IS A government policy to reduce wait times for cataract surgery effective? This is the basic question addressed in a series of studies by Canadian researchers who compared two cohorts of patients:one group that had cataracts treated prior to the implementation of a national policy to reduce wait times,and the second a couple of years after the policy was introduced. Findings were presented at this year's meeting of the Association for Research in Vision and Ophthalmology (ARVO). Among the highlights of the findings are a series of good-news messages.Most patients now report that wait times are acceptable;shorter wait times for cataract surgery are associated with fewer accidents triggered by vision problems;and patients are now presenting with less cataract symptoms,according to Ellen Freeman, PhD,assistant research professor of ophthalmology,University of Montreal, Quebec. Cataract surgery is the highest-volume surgical procedure in Canada with over 200,000 performed each year.The majority of procedures are performed on people aged 65 or older.In the past,patients had to wait up to a year for surgery.In 2004, the government of Canada passed legislation to reduce wait times to six months or less. Researchers compared one group of 509 people who waited a median of 153 days in 1999 to 2000 (prior to the shorter wait policy),and the second group consisted of 163 patients who waited a median of 119 days in 2006 and 2007.Patients all presented at a Montreal hospital. Fewer symptoms One part of the study compared pre- surgery vision and health characteristics of both cohorts.All patients underwent their first cataract removal.Wait times were determined by taking the date patients were entered into the hospital wait list and the actual date of surgery.This did not take into account the amount of time patients waited to see an ophthalmologist for an initial assessment. The rate of cataract surgery performed increased from 1999 to 2006 by 59 per cent,from 3.2 to 7.8 per 1,000 population. Overall,mean wait times dropped from 6.1 months in the 1999 to 2000 cohort to 4.7 months in the more recent cohort.Patients in 2006 to 2007 had better visual function than those in the earlier cohort.The median visual acuity in the surgical eye, Visual Function Index (VF-14) score,and Cataract Symptoms scale (CS-S5) scores were also significantly better in the 2006- 2007 cohort than in the earlier cohort.The two groups of patients were similar in terms of age,sex,number of co-morbidities and Geriatric Depression Scale (GDS). The study showed that cataract patients now present with less acuity loss,fewer cataract symptoms,and fewer visual difficulties than the earlier cohort,Dr Freeman said.Legislative changes to reduce cataract surgery wait times and techniques to improve surgical efficiency seem to have benefited cataract patients by allowing physicians to treat them sooner in the disease process,she said. Carolyn De Coster,PhD,research assistant professor of health policy at the University of Calgary has also studied the effects of wait times on patients,but was not involved in the Montreal studies.In an interview with EuroTimes,she noted, “the findings that patients are reporting less visual loss and better visual acuity is both good and bad.Assuming that all the patients were appropriate for cataract surgery,it's reassuring to know that they are coming to surgery sooner.But the question of appropriateness also arises:are there patients who shouldn't be receiving cataract surgery?” Variation in wait times Even though wait times for Montreal patients decreased,there are still some discrepancies in terms of how long individual patients wait.In fact,three factors stood out as reasons why some patients still wait longer than others,even with the shorter wait policy,Dr Freeman said. Those factors were systemic co- morbidities (the more co-morbidities patients had,the longer their wait),and the specific surgeon (certain surgeons had significantly longer wait times).There was also a minor effect seen depending on the sex of the surgeon (patients of female surgeons had shorter wait times than patients of male surgeons). In a publicly funded health system,it's worth learning about the reasons why waits can vary between different subgroups of patients.Once the reasons are understood, ways can be developed to help reduce wait times further,Dr Freeman said. One factor stood out as being the most significant predictor of increased wait time, and this was which surgeon a patient saw. Researchers looked at whether surgeons had additional duties like administration or research.A total of 78 per cent of patients whose surgery was booked with a surgeon who also had administrative or research demands waited a minimum of six months for surgery compared to only 40 per cent of patients whose surgeons did not have these extra demands on their time. "We think this indicates that these surgeons have less time flexibility to operate when they need to," Dr Freeman said. Indeed,the findings agree with those from a study in 2005 by Dr De Coster and colleagues who also reported wait times varied substantially between surgeons. Waits between specific surgeons ranged from 61 to 399 days.The reason for the difference in that study was unclear. Dr De Coster speculated that the differences could be connected to referral patterns.Often,“an optometrist or ophthalmologist will have a relation with a particular surgical ophthalmologist and always refer to that person.But it's been demonstrated that if all patients are assigned to the next available surgeon – kind of like the way people queue for tellers at a bank – the overall wait time is shorter,” she said.On the other hand,she notes that having a wait list represents security,status and a future income stream. Acceptability In the Montreal study,researchers investigated whether patients thought the current wait times were acceptable via a survey.In the 1999-2000 cohort,30 per cent of patients thought their wait was unacceptable,while in the 2006-2007 cohort,which had shorter wait times only 12 per cent said it was unacceptable. "One thing that surprised me was how such a low percentage of people said their wait time was unacceptable.The median wait time is still four months," said Dr Freeman.Part of her surprise is due to the fact she is originally from the US. "I'm a bit unfamiliar with having to wait several months for a surgical procedure. People here (in Canada) really seem to value that everyone has equal access to healthcare and they seem more willing to wait than what most Americans would be,I think," she said. The patients who said their waits were not acceptable had worse vision than those who said their waits were very acceptable. Fewer accidents with shorter waits Shorter waits are also associated with fewer accidents triggered by vision problems.Patients were asked,“while waiting for cataract surgery did you have an accident caused by your vision problem? (such as a fall,burn,etc.)” Patients who said ‘yes’ were asked details about the severity and type of accident.In addition,the researchers compared responses to the length of time patients waited for surgery, severity of cataract,and visual acuity. A total of 65 (13 per cent) of the patients in the longer-wait cohort reported an accident,compared to only eight (five per cent) in the shorter wait group. Of the accidents,38 were falls,five were automobile accidents,and three were burns.Only nine patients said they saw a doctor or went to hospital because of the accident. The researchers concluded the data “indicate that a longer wait for cataract surgery,worse acuity,and worse cataract symptoms are associated with a greater odds of having an accident thought to be due to vision.” However,there may be limitations in the validity of asking patients whether they thought vision was the cause of the accident,Dr Freeman said. Dr De Coster says her own research also found reduced chance of injury among people with shorter wait times.“It's an important piece of information in trying to assess how long patients should wait for surgery,” she said. ellen.e.freeman@umontreal.ca Carolyn.DeCoster@calgaryhealthregion.ca “But the question of appropriateness also arises: are there patients who shouldn't be receiving cataract surgery?” Carolyn De Coster MD Study confirms benefits of reduced wait times for cataract surgery Cataract Update Ellen Freeman 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?

Dermot McGrath in Vienna PARS plana vitrectomy (PPV) combined with cataract surgery may offer a safe and effective approach to managing a variety of vitreoretinal diseases in patients over the age of 60,according to a German study presented here. “For patients over a certain age,we know that there is a very high risk of cataract formation after PPV for macular hole,epiretinal membrane and diabetic retinopathy,so it makes sense to try to combine these procedures in one operation for these elderly patients,” explained Gisbert W Richard MD. Addressing the annual meeting of the European Society of Retina Specialists (EURETINA),Dr Richard,University Eye Hospital,Hamburg-Eppendor,said that it was important to use a slightly modified surgical technique to ensure optimal outcomes in these patients. “If you combine both surgeries,it is very important to open the anterior chamber through a long corneal-scleral tunnel in order to tolerate possible pressure increase and allow a sufficiently large opening for cataract surgery,” he said. Dr Richard advised starting first with the cataract surgery. “I usually fixate two eye muscles and it is important to have a long and extremely precise tunnel construction of greater than 3.5mm in length,” he said. Dr Richard noted that the drive towards smaller incisions has guided technological development in both anterior and posterior segment ophthalmic surgery. “We have seen an evolution in phaco techniques that allows us to use 1.6mm incisions and we now also have transconjunctival,pars plana vitrectomy which may help to reduce patient discomfort,surgical trauma,and perhaps also the surgical time,” he said. He advised that the combined phacoemulsification and vitrectomy procedure should only be attempted by experienced posterior segment surgeons. “If the surgeon is not experienced,he or she may encounter problems during surgery that will later become real clinical problems.For instance,peeling the interior limiting membrane or other membranes may result later on in cystoid macular oedema if not handled correctly.So it is critical to have the phaco as atraumatic as possible and to avoid damaging the endothelium in these patients,” he said. Dr Richard said that the standard of care today means that surgeons are expected to perform rigorous cataract surgery in addition to a well-executed vitrectomy. “Patients expect good postoperative visual acuity and this means taking account of astigmatism.With this in mind,a corneal or corneal-scleral incision should be made in the steep axis and the surgeon can make an additional T-cut if deemed necessary.It is also possible to make a corneal incision in one side and then a limbal relaxing incision on the opposite side to counter the astigmatism,” he said. Dr Richard said that his own preference is to use a Venturi pump with high- powered vacuum settings up to 600 mmHg and a phaco power setting of 20 per cent to 30 per cent.He advised a short phaco ‘On’ time of less than 30 seconds to avoid the risk of corneal burn.A thorough cleaning of the capsular bag is also advisable,he said,and can be more easily achieved using a bimanual technique. Anaesthesia options In terms of anaesthesia,Dr Richard said that he prefers to avoid general anaesthesia where possible.For pars plana vitrectomy without membrane peeling,local sub- conjunctival anaesthesia combined with two per cent preservative-free intracameral lidocaine may be sufficient, while patients undergoing PPV with membrane peeling may require peribulbar or retrobulbar block. Dr Richard emphasised the importance of maintaining a stable anterior chamber in these combination cases and adhering to rigorous surgical technique. “It is important to have a large curvilinear capsulorhexis of about 5.0mm. Implant the IOL if possible into the capsular bag or into the sulcus if the capsular bag is not an option.For the IOL it is better to select a lens with a large optic of at least 6.0 to 6.5mm.And also avoid silicone lenses,as we must anticipate that these IOLs may well come into contact with silicone oil which will compromise their effectiveness,” he said. For the vitrectomy,Dr Richard said he found the 25-gauge cutter too flexible and preferred to use a 23-gauge model.He also advised not using too much light,whether halogen or xenon based,as he believes that phototoxicity is an underrated problem in these procedures. Based on his own experience,he said that the best candidates for 23-gauge vitrectomy are those with vitreous haemorrhage,macular pucker,macular hole and retinal detachment.Patients who are not good candidates for this approach include those with a blue or thin sclera, ocular trauma or where the surgeon needs to use a silicon oil endo-tamponade. Dr Richard said that using a high-speed cutter is advantageous in combination patients,particularly if patients have a detached retina. “It is best to use only low traction with a high cutting rate.However,if you are dealing with a flat retina,the Venturi pump helps to speed up the entire surgical procedure.However,if the retina is detached,a peristaltic pump may be favourable,” he said. Dr Richard said that while 23-gauge vitrectomy may help to increase patient comfort,protect the sclera and offer a quicker recovery time of the conjunctiva, there is a higher risk of endophthalmitis associated with the procedure. Turning to his own clinical experience, Dr Richard presented the results of 230 epiretinal membrane patients with a mean age of 65 years treated with combined PPV and cataract surgery and a mean follow-up of 18 months.These included 160 patients with idiopathic epiretinal membrane and 70 patients with epiretinal membrane secondary to diabetic retinopathy,previous retinal surgery,branch retinal vein occlusion,uveitis and ocular trauma. The results were very good for the idiopathic epiretinal membrane patients, with an increase of at least two lines of Snellen visual acuity in 82 per cent of the patients and a low rate of complications. The results were less positive for the diabetic patients,noted Dr Richard,with quite a high rate of retinal detachment, macular detachment,posterior synechiae and an increase incidence of after-cataract formation. Dr Richard concluded that combined PPV and cataract surgery offers patients over 60 years of age the chance of a good visual outcome with a low risk of serious complications.Moreover the surgery can usually be performed in an ambulatory setting and avoids the need for the patient to undergo two separate interventions with the attendant costs,risks and recoveries. richard@uke.uni-hamburg.de 20 Gisbert Richard Combined vitrectomy and cataract surgery delivers good results in elderly patients Cataract Update E-Times is EuroTimes’ bi-monthly newsletter with the latest breaking news from the ESCRS and the world of ophthalmology. We offer exclusive access to upcoming EuroTimescontent where subscribers can read our stories first online. To subscribe to this exciting new service log on to the ESCRS website at www.escrs.org. DDoonn’’tt MMiissss EEUUMMaatttteerrss Page 42 “We have seen an evolution in phaco techniques that allows us to use 1.6mm incisions and we now also have transconjunctival, pars plana vitrectomy which may help to reduce patient discomfort, surgical trauma, and perhaps also the surgical time”

Roibeard O’hEineachain in Liverpool THE HumanOptics microincision IOL provides an optical performance comparable to that of a standard AcrySof lens (Alcon),but much of what might be gained through a reduced incision size may be lost through an increased amount of posterior capsule opacification,said Georgia Cleary MRCOphth,St Thomas’ Hospital, London UK. “In order to really get the benefits of microincision surgery we must have available to us IOLs that can be inserted through these small incisions without the need for enlarging the wound.These lenses must maintain the same standard of visual and optical performance as conventional IOLs and this includes maintaining low rates of PCO,” Dr Cleary told the 20th Anniversary Annual Congress of the Royal College of Ophthalmologists. Dr Cleary presented the results of a prospective randomised fellow eye comparison study involving 32 bilateral cataract patients who received a HumanOptics MC611MI microincision IOL in one eye and an AcrySof MA60AC IOL (Alcon) in the other eye.All surgeries were performed by a single surgeon,using a 2.75mm incision and a 5.0mm capsulorrhexis. The hydrophilic acrylic HumanOptics lens has a 6.0mm optic diameter and is injectable through an incision of 1.8mm or larger.The Alcon MA60 is a hydrophobic acrylic IOL and has a long track record of excellent clinical performance.Many consider it to be the gold standard regarding PCO and it is therefore a logical lens to use for comparison,Dr Cleary said. She noted that the logMAR visual acuity was significantly worse in the microincision lens group than in the AcrySof group at three,six and 12 months of follow-up.The mean logMAR visual acuities for the AcrySof and microincision lens were,respectively,0.010 and 0.040 at three months (p=0.026),0.004 and 0.031 at six months (p=0.034),0.005 and 0.040 at 12 months (p=0.032) and -0.01 and 0.02 at 24 months (p=0.109). The poorer visual outcome achieved with the microincision lens did not appear to result from any optical irregularity. Wavefront analysis using an iTrace Tracey aberrometer showed no significant difference between the lenses in terms of higher order aberrations,which in turn suggested that the microincision IOL did not bend or fold within the capsular bag. Furthermore,there was no significant difference between the two lens groups regarding modulation transfer function. However,digital retroillumination photographs analysed with POCO software showed that the amount of PCO was significantly higher in eyes implanted with the microincision lens from 12 months onwards.The mean percentage area PCO in the HumanOptics and AcrySof groups was,respectively,5.16 per cent and 3.22 per cent at three months (p=0.282),9.23 per cent and 4.42 per cent at six months (p=0.152),17.03 per cent and 5.10 per cent at 12 months (p=0.031) and 25.45 and 7.82 per cent at 24 months (p=0.029). “As a result of PCO,visual acuity was worse in the microlens group at all times and was statistically significant from three to 12 months.So the most important finding from this study is that PCO is greater with the microlens,” she said The higher rate of PCO in the micro- incision lens group most likely results from the design of the lens,Dr Cleary noted. The HumanOptics IOL has four broad optic- haptic junctions that can serve as a point of entry for lens epithelial cells to migrate from the equatorial capsule onto the posterior capsule,in what is called a through-haptic pattern of PCO, she said. “In conclusion we can say that the HumanOptics microlens demonstrated an optical performance equivalent to the MA60 with no distortion of the IOL within the capsular bag.However,in the case of this particular IOL we found that small incision size may come at the expense of poorer PCO performance and thus poorer visual acuity,” Dr Cleary added. georgia.cleary@gmail.com 21 Higher incidence of PCO with microincision IOL Cataract Update Georgia Cleary Best corrected logMAR visual acuity Percentage area posterior capsule opacification, calculated from retroillumination images with POCO software Courtesy of Georgia Cleary MCROphth

Dermot McGrath in Paris A NEW preloaded injector system (AcrySert,Alcon Inc) offers surgeons a safe,reproducible and efficient means of delivering a premium intraocular lens into the capsular bag,according to Thierry Amzallag MD. “The performance in terms of reproducibility and ergonomics of this preloaded delivery system has been very satisfactory in over 250 AcrySof IQ lenses that have been implanted in our clinic. Using this preloaded system greatly reduces the risk of contamination or damage to the implant that comes from handling of the IOL.There is also a very short learning curve for surgeons to master the insertion technique and it can be used with either a single-handed or bimanual approach,” he said. Speaking at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR),Dr Amzallag,in private practice at the Ophthalmic Institute of Somain in Somain,France,said that the AcrySert injector was a step in the right direction towards the ideal IOL delivery system. “The ideal IOL delivery system is single- use,preloaded and should deliver the implant into the capsular bag without it being touched or handled by the surgeon. It should be efficient,easy to handle and not require any extensive training in order for surgeons to become familiar with its use,” he said. He noted that the ideal injector system should be capable of delivering a premium IOL into the capsular bag,giving patients optimal quality of vision without compromising safety. While IOL manufacturers are moving towards offering a greater choice of preloaded systems in the future,Dr Amzallag said that the next critical step is to make these delivery systems more compatible with the drive towards ever- smaller incisions.The AcrySert,for example,is used through a 3.2mm incision,while the I-sert preloaded injector (Hoya Medical) goes through a 2.5mm incision. Turning to IOL design,Dr Amzallag said that the AcrySof IQ is made of hydrophobic acrylic material,which makes it particularly suitable for use in a preloaded system like the AcrySert.“Hydrophobic acrylic is a flexible and robust material with proven biocompatibility and is well tolerated in the capsular bag.It is also known for its propensity to reduce the formation of posterior capsular opacification which remains one of the main complications of IOL implantation after cataract surgery,” he said. Dr Amzallag noted that some of the IOLs delivered by the first-generation of preloaded systems suffered from problems of PCO,capsular retraction,subluxation and inflammatory reactions. “While the cause of the biological toxicity with the early injector systems has not been clearly established,it is now believed that thoroughly cleaning the preloaded implants with BSS before injection may reduce the risk of toxic reaction associated with their implantation,” he said. Dr Amzallag’s study included 250 consecutive patients with a mean age of 77 years who were unilaterally implanted with the AcrySof IQ (Alcon Inc) SN60WF IOL,a one-piece,aspheric lens with a blue-light filter.All IOLs were implanted with the AcrySert injector. During the procedure,investigators recorded the operating room temperature,injection time,surgery time, the status of the optics and haptics after injection,incision architecture and incision size before and after injection.The collected data was then reviewed to determine the parameters that resulted in optimised outcomes,said Dr Amzallag. OR temperature crucial Dr Amzallag stressed the importance of maintaining a stable operating room (OR) temperature. “In our study,the average OR temperature was 21.2 Celsius and it should be between 18 and 23 degrees Celsius in order to ensure the integrity of the implant.It is also advisable to ensure that the temperature of the storage area for the IOL is constant and is kept as close as possible to the temperature of the operating theatre,” he said. Dr Amzallag noted that there was a statistically significant difference in surgical time and injection time between the first 20 cases and the final 20 cases,as the surgeon became more familiar with the technique.The average surgical time for the first 20 patients was nine minutes compared to seven minutes for the final 20 patients in the series.The average injection time of 30 seconds for the first 20 patients was reduced to 18 seconds for the 20 final procedures. There was no damage observed to the optics or haptics in any of the implanted IOLs,said Dr Amzallag. “We had two cases of adhesion of the haptics which were easily dealt with.We also observed a good preservation of the incision architecture after implantation with excellent self-sealing closure of the wounds,” he said. Summing up,Dr Amzallag said that key parameters to bear in mind using the AcrySert injector are to carefully control the temperature of the implant in both storage and operating rooms and to ensure a slow controlled injection of the leading haptic in order to allow time for the plunger to fold the rest of the IOL for eventual delivery into the capsular bag. “The reproducibility and ergonomics of the AcrySert injector were excellent.Using these technical and environmental recommendations allows the insertion of a premium IOL with a reduced time of implantation and surgery.AcrySert also allows the injection of the SN60WF IOL without any handling of the IOL for a safer procedure overall,” he concluded. thierry.amzallag@institut-ophtalmique.fr 22 Thierry Amzallag Encouraging results with preloaded IOL delivery system Cataract Update AcrySert preloaded injector injection technique Courtesy of Thierry Amzallag MD

Stefanie Petrou Binder MD in Heidelberg THE NPReading Test is a newly developed reading test designed to assess functional vision as it pertains to everyday visual activities,from Magill Research Center for Vision Correction,Storm Eye Institute, Medical University of South Carolina, Charleston,South Carolina,US.Used in a prospective,randomised,double-masked study in patients receiving ReZoom and ReSTOR intraocular lenses (IOL),the results of this novel test provide a better insight into near and intermediate functional visual outcomes from these lenses. “The truth is not always in the numbers.We need to measure and evaluate the criteria that are important to our patients.We must have realistic goals and expectations,which is critical with increasing refractive lens surgery for presbyopia,” said Helga P Sandoval MD, MSCR at the 22nd Congress of the German-speaking Society for Intraocular Lens Implantation,Interventional,and Refractive Surgery (DGII). Functional vision is what people use in real-world activities,like reading or driving,she explained.Current visual acuity charts do not measure functional vision,she said. Dr Sandoval and her colleagues used different resources to design the NPReading Test,such as newspapers and phone books,which use many different font sizes.The NPReading Test looks like a regular newspaper using the Post and Courier typeface,but varying print sizes of American point-point type 24 to 3 that correspond to Snellen 20/200 to 20/20, Jaeger 14 to 1,and logMAR 1.0 to 0,for a standard reading distance of 32 centimetres. Dr Sandoval asked her patients to read with both eyes,at a distance of 32 centimetres,at a constant chart luminance of 80-100 cd/mÇ as measured with a light metre.She instructed patients to read out loud a selected,marked paragraph,for each of eight different font sizes,and to read without correcting any reading error,starting from the largest to the smallest font. The trial included 44 patients and compared functional near and intermediate vision and patient satisfaction in patients after bilateral cataract surgery with phacoemulsification and IOL implantation. Dr Sandoval divided the participants into three groups based on the type of IOL implanted.Group A received mix/match (ReZoom (AMO)/ReSTOR (Alcon)),and had an average age of 65.7 years.Patients in Group B received bilateral ReSTOR,and had an average age of 66.9 years.Group C received blended ReSTOR (ReSTOR/ReSTOR blended) and had an average age of 66.6 years.In group C the target for postoperative refraction was plano for the dominant eye and -1D for the non- dominant eye. The investigators had two control groups; one was comprised of phakic patients aged under 35 years and the other of pseudophakic patients over 60 years. Dr Sandoval evaluated bilateral near and intermediate vision without correction and wearing the best distance correction using the NPReading test.Reading speed in words per minute at the different font sizes was compared among the groups. Uncorrected near and intermediate vision were quite similar.Group A achieved an average 179.8 words per minute and 173.3 words per minute at near and intermediate ranges respectively.Group B read 183.3 words per minute at near and 174.6 words at intermediate distances.Group C read 179.3 and 172.7 words per minute,for uncorrected near and intermediate vision, respectively. With best correction,reading speed to 189.2 and 169.0 words per minute, respectively in the ReZoom/ReSTOR group. Bilateral ReSTOR patients with best distance corrected near vision recorded190.9 words per minute and best distance corrected intermediate vision 168.8 words per minute. The blended ReSTOR group achieved 172.5 and 153.5 words per minute in best distance corrected near and intermediate vision, respectively. Percentages of patients able to read different font sizes without correction showed difficulty at font sizes of 0.7 (20/30) and 1.0 (20/20).The bilateral ReSTOR group (Group B) performed best,reading over 70 per cent,with only the under-35 control group achieving a better score of 100 per cent.The number of patients that were able to read decreased as the font size decreased, Dr Sandoval noted. Patients who were able to read different font sizes with best corrected vision again revealed a decrease in the ability to read the smallest two font sizes,0.7 and 1.0,with bilateral ReSTOR again showing the best performance at font size 1.0. Overall,patient reading results formed a similar inverted U-shaped pattern,Dr Sandoval said. Functional near and intermediate vision of the patients in Group B was slightly better when compared to the patients in group A and C.The combination of bilateral ReSTOR was best for reading fine print,she said. Dr Sandoval and her colleagues developed this new reading test because in reviewing peer- reviewed literature it became apparent that visual acuity tests were not representative of the vision that patients actually achieved,but overstated the results.In fact, most patients treated for presbyopia achieve between J1 and J3,she noted. “Why does the data always look better than the actual procedure? Patients who achieve good scores say that they cannot function all that well in real life.The answer is that maybe we are not obtaining the correct information,” she said. Current tests include Snellen visual acuity tests and near vision charts that use random letters or numbers.Measuring visual acuity by chart testing still has some limitations,such as variations in testing and ending procedures,restrictions of numbers and sizes of optotypes,and optotype memorisation. For new presbyopia treatments,however, testing one’s ability to read letters does not represent reading or functional vision,she noted. Other reading tests,such as the MNRead Acuity chart and the Radner reading charts have been used in clinical studies to demonstrate reading performance in relation to refractive errors,cataract,multifocal IOL systems,and maculopathy.They are,however, similar to visual acuity charts,using black letters on a backlit high contrast background. sandoval@musc.edu 23 Helga Sandoval Bilateral ReSTOR scores best results according to the NPReading Test Refractive Lens “The truth is not always in the numbers. We need to measure and evaluate the criteria that are important to our patients. We must have realistic goals and expectations, which is critical with increasing refractive lens surgery for presbyopia” “Why does the data always look better than the actual procedure? Patients who achieve good scores say that they cannot function all that well in real life. The answer is that maybe we are not obtaining the correct information”

Cheryl Guttman in Fort Lauderdale INITIAL clinical trial results suggest monocular placement of the PresbylensTM Corneal Inlay (ReVision Optics) is a promising method for treating presbyopia in emmetropic patients who are tolerant of monovision. The inlay is designed for intrastromal placement in the non-dominant eye to provide monocular near vision and bilateral distance vision.Inlay implantation recontours the central anterior corneal surface and increases the central power while leaving the peripheral corneal curvature nearly unchanged.A paracentral intermediate zone is also created as a result of corneal flap draping over the outer margins of the inlay and patients may benefit with some improvement in intermediate vision. At the annual meeting of the Association for Research in Vision and Ophthalmology,visual acuity outcomes were reported from 33 patients,of whom 32 were seen at three months.All patients had the intracorneal inlay implanted under a LASIK-style flap. The patients benefited with rapid and significant improvement in monocular and binocular near UCVA.UCVA at distance was relatively well maintained in the treated eye,and binocularity was excellent and superior to that expected with a conventional monovision treatment, reported Keith Holliday PhD,vice- president,research and development, ReVision Optics,Lake Forest,CA. “We are continuing our clinical development and follow-up in this study is ongoing to evaluate longer term safety and efficacy.We look forward to even better outcomes with respect to predictability and maintenance of distance vision in the treated eyes through future refinements in the technology and surgical technique.However,we are very pleased with these initial results,” he said. The inlay is constructed of a biocompatible hydrogel material that has the same index of refraction as the cornea.It has a meniscus shape and measures 1.5mm in diameter and is less than 50 microns thick. The clinical study evaluating the inlay is under way in Mexico where Arturo Chayet MD,Tijuana,Mexico,and Enrique Barragan MD,Monterrey,are the investigators. “Inlay technology is very promising and my current patients are among the first to benefit from ReVision Optics monocular treatment for emmetropic presbyopes. Together we have developed the right combination of lens design,inserter engineering,and surgical technique.My patients’ near vision improves and small changes in distance vision have rarely caused problems.This results in most patients reporting an improvement in quality of life,” Dr Barragan told EuroTimes. Initial study eligibility criteria allowed enrolment of patients with near UCVA of 20/40 or worse and distance UCVA of 20/32 or better,although the protocol was subsequently modified to require near UCVA worse than 20/40.In addition, patients must have no more than 0.5 D of cylinder and demonstrate tolerance to monovision in a screening trial. The mean age of the 33 patients in the study was 50 years.Preoperatively,they had a mean SE of +0.27 D (range -0.25 to +0.87) and a mean near add of +1.9 D (range +1.25 to +2.5). In monocular vision testing, preoperative UCVA at near in the treated eye ranged from 20/40 to worse than 20/100,with almost half of the eyes seeing 20/80 or worse.At three months,60 per cent of eyes achieved near UCVA of 20/25 or better and the group gained an average of 3.6 lines at near.Ninety-seven per cent of eyes had near UCVA of 20/40 or better,and in binocular testing 90 per cent could see 20/32 or better at near. “Almost all of the improvement in near vision was achieved by the first day after surgery,and so like LASIK,this procedure has the benefit of rapid visual rehabilitation,” noted Dr Holliday. In the treated eye,patients lost an average of 1.5 lines of distance UCVA, although 45 per cent of eyes achieved 20/25 or better and two-thirds could see 20/32 or better. “The vast majority of patients are retaining 20/40 or better distance vision in the treated eye.While a few patients had some loss,binocular distance UCVA has not deteriorated significantly,” noted Dr Holliday. In binocular testing,79 per cent of patients achieved distance UCVA of 20/20, 91 per cent were seeing 20/25 or better, and all are 20/32 or better. Results from preoperative defocus blur measurements also showed the inlay procedure provided significantly better binocular distance vision compared with what would be achieved using conventional monovision correction for presbyopia.With +2 D of correction, which was associated with near vision of 20/20 or better in all eyes,monocular distance vision ranged from 20/50 to 20/200 and was 20/80 or worse in about three-fourths of patients. “Distance vision in the treated eye in the small minority of patients who represent the worst case PresbylensTM outcomes was about equivalent to the best case scenario for monovision,” noted Dr Holliday. In the clinical study,near BCVA was 20/25 or better in 100 per cent of eyes preoperatively and in 97 per cent postoperatively.BCVA at distance was 20/32 in all eyes preoperatively and postoperatively.In addition,there have been few problems with haze,adverse tissue reactions or visual symptoms such as glare or haloes.The lack of these complications can be attributed to the inlay’s biocompatibility and index of refraction,he said. New placement technique Of the 33 patients in the clinical study,22 had the flap created with a mechanical microkeratome and 11 had a femtosecond laser-created flap.One strategy being investigated to achieve better results in the future is to introduce the inlay into an intrastromal pocket using a shooter device. “The pocket has several theoretical advantages relative to a flap.It would be associated with better preservation of corneal and corneal nerve integrity,and it is expected to improve inlay positioning. Early experience indicates that outcome predictability is improved with this technique,” Dr Holliday told EuroTimes. There have not been problems with inlay migration in eyes with placement under a flap,but rather there have been a few cases where the device was not precisely centred over the constricted pupil intraoperatively.The pocket technique is expected to minimise this problem. “We’ve found that patients can still do well visually if the inlay is as much as 1.0mm off from the target position.With poorer centration,corneal curvature is changed outside of the pupillary area.In that situation,there is no harm optically, but the patient does not derive any near vision effect,” Dr Holliday explained. 26 Inlay procedure targets presbyopia correction for emmetropes Refractive Lens Expert Online SupportEuropean Society of Cataract & Refractive Surgeonswww.escrs.org

Cheryl Guttman in Hong Kong REFRACTIVE laser surgery represents a viable long-term solution for the treatment of refractive errors in appropriately selected paediatric patients,reported William F Astle MD at the 2008 World Ophthalmology Congress. Dr Astle,professor of surgery (ophthalmology),University of Calgary, Alberta,Canada,together with Peter T Huang MD,began performing laser surgery to treat anisometropia and congenital high myopia in children more than nine years ago.Their experience over that time encompasses 287 eyes of 188 patients who ranged in age from 10 months to over 17 years at the time of surgery. Initially,treatment was performed using PRK and was limited to children who had large refractive errors and associated developmental/health issues that made it impossible for them to wear glasses and/or contact lenses.Subsequently,they transitioned to LASEK and expanded the candidate pool to include normal children with anisometropic amblyopia who failed previous traditional treatment. Dr Astle presented analyses of long-term follow-up (3.5 years or more) based on 56 eyes of 39 patients.He also reviewed one- year outcomes of 56 children treated for anisometropia.The results showed reasonable stability of refractive outcomes, no safety concerns,and benefits that included gains in vision,stereopsis,and binocular fusion accompanied by improved psychosocial functioning. “We have been very excited by the outcomes achieved through our innovative work performing laser surgery in children who could not use or had failed traditional methods of refractive correction. Furthermore,over a lifetime,laser surgery may be less expensive than glasses,contact lenses,and other treatments.Based on our experience,we believe laser refractive surgery is something that all clinicians should consider for paediatric patients who cannot be managed with traditional therapies,” commented Dr Astle,who is also director of the vision clinic,Alberta Children’s Hospital,Calgary. Dr Astle,Dr Huang and colleagues have published five papers in the Journal of Cataract & Refractive Surgerydescribing their experience with paediatric laser refractive surgery.All procedures were performed under general anaesthesia in a non-hospital surgical facility using either a laryngeal mask or nasopharyngeal airway for airway maintenance. “Initially,we received a lot of criticism for performing this surgery.However,based on our large experience,we can conclude the anaesthesia technique is standard and safe,” Dr Astle told EuroTimes. The 39 patients included in the long-term analysis had a mean age of 6.5 years at the time of surgery (range 10 months to 17.4 years) and were followed for a mean of 5.15 years (range 3.5 to 7.8 years).Of the 56 eyes,27 were treated with PRK and 29 with LASEK. In all eyes,preoperative SE ranged from +1.75 D to -27.0 D with a mean of -10.4 D. Mean SE at last follow-up was -1.73 D (range -9.50 to +2.25 D). Among patients treated with PRK,mean SE was reduced from -11.9 D preoperatively to -3.20 D at last visit.In the LASEK cohort,mean SE was -9.01 D preoperatively and -1.37 D at the last visit. Refraction was relatively stable,although a little better after LASEK than PRK. However,there was some myopic shift over time,and 43 per cent of eyes received a second laser treatment for myopic regression at a mean of 26 months postoperatively. “There is still some room for improvement in outcomes,but the second surgery was effective in achieving refractive stability over time.Still,these data highlight the importance of informing families of the possibility of needing additional surgery in the future,” Dr Astle said. At last follow-up,SE was within 3 D of the refractive target in 77 per cent of eyes, while achieved SE was within 1.0 D in 45 per cent of eyes and within 2.0 D in 66 per cent of eyes. Vision outcomes were favourable, although Dr Astle noted that in this population including many children who are very young and/or have disabilities, obtaining an objective measure of vision is difficult.Among 28 evaluable eyes,there were no losses of BCVA,and 12 eyes had an improvement ranging from 1 to 7 lines (mean 1.6). Stereopsis also improved with an increase of 31 per cent in the proportion of patients with measurable stereopsis from seven patients (18 per cent) preoperatively to 19 patients (49 per cent) postoperatively.There were no cases of loss of binocular fusion. Trace haze developed in 10 eyes,was less common after LASEK compared with PRK, but resolved in all cases. “When we were performing PRK originally,corneal haze was our only ‘major’ complication.In terms of severity,it was relatively minor,but we switched to LASEK and now perform LASEK exclusively,” Dr Astle said. LASEK was performed in all 53 patients who were included in the analysis of one- year outcomes after treatment for anisometropia.These patients were no longer responding to traditional therapy and were selected for laser surgery based on evidence-based guidelines for amblyogenic risk factors published in 2006. The patients ranged in age from 10 months to 16 years.Preoperatively they had a mean refractive difference between eyes of about 7.0 D that was reduced to 1.81 D at one year.Subgroup analyses showed the refractive difference between eyes was reduced from 9.48 D to 2.43 D in 31 patients treated for myopic anisometropia, 3.13 D to 0.74 D in 19 patients with astigmatic anisometropia,and from 6.98 D to 1.81 D in three patients with hyperopic anisometropia.At one year,80 per cent of patients maintained a refractive difference between eyes within 3 D,and in about two- thirds of patients,the LASEK-treated eye was within 2 D of the fellow eye. “Preoperatively,these patients were stuck at a point where vision was in the 20/60 to 20/80 range.Theoretically,the treatment brought them to a situation where their vision could start to improve,” Dr Astle said. Consistent with that concept,in 33 eyes that could be evaluated for vision,64 per cent had improved BCVA at one year while none showed worsening.In addition, whereas 58 per cent of children had no stereopsis of any kind pre-LASEK,the majority were seeing better and had improved fusion.At last visit,stereopsis was absent in only 12 per cent of children. In the anisomyopic group,there was some myopic shift between two months and one year;the mean refractive difference was 1.09 D at two months and increased to 2.43 D at one year.In the anisoastigmatic group,there was only a 0.1 D mean change in refractive difference comparing the month two and month 12 results. “The greater shift in the anisomyopic group probably relates more to the fact that these children’s eyes are still growing rather than being a true myopic shift after laser treatment.Therefore,it makes inherent sense that the anisoastigmatic group showed better refractive stability,” Dr Astle said. In order to gain additional insight into the benefits of the treatment,parents were asked to complete a quality of life questionnaire.Their responses showed significant improvement overall in the children’s behaviour and ability to function in their environment.The majority of parents noted improvements in posture, frustration/stress level,self-confidence, walking/mobility,and balance in sitting and standing.There were no reports of any negative changes. “Parents indicated their children started feeding independently and autistic-like behaviours improved.Almost all families,92 per cent,said they would recommend LASEK for other children,” said Dr Astle. william.astle@calgaryhealthregion.ca 28 “Based on our large experience, we can conclude the anaesthesia technique is standard and safe” Long-term experience supports value of laser refractive surgery in children Refractive Laser

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

Roibeard O’hEineachain in Liverpool THE benefit obtained from reducing moderately elevated IOP to low-target levels in glaucoma patients remains controversial and surgeons should therefore be cautious about performing invasive procedures which may do more harm than good,said Peter K Wishart FRCOphth,St Paul's Eye Unit,Royal Liverpool and Broadgreen University Hospital,Liverpool,UK. Speaking at the Royal College of Ophthalmologists Annual Congress,Dr Wishart emphasised that the ultimate goal of glaucoma treatment is not the lowering of IOP but the preservation of vision.He added that,contrary to an oft-promoted view,the many landmark studies published over the past decade do not make clear what level of IOP is safe for the eye,or even that the visual prognosis of glaucoma patients with lower IOP will necessarily be better than that of those with higher IOP. “All of these studies have cost upwards of $60m each and yet they haven’t answered the question of what a safe level of IOP is.That is because glaucoma is a progressive disease and its progression is non-linear.A period of stability may be natural and when we recruit patients to a trial we don’t know whether they are in a quiescent phase of the disease,” he said. He noted,for example,that in the OHTS study IOP-reducing treatment appeared to reduce the incidence of glaucoma among ocular hypertensives by about half,from 9.5 per cent to 4.4 per cent.However,that interpretation depends on a fairly loose definition of glaucoma. That is,in 55 per cent of cases the OHTS researchers made the finding of conversion based on disc photo deterioration alone, without field loss.But if one were to base the finding of glaucoma on both disc deterioration and field loss,as is traditional, one would find no significant difference between the treatment and no treatment groups,which had conversion rates,on that basis,of around eight per cent and 10 per cent,respectively,Dr Wishart pointed out. Low-target IOP called into question Meanwhile,the results of the Advanced Glaucoma Intervention Study (AGIS) appear at first glance to suggest that visual field progression did not occur in glaucoma patients who had an IOP of lower than 18.0 mmHg at all visits during a nine-year follow- up.However,it was the mean of the visual field scores that did not change in those patients.The 15 per cent of patients who got better in that group balanced out the 15 per cent who got worse,Dr Wishart noted. Moreover,the AGIS authors themselves maintained that,based on their study’s results,keeping IOP below 18.0 mmHg does not ensure visual field preservation. Furthermore,a linear regression analysis of the study data by AGIS investigator,Joe Caprioli MD,showed no correlation between mean IOP and visual field loss. And while the Early Manifest Glaucoma Trial (EMGT) famously showed that for every millimetre of mercury of IOP reduction there was a 10 per cent reduced risk of progression,IOP-lowering treatment ultimately only reduced the rate of progression from 62 per cent on no treatment to 45 per cent on treatment after six years. Furthermore,in the Collaborative Initial Glaucoma Treatment Study (CIGTS) – which compared outcomes with trabeculectomy and medication as first-line treatments – the mean IOP was two to three millimetres of mercury lower in surgical group than it was in the medical group,and yet during the first three years of treatment the rate of substantial visual field loss was higher in the surgery group. “George Spaeth MD,a CIGTS investigator,has pointed out that CIGTS showed no relationship between field loss and IOP below 30.0 mmHg.Above 30.0 mmHg there was a link but not below 30 mmHg,” he added. There are also several less often discussed studies which failed to demonstrate that achieving a low-target IOP will prevent glaucoma progression.For example,in the Moorfields Primary Treatment of Glaucoma trial,newly diagnosed patients had the same rate of visual field loss whether they underwent surgery and achieved a mean pressure of 14 mmHg or received medicine and achieved a mean pressure of 19 mmHg when tested with automated perimetry. In another study (Parc et al,AJO 2001; 132:27-35),eyes that retained vision over a 20-year follow-up period following trabeculectomy had a higher mean IOP than that of those that went blind following the procedure. Trabeculectomy – a hazardous option Trabeculectomy with mitomycin-C has been the treatment of choice for over a decade in both the UK and the US for treating glaucoma patients who do not achieve their target IOP with medication,Dr Wishart noted.However,the complications of such procedures can cause considerable loss of vision in some patients,many of whom might otherwise have had unchanged vision for years or even decades,he pointed out. For example,the one-year results of the tube versus trabeculectomy study showed that both tube shunts and trabeculectomy resulted in dramatic decreases in IOP.But in the trabeculectomy group,two per cent had blebitis and one per cent had endophthalmitis within a year,45 per cent showed cataract progression,10 per cent had flat anterior chambers,11.0 per cent had leaking blebs,and 3.0 per cent had hypotony maculopathy. In addition,over 60 per cent of eyes in the trabeculectomy arm of the trial required secondary invasive interventions such as needling,suture lysis,flat anterior chamber reformations,5 FU injections and mitomycin-C injections,all of which entail their own complications,including blebitis, which can be a precursor to endophthalmitis. Dr Wishart noted that there are an estimated 5,000 cases of bleb-related endophthalmitis per annum in the US,and a review of 49 eyes with late onset bleb- associated endophthalmitis carried out at the Bascom Palmer Institute in Miami Florida showed that 35 per cent ended up with no light perception,including the 22 per cent which underwent enucleation or evisceration (Song et al,Ophthalmology, 2002;109:985 – 991). “This is not like post-cataract surgery endophthalmitis,which people pretty much can fix nowadays,bleb-related endophthalmitis remains a visual disaster,” he said. Non-penetrating procedures safer Non-penetrating procedures,such as deep sclerectomy and viscocanalostomy,provide IOP reduction comparable to trabeculectomy with fewer complications in eyes with primary open-angle glaucoma. However,many glaucoma surgeons have been reluctant to adopt such techniques, partly because they can be difficult to master at first and partly because non- penetrating procedures did not produce as good results in the early studies. In more recent trials,non-penetrating surgery has consistently lowered IOP to the lower teens in open-angle glaucoma patients,with no incidence of hypotony or endophthalmitis and no apparent increased risk of cataract.But since there have as yet been no large-scale randomised controlled trials directly comparing trabeculectomy with non-penetrating procedures,many surgeons remain wary of the newer techniques. However,Dr Wishart argued that large randomised trials involving large numbers of patients undergoing trabeculectomy would be unethical in view of the procedure’s proven rate of complications and unproven efficacy in preventing blindness. “My take-home message is this,we don’t know what the safe pressure is,but when we want to get the pressure down let’s end the tyranny of the bleb and let’s move to safe surgery,like deep sclerectomy and viscocanalostomy,” he added. peter.wishart@rlbuht.nhs.uk 30 Peter K Wishart Value of low-target IOP in glaucoma patients open to question Glaucoma Update The picture shows on the left ‘an infected trabeculectomy drainage bleb’ with, on the right, ‘endophthalmitis of the same eye with hypopyon’

Dermot McGrath in Vienna USING the anti-VEGF agent pegaptanib sodium (Macugen,Pfizer) as a primary treatment for choroidal neovascularisation secondary to age-related macular degeneration (AMD) may result in better visual outcomes than those reported in previous clinical trials of the drug,according to a study presented here. “In our pan-European audit,patients treated with pegaptanib sodium experienced visual acuity outcomes superior to those reported in the VISION trial despite the application of a PRN (as needed) dosing schedule,” said Sobha Sivaprasad FRCS, Medical Retina Service,Moorfields Eye Hospital,United Kingdom. Addressing the annual meeting of the European Society of Retina Specialists (EURETINA),Dr Sivaprasad said that Macugen had been licensed for the treatment of neovascular AMD in Europe in early 2006 based on the results of the VEGF Inhibition Study in Ocular Neovascularisation (VISION) trial. The VISION trial,a randomised, controlled,double-masked study of 1,200 patients with subfoveal neovascular AMD, showed that intravitreal injections of 0.3mg pegaptanib sodium every six weeks resulted in a stabilisation of vision (defined as a loss of less than 15 letters after 54 weeks) for 70 per cent of patients.Six per cent of patients gained 15 letters of vision versus two per cent of patients receiving usual care,she said. To compare the VISION trial results with real-life clinical experience,Dr Sivaprasad and colleagues carried out an audit and retrospective chart review of 256 patients treated with Macugen in eight European countries:Czech Republic,Germany,Ireland, Italy,Portugal,Spain,Turkey and the UK. The study included consecutive patients with any angiographic subtype of neovascular membranes and a best- corrected visual acuity of between 20/40 and 20/800 in the study eye.This compared to BCVA range of 20/40 to 20/320 in the VISION trial.All patients received 0.3mg of Macugen as first-line treatment every six weeks at baseline for two cycles followed by PRN dosing at subsequent evaluations through week 24.A total of 256 patients completed at least six months of follow-up, and data at 54 weeks was reported for 70 patients. Focusing on the baseline ocular characteristics,Dr Sivaprasad noted that 180 patients presented with occult membranes,37 with minimally classic and 39 predominantly classic,with a mean visual acuity of 46.9 letters. Improvements in visual acuity occurred within six weeks and were maintained throughout the evaluation period,said Dr Sivaprasad.Vision loss stopped by week six in around 93 per cent of patients and that visual acuity remained stabilised through week 24.The researchers found no variation in the rate of response according to CNV subtype. The chart review of the 240 patients showed that 93 per cent lost less than or equal to 15 letters at 24 weeks,73 per cent gained zero to five letters,36 per cent gained five or more letters,20 per cent gained 10 or more letters and 11 per cent gained more than 15 letters.Of the 70 patients who were evaluated at one year,91 per cent lost less than or equal to 15 letters,71 per cent gained zero to five letters,27 per cent gained five or more letters,16 per cent gained 10 or more letters,and nine per cent gained 15 or more letters. Summing up,Dr Sivaprasad said that the results showed that Macugen was performing better in real-life scenarios than previously published clinical trial data. “Despite the restrictions of this audit and despite the fact that retinal specialists used a PRN dosing scenario,this cohort of patients showed a 93 per cent response to treatment and 11 per cent of patients gained vision at six months and 8.6 per cent at 12 months.These real-life visual acuity findings,with investigator-determined pegaptanib use,are more favourable than those previously reported in the literature,” she said. Dr Sivaprasad noted that the results should be treated with some caution, however,as the data only included those patients who were initiated and maintained on Macugen alone.“In real life,we know that there are patients who have been switched from Macugen to other forms of therapy during the course of their treatment,and those patients have not been included in this audit,” she said. 31 Pegaptanib sodium shows better results in real-life scenarios Retina Update

Dermot McGrath in Vienna REFRACTIVE surgeons need to be aware of the potential for serious retinal complications arising from performing refractive surgery,and especially LASIK procedures,in certain high-risk cases, according to Thomas J Wolfensberger MD. “Looking at the overall scientific evidence,we can highlight some relative contraindications for LASIK surgery. Surgeons should be particularly wary of patients with high myopia and lacquer cracks,angoid streaks,traumatic choroidal ruptures,stage-one macular holes and ischemic retino- and neuropathies,” said Dr Wolfensberger,Jules Gonin Eye Hospital, Lausanne,Switzerland. Presenting an overview of the posterior segment complications associated with refractive surgery,Dr Wolfensberger told delegates attending the annual meeting of the European Society of Retina Specialists (EURETINA) that such complications can be related to two broad categories of surgical interventions:intraocular and extraocular. Focusing initially on intraocular procedures,Dr Wolfensberger noted that clear lens extraction is one of the oldest known forms of refractive surgery,with a provenance dating back to Japan in the 19th century.Complications associated with lens extraction include a rate of posterior vitreous detachment of up to 16.3 per cent and possible consecutive retinal detachment of 8.1 per cent over a seven-year period,he said. Turning to phakic intraocular lenses,Dr Wolfensberger said that various studies of the implantable contact lens (ICL) show a retinal detachment rate of between 0.8 and 2.0 per cent with a follow-up of between 11 to 28 months for this type of IOL. “It appears that the incidence of retinal detachment is below the average incidence of retinal detachment as part of the natural history in similarly myopic eyes,” said Dr Wolfensberger. He noted,however,a case study in the scientific literature that described a patient with a giant retinal tear one month after ICL implantation. “The likely explanation for this complication is that if you implant an oversized ICL it may irritate the ciliary body and induce inflammation with peripheral contraction of the vitreous and consecutive retinal detachment due to the giant retinal tear,” he said. For anterior chamber phakic IOLs,Dr Wolfensberger said that the reported retinal complication rates of between 0.6 per cent and 0.8 per cent are well within the range of the natural history. Turning to extraocular procedures,Dr Wolfensberger said that there is very little reliable data to suggest an increased risk of retinal detachment in patients who have undergone either radial keratotomy or PRK. “It was really only when LASIK came on the market and became the refractive procedure of choice that surgeons began to look at the possible vitreoretinal complications in greater detail,” he said. Dr Wolfensberger cited a study by Faghihi et al in Tehran in 2006 that found a cumulative incidence of retinal detachment of just 0.082 per cent and a yearly incidence of 0.032 per cent in over 59,000 LASIK patients.Male sex,older age,and higher preoperative myopia were significantly related to the incidence of rhegmatogenous retinal detachment after LASIK,the authors concluded,although there was no evidence that the incidence of detachment was increased by the LASIK procedure itself. Another experimental study by Chris Flaxel suggested that the proposed mechanism of retinal tears after LASIK may be due to the application of the suction ring during flap creation. “The study authors concluded that the axial length increases with anterior displacement of the vitreous base during suction ring placement,which might predispose susceptible eyes to anterior retinal tears during and after LASIK,” said Dr Wolfensberger. The hypothesis was backed up by a further study by Mirshahi and Kohnen that found that the crystalline lens thickness decreases during application of the microkeratome suction whereas the vitreous distance from the posterior lens capsule to the posterior pole increases, suggesting anterior traction on the posterior segment. Dr Wolfensberger cited another study by Luna et al which showed a clear difference in ultrasound B-scans of the posterior vitreous before and after LASIK. “The authors induced a posterior vitreous detachment in over 24 per cent of cases.A further experimental study in porcine eyes by the same group produced similar results and showed again that there is a lot of movement in the globe during LASIK procedures,” he said. Putting all the available data into perspective,Dr Wolfensberger said that there is no evidence to show that patients who have undergone LASIK are at a higher risk of retinal detachment than the general population. Shaking the tree “I think the analogy of the apple tree explains the situation succinctly.If one waits long enough the apple will eventually drop from the tree without any intervention from the person underneath.However,if the person shakes the tree,the apple will drop much quicker.And this is really what happens during LASIK with posterior vitreous detachment – the surgeon is simply triggering something that would have happened anyway,” he said. While prophylactic laser treatment of peripheral retinal pathologies such as lattice degeneration has been advocated,Dr Wolfensberger said that the success of such treatment is limited since most retinal detachments arise from breaks in a retina that appears clinically normal but with an irregularly shaped insertion of the posterior edge of the vitreous base. Ischemic optic neuropathy is another complication to be aware of,said Dr Wolfensberger,and may be caused by the intraocular pressure spike that occurs during LASIK flap construction.Other potential problems related to increased IOP during LASIK include retinal haemorrhage,deep retinal haemorrhage, Valsalva-like retinopathy,lacquer cracks,and choroidal neovascular membranes. Dr Wolfensberger warned that surgeons who attempt refractive surgery after retinal detachment may be “wading into very deep waters indeed” and should proceed with extreme caution. “You may not have enough suction because the conjunctiva is scarred in a way that prevents you putting the suction ring on p